Cardiovascular disease, osteoporosis and HRT

This week, Dr Louise speaks to Italian Menopause Society president Dr Marco Gambacciani.

Early in his career Dr Marco specialised in reproductive endocrinology. He became interested in the occurrence of cardiovascular disease and osteoporosis during the menopause, and his menopause clinic was the first in Italy to have a bone density scanner. On a personal level, Dr Marco saw the devastating effects of osteoporosis first-hand after his grandmother was diagnosed with the condition. Dr Marco also shares his frustrations on the lack of understanding of how hormones can affect women’s cardiovascular health. On a more hopeful note, he is urging the Italian government to make menopause clinics available all over Italy. 

Finally, Dr Marco shares the three reasons why he believes women should consider HRT when they’re younger:

1. To improve quality of life. By reducing menopause symptoms, you improve quality of life and you help prevent chronic diseases
2. To help improve your performance at work – why should a woman have to lose opportunities just because she’s having flushes or not sleeping well?
3. It’s important for women to maintain the possibility of an enjoyable sex life ­ – low oestrogen levels can lead to low sexual desire or painful sex.

Follow Dr Marco on Instagram @m.gambacciani

This World Menopause Month, help us start the most menopause conversations – ever. Everyone’s menopause is individual and to help others understand and manage their menopause, we must break taboos, educate and start the conversation.

How to get involved

1. Have a conversation about the menopause
2. Log your conversation on the balance website
3. Share that you’ve got involved by tagging us on social media, using the hashtag #PauseToTalk

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’ve got a very important guest with me, someone from Italy, who I have known for a little while, but he hasn’t known me, I suppose. I’ve read a lot of his papers and had the privilege of meeting him face to face recently at a conference in Florence. So Professor Marco Gambacciani runs a menopause clinic in Italy and is very academic as well. So it’s a great pleasure to introduce you today. Thank you for joining me, Marco. [00:01:30][79.9]

Dr Marco Gambacciani: [00:01:31] Thank you for the invitation, I’m really proud of it. Thank you very much. [00:01:35][3.8]

Dr Louise Newson: [00:01:36] Ah, so I have read a lot of your work in the past and as a physician, as you know, I’m not a gynaecologist, I am very interested in science and I’m very interested in pathology, and I’m very interested in the way our hormones work all over our body. And when I heard you talk in Florence recently, you were talking about heart disease as well. And you also were talking about how there’s a lot of interest in the UK and there’s a lot happening in the UK and other countries need to learn from what we’re doing over here. And I was really interested because I, every day, feel that we’re not doing enough and I don’t feel I’m doing enough. And I feel like in the UK we’re not doing enough. We’re denying so many women of evidence based treatment. When I was sitting there I thought, Yes, you’re right, we are doing well, but we’re not doing well enough. But it doesn’t show how badly other countries are doing. And there’s 30 million women in Italy and only the minority of them are taking HRT. So I’m really keen before we go into that, can I just ask you a bit about your background and how you got to working in menopause? [00:02:46][69.7]

Dr Marco Gambacciani: [00:02:47] Oh yeah, starting from scratch. I had my thesis on PCOS syndrome and therefore when I got my degree I thought that to be entitled to start working on PCOS. My boss, and you, you know, in Italy we don’t say no to our bosses. And the bosses said, Marco, you are going to run the menopause clinic with a doctorate, by the way. And I was really disappointed. And Professor Ferretti saw my face and he asked me why, Marco, you are so upset about my decision that you are going to be the menopause guy of our group. Because, you know, I did my thesis on PCOS, and Professor Ferretti told me, Marco, think that in 20 years, the vast majority of our women, they are going to be menopausal. And so you are going to be the expert in the field that is going to be the most important in gynaecology. I was thinking about that for ages, for months, and that actually he was right. And I have to thank him for his decision, because since then I was interested first in the symptoms. We were doing some work also on neuroendocrinology, of hot flashes, and I studied the hot flashes also following the Professor Yen studies back in the 70s and early 80s conducted in La Jolla in California. I was with him for three years working on neuroendocrine regulation of hypothalamus pituitary axis, and afterwards I was interested also in cardiovascular disease, lipid changes around the time of menopause and definitely osteoporosis. We were the first gynae clinic in Italy to have a bone densitometer. At that time we were using the bone densitometry in the arm. Like Bob Lindsay did beautiful work and it gave us seminal data on bone density after oophorectomy, measuring bone density at the wrist. And I was fascinated by those data and that we tried to repeat it, to replicate these data, treating women with different compounds rather than mestranol, like Bob did at that time. And afterwards, after osteoporosis, we were starting doing some work also on vaginal atrophy. Okay, this is in summary, my background. [00:05:44][176.7]

