March 27, 2025 • 29 mins
In this popular episode, Dr. Talat Uppal, an obstetrician-gynecologist specialising in heavy menstrual bleeding, shares her expertise on a condition affecting one in four women yet rarely discussed openly.
This eye-opening conversation sheds light on how women often normalise suffering through periods that drastically impact their quality of life.
The discussion reveals shocking statistics: 25% of women experience heavy menstrual bleeding, yet more than half never seek medical help.
Dr. Uppal provides clear indicators of abnormal bleeding – passing large clots, changing protection every 1-2 hours, waking at night to change, using multiple protection types simultaneously, and embarrassing "flooding" episodes. These symptoms can lead to iron deficiency, anaemia, and significant quality of life impacts.
Learn about the spectrum of treatment options, from medications like Tranexamic Acid to the highly effective Mirena IUD and surgical interventions including endometrial ablation. She emphasises that most women find significant relief once properly treated, with many asking, "Why didn't I have this earlier? Why did I suffer so much?"
Perhaps most powerful is the exploration of how heavy bleeding becomes normalised at multiple levels – by women themselves, healthcare providers who don't offer full treatment options, and society that suggests women should simply endure until menopause. This normalisation condemns many to years of unnecessary suffering when effective solutions exist.
The conversation offers practical advice for women seeking help, emphasising the importance of advocating for yourself and being knowledgeable about available options.
Have you been suffering in silence? This conversation might be the catalyst for transforming your quality of life. Listen, learn, and advocate for your menstrual health.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Sonya (00:01):
Welcome to the Dear Menopause podcast, where we
discuss the menopause transitionto help make everyday life a
little easier for women.
Hi, my name is Sonya and I amyour host of Dear Menopause.
Today, I have a very specialguest with me, Dr Talat Uppal.
Talat is an obstetriciangynecologist specializing in
(00:25):
heavy menstrual bleeding.
This is an area I did not knowa lot about, so I found our
conversation absolutelyfascinating.
If you're a woman and youmenstruate, this is an episode
that you will find absolutelyfascinating.
Talat, welcome to DearMenopause.
Talat (00:43):
Thank you so much for this opportunity, Sonya, and
what wonderful work you do.
Sonya (00:49):
Oh, thank you.
Now.
Today we are going to have ajuicy conversation about
menstrual bleeding, but yourspeciality is heavy menstrual
bleeding, so would you like togive us a little bit of an intro
on who you are and the workthat you do?
Talat (01:09):
Thanks, Sonya.
So I'm a gynaecologist that'sbased in the northern beaches of
Sydney and I have an interestin clinical education as well,
particularly general practiceand primary care-based education
, because I think they doamazing heavy lifting in women's
health space, amazing heavylifting in women's health space.
(01:30):
I also am trained in ultrasoundand I have set up a
organization called Women'sHealth Road, which is a medical
center, sonya, and it's locatedopposite the Northern Beaches
Hospital and it's like acollaborative, multidisciplinary
team.
So we're kind of a little bitmore holistic in our approach
and we value, for example,mental health or the expertise
of physio, allied health.
So it's quite a well-roundedteam and, like you mentioned my
(01:54):
interest, my primary interest,is management of women with
abnormal bleeding andparticularly heavy menstrual
bleeding.
Sonya (02:01):
I love your multidisciplinary team.
I think it's absolutelywonderful to think that we can
have a model for healthcare,particularly for women because
that's where my passion liesthat does offer so many of the
services that can be so hard togo out and find, because I know
you've got Penny Hanlon workingwith you as a physio and penny
(02:22):
is amazing at women's pelvicfloor health as a
physiotherapist and it can bereally hard for women to find a
physio that does specialize in,um, you know, women's pelvic
floor health.
So to have a kind of thisone-stop clinic where women can
get, like you say, the mentalhealth support, the physio
support, you know I think you'vegot at least one great.
(02:44):
GP on board as well.
Yes, yeah, I really, reallyhope that this is a model that
we can see rolling out, you know, across the country for more
women.
So thank you for setting thatup.
Talat (02:55):
Thank you, sonya.
I agree that these are thestandards that women deserve and
should access, and I havehonestly learned so much from my
peers.
I think that those days of justa specialist with 40 patients
and just one person seeing arelong gone.
The future of health iscollaboration, and we all bring
a unique skill and talent thatadds to the woman's journey if
(03:19):
she wishes to reach out.
And what I like about suchmodels is that it allows women
to decide well, what part of myhealthcare that I'm being
offered is more important for meto prioritize and what package
should I individualize for me asa person.
Sonya (03:34):
Yeah, so important to put that patient front and center.
I love that so much.
Okay, so onto our topic.
Can you give us a descriptionand an understanding for someone
like me that has neverexperienced heavy menstrual
bleeding?
What defines heavy menstrualbleeding over what I would
consider a normal period?
Talat (03:53):
So excellent question, sonia.
There are two concepts.
First of all, heavy menstrualbleeding is basically we need to
sort of gauge it againstquality of life in the first
instance, and quality of lifefor women.
Sonia has been so undervaluedfor so long really, and quality
of life, as you well know, is avery broad spectrum of facets.
(04:15):
So it includes her physicalwell-being, it includes her
emotional well-being, itincludes your you know social
well-being and it also includesyour material well-being.
So there's a productivity know,social well-being and it also
includes your materialwell-being.
So there's a productivity issuewhen we're talking about heavy
menstrual bleeding, because weall know women who either are
unable to focus at work or haveto take time off, etc.
So that's one way of looking atit, which you know.
(04:40):
If these periods are affectingme in some way, then it is a
problem, and the other way,obviously we need to have some
flags or what could guide us, orwhat are the clues that these
periods may be heavy, and thesecould include look, am I passing
clots that are, for example,bigger than 50 cent pieces?
Am I changing my sanitaryprotection every one to two
(05:03):
hours?
Am I having to wake up at nightto change my sanitary
protection?
Am I having to use multipletypes?
Women tell me they've used twoor three different types of
sanitary protection.
That's not normal.
Or have I had episodes offlooding through my clothes,
which can obviously be veryembarrassing?
Or, sonia, because they'rehaving such heavy losses, then
(05:25):
women may become iron deficientor may have anemia, and so then
they would get dizziness,tiredness, profuse tiredness
sometimes, and they might havepalpitations.
So you get another cohort ofsymptoms that are actually
because of the losses that theyhave had.
Sonya (05:43):
I wonder if there are.
