Health risks and treatment of surgical menopause with Dr Walter Rocca
Dr Walter Rocca is a neurologist from the Mayo Clinic in Minnesota, USA, where he studies common neurological diseases as well as the aging processes between men and women. He has a particular focus on estrogen and the effects of menopause on health risks.
In this episode, Dr Rocca explains how sex hormones have a much greater role in many of the body’s functions than simply regulating the menstrual cycle and reproduction. He explains why it’s so important to treat women with hormone replacement after bilateral oophorectomy with or without hysterectomy or early menopause, especially younger women.
Dr Rocca’s three take home messages:
- The ovaries are a tremendously important organ for healthy functioning of our heart, brain, bones, kidneys, lungs and more.
- For healthcare professionals: be very careful when thinking about removing the ovaries and/or the uterus, unless there is a very clear clinical indication. The longer-term harmful effects of these surgeries are greater than the apparent short-term benefit to symptoms.
- If a woman has a high genetic risk of ovarian cancer (>40% risk level), removal of the ovaries is appropriate, but she should be given estrogen therapy afterwards as the risk associated with this treatment is very low (including for BRCA carriers). If a natural menopause occurs early or prematurely, these women should also be offered estrogen therapy, unless there is a specific counterindication.
Dr Louise Newson [00:00:09] Hello, I’m Dr. Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of the Menopause charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today I’m very, very excited actually, to introduce to you someone that I’ve been stalking from afar without him realising for quite a few years, someone called Dr. Walter Rocca, who works out of the Mayo Clinic in Minnesota. I first heard him lecture a few years ago at a conference about what happens when younger women have their ovaries removed and the changes that occur, especially the health risks that occur. And everything he lectured on made sense. And I thought, how do I get hold of this person? So I’ve been reading a lot of information and emailing him from afar, and then I have the privilege of meeting him in real life at the International Menopause Society in Lisbon last year, in 2022. And now he’s here that I can speak to in my studio. So thanks ever so much, Walter, for joining me today.
Dr Walter Rocca [00:01:33] You’re welcome. It’s a pleasure.
Dr Louise Newson [00:01:35] So tell me about your work and your background and why you do what you do, if you don’t mind.
Dr Walter Rocca [00:01:41] Well, that can be a long, long question, but I’ll try to keep it focused if we can. I by training am a neurologist. So, a brain specialist. But I also spent quite some time learning research methods. So how can you use data to answer questions in medicine? You know, like in medicine, we are dealing with a lot of uncertainties, a lot of things that are not clear or that are not resolved. And then we progress by creating evidence or data or pieces of knowledge on which we can then build a bigger theory. And so I got trained formally in research methodology, and then I tried to work on neurological diseases. And while I was doing neurological diseases, primarily dementia and Parkinson’s disease, I discovered that they were potentially connected with reproductive issues, which at the beginning I thought was strange because we think of the head and the pelvis far away.
Dr Louise Newson [00:02:51] Of course.
Dr Walter Rocca [00:02:52] And so I said, oh, so the pelvis and the brain are connected. And so then I started doing work on endocrinology, like the production of sex hormones by the genitalia and the relation of that to the brain. And that’s how some of the stories developed.
Dr Louise Newson [00:03:07] Very interesting. And it is very interesting for lots of reasons, because when we think about the menopause it’s often defined as loss of ovarian function, so our ovaries stop working, but actually breaking down the word menopause is about our periods stopping. So, a lot of people think it’s related to our endometrium, the lining of our womb, or it’s related to fertility stopping, you know, being able to have children. Now, I’m a menopausal woman and I don’t really care about my fertility because age 52, I really shouldn’t be having children. I’m, you know, very fortunate. I have three daughters, but also, I’ve had a hysterectomy. So I don’t have periods. So I can’t be defined by my menstruation because obviously I’m not going to bleed because I haven’t got a womb. So, then it’s really if you think about ovarian function, some people don’t have their ovaries. So, for me it’s more about the hormones not being there in our body or if they are, they’re in there in at low levels and about our hormones being biologically active throughout our body, whereas for a lot of people they just think our ovaries are about our womb and they regulate our womb and don’t realise that actually these hormones get into our brain and the neurotransmitters and they get everywhere in our body, don’t they?