Dr Louise Newson: [00:05:44] Now, it’s very interesting because when I opened my menopause clinic over here four and a half years ago, one of the first things I did was get a DEXA machine, a bone density machine, for the clinic. And I opened my clinic with just a bank loan, I didn’t have any money, and my finance director said, That’s crazy. Why are you buying a bone density machine? And I said, Because I feel very strongly that every woman, but actually probably every man as well, should have a bone density scan. And where I worked before at the hospital, I had persuaded the chief executive to rent a DEXA scan. We had a van that came once a week when I was doing my clinic. And I encouraged a lot of women to have bone density scans then. And it was mad because there were orthopaedic surgeons, there were rheumatologists working at the clinic with me, but none of them referred for a DEXA scan. But quite a few women did go to the DEXA scan, and I picked up a lot of osteoporosis, actually, and asymptomatic women who’d never had a fracture. Some of them had had a family history of osteoporosis. And so when I opened the clinic, I called it a menopause and wellbeing centre. Didn’t even call it a clinic, because I want people to think in a very holistic way how they can help. So hormones are part of it, but actually it’s looking at our bone density is so important because osteoporosis is more common than heart disease. It’s more common than breast cancer, it’s more common than dementia, yet we don’t talk about it. And as a physician, I’ve done a lot of rheumatology jobs and as a GP, I’ve gone to a lot of people in nursing homes and people who are housebound, who have osteoporosis of the spine and they’re in pain. They can’t digest food properly because of the curvature of their spine. They can’t breathe properly because they can’t inflate their lungs because their spine is curved. They can’t hug their grandchildren because every time they do, they get pain or a fracture. And you’re nodding. So I know you’ve seen similar women. Yet we don’t talk about it. And once we have it, it’s so much harder to treat. Like lots of things in medicine, it’s better to prevent than to treat. So awareness is the most important thing before you even think about how to prevent. It’s just knowing. So having a DEXA machine looking at bone density, which is the gold standard, as you know, for diagnosing osteoporosis, looking at osteopenia is really important. But it’s hard, isn’t it, when people think about hormones as affecting fertility or affecting periods? How do our hormones even get into our bones and why should we be thinking in this way? [00:08:27][162.1]

Dr Marco Gambacciani: [00:08:28] I cannot agree more with you. Because you know something that I didn’t tell you yet, that I became fascinated by the effects of, almost on bone. Just because, my grandmother in the early 30s, after the delivery of my uncle, she got haemorrhage, a tremendous haemorrhage. At that time was fashionable to treat everything with the x-rays in the 30s, and she got the…on the pelvis to block the bleeding, and she became menopausal in the late 20s. And my grandmother, she was a very, well, healthy woman, but she got tremendous osteoporosis. She spent the last 20 years of her life in bed or chair. That’s what, she was terrible. She was breaking her bones. You know, just lifting my daughter. And therefore, I cannot agree more with you. A woman must have a bone scan around the time of menopause. If this is okay, we can repeat a scan after two years, three years, five years or whatever. But I completely agree with you. And that time we can identify with a lot of women that are osteopenic. And there are data showing that the vast majority of women that are going to have bone fractures are those that they are aware osteopenic maybe five, ten years before. And then we can really prevent. Measuring bone density at 65, like in the National Health Service in Italy they recommend, is like to measure blood pressure in a ictus centre, in a stroke centre. They already have the disease. So why should be concerned about blood pressure. They already had the stroke. And the same is measuring the bone density at 65, 70, they already had the fractures because you know that they’re post-menopausal osteoporosis was defined by the decrease in the height of the women. Just because they have small fractures in their bones, in their vertebra. And Fuller Albright [endocrinologist] demonstrated that does the measuring the height of the women without any scans, any bone density, you’re not just measuring the fact that the women after menopause decrease in their height just because the vertebra crushes. [00:11:26][177.8]