You will be able to confirmthis.
There are women that experienceheavy menstrual bleeding or
menstrual bleeding that'soutside of the norms, but they
don't know that it's actuallynot normal because that's the
only thing they've ever known,and we don't talk about our
periods.
We don't necessarily haveconversations about menstrual
(06:04):
bleeding to say, hey, this iswhat you should expect If you're
experiencing this, that's notnormal, Seek some help.
So I wonder how many women youcome across that have been
experiencing this and not soughthelp for it?
Talat (06:17):
Sonya, this is my weekly reflection because every week I
sit down and I think how and youcan imagine, sonya, that I work
in Northern beaches Often womenI'm caring for I think really
proactive ownership of theirhealth.
They are worrying about theirdiet, they're taking care of
their exercise regime, but stillI reflect that their health
(06:38):
literacy, for many women that Ilook after, is actually quite
basic.
When it comes to menstrualhealth and I know that you know
there's that concept around 28day, five day periods, but there
is a variation in normal and Ithink, like you rightly pointed
out, there can be a big struggleand trivialization of symptoms,
(06:58):
and so we kind of do say, look,if your periods are lasting
longer than seven days, but thensome women are bleeding so
heavily, so because there arethose two, three concepts of are
your period cycles comingaround more frequently, which
often happens at the start ofperimenopause is the volume
heavier?
Or and or, and these are alland or situations, because
(07:19):
obviously if she's bleeding formore than seven days, then you
know she's going to bleed morevolume and so therefore that's
heavy as well.
So I think that there isconstantly trivialization or
minimization of symptoms bywomen and I feel that they're
just resilient.
We women are just so resilient,we're used to juggling so many
(07:39):
things, we're just used toputting up with things, and so
that sort of philosophy carrieson in menstrual well-being and
they just say, oh well, you know, this must be normal.
And then, sonya, it's not justthe women themselves,
unfortunately, even though wehave excellent clinicians and I
think that a lot of cliniciansdo amazing work unfortunately
there are people, when women goto them as clinicians, who will
(08:03):
just say, oh, they're there togo away, or will sort of
reassure them but not actuallyproactively offer them the full
suite of management options thatare available.
And then, third level ofnormalization of abnormal
periods is by society.
So they might have an auntiethat says, oh, oh, hang on, I
(08:23):
also had this.
And then, you know, it finished.
But, yes, hello, it finishedafter menopause.
And this person's only 42.
So we have basically condemnedher to a decade of suffering, a
potential decade of suffering.
So I think those are theconcepts where we are wanting to
raise awareness, so that womencan actually say, hey, hang on,
maybe what's going on with me isnot quite right, and there is a
(08:46):
lot of management options.
I think, sonia, that's theother thing that bothers me is
that, because it's a problem notwith one solution, with so many
solutions, and because I alsosee women obviously at the other
end of the treatment journey,and our most common feedback is
why didn't I have this earlier?
(09:07):
Why did I suffer so much?
Sonya (09:10):
Wow, and that's really heartbreaking to think that of
knowledge or a support of aclinician that hasn't been able
(09:38):
to get them to a place wherethey needed to be.
So then let's talk about whatthose options are for women that
perhaps are listening and arekind of going hang on a second.
So maybe what I've beenexperiencing isn't normal, but I
should maybe see someone.
Talat (09:53):
There are a number of options and obviously they need
to be tailored to the woman'spreference and also to certain
risks that she may have in herjourney, in her health journey.
So usually if I see a womanbefore I go into options.
I'm actually thinking look, whyis this woman bleeding heavily?
And so we're thinking throughlook, is this a structural cause
(10:13):
in the uterus itself?
Like, for example, is theuterus having a polyp?
These are like fleshychandeliers in the uterus.
Most of them are benign.
Or maybe she has fibroids, ormaybe she has a variety of
endometriosis that's calledadenomyosis, in which the wall
of the uterus has the lining,and so that makes women bleed
more heavily than usual.
(10:35):
And a tiny number, sonia, areactually harboring a cancer or a
pre-cancer.
And if we're going to look atstatistics, sonia, it's about
one in 44, the lifetime risk forwomen and sort of.
If you compare that with breastcancer, which is about one in
eight women, it's actually rarer, it's less common, but
obviously women that arebleeding abnormally are more
(10:56):
likely to have it.
So, again, you know, therein isthe importance of making sure
that, even though somethingmight be rare, it is important
to rule that out.
And then, outside that, you canhave external factors that are
making the woman bleed heavily,like, for example, just a lack
of ovulation, and this happensin the ends of reproductive life
, so for example, in adolescenceand in perimenopausal women,
(11:19):
and that can predispose this.
At times it could be ablood-related issue.
That is a more generalizedissue and you ask the history of
these women have had you knowlike for example, they bleed
more at the dentist as well.
So it's a more generalized thingthat's also affecting the
uterus.
So there can be a number ofcauses, and so the first thing I
try and do is try and establishwell, is there an obvious cause
(11:40):
?
Because the cause alsosometimes guides the management.
So certain options wouldn't besuitable for women, for example,
let's say, with massivefibroids I might refer another
thing.
So, not only to try and giveher answers, but also to rule
out something really nasty likea cancer or pre-cancer, but also
to help us tailor management.
And this is a space, sonia,that's really meant to be shared
(12:04):
decision making.
So it's meant to be.
We do want women to articulate.
So I appreciate it when someonesays, hey look, I don't really
like hormones, or I'm worriedabout going to theater, I don't
want to go for surgery.
So even though sometimes I findafter we share information
together, people do change theirminds and sometimes they say,
oh well, actually, you know what, I don't mind that option, I
(12:25):
might actually take that, and soit's really important to.
But it's really important toarticulate not only the fact to
help diagnose if there is anissue, but be really active in
what sort of management plan youfeel is best for you.
So in terms of the actualoptions available, there are
certain tablets.
There's one called tranexamicacid and also a common drug that
(12:47):
is known as Ponstan, which ismethanamic acid.
This combination can be forwomen that want to just sort of
band-aid the situation.
They want to just use it duringthe time that they're heavy
bleeding and they want to sortthat out.
They really do not wantanything more elaborate than
that.
So the next tier up, orgenerally one of the most
effective options, is what ispopularly known as Mirena, which
(13:09):
is a progesterone-basedintrauterine device and so that
can be inserted, son Sonia, andbasically gets a lot of traction
on the heaviness of the cycle.
