Gaslighting of genitourinary symptoms of the menopause

This week on the podcast Dr Louise speaks to Dr Ashley Winter, a urologist and sexual medicine specialist, based in Los Angeles.

Dr Ashley has seen the transformative effects of vaginal hormones on women – not only those who are menopausal, but also women who experience cyclical symptoms of bladder pain, UTIs and painful sex.

She shares her frustration on the situation in the US, where inaccurate and harmful warnings are included in every oestrogen product available, and her hopes of dispelling the fearmongering by talking, looking at the evidence and sharing her clinical experience.

Finally, Dr Ashley gives three reasons why women should use vaginal hormones:

1. It’s extraordinarily safe. No risk of any cancer or blood clots, 100% safe.
2. It can prevent you from needing so many other unnecessary treatments that don’t address root causes, and so you will probably save money.
3. It is not just a vaginal treatment. It is a bladder treatment, a urethral treatment, a vulva treatment. The medication acts locally, but acts locally throughout the pelvis.

Follow Ashley on X and Instagram @ashleygwinter

Transcript

Dr Louise Newson: [00:00:11] Hello. I’m Dr Louise Newson. I’m a GP and menopause specialist, and I’m also the founder of the Newson Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. I’m also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newson Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. Today on the podcast, I’m super excited actually, to introduce to you Ashley Winter, who is a Los Angeles board-certified urologist, but she also has a fellowship in sexual health for men and women. And I’ve been avidly stalking her on social media for a little while now, and I love her robustness and gobbiness and just getting it all out there, really. So I’m delighted that she’s taking some time away from her ten-month-old daughter to record the podcast today. So welcome Ashley. [00:01:34][83.0]

Dr Ashley Winter: [00:01:35] Thank you so much. I am so happy to be here and honoured that you reached out and asked to have me on. So, yeah, thank you for having me on. My husband is desperately trying to keep up with our ten month old right now. She has far too much energy for him. [00:01:50][14.8]

Dr Louise Newson: [00:01:52] So it’s really interesting because the more work I do, the more frustrated I get, actually, because there’s just suffering wherever you look. And obviously, the menopause affects 51% of the population. And it was interesting, actually, I’ve just come back from Australia and a report came out at the time that I was there saying that 70% of women don’t suffer severe symptoms. And it was almost stating that we’re overexaggerating, especially on social media, actually how women are suffering. Now, in my mind, that was just ridiculous. And there were lots of people in Australia were really cross with this report because it still meant that 30% of women have severe symptoms. Now, symptoms, as you know, can really vary. And for many years it’s always been about hot flushes, night sweats and some vaginal dryness. And that’s where it goes on and on and on. Now, if we look at vaginal dryness, I don’t like the word dryness. I think it’s a weird adjective for someone’s anatomy, but the symptoms around the area of the vagina, so we’re talking about the vulva, the vagina, but also the urinary tract, which sits, as you know, just next to it, are very, very common, actually, more common than the flushes and the sweats. And as many of you might know, it used to be called vulvovaginal atrophy. And if you look up the definition of atrophy, it means withering or wasting away. Now, I don’t want to be thinking of any of my anatomy withering or wasting away. So it was changed a few years ago to GSM genitourinary syndrome of the menopause, which is quite a mouthful. And I still think that’s confusing because it can occur in the perimenopause in younger women. And so we don’t have to wait till we’re menopausal to have GSM. But it does encompass the urinary symptoms. And living with a urologist who is now converted into the importance of female hormones, it’s really interesting to reach out to other urologists because for too long, I think, and I certainly see so many women in my clinic who have been investigated by gynaecologists and urologists for bladder symptoms, for recurrent urinary tract infections. They’ve had all sorts of weird and wonderful treatments, and no one has ever spoken to them about the role of hormones in their causation of their symptoms, but also treatment as well. So you’re a urologist Ashley, just before we start talking too much in depth, tell me why you decided to be a urologist. [00:04:21][149.6]