Dr Louise Newson: [00:11:27] Yes. [00:11:27][0.0]

Dr Marco Gambacciani: [00:11:27] And not only the vertebra, we demonstrate also and Mark Brincat, that is a fellow of the British Menopause Society and he was the head of the Malta OB-GYN department that he demonstrated, that both were demonstrated in the same years, that after menopause you have the decrease also in the height of intervertebral discs. [00:11:48][20.1]

Dr Louise Newson: [00:11:49] So it’s not just the bones. [00:11:49][0.7]

Marco Gambacciani: [00:11:49] Intervertebral discs as a sharp shock absorber. It was not the Nike inventing the shock absorber for the shoes. That was our God that invented the shock absorbers in between the two different vertebra. And in the postmenopausal women losing the oestrogen and losing a lot of water and the good collagen in their body, they lose also the height. Indeed intervertebral disc. This one is one other risk factor for vertebral fractures in postmenopausal women. I mean, so that the bone is something that the gynaecologist must be concerned. Bone health is something that we had need to be concerned around the time of menopause. [00:12:40][50.3]

Dr Louise Newson: [00:12:40] Absolutely. And we know the longer a woman is without her hormones, the greater the risk. So I don’t know the exact figures. No one does. But it’s around 3% of women under the age of 40 have an early menopause. And we see a lot of women in my clinic who have had an oophorectomy, they’ve had both their ovaries removed, yet they’ve never been given hormone replacement and they’ve had their ovaries removed and they’re sometimes their 20s, their 30s, and so they’ll have longer without hormones and obviously that means they might experience symptoms. But whether they have symptoms or not, they’ve still got these bone changes which aren’t being addressed, which is a real concern. And we work out of the NICE guidance, the NICE menopause guidance as you know was produced seven years ago now, and we’ve got the International Menopause Society guidance that came out in 2016 and they do show that there is evidence that giving HRT to reduce fragility fractures, so these are the fractures that occur with low impact, usually due to osteoporosis, yet most rheumatologist, most osteoporosis specialists in the UK, will never recommend HRT or prescribe HRT. What’s it like in Italy? [00:13:50][69.9]

Dr Marco Gambacciani: [00:13:51] Is the same. Is the same and you know the internist, rheumatologist, endocrinologists are not familiar with the HRT prescription. They don’t know how to deal with the bleeding. They don’t know how to deal with press tensions. They don’t know how to be in general with the women complaints. They just say that the hot flashes something that are natural to have. Don’t worry, everything is going to be alright in a couple of months, or a year, don’t take all this stuff, that it causes cancer and clots and is very dangerous treatment. So on and so forth. And unfortunately, yes, we lose the possibility to prevent the vast majority of fractures. And you know that the North American Menopause Society released the recommendation for the osteoporosis prevention and treatment, saying that the hormones are the most effective agents able to prevent and treat peri and postmenopausal women because there are no data showing in bone specific agents like bisphosphonates are working in women under 50. Nevertheless, a lot of physicians, they prescribe bisphosphonates in premature menopausal women or they prescribe hormones for a couple of years. And after they stop, no matter how old is the woman. Last week I saw a 47 year old woman. She was menopausal. She went through the menopause around the 39, 40. She got the five-year hormone replacement therapy. And after replacement therapy was stopped for the fear of breast cancer. And she got the terrible hot flashes, night sweats and so on and so forth. But in a couple years, she lost 5% of bone density at this point. And this is one of the results of the full cultural level of our colleagues out there about the timing of HRT and the treatment of premature menopause. But this should say the treatment of menopause. Women are suffering from that. [00:16:23][151.9]

Dr Louise Newson: [00:16:23] Totally, and it seems the same globally, which is incredibly frustrating. And recently, Rebecca Lewis, one of my colleagues who you met actually in Italy, lectured at the British Society of Rheumatology about bones and menopause. And actually there was a lot of interest and a few rheumatologists afterwards said, how do we learn how to prescribe HRT? And I didn’t know it was safe. I didn’t know there was no clot risk when it’s through the skin. And I didn’t know the risk of breast cancer, if it is there, is so low anyway. And they also then have been saying, well, what about women with fibromyalgia? We see a lot of people with fibromyalgia and perhaps we should be considering hormones for them as well. And obviously we’re talking about oestrogen, but also testosterone for women is probably likely to help with bone density and muscle strength as well. And the muscles that support our bones, it’s really important that they’re strong as well, isn’t it? [00:17:19][55.3]