Now sometimes women can haveirregular cycles, so one may
move from a really heavy cycleto one where they're actually
spotting for quite a while,especially in the first four to
six months.
(13:30):
So there can be some patientsrequired before.
Sometimes the Mirena often isin research settings.
When those pads have beenweighed Women have actually bled
less, even when it's spread out.
But some people might have, youknow, might find that quite an
instance value that now they'reactually bleeding more days.
So that's one thing to considerand the good thing about Myrina,
(13:52):
though, sonia, is that itoffers you contraception, which
is also a need of us, of theperimenopausal women, for some
patients, and also once we havefigured out what's going on.
We're sure there's nothing likepre-cancer or cancer going on.
We've sorted out if the womanprefers to have a Mirena or a
levonorgestrel IUD, as it'scalled, she may choose to have
(14:14):
that as part of a hormonetherapy, you know vehicle.
So that could be theprogesterone equivalent for her.
So it's kind of ticking threeboxes for that person if they
need contraceptive support.
And then the next level up thereis basically going to theatre,
and we may also need to go forsurgery for diagnostic reasons.
So if they have a high qualityultrasound and it shows, for
(14:37):
example, that there's someconcern about the lining and
we're worried about thepotential cancer, we may elect
to go to theatre for that reason.
So some sort of some patientsmight be recommended to have a
biopsy of the lining.
In theatre we can offer lowrisk, minimally invasive, lower
(15:07):
tier of surgery which is like anablation or certain fibroids or
polyps can be removed from theinside of the uterus if they're
contributing, felt to becontributing to her clinical
situation and, in the lastresort, or for some women that
might have a massive uterus orconcern around malignancy, a
hysterectomy could be the bestfit option for them, or for the
person.
Sonia, who has gone through allthese layers of options and
hasn't actually gotten anywhere,is still bleeding heavily,
which is a very tiny minority ofwomen.
Honestly, majority of women areactually even I wouldn't say
(15:31):
fixed, but they move to spaceswhich are far more comfortable.
So obviously not all of ourpatients stop bleeding, but even
some of our patients just moveback to what a normal period is,
and so for them, becausethey've been used to such
torrential bleeding.
They're like so grateful.
They're like, oh, I just have anormal period, that's fine,
that's okay, that's nothing,that's a piece of cake.
You know, it's really veryrelative, isn't it?
Sonya (15:53):
Yeah, it is, and it's fascinating for me as someone
who has never experienced anyabnormal menstrual issues at all
.
So I've heard words likeablation and I mean obviously
I'm familiar with hysterectomy,but yet to understand that there
are so many options availableand you can start by minimally,
(16:15):
I guess, with the medication,Everything doesn't mean you have
to go to surgery.
Talat (16:20):
Absolutely, and sometimes the surgery.
I think women are more fixatedon hysterectomies but don't
always, like you said,appreciate ablation.
Or there's another conditioncalled uterine embolisation and
radiological context.
That's an option as well, butlike the ablation, sonia, it
takes like literally less thantwo minutes.
(16:41):
The actual procedure obviouslysetting up, going to sleep and
all that takes much longer, butthe actual procedure takes me
less than two minutes to do andI think this woman has suffered
for four years for want of like.
It's a day surgical procedurefor some women who are suitable
and not everyone is suitable orwill opt for that, but it really
(17:01):
is life changing.
Sonya (17:03):
I can imagine, I can only imagine how life changing it
must be.
Are there also lifestylefactors that come into play with
this as well, where women canmake adjustments in their life?
Talat (17:13):
Like you know, stopping smoking is something that can
make a big impact for women so Ithink, sonia, look in general,
obviously a good diet,particularly iron rich diet,
because we are, we are oftenbattling significant losses in
these women and they're oftenquite in negative balance and
that recognition that they maynot be anemic but if their iron
(17:34):
stores are low, that's anindependent risk of getting
tiredness and exhaustion andsymptomatic.
So obviously, from thatperspective, a good diet would
help to minimize that.
But, to be honest, the kind offlooding that some women are
facing you know how much you eat, or even orally there's a
certain limit that your bodywill absorb and so we are having
(17:56):
to give IV infusions.
But that's also a myth, sonia,that sometimes women say to me
I'm like, okay, what treatmenthave you had?
And I've had two or three, I'vehad an IV infusion every six
months and I say that's notreally a treatment that is
actually replacing your losses,and so I think that also needs
to be clarified, that it is partof the management plan.
It's not actually fixing theproblem.
(18:20):
Obviously, in general,especially women battling
perimenopause, we alwaysencourage them to minimize
triggers for other things,because what I find, sonia, and
actually my, you know, interestin menopause, was because I love
looking after women withabnormal bleeding.
And so what we would do is wewould try and find a cause, we
would try and stop or reduce thetap, we would try and make sure
(18:41):
they didn't have cancer, wewould replace their iron.
But I still felt there wassomething missing, without you
know, addressing theperimenopausal other symptoms.
And so, because we had aquestionnaire that sort of said
look, are you experiencing hotflashes, you're getting night
sweats, what's your sleep like?
What is your vaginal dryness?
And so because we wereproactively asking in that tool,
(19:02):
I was then finding oh okay,although she's come to me for
bleeding, but actually she'sticked these three other boxes,
and so I think if we hadn'tasked, it may have been, so the
heavy bleeding has been sooverwhelming it may not even
have been uncovered at thatpoint.
And then that made me thinkactually, no, there's more role
of actually having a menopausebased discussion as well, in
(19:25):
more detail than just you know Iworried this or something basic
like that.
So I agree that there's supportfor that, but I don't know that
there's a lot that we can dothat would necessarily minimize
the bleeding itself, especiallyif there's a structural cause
like yes, of course early canceror something I don't know that
there's any diet or or exercisethat reverse that.
Sonya (19:47):
So if a woman is listening today and she is
really resonating with some ofthe things that we've talked
about and she she goes off tosee her gp or her clinician,
what are your top tips for her?
Having a conversation withsomeone about this?
Talat (20:03):
So, first of all, I would encourage her to be quite
confident and to share that shehas what she feels is a problem
and this is why, and that she'shere to seek a solution and a
management plan.
So ideally, women who haveheavy bleeding should then be
guided to some blood tests andbe encouraged to have those.
(20:24):
We obviously need to, sonia,make sure that someone's not
pregnant without knowing that,and we also want to make sure
that we're not.
You know we're checking, likewe've mentioned multiple times
today, anemia and iron studies.