Dr Ashley Winter: [00:04:22] Oh, gosh. The very honest answer, which is not a very sexy answer, is I was in college undergrad, and I was actually studying engineering, which is my undergrad degree, and I decided that I didn’t want to do that as a profession. And at the time, a family member of mine came home from a doctor’s appointment and they had seen a urologist and they had had a cystoscopy, which is where you put a camera inside the bladder and they were suffering with bladder pain, you know, something that is commonly called interstitial cystitis and was frustrated that people weren’t really understanding their concerns and resolving the issue. And I said, that sounds like a very interesting thing to do. I’m going to go become a urologist. And then I went to med school to become a urologist. That’s a very weird… and then I would say, going through all my training, you know, all my rotations in medical school and whatnot, that just reinforced that my preconceived notion of being a urologist was a great idea. So, yeah, that’s the basic thing behind it. [00:05:27][64.8]

Dr Louise Newson: [00:05:28] Well, that’s fair enough. You would have seen lots of people with interstitial cystitis, presumably as part of your training and now, you know, in your day to day practice, presumably. [00:05:37][9.0]

Dr Ashley Winter: [00:05:37] Yes. Well, this is a very interesting question, because I do believe that what is called interstitial cystitis is most commonly either genitourinary syndrome of menopause or changes related to perimenopause. So genitourinary syndrome of perimenopause, if you will, and then in a younger population oftentimes it’s actually related to use of combined oral contraceptives, which we know, you know, suppress the bioavailable testosterone and can cause atrophic changes in the genitalia. And, you know, there’s a fascinating, since we’re nerding out on the GSM, there’s a really fascinating study that was published in 2003 in the European Journal of Urology, which happens to be the highest impact factor urology journal in the world. So that means, you know, kind of the best journal. And they took a bunch of women who are actually having recurrent UTIs and they were in their early 20s and they were on oral contraceptives and they had signs of genital atrophy on exam and they gave them even just one month of low dose, topical vaginal oestrogen. And all those women had a tremendous amount of inflammation in their bladder. And after treatment with the hormone, the inflammation resolved and their urinary tract infections resolved and their pain resolved. And I can say in my practice as a urologist, you know, so much of what we just kind of lump into this diagnosis of interstitial cystitis, which is, you know, people manifesting with essentially chronic bladder pain related to filling and other activities. A tremendous amount of the time I use low dose topical hormones, which are incredibly safe and the symptoms are resolved entirely. And I just, kind of it circles back to, you know, you talking about only 30% of women having symptomatic menopause. I mean, how many people out there are being diagnosed with interstitial cystitis, which was does not fall necessarily under the basket of menopause. And that diagnosis may be a direct consequence of the physiology of, you know, a lack of hormones in the body. [00:07:44][126.9]

Dr Louise Newson: [00:07:45] Yeah, and it’s so interesting, actually. So, when I eventually did some menopause training, which was only a few years ago now compared to being decades as a doctor, I was taught this sort of criteria about symptoms and it was always that people have vasomotor symptoms, flushes, sweats. They might then get the psychological symptoms and then the symptoms related to GSM occur later. And so there’s sort of this path. Now in my clinical experience, that just doesn’t happen at all. I’ve seen a lot of women whose presenting complaint has been either pain and discomfort in the genital area or urinary symptoms. And I’ve known that it’s been related because by the time they see me, it’s sort of five, ten years later. And they then started to have some muscle and joint pain, some headaches and other symptoms suggestive of their hormones. But that’s been their presenting complaint. And so is that the same in your practice? [00:08:44][59.5]

Dr Ashley Winter: [00:08:45] Absolutely. Absolutely. And I think this comes to some extent to the gaslighting of the symptoms that women feel, because we say that the genitourinary syndromes come later, in part because this profound anatomic changes associated with low oestrogen state, such as labial thinning, prolapse of the urethra, narrowing of the introitus, visible anatomic changes often come later and are delayed by a number of years. But that doesn’t mean that in the perimenopause period we are not experiencing pain related to low oestrogen levels, bladder urgency and frequency related to low oestrogen levels. Small amounts of blood in the urine related to low oestrogen levels, recurrent UTIs. And it is fascinating to me because I have had a number of women who are in their, let’s say, early, mid-40s and they have cyclical onset of these symptoms, bladder pain, urgency frequency, UTIs, painful sex. And oftentimes it’s right around the time of menses, right, when oestrogen is lowest in the cycle. And they get told it couldn’t possibly be related to their hormones because they’re still menstruating and because they’re not menopausal, right. Even times I’ve had women manifesting with these symptoms and their last menstrual period was ten months ago, but because it wasn’t a year ago, they don’t classically fit this strict definition of menopause and they’re told it couldn’t be related to their hormones. And they feel like they’re going crazy because they notice a relationship. And when I finally give them the low dose vaginal oestrogen, their symptoms will completely, completely resolve. I had a woman recently who is in her early 40s, and she was getting such bad urinary infections around the time of her menses that she ended up hospitalised with sepsis of urinary origin. And we put her on vaginal oestrogen and she said, You have saved my life. It’s just wild. So I 100% agree with you that those symptoms begin much earlier than we recognise. And just because the anatomy hasn’t made these drastic changes doesn’t mean the physiology isn’t changing. [00:11:05][139.6]