Dr Marco Gambacciani: [00:17:19] Sure, sure. Sarcopenia and osteoporosis are parallel syndromes in our as we age, both male and female, we do have both sarcopenia and osteoporosis. And definitely hormones, particularly oestrogen and testosterone, are very important, both in men and women to support the bones, joints, muscles and so on and so forth. And the collagen in general. You know, and therefore I think that we need that to have discussion, interactions with a dermatologist. I am a lucky guy. I have a friend of mine, she’s a dermatologist, that she’s interested in fibromyalgia and that she send me a lot of patients suffering from fibromyalgia that are decreasing their quality of life for the symptoms of fibromyalgia around the time of menopause. And we definitely we treat them with hormones. Those kind of patient I do prefer to use a transdermal, always transdermals because sometimes they do have some problems that can increase also the blood clots risks and therefore in those kind of patients I usually prescribe even without any evidence of need to be prescribing it just to prescribe it as transdermal. I prefer, I’m more confident in prescribing transdermal in those patients. [00:18:53][93.8]

Dr Louise Newson: [00:18:53] Yeah, to be honest, certainly in our practice, in my clinic we usually prescribe transdermal first line actually for all women because it’s easier to tailor the amount according to their individual needs to titrate the dose according to their symptoms. And obviously there’s no clot risk as well, which is also beneficial, especially as people get older. So when I’m comparing when I was younger as a junior doctor, we used to prescribe a lot of bisphosphonates without really thinking about how difficult they were to take, because you have to be sitting upright, you have to not eat for a certain length of time, they can cause side effects. I used to write them up a lot because my consultant told me to, but actually they might help some women. Obviously, we know reducing risk of osteoporotic fractures, but that’s about all they’ll do. Whereas if we think about HRT, we know that it will help improve bone density. We know it will reduce risk of osteoporosis and strengthen bones. But it also has other beneficial effects to our body as well, doesn’t it? So the biggest killer of women globally is heart disease, cardiovascular disease and dementia. They’re sort of running closely together. It depends on what you read, whether it’s cardiovascular disease or dementia. And cardiovascular disease is far more common. In fact, the only menopause training I had in retrospect as a student was a physiology lecture where they said women are protected against heart disease until the age of 50, and then the protection goes and the risk increases. When women have a heart attack over the age of 50, they’re more likely to die, less likely to have typical symptoms. And what a shame for women. But no one mentioned the word oestrogen or hormones. They just said age 50 and it set alarm bells. And I’ve got quite a inquisitive mind. So I said to my husband, because I met my husband when I was 18, and we always sat next to each other in lecture theatres. I said Paul that doesn’t make sense. It’s not a birthday present that we get when we’re 50. There must be something happening in our bodies. And then the year after that lecture, I did a pathology degree and I learned a lot more about hormones and about our immune system and about inflammation and the inflammatory diseases, of course, which osteoporosis is one, but also with cardiovascular disease and dementia and diabetes and clinical depression and schizophrenia and Parkinson’s disease. And without oestrogen, we get pro inflammation so our bodies don’t work so well. We’ve known for decades really, haven’t we, Marco, that the longer a woman is without her hormones, the greater the risk of heart disease. The greater the risk of dementia, the greater the level of LDL cholesterol, which is the so-called bad cholesterol. We know this for many years, yet the evidence regarding what about taking HRT to reduce those risk of diseases is quite clouded because we’ve been looking at lots of different types of HRT and lots of different groups of women, and people tend to group everything together and we can always skew data. We can always make it very, very complicated and messy. So then the results maybe suit what we need. But we do have evidence, don’t we, that taking HRT reduces future risk of cardiovascular disease? [00:22:09][196.1]