We also would like to do anultrasound For patients.
They merit an ultrasound.
The gp should be volunteeringthat and most gps, I must say,
are quite good at that sort ofum.
(20:46):
It's more around the actualtreatment options that um and
and we have a lot of sympathybecause gps are also quite time
poor, we know so it's a very,very complex space that, you
know, it's not that anyone'sdeliberately not trying to help
is, I think, more that the woman, and it's unfortunate for us to
say that, look, it's the womenthat should drive this.
But a lot of good change forwomen have come when the women
(21:09):
themselves have demanded goodcare and they have said, look, I
need the options.
I've actually read about theseand a number of patients now are
saying, hey, you know what I'mactually thinking of having
another baby, so for me a Mirenamight be a good fit.
How can I get this organized?
So the discussion is startingat a more mature level than
saying I'm actually bleedingheavily, what do I do.
(21:31):
I always find that it's helpfulwhen women have had some
information about heavymenstrual bleeding options,
because we very much value theiropinions and their preferences
and so once they see their GPthey can actually institute very
solid primary care options anda management plan.
And really the recommendationsare that you know if six months
(21:52):
are not working of variousoptions, then refer to a
gynaecologist.
Or if there are concerns aroundyou know, like we've mentioned
previous, concerns aroundmalignancy, or you know if it's
a massive uterus with fibroidsor certain very obvious
gynaecological pathology, sothose women should be triaged
earlier, or if we find we're notwinning.
So I don't expect patients tobe bleeding heavily for six
(22:14):
months before they seekgynaecological care.
But the GPs have a very solidprimary care role in supporting
the patients and I think moreand more awareness is leading to
more and more cliniciansactually doing that.
Sonya (22:28):
Yeah, fantastic, great advice.
Thank you so much.
And you mentioned that you havesome resources that we can
share in the show notes.
Talat (22:35):
I forgot to say there's a quarter of women have heavy
menstrual bleeding.
Let that sink in One out of 25%of us, and I also wanted to
mention that there was a recentonline survey by Hologic, and
this was carried out by anindependent research company
called Two Blind Mice, and 5,000women participated, sonia, they
(22:58):
were.
Basically the plan was to tryand figure out what are the
attitudes to thisunder-recognized condition, and
no surprises we saw that 9% ofwomen were actually saying they
always have heavy periods.
19% of women, sonia, said thatthey often have heavy periods.
Three-quarters of women had hadheavy periods at some point in
(23:20):
their life.
So we were still somewhereabove that one-quarter number
where, you know, women are oftenhaving heavy periods, or always
, and more than half of womenwere yet to see a medical doctor
.
So that was in these days.
(23:40):
And then, basically, the otherthing that came out was that 69%
had had some embarrassingepisode, and we know that it can
be quite awkward for women ifthey flat at work, or we know
there's so many women that don'tgo swimming or different sort
of activities they then refrainfrom.
But the most interestingstatistic to me was that 92% of
(24:03):
women want more conversation,sonia, and so thank you for this
morning because this is exactlywhat the women have asked for.
We have recognized that there'sshame, there's taboo, there is
so much secrecy around menstrualhealth that needs to be changed
and, like I mentioned earlier,that this is clustered to
(24:24):
adolescence as well, and it's soheartwarming for me when women
bring their daughters and theysay we didn't get an opportunity
to talk about our gynecologicalor our perimenopausal concerns.
We are doing different for ourchildren.
Sonya (24:39):
That's awesome.
It's sad that the mum had tomiss out, but it's great that
there's that.
You know not wanting to passthat baton on as such to the
next generation, so yay forwomen that are doing that.
That's fantastic.
And that survey, thosestatistics, wow.
Talat (24:56):
Shocking, they're really shocking.
And that survey, thosestatistics, wow, shocking,
they're really shocking.
And it is just sad to see that,like I said, a space with so
much support.
But again, basically, whenwomen were asked why they
haven't seeked care, the firstone was that they had
deprioritized themselves.
And I hear this every day,sonia women are caring for their
(25:17):
elderly parents, for theirchildren's issues, for even
their work related peopletelling me that oh no, I have
this deadline at work and I'mthinking but you're not
functioning well.
You're telling me you're sotired you're not able to focus.
So it's a and and you know thejoys of perimenopause.
Imagine that layered over, um,someone that has a ferritin of
four or has next to no iron andis then anxious.
(25:38):
I think the emotional side ofperimenopause in itself can be
very overwhelming.
And then if you layer themisery of bleeding heavily, the
hygiene issues, the quality oflife impact, it's just a very
negative space that we need toactually support women to come
out of that cycle?
Sonya (25:59):
Yeah, absolutely.
Now I do have a question around.
If someone's listening to thisand one of the things that I
find so frustrating for women inAustralia is you and I sit here
in a city.
We have great options availableto us to seek support from
multiple GPs.
We have, you know, multiplegynecologists to choose from.
(26:20):
If someone's listening that'sin a more remote or regional
area, what are their options ifperhaps there's not a
gynecologist in town?
And you know, I know, that wehave telehealth services for
some healthcare Is there sometelehealth available around?
You know, gynecological care?
Talat (26:44):
So we have set up at Women's Health Road, basically a
national option.
So it's a hybrid care model.
We are happy to have telehealthfrom anyone and we're happy to
connect with that person'sgeneral practitioner to then
sort of work in partnership withthem and to support them in
trying to see identifyingwhere's your nearest public
gynecology clinic.
You know, see identifying.
You know where's your nearestpublic gynecology clinic, for
example.
If things are not being sortedout at that level, certainly we
are offering that, sonia.
(27:05):
Some of the other directions ourpractice is embarking on is
we're trying to request for ainternational heavy menstrual
bleeding day for a conditionthat affects a quarter of women.
I am a bit grieved that wedon't have a day for this.
So I think that that would be away of raising awareness for
everybody.
And then we're also trying tolook at some digital technology,
(27:28):
and the great thing aboutdigital technology is not about
replacing the clinicians, it'sabout empowering the patient to
be able to sort of, you know, atleast get some degree of
support, which is notnecessarily in BRICS and
geographically, you know,restricted.
So that is one of our agendafor 2024 to be able to roll out
(27:52):
a program that encourages adigital support for women and
that makes some of their journeyeasier and less dependent on
the actual local availability ofresources.
Sonya (28:03):
Yeah, fantastic, tella, you are doing amazing work in
this space and I'm so gratefulon behalf of everybody listening
.