Dr Louise Newson: [00:11:05] Absolutely. And certainly what people’s vulva, vagina looks like, doesn’t correlate with symptoms as well. And that’s really important for people to be aware. And, and actually, my one of my children had a piercing on her eyebrow, as you do when you are 20. But she.. the piercer was talking about, well they were just having a general conversation and she said, oh, I’m really struggling with my health. And Jessica said, Oh, what’s going on? Do you mind me asking? And she said, Oh, well. She said, I’ve been having so many urinary tract infections, I’ve got this thing called interstitial cystitis. I’ve been under the top urologist. I’ve had this treatment, that treatment, this investigation. And I’ve had sepsis a few times. And I’m also incredibly tired. I get night sweats. I used to work out in the gym and now I don’t, I have a rest every day. And my boyfriend is really kind and I’ve had all these blood tests, everything’s normal. So when Jessica left, she said, Oh, you might want to just look up my mum. She does a lot of work in this area. And then she came out of the building and phoned me. And she said oh Mummy I’m feel really sorry for this woman. And I actually had her piercing in my ear, and I’ve got a few sort of rebellion piercings in my ear…so I had my cartilage done by her a few months ago, so. And she was a lovely, lovely lady, or she still is. So I said to Jessica, Do you know what? She probably just needs some really simple treatment, but I’m sure she’s got no money. So I said, Look, why don’t you just go back, get her email address and I’ll just give her a quick ring. I won’t do a full on consultation, but I’ll just give her a ring and some advice. So she went running back in and she came out crying. Jessica, my daughter said, Mummy, she was so emotional, she couldn’t believe it. And then the next day I spoke to her and she said she’d stayed up all night, downloading balance, listening to podcasts. And she said, Everything you say makes sense. But I’ve been asking for years for some treatment, thinking it’s my hormones. People in my family have had an early menopause, yet no one will give me even any vaginal hormones. And of course I recommended her to have some vaginal hormones and I spoke to her recently to see how she was. And she’s still having systemic symptoms. But I arranged a blood test. Her oestrogen is very low. Her testosterone is very low. But her local symptoms, she said, I am not getting up in the night anymore. She said that whole irritation has calmed down. You have, even if this is as good as I’m going to get, this has been transformational for me. Now she’s only 31. You know, it’s just shocking, actually, because vaginal hormones, so we’ve got vaginal oestrogen and we’ve also got this other vaginal DHEA, which is prasterone which converts to oestrogen and testosterone, but it’s only localised. So I can’t think of many things that are safer than vaginal hormones that we prescribe. Can you? [00:13:52][166.6]

Dr Ashley Winter: [00:13:52] Oh, absolutely not. I mean, it’s safer than acetaminophen, which is what is that called in the UK? [00:13:57][4.7]

Dr Louise Newson: [00:13:58] Paracetamol. [00:13:58][0.0]

Dr Louise Newson: [00:13:59] Yeah. I mean, it’s so safe. I mean, I see this all the time. I think vaginal hormones should be over-the-counter. [00:14:03][4.5]

Dr Louise Newson: [00:14:05] And so why aren’t they over-the-counter? I mean, how is it that men can buy Viagra, certainly in the UK over the counter, as long as they’ve got a credit card or some money they can get them? But why vaginal hormones? What is the reason other than it’s a female preparation? But why? Why do you think we can’t have them over the counter? [00:14:23][18.0]

