April 24, 2025
118: Postmenopausal Bleeding: Causes, Concerns, and When to Seek Help
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Postmenopausal bleeding can be an alarming experience, especially when you've gone years without a period. What causes this unexpected bleeding? When should you be concerned?
Dr Ceri Cashell joins me to demystify this common but often distressing symptom.
We dive into the definition of postmenopausal bleeding - any bleeding that occurs after 12 months without periods - and explore the various causes, from hormone imbalances to more serious conditions that require immediate attention. Dr Ceri uses a brilliant analogy, comparing the uterus to a jumbo jet where multiple hormone "switches" need perfect alignment for smooth operation.
For women recently started HRT, bleeding can be a side effect, particularly in the first three to six months or after dosage adjustments. However, Dr Ceri emphasises that certain risk factors like obesity, family history, tamoxifen use, and smoking warrant prompt investigation.
We walk through exactly what happens during medical assessment - from initial GP visits to ultrasounds that measure endometrial thickness and potentially hysteroscopy procedures.
My own experience with unexpected bleeding after eight years without periods highlights how confronting this symptom can be.
Dr. Ceri reminds us that while HRT offers tremendous benefits, it's not a perfect solution and may require personalised adjustments to find your hormone sweet spot. Most importantly, she urges women not to dismiss or normalise symptoms that could indicate something serious - "Women are far too good at sucking things up," she notes, encouraging listeners to prioritise their health concerns.
Have you experienced unexpected bleeding after menopause? Don't wait - speak with your healthcare provider today and get the answers and reassurance you deserve.
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WEBVTT
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Welcome to the Dear Menopause podcast.
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I'm Sonya Lovell, your host Now.
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I've been bringing you conversations with amazing menopause experts for over two years now.
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This way, more people can find these amazing conversations.
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Hi everybody, welcome to this week's episode of Dear Menopause.
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Now, this is a little bit of a shorter episode this week because I am joined by my very good friend, Dr Ceri Cashell.
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Ceri and I have jumped on to have a conversation about a topic that I personally have noticed is being spoken about a little bit more, and Ceri is absolutely the person to get to the bottom of this for us.
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Ceri, welcome to the podcast.
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Hi Sonya, Thanks for having me again.
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Always a pleasure, Ceri.
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Today we're going to talk about postmenopausal bleeding, the reasons why, the reasons when, to get it checked out and to alleviate any concerns when it starts happening and it does happen, yeah.
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So I think postmenopausal bleeding is something that is really quite common, especially for women who are on hormone replacement therapy, but can absolutely occur for women who are not on hormone replacement therapy, and I suppose it's always important to go back to those basic definitions.
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So menopause is 12 months after your last menstrual period, so you've had 12 months where you haven't had any bleeding, and then postmenopause is everything after that.
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So, technically, postmenopausal bleeding is bleeding that occurs after a year of no periods at this time in a woman's life, which is different to somebody that maybe hasn't had periods for different reasons when they're younger.
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And postmenopausal bleeding can, on occasion, be a sign of something serious going on within the uterus or the cervix, rarely in the vulva and vagina, but the big thing we're trying not to miss is a cancer, of course, and that's why it is very important for women to get checked when this happens.
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So there's lots of different reasons for postmenopausal bleeding.
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A common cause would be just an imbalance in the hormones in your hormone replacement therapy.
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So there's a very good analogy of looking at the uterus like a jumbo jet where you want all the switches to be aligned for it to fly safely cruise control and the sex hormones the oestrogen, the progesterone, the testosterone are probably just three of those switches.
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There's lots of other things that will impact the lining of the womb things like insulin, probably other hormones like vitamin D.
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We know there's lots of these other hormones that are playing a role in all of our pathways throughout the body, so including the uterus.
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So we are really looking at trying to get a Goldilocks sweet spot with each of our different hormones for women that are on HRT, and it's really important that women do appreciate when they start HRT in the not had periods for a year or five years or 10 years, it can be really quite frightening to suddenly have a period if you haven't been aware of it.
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For most women it's not heavy and I have had some patients who've had some very heavy bleeding and that has been really very traumatic for them and again, that's something that they really do need to get checked out with their doctor.
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So it's really any type of bleeding, whether it's as simple as some spotting through to more heavy, almost kind of flooding, unexpectedly bleeding once you're postmenopausal.
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Obviously your first port of call with any time that happens is straight to your GP to ask some questions and do a bit of an investigation.
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Yeah, absolutely.