Talat (28:10):
All good.
Sonia, Thank you so much forthe time today and I really
appreciate the amazing work youdo with Dear Menopause.
It's such amazing advocacy.
Sonya (28:19):
Thank you, tela.
I appreciate that and thank youfor your time today.
Thank you for listening today.
I am so grateful to have theseconversations with incredible
women and experts and I'mgrateful that you chose to hit
play on this episode of DearMenopause.
If you have a minute of timetoday, please leave a rating or
(28:42):
a review.
I would love to hear from you,because you are my biggest
driver for doing this work.
If this chat went way too fastfor you and you want more, head
over to stellarwomencomau slashpodcast for the show notes and,
while you're there, take mymidlife quiz to see why it feels
(29:04):
like midlife is messing withyour head.
Welcome to the Dear Menopause podcast, where we
discuss the menopause transitionto help make everyday life a
little easier for women.
Hi, my name is Sonya and I amyour host of Dear Menopause.
Today, I have a very specialguest with me, Dr Talat Uppal.
Talat is an obstetriciangynecologist specializing in
(00:25):
heavy menstrual bleeding.
This is an area I did not knowa lot about, so I found our
conversation absolutelyfascinating.
If you're a woman and youmenstruate, this is an episode
that you will find absolutelyfascinating.
Talat, welcome to DearMenopause.
Talat (00:43):
Thank you so much for this opportunity, Sonya, and
what wonderful work you do.
Sonya (00:49):
Oh, thank you.
Now.
Today we are going to have ajuicy conversation about
menstrual bleeding, but yourspeciality is heavy menstrual
bleeding, so would you like togive us a little bit of an intro
on who you are and the workthat you do?
Talat (01:09):
Thanks, Sonya.
So I'm a gynaecologist that'sbased in the northern beaches of
Sydney and I have an interestin clinical education as well,
particularly general practiceand primary care-based education
, because I think they doamazing heavy lifting in women's
health space, amazing heavylifting in women's health space.
(01:30):
I also am trained in ultrasoundand I have set up a
organization called Women'sHealth Road, which is a medical
center, sonya, and it's locatedopposite the Northern Beaches
Hospital and it's like acollaborative, multidisciplinary
team.
So we're kind of a little bitmore holistic in our approach
and we value, for example,mental health or the expertise
of physio, allied health.
So it's quite a well-roundedteam and, like you mentioned my
(01:54):
interest, my primary interest,is management of women with
abnormal bleeding andparticularly heavy menstrual
bleeding.
Sonya (02:01):
I love your multidisciplinary team.
I think it's absolutelywonderful to think that we can
have a model for healthcare,particularly for women because
that's where my passion liesthat does offer so many of the
services that can be so hard togo out and find, because I know
you've got Penny Hanlon workingwith you as a physio and penny
(02:22):
is amazing at women's pelvicfloor health as a
physiotherapist and it can bereally hard for women to find a
physio that does specialize in,um, you know, women's pelvic
floor health.
So to have a kind of thisone-stop clinic where women can
get, like you say, the mentalhealth support, the physio
support, you know I think you'vegot at least one great.
(02:44):
GP on board as well.
Yes, yeah, I really, reallyhope that this is a model that
we can see rolling out, you know, across the country for more
women.
So thank you for setting thatup.
Talat (02:55):
Thank you, sonya.
I agree that these are thestandards that women deserve and
should access, and I havehonestly learned so much from my
peers.
I think that those days of justa specialist with 40 patients
and just one person seeing arelong gone.
The future of health iscollaboration, and we all bring
a unique skill and talent thatadds to the woman's journey if
(03:19):
she wishes to reach out.
And what I like about suchmodels is that it allows women
to decide well, what part of myhealthcare that I'm being
offered is more important for meto prioritize and what package
should I individualize for me asa person.
Sonya (03:34):
Yeah, so important to put that patient front and center.
I love that so much.
Okay, so onto our topic.
Can you give us a descriptionand an understanding for someone
like me that has neverexperienced heavy menstrual
bleeding?
What defines heavy menstrualbleeding over what I would
consider a normal period?
Talat (03:53):
So excellent question, sonia.
There are two concepts.
First of all, heavy menstrualbleeding is basically we need to
sort of gauge it againstquality of life in the first
instance, and quality of lifefor women.
Sonia has been so undervaluedfor so long really, and quality
of life, as you well know, is avery broad spectrum of facets.
(04:15):
So it includes her physicalwell-being, it includes her
emotional well-being, itincludes your you know social
well-being and it also includesyour material well-being.
So there's a productivity know,social well-being and it also
includes your materialwell-being.
So there's a productivity issuewhen we're talking about heavy
menstrual bleeding, because weall know women who either are
unable to focus at work or haveto take time off, etc.
So that's one way of looking atit, which you know.
(04:40):
If these periods are affectingme in some way, then it is a
problem, and the other way,obviously we need to have some
flags or what could guide us, orwhat are the clues that these
periods may be heavy, and thesecould include look, am I passing
clots that are, for example,bigger than 50 cent pieces?
Am I changing my sanitaryprotection every one to two
(05:03):
hours?
Am I having to wake up at nightto change my sanitary
protection?
Am I having to use multipletypes?
Women tell me they've used twoor three different types of
sanitary protection.
That's not normal.
Or have I had episodes offlooding through my clothes,
which can obviously be veryembarrassing?
Or, sonia, because they'rehaving such heavy losses, then
(05:25):
women may become iron deficientor may have anemia, and so then
they would get dizziness,tiredness, profuse tiredness
sometimes, and they might havepalpitations.
So you get another cohort ofsymptoms that are actually
because of the losses that theyhave had.
Sonya (05:43):
I wonder if there are.
You will be able to confirmthis.
There are women that experienceheavy menstrual bleeding or
menstrual bleeding that'soutside of the norms, but they
don't know that it's actuallynot normal because that's the
only thing they've ever known,and we don't talk about our
periods.
We don't necessarily haveconversations about menstrual
(06:04):
bleeding to say, hey, this iswhat you should expect If you're
experiencing this, that's notnormal, Seek some help.
So I wonder how many women youcome across that have been
experiencing this and not soughthelp for it?
Talat (06:17):
Sonya, this is my weekly reflection because every week I
sit down and I think how and youcan imagine, sonya, that I work
in Northern beaches Often womenI'm caring for I think really
proactive ownership of theirhealth.