Dr Marco Gambacciani: [00:22:10] Yeah, you’re completely right. But what is astonishing when they say cardiologists say yes, women are protected till the time of menopause and afterwards and so on, they never pronounce the word oestrogens. And also in the JAMA a few weeks ago, they published the guideline for the prevention of chronic disease and so on and so forth. They were describing cardiovascular disease in women. They were describing the fact that women but they say hormone replacement. They don’t say replacement. They say hormone therapy. We should discuss also about definitions. Hormone therapy is not indicated, but different mention of cardiovascular disease. I mean, say exactly the opposite of what they were saying a few paragraphs about, you know, is unreasonable, completely unreasonable. And yes, you’re right. All these chronic disease, inflammatory, low grade inflammation that we have in our bodies as we age, you know, can be counteracted at least in part by hormones, in particularly in women, by oestrogens. And we need to keep an eye on androgens, because I saw a beautiful study published last week in the EPIC study, a subgroup of women and men they were measuring over the years, the DHA levels, and the women and men with a very low levels of DHA they are at higher risk of cancer, and they’re a higher risk of cardiovascular disease. But also, subjects with very high levels of DHA are at risk of cancer and cardiovascular disease. So the curve is a U-shaped curve and the best is around 200. So also prescribing these supplement containing DHA as they were completely safe. I’d rather be concerned, as we should be concerned every time we prescribe hormones, hormones are very powerful. Therefore, if we know hormones, we know how to prescribe. But I like the possibility to discuss with my patient the risks, the benefits. I always say don’t take the Google advice and don’t buy those supplements on Amazon because they can be risky. Or the vast majority of cases they don’t do anything. I mean, they just, it’s a waste of money, but they can be also risky. [00:25:05][175.4]

Dr Louise Newson: [00:25:06] Yeah, you’re absolutely right. We see a lot of people that buy all sorts of things over the internet and often you’ve got no idea what they are. And I certainly, in our clinic, and I’m sure the same is all I do is replace to a physiological level. So we’re just replacing or when they’re perimenopausal, we’re just topping it up really. [00:25:23][16.6]

Dr Marco Gambacciani: [00:25:25] I interrupt you. This is the concept of HRT. Why the R must be there. You are completely right. I’m fighting to have the definition HRT rather than HT on the library’s HT means hypertension. Non-hormone therapy. Yes. Sorry, interrupting you, but you are completely right. [00:25:46][21.3]

Dr Louise Newson: [00:25:48] You’re absolutely right. And it’s so important because people seem to be very scared of hormones. And it’s the same with any other medication. If I was giving someone a blood pressure lowering medication, I would change the dose according to their blood pressure and get them into a nice, normal level. And then with time, actually, I used to spend a lot of time reducing blood pressure medication because often people would exercise more, they would eat better, they might lose weight, they might drink less alcohol. And so we’re constantly adjusting doses of medications. That’s what we do as physicians. And it’s the same with hormones. We can start at one dose and then we might change, but we just keep it in the normal female range. But allowing people to improve their symptoms, but for me especially is optimizing their future health. So we’ve got the USA telling us, you say this recent paper that was in JAMA that we wrote a letter as a response to actually saying that there isn’t enough evidence to recommend HRT for primary prevention of any diseases. When I’ve done work with NHS England, they’ve again said there isn’t enough evidence. And I’ve said to them, Well, I don’t think you’ve read the papers properly and I get into trouble for talking like that. But actually there is evidence, good evidence actually, especially when you’re looking at heart disease and osteoporosis. Wouldn’t you agree? [00:27:02][74.3]

Dr Marco Gambacciani: [00:27:02] I completely agree with you because all the data showing the effects of hormone replacement in young women and let’s say so also in young symptomatic women in their 50s, they all of them are demonstrating the reduction of osteoporosis in fracture, the reduction of blood pressure levels, better control of blood pressure, better control of lipids, better control of glucose tolerance, better control of everything that is related to the increase in chronic diseases, mainly osteoporosis and cardiovascular disease. When you start hormones after 60 like they did in the WHI, you lose the opportunity to prevent. Maybe you are effective on those women that still had symptoms, but definitely in a 65 year old woman, she already developed osteoporosis and therefore the risk of fracture. You already developed the risk of cardiovascular disease. And so with hormones, you cannot prevent after 65 what you can prevent when you are treating women around menopause. [00:28:28][85.4]

Dr Louise Newson: [00:28:28] Yeah, I mean, it’s certainly, certainly the earlier we start HRT, the better. We do see quite a few women who have missed out on HRT for various reasons and come to us when they’re older. But even a low dose of oestrogen can help improve their bone density for some people. [00:28:46][17.6]