Dr Ashley Winter: [00:14:23] Yeah, this is a great question. So at least in the US, we have something called class labelling on all hormones. So what that means is that every single oestrogen product in the US has a very scary black box warning on it, saying that the Women’s Health Initiative study showed that oestrogen and progesterone combinations can cause breast cancer, uterine cancer, blood clots and all these terrible things. Right. So, of course, what we know is that the Women’s Health Initiative never showed that oestrogen alone causes breast cancer or blood clots or any of that. So and certainly not in transdermal preparations or transvaginal preparations, but also that low-dose vaginal preparations do not enter the bloodstream, do not change the systemic levels of oestrogen. And so that black box warning is not only wrong, but it’s incredibly harmful because a patient will be prescribed this treatment and they read it and they get scared and they do not ever take it. And I found in my practice, as you know, attending physician in the United States, unless I spent so much time unravelling all this fear related to hormones, they would not take this treatment. So, you know, part of the reason I think there are no over-the-counter vaginal hormones in the United States is because even our regulatory institutions will not remove this fear mongering, inaccurate labelling. And the North American Menopause Society has asked the Federal Drug Administration, which is our medical regulatory agency, to remove that black box warning, citing large retrospective studies showing that low dose vaginal oestrogen does not cause any of these problems whatsoever and they won’t do it. And I do not know why. It is incredibly harmful. [00:16:29][125.9]

Dr Louise Newson: [00:16:30] And it’s the same. We don’t have the same warning, but we still have the same words. And it’s our MHRA, which is exactly the same. And I sort of sometimes compare it with other medication that we use systemically and topically. So for example, if you had asthma and you had a flare up of your asthma and I gave you steroid tablets to calm it down, the tablets would warn that there’s a risk of immunosuppression and various side effects, quite rightly so, because that’s absolutely accurate. If you had a bit of eczema on your hand or arm and I gave you a low dose hydrocortisone cream, so it’s still a steroid, but it’s a really, really low dose. You put it on your eczema, it doesn’t really get into the bloodstream and the bit that does is really low. So it doesn’t make any difference. It doesn’t have the same warning of immunosuppression and everything else. So it’s the exactly the same with what we’re doing with our hormones systemically and vaginally. And so it seems completely wrong that whether it’s available over the counter or not is one conversation. The other conversation is the warning of these inserts. And you’re absolutely right, we spend a lot of time in the clinic saying to people, actually, don’t read what’s in the insert because it’s not right. And that’s quite hard to… it looks like we’re making something up and we’re not. And it just doesn’t make sense that we’re trying to dissuade women from having a treatment that can be really transformational for them and we know is safe. [00:17:59][89.0]

Dr Ashley Winter: [00:17:59] Transformational and safe. And I think, for example, in the case of genitourinary syndrome of menopause, right. What is one common symptom, like overactive bladder, right? And because of the fearmongering related to the low dose topical hormones, which essentially have almost no side effects and definitely, you know, essentially no danger, we instead will put women on anticholinergic medications. Right. Which are a common medication for overactive bladder. And those medications cause dry mouth. They cause constipation. They have been linked to increased risk of dementia. Right. And they don’t work very well. They work poorly and they don’t address the root cause. Right. I was looking at an interesting study. And they’ve done in animal studies and showed that as oestrogen levels go down in the body, the bladder lining has an upregulation of mechanoreceptors. So what this means is that in the bladder itself, your bladder becomes more sensitive to distension, filling with urine when oestrogen levels go down. So this is an innate fact of our bladder is that you can develop overactive bladder when your oestrogen levels go down. And if you take a low dose vaginal oestrogen, that will permeate into the…from the vagina into the surrounding tissues, the urethra, the bladder, and you will actually address the root cause, right. You can cause downregulation of those mechanoreceptors and not just put a patch on your overactive bladder, but you could cure. Right? You could cure your overactive bladder. But because of our fear mongering around hormones and the way we gaslight menopause symptoms and the way we take symptoms that are so common and pretend they’re not related to hormonal levels, we have somebody on anticholinergics. We have women getting menopause, I mean, dementia directly from our treatments. And it’s just it’s mind boggling. And this is why I have to talk about it all the time. [00:20:06][126.3]