They are worrying about theirdiet, they're taking care of
their exercise regime, but stillI reflect that their health
(06:38):
literacy, for many women that Ilook after, is actually quite
basic.
When it comes to menstrualhealth and I know that you know
there's that concept around 28day, five day periods, but there
is a variation in normal and Ithink, like you rightly pointed
out, there can be a big struggleand trivialization of symptoms,
(06:58):
and so we kind of do say, look,if your periods are lasting
longer than seven days, but thensome women are bleeding so
heavily, so because there arethose two, three concepts of are
your period cycles comingaround more frequently, which
often happens at the start ofperimenopause is the volume
heavier?
Or and or, and these are alland or situations, because
(07:19):
obviously if she's bleeding formore than seven days, then you
know she's going to bleed morevolume and so therefore that's
heavy as well.
So I think that there isconstantly trivialization or
minimization of symptoms bywomen and I feel that they're
just resilient.
We women are just so resilient,we're used to juggling so many
(07:39):
things, we're just used toputting up with things, and so
that sort of philosophy carrieson in menstrual well-being and
they just say, oh well, you know, this must be normal.
And then, sonya, it's not justthe women themselves,
unfortunately, even though wehave excellent clinicians and I
think that a lot of cliniciansdo amazing work unfortunately
there are people, when women goto them as clinicians, who will
(08:03):
just say, oh, they're there togo away, or will sort of
reassure them but not actuallyproactively offer them the full
suite of management options thatare available.
And then, third level ofnormalization of abnormal
periods is by society.
So they might have an auntiethat says, oh, oh, hang on, I
(08:23):
also had this.
And then, you know, it finished.
But, yes, hello, it finishedafter menopause.
And this person's only 42.
So we have basically condemnedher to a decade of suffering, a
potential decade of suffering.
So I think those are theconcepts where we are wanting to
raise awareness, so that womencan actually say, hey, hang on,
maybe what's going on with me isnot quite right, and there is a
(08:46):
lot of management options.
I think, sonia, that's theother thing that bothers me is
that, because it's a problem notwith one solution, with so many
solutions, and because I alsosee women obviously at the other
end of the treatment journey,and our most common feedback is
why didn't I have this earlier?
(09:07):
Why did I suffer so much?
Sonya (09:10):
Wow, and that's really heartbreaking to think that of
knowledge or a support of aclinician that hasn't been able
(09:38):
to get them to a place wherethey needed to be.
So then let's talk about whatthose options are for women that
perhaps are listening and arekind of going hang on a second.
So maybe what I've beenexperiencing isn't normal, but I
should maybe see someone.
Talat (09:53):
There are a number of options and obviously they need
to be tailored to the woman'spreference and also to certain
risks that she may have in herjourney, in her health journey.
So usually if I see a womanbefore I go into options.
I'm actually thinking look, whyis this woman bleeding heavily?
And so we're thinking throughlook, is this a structural cause
(10:13):
in the uterus itself?
Like, for example, is theuterus having a polyp?
These are like fleshychandeliers in the uterus.
Most of them are benign.
Or maybe she has fibroids, ormaybe she has a variety of
endometriosis that's calledadenomyosis, in which the wall
of the uterus has the lining,and so that makes women bleed
more heavily than usual.
(10:35):
And a tiny number, sonia, areactually harboring a cancer or a
pre-cancer.
And if we're going to look atstatistics, sonia, it's about
one in 44, the lifetime risk forwomen and sort of.
If you compare that with breastcancer, which is about one in
eight women, it's actually rarer, it's less common, but
obviously women that arebleeding abnormally are more
(10:56):
likely to have it.
So, again, you know, therein isthe importance of making sure
that, even though somethingmight be rare, it is important
to rule that out.
And then, outside that, you canhave external factors that are
making the woman bleed heavily,like, for example, just a lack
of ovulation, and this happensin the ends of reproductive life
, so for example, in adolescenceand in perimenopausal women,
(11:19):
and that can predispose this.
At times it could be ablood-related issue.
That is a more generalizedissue and you ask the history of
these women have had you knowlike for example, they bleed
more at the dentist as well.
So it's a more generalized thingthat's also affecting the
uterus.
So there can be a number ofcauses, and so the first thing I
try and do is try and establishwell, is there an obvious cause
(11:40):
?
Because the cause alsosometimes guides the management.
So certain options wouldn't besuitable for women, for example,
let's say, with massivefibroids I might refer another
thing.
So, not only to try and giveher answers, but also to rule
out something really nasty likea cancer or pre-cancer, but also
to help us tailor management.
And this is a space, sonia,that's really meant to be shared
(12:04):
decision making.
So it's meant to be.
We do want women to articulate.
So I appreciate it when someonesays, hey look, I don't really
like hormones, or I'm worriedabout going to theater, I don't
want to go for surgery.
So even though sometimes I findafter we share information
together, people do change theirminds and sometimes they say,
oh well, actually, you know what, I don't mind that option, I
(12:25):
might actually take that, and soit's really important to.
But it's really important toarticulate not only the fact to
help diagnose if there is anissue, but be really active in
what sort of management plan youfeel is best for you.
So in terms of the actualoptions available, there are
certain tablets.
There's one called tranexamicacid and also a common drug that
(12:47):
is known as Ponstan, which ismethanamic acid.
This combination can be forwomen that want to just sort of
band-aid the situation.
They want to just use it duringthe time that they're heavy
bleeding and they want to sortthat out.
They really do not wantanything more elaborate than
that.
So the next tier up, orgenerally one of the most
effective options, is what ispopularly known as Mirena, which
(13:09):
is a progesterone-basedintrauterine device and so that
can be inserted, son Sonia, andbasically gets a lot of traction
on the heaviness of the cycle.
Now sometimes women can haveirregular cycles, so one may
move from a really heavy cycleto one where they're actually
spotting for quite a while,especially in the first four to
six months.
(13:30):
So there can be some patientsrequired before.
Sometimes the Mirena often isin research settings.
When those pads have beenweighed Women have actually bled
less, even when it's spread out.
But some people might have, youknow, might find that quite an
instance value that now they'reactually bleeding more days.
So that's one thing to considerand the good thing about Myrina,
(13:52):
though, sonia, is that itoffers you contraception, which
is also a need of us, of theperimenopausal women, for some
patients, and also once we havefigured out what's going on.
We're sure there's nothing likepre-cancer or cancer going on.
We've sorted out if the womanprefers to have a Mirena or a
levonorgestrel IUD, as it'scalled, she may choose to have
(14:14):
that as part of a hormonetherapy, you know vehicle.