Dr Marco Gambacciani: [00:28:47] Yeah, that’s for sure. [00:28:48][1.0]

Dr Louise Newson: [00:28:48] And also we’ve seen people, lose, you know, their blood pressure’s reduced, they’ve able to lose weight. For some women, it means they don’t have pain in their joints and they can go out and walk or they sleep better. And we know if you sleep better, your risk of diseases improves, doesn’t it? [00:29:04][15.8]

Dr Marco Gambacciani: [00:29:04] No doubts. But the best is to start around the time of menopause and you prolong the beneficial effects of endogenous oestrogens that unfortunately are not produced anymore. Are you prolonging the beneficial effects of hormones on woman’s body? This is important not only for quality of life, but also for disease prevention. I hope to have a meeting with our new government and I hope they are going to be listening to the needs of women today. We are, I mean, the ambassadors of women or women’s needs, and that as ambassador we need to to underline that menopause clinic must be all over Italy, I should say so. And the medications that can help women, first of all, must be available because not only in the UK, I saw the problem of Utrogestan availability in your country, but in Italy is the same. A lot of different products are not available. Are registered but are not available and therefore for women is a problem, also cause a problem. Because if I prescribe, let’s see, Bijuve, one, OK, and the woman goes to the pharmacy and she asks for Bijuve and the pharmacist says no is not available anymore, is not available, they don’t produce anymore. The general idea is that first of all, the product is not a good product. It is not helpful because this is not produced, is not distributed. Is this something that is meaningless for women. Otherwise it should be there, it should be in the pharmacy. And therefore we must fight also to have the pharmaceutical companies to have the products that are licensed in the market, to be able to prescribe it, to be sure that when you are prescribing something, women are going to find it. Otherwise, the general idea that we can generate is that what we are prescribing is meaningless, is not important. A lot of women, they told me Dr Gambacciani, if they don’t have it, it means that is not important. Why you did prescribing me. And this is not good as a physician to have women asking you something like, a question like that. You know, it is embarrassing, you know. You need that, you need to explain. [00:31:49][164.4]

Dr Louise Newson: [00:31:50] Yeah, I totally agree. And, you know, certainly there’s quite a few people over here that just think HRT is a lifestyle drug. We just want nice hair and good skin. They don’t think about the importance. So I’m very grateful for your time today to help me unpick some of the evidence and be clear about the disease-preventative effects of HRT, especially when started in younger women. Before we finish, I always ask for three take home tips, so I’d really like you to give me three reasons why women should consider HRT when they’re younger to reduce their risk of disease. [00:32:24][33.9]

Dr Marco Gambacciani: [00:32:25] I think that the major reason is to improve their quality of life, to reduce the symptoms. Because reducing the symptoms it has been demonstrated that there are all evidence based medicine there to support the fact that when we are reducing the symptoms and improving the quality of life, we also do a good prevention of the chronic disease. This is the major problem. The second reason is that improving the quality of life you improve your performances. Usually today a woman around 50, she’s a worker and she’s easing the top of her career. Why she has to lose opportunities just because she’s flashing, she’s not sleeping well. Is it foolish? And the third major concern is the sex. Women they need to maintain the possibility to have enjoyable sex. And definitely with the low oestrogen levels around her body as a woman, as a low sexual desire, poor vaginal performances, and there are no reasons to wait to the dyspareunia [painful sex] to treat women and maintain the vaginal functions. So I think that the woman, they must be treated, when we can treat women with HRT for their symptoms, preventing the chronic disease and in maintaining an enjoyable sexual life. [00:34:06][101.4]

Dr Louise Newson: [00:34:07] All sounds very good. So I very much agree with everything that you’ve said, and I’m very grateful for your time today, and I look forward to seeing you again in Italy or welcoming you over here to UK. So thanks again for your time today. Marco. [00:34:20][12.5]

Dr Marco Gambacciani: [00:34:20] Thank you Louise. [00:34:21][0.4]

Dr Louise Newson: [00:34:25] You can find out more about Newson Health Group by visiting www.newsonhealth.co.uk and you can download the free balance app on the App Store or Google Play. [00:34:25][0.0]

ENDS