Dr Louise Newson: [00:20:07] So you totally you’re totally right. My oldest daughter has asthma, actually, and she was given one of her inhalers was an antimuscarinic. So it was the same as having one of these acetylcholine on drugs like Oxybutynin. And very frustratingly it really affected her memory. So it was quite quick that it worked or had these side effects. But she is a trombonist, so she was finding it really difficult to read music because she couldn’t remember the note, she couldn’t remember the position on her slides. Once she phoned me up in a supermarket and said, I’ve come to make some bolognese, but I don’t know what I need. And I was like, Oh, you need some mince, you need some onions. She goes, Well, where do I look for those? Jessica are you alright? And she doesn’t drink alcohol. I knew there was nothing else. [00:20:50][42.9]

Dr Ashley Winter: [00:20:50] Yeah. [00:20:50][0.0]

Dr Louise Newson: [00:20:51] And then I said, Just tell me again which inhaler you’ve been given recently. And she told me, Oh my gosh, you’ve got to stop it. And she was also telling me that her mouth was very dry, which is a real problem for a trombonist of course. But she said, my eyes are dry. I can’t read my screen on my phone very well. And then she also had the most horrendous vaginal soreness and itching and skin and then all these antimuscarinic side effects and actually then recently I was telling her you know when people don’t take HRT one of the treatments that sometimes are given for hot flushes actually is this drug and it has the same side effects as the asthma inhaler you had. And especially when women who have had breast cancer, they often are given this drug. And she’s not that emotional a person. But she burst into tears and she said, I cannot imagine having that drug as a tablet. What are they doing to people? And I said, well, we know it increases risk of dementia. And actually a study in the British Medical Journal last week showed it increases risk of cardiovascular disease as well. I’m not surprised. So there’s one thing not giving treatment, which I think is bad enough, but there’s another thing giving treatment that A isn’t treating the underlying cause, but B is potentially causing harm. You know, there’s always a balance of benefit versus harm for anything we do. Getting up in the morning, driving a car, whatever we eat, whatever we do. But actually hormones are the safest thing because it’s just what we naturally are producing anyway. And even vaginal hormones, you know, are usually very safe in women who choose not to take HRT or women who’ve had breast cancer. And we see a lot of women who’ve had breast cancer and talk to a lot of women who, their urinary symptoms are the really main symptoms of their, you know, their menopause or perimenopause and they’ve been told, oh, just be lucky that you’re still alive and you’ve got through cancer treatment. And, you know, I’m sure you’re the same that, you know, I’m very confident in prescribing localised hormones to these women. [00:22:52][121.4]

Dr Ashley Winter: [00:22:53] Oh, I absolutely agree with you. And I mean, if there was one thing I could accomplish in my entire career, it would be to have every, every, every single woman use vaginal hormones or at least have a discussion about vaginal hormones, be offered vaginal hormones, and not just do it in response to development of symptoms, but really do it as a preventative measure. So when you’re entering the age of perimenopause to discuss what are the signs and symptoms associated with reduction in oestrogen, in the tissue of the bladder and the urethra and the vagina and oestrogen and testosterone, to be frank, and say, you know, this is something that is safe for you to take from now until the day you die and it will not give you breast cancer. It will not give you uterine cancer. You do not have to check blood levels of anything to take this. And it can prevent overactive bladder, recurrent UTIs, painful sex, vaginal dryness. You can be offered this, right? I mean, like I say, we don’t wait for somebody to have a heart attack to be put on cholesterol medication. I mean, why do we wait for a woman to have five, six, seven urinary tract infections, be put on quite dangerous antibiotics, potentially get C. Diff colitis, antibiotic bacteria, multidrug resistant organisms in their body. Why do we wait for that to institute something that we’ve known with level one evidence for over 30 years prevents about 80% of urinary tract infections in women after menopause. I mean, why why do we do that? Nowhere else in medicine would we do that? [00:24:35][102.4]