So that could be theprogesterone equivalent for her.
So it's kind of ticking threeboxes for that person if they
need contraceptive support.
And then the next level up thereis basically going to theatre,
and we may also need to go forsurgery for diagnostic reasons.
So if they have a high qualityultrasound and it shows, for
(14:37):
example, that there's someconcern about the lining and
we're worried about thepotential cancer, we may elect
to go to theatre for that reason.
So some sort of some patientsmight be recommended to have a
biopsy of the lining.
In theatre we can offer lowrisk, minimally invasive, lower
(15:07):
tier of surgery which is like anablation or certain fibroids or
polyps can be removed from theinside of the uterus if they're
contributing, felt to becontributing to her clinical
situation and, in the lastresort, or for some women that
might have a massive uterus orconcern around malignancy, a
hysterectomy could be the bestfit option for them, or for the
person.
Sonia, who has gone through allthese layers of options and
hasn't actually gotten anywhere,is still bleeding heavily,
which is a very tiny minority ofwomen.
Honestly, majority of women areactually even I wouldn't say
(15:31):
fixed, but they move to spaceswhich are far more comfortable.
So obviously not all of ourpatients stop bleeding, but even
some of our patients just moveback to what a normal period is,
and so for them, becausethey've been used to such
torrential bleeding.
They're like so grateful.
They're like, oh, I just have anormal period, that's fine,
that's okay, that's nothing,that's a piece of cake.
You know, it's really veryrelative, isn't it?
Sonya (15:53):
Yeah, it is, and it's fascinating for me as someone
who has never experienced anyabnormal menstrual issues at all
.
So I've heard words likeablation and I mean obviously
I'm familiar with hysterectomy,but yet to understand that there
are so many options availableand you can start by minimally,
(16:15):
I guess, with the medication,Everything doesn't mean you have
to go to surgery.
Talat (16:20):
Absolutely, and sometimes the surgery.
I think women are more fixatedon hysterectomies but don't
always, like you said,appreciate ablation.
Or there's another conditioncalled uterine embolisation and
radiological context.
That's an option as well, butlike the ablation, sonia, it
takes like literally less thantwo minutes.
(16:41):
The actual procedure obviouslysetting up, going to sleep and
all that takes much longer, butthe actual procedure takes me
less than two minutes to do andI think this woman has suffered
for four years for want of like.
It's a day surgical procedurefor some women who are suitable
and not everyone is suitable orwill opt for that, but it really
(17:01):
is life changing.
Sonya (17:03):
I can imagine, I can only imagine how life changing it
must be.
Are there also lifestylefactors that come into play with
this as well, where women canmake adjustments in their life?
Talat (17:13):
Like you know, stopping smoking is something that can
make a big impact for women so Ithink, sonia, look in general,
obviously a good diet,particularly iron rich diet,
because we are, we are oftenbattling significant losses in
these women and they're oftenquite in negative balance and
that recognition that they maynot be anemic but if their iron
(17:34):
stores are low, that's anindependent risk of getting
tiredness and exhaustion andsymptomatic.
So obviously, from thatperspective, a good diet would
help to minimize that.
But, to be honest, the kind offlooding that some women are
facing you know how much you eat, or even orally there's a
certain limit that your bodywill absorb and so we are having
(17:56):
to give IV infusions.
But that's also a myth, sonia,that sometimes women say to me
I'm like, okay, what treatmenthave you had?
And I've had two or three, I'vehad an IV infusion every six
months and I say that's notreally a treatment that is
actually replacing your losses,and so I think that also needs
to be clarified, that it is partof the management plan.
It's not actually fixing theproblem.
(18:20):
Obviously, in general,especially women battling
perimenopause, we alwaysencourage them to minimize
triggers for other things,because what I find, sonia, and
actually my, you know, interestin menopause, was because I love
looking after women withabnormal bleeding.
And so what we would do is wewould try and find a cause, we
would try and stop or reduce thetap, we would try and make sure
(18:41):
they didn't have cancer, wewould replace their iron.
But I still felt there wassomething missing, without you
know, addressing theperimenopausal other symptoms.
And so, because we had aquestionnaire that sort of said
look, are you experiencing hotflashes, you're getting night
sweats, what's your sleep like?
What is your vaginal dryness?
And so because we wereproactively asking in that tool,
(19:02):
I was then finding oh okay,although she's come to me for
bleeding, but actually she'sticked these three other boxes,
and so I think if we hadn'tasked, it may have been, so the
heavy bleeding has been sooverwhelming it may not even
have been uncovered at thatpoint.
And then that made me thinkactually, no, there's more role
of actually having a menopausebased discussion as well, in
(19:25):
more detail than just you know Iworried this or something basic
like that.
So I agree that there's supportfor that, but I don't know that
there's a lot that we can dothat would necessarily minimize
the bleeding itself, especiallyif there's a structural cause
like yes, of course early canceror something I don't know that
there's any diet or or exercisethat reverse that.
Sonya (19:47):
So if a woman is listening today and she is
really resonating with some ofthe things that we've talked
about and she she goes off tosee her gp or her clinician,
what are your top tips for her?
Having a conversation withsomeone about this?
Talat (20:03):
So, first of all, I would encourage her to be quite
confident and to share that shehas what she feels is a problem
and this is why, and that she'shere to seek a solution and a
management plan.
So ideally, women who haveheavy bleeding should then be
guided to some blood tests andbe encouraged to have those.
(20:24):
We obviously need to, sonia,make sure that someone's not
pregnant without knowing that,and we also want to make sure
that we're not.
You know we're checking, likewe've mentioned multiple times
today, anemia and iron studies.
We also would like to do anultrasound For patients.
They merit an ultrasound.
The gp should be volunteeringthat and most gps, I must say,
are quite good at that sort ofum.
(20:46):
It's more around the actualtreatment options that um and
and we have a lot of sympathybecause gps are also quite time
poor, we know so it's a very,very complex space that, you
know, it's not that anyone'sdeliberately not trying to help
is, I think, more that the woman, and it's unfortunate for us to
say that, look, it's the womenthat should drive this.
But a lot of good change forwomen have come when the women
(21:09):
themselves have demanded goodcare and they have said, look, I
need the options.
I've actually read about theseand a number of patients now are
saying, hey, you know what I'mactually thinking of having
another baby, so for me a Mirenamight be a good fit.
How can I get this organized?