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The thing that we really don't want is for women one to be sitting at home getting very anxious, but two also that you're not sitting at home with heavy bleeding, putting yourself at risk of losing blood.
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That would make you amount of blood that would make you anemic or iron deficient, or also that we could be missing something.
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That is much more serious.
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So when I see a woman with postmenopausal bleeding, irrespective of whether she is on hormone replacement therapy or not, the first thing we look at is different risk factors and what else is going on with her.
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So, depending on how heavy the bleeding is, it is important to examine a woman in the surgery.
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So we're wanting to look and see if there's another source of bleeding.
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Sometimes women get little varicose veins in their vulva and vagina that can bleed.
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That's not so common, but it is something that can happen.
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If you're able to see the cervix, sometimes you'll see a pull-up.
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That's bleeding.
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Sometimes you'll see an abnormality there that might be more serious.
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But we can't look into the womb inside the uterus in a GP surgery.
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So that's really where we need the expertise of our gynecology colleagues.
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So first thing is to come and see the doctor.
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They can check your blood pressure, check you're not bleeding so much that you've dropped your blood pressure.
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That's very important.
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We can obviously check your bloods and make sure that you're not anemic.
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But then usually we are sending you off to get an ultrasound.
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Ideally we use somebody that is used to doing what we call gynecology ultrasound, so that's a gynecologist that's been trained both as a gynecologist but also as a radiographer or sonographer, very used to doing these transvaginal ultrasounds, looking at the womb.
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So off to see them.
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They will have a look and then they can grade whether the womb lining looks like it is of concern or not.
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And there are different guidelines in different countries that give you a cutoff thickness of the womb as to when we think we should be concerned.
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So at the minute the guidance would be around about four millimetres.
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So the person who does the scan will give an endometrial thickness.
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Dependent on that will determine how aggressive or how concerned we would be about the next stage.
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So four millimetres would be considered a cut off where you're very unlikely.
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If it's less than four millimetres, it's very unlikely that you've got anything serious going on within your womb.
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It's actually probably closer to nine millimetres where the risk of cancer really goes up.
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But we have to always put that in the context of the woman herself.
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So there are other factors that mean a woman might be more likely to have a serious process like a cancer going on the womb.
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And unfortunately, women who are overweight, who are carrying a lot of extra weight, do have an increased risk of endometrial cancer.
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Women who have a family history are at an increased risk.
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Women who have been on tamoxifen or who are on tamoxifen are also at an increased risk, and smoking, of course.
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So looking at those as risk factors, hrt probably isn't considered a risk factor for endometrial cancer, but postmenopausal bleeding is definitely increased in women who are on HRT.
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So I would see somebody examine them, send them for an ultrasound, and I would tend to have quite a low threshold for getting a gynaecologist to consider whether they would then have a direct look into the womb.
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They can take a biopsy.
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They can actually see what the tissue looks like under a microscope, and that can be very reassuring for everybody involved.
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Yeah.
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So my gynaecologist I love this analogy.
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She describes it in this beautiful way where she's like imagine it's a garden and you have your lawn and you want your lawn length to be, as you said, that endometrial thickness, to be at a particular level, and if your lawn is a bit overgrown and maybe you've got some weeds in there.
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So she was referring in my specific instance to some fibroids and some polyps.
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She goes, you know, and this was a procedure that I had done recently through a hysteroscopy where they go in and they mow the lawns as she described, and she pulled out some weeds.
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But it was a really good analogy for me to understand that endometrial lining.
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I guess that it can kind of get a little bit out of control and there are other things that can grow in there the fibroids, the polyps and obviously, wanting to eliminate any concerns around there being a cancer growing in there as well, yeah, absolutely.
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And for a lot of women finding something like a polyp and removing the polyp in that hysteroscopy is perfect, because then the bleeding source is often removed.
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They're the women that will bleed because their womb lining has got so the grass has got a little bit long.
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But you also know when your grass gets a bit short and a bit dry that it can also bleed, and we know that is.
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Another cause of post-menopausal bleeding is actually the womb lining is too thin.
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It can sometimes be that the little superficial veins in the uterus become a bit dilated.
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That sometimes is related to too much progestogen and they actually bleed because we're kind of thinning the womb lining too much and that can require a slightly different approach.
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It's not serious, but it is a cause of that persistent bleeding which certainly can be a nuisance for women.
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So the approach really is one very important that we rule out that there's not anything sinister going on.
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And then two then what we do to manage your bleeding can be very different depending on what we find in that ultrasound or that hysteroscopy.
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Yeah, fantastic.