Dr Louise Newson: [00:24:36] No, you’re absolutely right it absolutely doesn’t make sense. And I do feel, you know, we should be twisting on its head and say, why are women not on a vaginal hormonal preparation. And certainly, like you say, any woman that has had any urinary symptoms or any urinary tract infection, it should be the number one treatment really to try. And I feel very strongly also in anything we do for medicine, it’s often we give a therapeutic challenge, don’t we? We try a medicine and see if it helps. With the vaginal treatments, women are inserting them themselves. So, you know, I have to say to patients, we’ll try a treatment for 3 to 6 months, see how you feel. And if it’s not helping, you don’t need to continue with it. And usually people it’s transformational. And even women who are on HRT, there’s still a considerable proportion, probably around 20%, maybe more, who still need to use vaginal hormones. And that’s really important as well. And I think a lot of people, when they haven’t had urinary symptoms, they don’t realise how disabling they are. I’ve had quite a few recurrent urinary tract infections and I wish I had started vaginal hormones when I was a lot younger. But actually when you’ve got pain in your urethra it is the most awful pain ever. You absolutely don’t know what to do with yourself. And I think it’s underestimated. And a lot of these people, you say gaslighting a lot, but a lot of these women have a lot of psychological symptoms as well. And it’s almost like, oh, there there you’re making a bit of a fuss. Well, they should be shouting from the rooftops because it’s horrendous what they’re experiencing. It really is. And I just think it’s underestimated the symptoms and the the suffering that goes on for these women. And it’s not just a one off urinary tract infection, you know, and it’s recurrent. It’s a horror and it ruins their lives. [00:26:25][108.9]

Dr Ashley Winter: [00:26:26] You know, it’s so great you touched on this, and this is something that I did not really point out, but there is a whole other cohort of patient that ends up in my office as a urologist, who is the woman who has recurrent UTI-like symptoms without infections. So this woman, every few weeks or even constantly feels extreme urethral pain, extreme urethral burning, frequency, severe pain and their, you know, GP or whoever is taking care of them, maybe the emergency room, you know, is getting urine cultures and they’re all coming back negative. And so people say, Hey, nothing’s wrong with you because you don’t have an infection. And the problem is something is wrong because they are experiencing those symptoms. And almost always this has an onset that coincides with some reduction in hormone levels, either perimenopause, menopause, you know, starting birth control or medications specifically for hormonal related acne. And those people, when I put them when I explain to them the physiology that their urethra can have, upregulation of pain receptors, of sensitivity, of friable tissue burning, that that can all be a direct consequence of their low hormonal state. And we put them on a topical low dose hormone. It completely resolves and they are back to themselves. So that is another cohort of these, not UTI, but feel like I have a UTI, that is just tremendous and probably also not falling under that category of symptomatic menopause, but really it is part of symptomatic menopause. [00:28:11][104.4]

Dr Louise Newson: [00:28:11] Absolutely. So anybody who’s been having any urinary symptoms and is listening to this really needs to talk to their healthcare provider about the possibility of vaginal hormones. And so I’m very grateful for your time, Ashley. But I’d like to finish with your three take home tips. So I would ask you to say three reasons why the majority of women at some stage in their life should be using vaginal hormones and once they start using them, continue forever. So just three reasons for that, please. [00:28:41][30.1]

Dr Ashley Winter: [00:28:42] Okay. One, it’s extraordinarily safe. No risk of any cancer or blood clots, 100% safe. So that’s number one. Number two is that it can prevent you from needing so many other unnecessary treatments that don’t address root causes. Right. This may prevent you from taking antibiotics, anticholinergics. I mean, maybe you don’t need vaginal moisturisers. I mean, who knows? You will probably save money. I know. So that’s number two And number three. Oh, gosh, I don’t I don’t know. I mean, that’s it’s safe and it fixes everything. I just can’t even. Not everything, but it fixes so much. Yeah. And number three is that it is not just a vaginal treatment. It is a bladder treatment, a urethral treatment, a vulva treatment. The medication acts locally, but acts locally throughout the pelvis. And so oftentimes, again, we think of menopause or hormones related specifically to sex organs. But it is not just quote unquote, sex organs. It is urinary organs as well. And those are hormonally sensitive. So safety, efficacy. And it is not just a vaginal treatment. It is a urinary treatment. So. [00:30:03][80.5]

Dr Louise Newson: [00:30:03] Very good. Excellent. So lots of really valid and important information in this podcast, and I’m very grateful for your time again Ashley. So thank you very much. [00:30:14][11.1]

Dr Ashley Winter: [00:30:15] Yeah. So thank you so much for having me on. [00:30:17][1.9]

Dr Louise Newson: [00:30:22] You can find out more about Newson House group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:30:22][0.0]

END