So the discussion is startingat a more mature level than
saying I'm actually bleedingheavily, what do I do.
(21:31):
I always find that it's helpfulwhen women have had some
information about heavymenstrual bleeding options,
because we very much value theiropinions and their preferences
and so once they see their GPthey can actually institute very
solid primary care options anda management plan.
And really the recommendationsare that you know if six months
(21:52):
are not working of variousoptions, then refer to a
gynaecologist.
Or if there are concerns aroundyou know, like we've mentioned
previous, concerns aroundmalignancy, or you know if it's
a massive uterus with fibroidsor certain very obvious
gynaecological pathology, sothose women should be triaged
earlier, or if we find we're notwinning.
So I don't expect patients tobe bleeding heavily for six
(22:14):
months before they seekgynaecological care.
But the GPs have a very solidprimary care role in supporting
the patients and I think moreand more awareness is leading to
more and more cliniciansactually doing that.
Sonya (22:28):
Yeah, fantastic, great advice.
Thank you so much.
And you mentioned that you havesome resources that we can
share in the show notes.
Talat (22:35):
I forgot to say there's a quarter of women have heavy
menstrual bleeding.
Let that sink in One out of 25%of us, and I also wanted to
mention that there was a recentonline survey by Hologic, and
this was carried out by anindependent research company
called Two Blind Mice, and 5,000women participated, sonia, they
(22:58):
were.
Basically the plan was to tryand figure out what are the
attitudes to thisunder-recognized condition, and
no surprises we saw that 9% ofwomen were actually saying they
always have heavy periods.
19% of women, sonia, said thatthey often have heavy periods.
Three-quarters of women had hadheavy periods at some point in
(23:20):
their life.
So we were still somewhereabove that one-quarter number
where, you know, women are oftenhaving heavy periods, or always
, and more than half of womenwere yet to see a medical doctor
.
So that was in these days.
(23:40):
And then, basically, the otherthing that came out was that 69%
had had some embarrassingepisode, and we know that it can
be quite awkward for women ifthey flat at work, or we know
there's so many women that don'tgo swimming or different sort
of activities they then refrainfrom.
But the most interestingstatistic to me was that 92% of
(24:03):
women want more conversation,sonia, and so thank you for this
morning because this is exactlywhat the women have asked for.
We have recognized that there'sshame, there's taboo, there is
so much secrecy around menstrualhealth that needs to be changed
and, like I mentioned earlier,that this is clustered to
(24:24):
adolescence as well, and it's soheartwarming for me when women
bring their daughters and theysay we didn't get an opportunity
to talk about our gynecologicalor our perimenopausal concerns.
We are doing different for ourchildren.
Sonya (24:39):
That's awesome.
It's sad that the mum had tomiss out, but it's great that
there's that.
You know not wanting to passthat baton on as such to the
next generation, so yay forwomen that are doing that.
That's fantastic.
And that survey, thosestatistics, wow.
Talat (24:56):
Shocking, they're really shocking.
And that survey, thosestatistics, wow, shocking,
they're really shocking.
And it is just sad to see that,like I said, a space with so
much support.
But again, basically, whenwomen were asked why they
haven't seeked care, the firstone was that they had
deprioritized themselves.
And I hear this every day,sonia women are caring for their
(25:17):
elderly parents, for theirchildren's issues, for even
their work related peopletelling me that oh no, I have
this deadline at work and I'mthinking but you're not
functioning well.
You're telling me you're sotired you're not able to focus.
So it's a and and you know thejoys of perimenopause.
Imagine that layered over, um,someone that has a ferritin of
four or has next to no iron andis then anxious.
(25:38):
I think the emotional side ofperimenopause in itself can be
very overwhelming.
And then if you layer themisery of bleeding heavily, the
hygiene issues, the quality oflife impact, it's just a very
negative space that we need toactually support women to come
out of that cycle?
Sonya (25:59):
Yeah, absolutely.
Now I do have a question around.
If someone's listening to thisand one of the things that I
find so frustrating for women inAustralia is you and I sit here
in a city.
We have great options availableto us to seek support from
multiple GPs.
We have, you know, multiplegynecologists to choose from.
(26:20):
If someone's listening that'sin a more remote or regional
area, what are their options ifperhaps there's not a
gynecologist in town?
And you know, I know, that wehave telehealth services for
some healthcare Is there sometelehealth available around?
You know, gynecological care?
Talat (26:44):
So we have set up at Women's Health Road, basically a
national option.
So it's a hybrid care model.
We are happy to have telehealthfrom anyone and we're happy to
connect with that person'sgeneral practitioner to then
sort of work in partnership withthem and to support them in
trying to see identifyingwhere's your nearest public
gynecology clinic.
You know, see identifying.
You know where's your nearestpublic gynecology clinic, for
example.
If things are not being sortedout at that level, certainly we
are offering that, sonia.
(27:05):
Some of the other directions ourpractice is embarking on is
we're trying to request for ainternational heavy menstrual
bleeding day for a conditionthat affects a quarter of women.
I am a bit grieved that wedon't have a day for this.
So I think that that would be away of raising awareness for
everybody.
And then we're also trying tolook at some digital technology,
(27:28):
and the great thing aboutdigital technology is not about
replacing the clinicians, it'sabout empowering the patient to
be able to sort of, you know, atleast get some degree of
support, which is notnecessarily in BRICS and
geographically, you know,restricted.
So that is one of our agendafor 2024 to be able to roll out
(27:52):
a program that encourages adigital support for women and
that makes some of their journeyeasier and less dependent on
the actual local availability ofresources.
Sonya (28:03):
Yeah, fantastic, tella, you are doing amazing work in
this space and I'm so gratefulon behalf of everybody listening
.
Talat (28:10):
All good.
Sonia, Thank you so much forthe time today and I really
appreciate the amazing work youdo with Dear Menopause.
It's such amazing advocacy.
Sonya (28:19):
Thank you, tela.
I appreciate that and thank youfor your time today.
Thank you for listening today.
I am so grateful to have theseconversations with incredible
women and experts and I'mgrateful that you chose to hit
play on this episode of DearMenopause.
If you have a minute of timetoday, please leave a rating or
(28:42):
a review.
I would love to hear from you,because you are my biggest
driver for doing this work.
If this chat went way too fastfor you and you want more, head
over to stellarwomencomau slashpodcast for the show notes and,
while you're there, take mymidlife quiz to see why it feels
(29:04):
like midlife is messing withyour head.
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