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So just a little bit of a recap, going back to what you mentioned at the start about for somebody that is perhaps starting HRT for the first time but they are postmenopausal that there is a chance that they may experience some bleeding.
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When is that most likely to occur?
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From when they start their HRT.
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So it's most likely to occur within the first three to six months of starting HRT or if you change the dose and obviously if you've been somebody that hasn't really been on medication, you can forget to take a couple of days of maybe your progesterone or your progestogen.
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Usually people are quite good at taking their oestrogen but definitely stopping and starting progesterone or the progestogen can trigger a bit of bleeding.
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So light bleeding within the first three to six months we wouldn't be so concerned about Anytime that it's heavier, like a period, and certainly if it's heavier than a period you should really be getting seen by your doctor like I would say really within a few days if it's heavier than a period.
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But it is a common side effect.
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So, being aware of that, so light bleeding within the first three to six months, you should still tell your doctor about it, but I wouldn't consider it an emergency.
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Heavy bleeding or bleeding that is beyond that three to six month of starting or changing dose definitely needs a consultation reasonably quickly to progress to other investigations.
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Yeah, great.
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And, as you said, those other factors to take into consideration.
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So if you were someone like myself, for example, who has taken tamoxifen, then you would want to make sure that you were having that conversation with your GP straight away, as soon as there was any bleeding, just to make sure that everything is as it should be.
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But there are some women who do have persistent bleeding.
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So you've done a scan and you've done a hysteroscopy and everything is fine and they continue to have bleeding and that certainly can be a nuisance.
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So it can be a process of trying to find out what is your Goldilocks for your oestrogen, progesterone and even testosterone has a role in bleeding.
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So trying to find out what's right for each woman can be a bit different, like everything else, between individuals.
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The Mirena IUD is a great option for women that tolerate it and you can use it in the postmenopause environment possible years.
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It does seem to really control bleeding.
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Progesterone the natural progesterone is not as effective as the synthetic progestins at keeping womb lining thin.
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So, you know, while it's great in the brain, it can take higher doses to keep the womb lining thin for women.
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So there is a lot of personalized, individualized titrating and tweaking of the medications to get it right, and that can certainly be quite frustrating for women who have loved the no period part of postmenopause that's the bit they're delighted about.
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And then you've put them back to having a period every two to three months, which is it's interesting, but some women that certainly does happen.
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And that was certainly my experience and my situation.
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I found it really confronting.
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I hadn't had a period for eight years and then all of a sudden I went to the bathroom and there was blood.
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And it is confronting, it's scary, and I was straight on the phone to you, who happens to be my GP, because it is something that kind of really does come out of left field that you weren't expecting, and for me it wasn't within those first few months of starting my HRT as well.
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So I guess this is also just a really good reminder that hormone therapy is very nuanced.
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It takes some tweaking for some women to get those levels of all three factors, if you're taking all three of the hormones, to get that interplay between them all right.
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And I loved your analogy at the beginning of the jumbo jet and making sure that all those little levers are sitting at the right levels to make sure your engine just hums along.
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And I think it is also like HRT although it is body identical hormones and it is extremely safe, it does still carry these side effects.
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So it is something that people have said we don't talk enough about that it's not a perfect magic wand.
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There are these side effects, and bleeding and irregular bleeding on HRT is certainly one of the biggest, most common and most troubling side effects of HRT for a proportion of women, as is breast tenderness and headaches, but certainly the bleeding is the thing that causes distress, causes concern and requires investigation.
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You know HRT is a wonderful treatment but it is not perfect.
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I think that's a really great reminder, and thank you for bringing it back to that really overarching theme of you.
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Know it must be investigated, because we always, always want to ensure that we've eliminated anything that could be a little bit more sinister than just getting your hormone levels right.
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Awesome, Kerry.
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Thank you so much for this quick chat.
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Was there anything else that you wanted to leave the listeners with today?
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No, I think that's perfect.
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So, always leaning into your body If something is concerning you.
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Your doctor is there to listen to your concerns, so never feel that you are bothering your doctor.
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Women are far too good at sucking things up.
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We are here to deal with your concerns, address your worries, make it's our job to make sure there's nothing serious going on.
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But we can only do that if you come and speak to us about it.
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Yeah, great point and a really good reminder for us to finish up on.
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Thank you, Ceri.
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I will point in the show notes to the amazing Healthy Hormones platform, which does provide an online community with access to amazing GPs like yourself, so there's a great opportunity for women to jump into that community, be able to ask any questions that do crop up, obviously working alongside their GPs as well at the same time.
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Thank you, thank you, Thank you.
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