Dr Walter Rocca [00:04:27] Yes. And this is the central misunderstanding. So for now, 30, 40 years there was this idea that the ovaries were very important to produce ova, which would then get fertilised and make babies okay, and they would also make hormones. But these hormones were important for the endometrium, for the vagina, for the breasts. They were sex hormones. They were not hormones for the body. And if you followed this misunderstanding and you think that the ovaries are reproductive organs, period, then you completely miss the point. So people were saying, okay, when a woman has completed her period, she does not plan to have additional children and she’s having any even minimal issues with bleeding or pain or anything, well, then we just take everything out. So if these organs are only reproductive and they are not “needed any more”, then we can just simply clean it all out and we will then protect these women from developing cancer of these tissues. Of course, if you don’t have the uterus, if you don’t have the ovaries, you will not develop ovarian cancer or uterine cancer. And there was also the belief that that would also reduce breast cancer. Well, unfortunately, that was a big misunderstanding because the ovaries produce estrogen, progesterone and testosterone in addition to other less important hormones which end up having effects on many, I would say almost all, organs and tissues and at the cellular level so that basically the full body of a woman is under endocrine control all the time. And the same for men with testosterone and estrogen. Of course, as you know, men have also organs equivalent that are the testis and they produce testosterone and estrogen and other steroids which are essential to control the body of man. And the body is all of the tissues. So whether it’s cardiovascular disease, your heart, your bones, your brain, your kidney, your lungs, your skin, your eyes. So it’s amazing, our complete misunderstanding. So, these became clear starting around 2005, 2006, there was a famous colleague from California, from Los Angeles, who in 2006 said, well, if you look at the data out there, there is some suspect that when you remove the ovaries to a premenopausal woman, yes, you have a reduction of ovarian cancer. Yes, you may have some reduction of breast cancer, but these women simply die faster than if you didn’t. This was 2005. And that was the first person that got to say, what we do may not be correct. And then, of course, now we are like 15 years later. And we can say pretty comfortably that we now know exactly what was going on. But for many, many years, the practice was done with complete confidence that it was based on good evidence. It was simply wrong evidence and was absence of evidence. So sometime medical practice is based on judgement, preference, human emotions, and it is not corresponding to evidence, meaning to any attempt of applying scientific methods to nature to understand what’s happening there. As you know, Western science started in the 1500s in Europe and was the idea of bringing people out of beliefs, the irrational belief, magic, religions into something that would be reproducible, trustable and that’s all the development of science. But even in 2023, we still have many things that we do that are not based on science, and they are based on tradition, preferences, who knows, anthropological phenomena.
Dr Louise Newson [00:08:54] Well, there’s always a combination, isn’t there? And often in medicine, it’s also what our peers are doing or how we’ve been taught. And that often can have a bigger impact than maybe an article that we’ve read or actually what happens now, everyone’s too busy, so they don’t always read the evidence. Or if the evidence is not quite what they thought, they tend to ignore it. And that’s what’s happens a lot with menopause, actually, because the more I talk about it as a hormone deficiency, the more actually on social media and everyone’s saying, how dare I? Of course, it’s not a hormone deficiency. Well, if I don’t have hormones being produced by my ovaries, I have a hormone deficiency. I don’t understand quite how else to explain it. But certainly when I was training as a medical student in the eighties and early nineties, you’re absolutely right. The standard practice was, oh, well, you might as well remove the ovaries, especially if they don’t need children or don’t want children. Take them out, then they won’t have ovarian cancer. But when I had my hysterectomy, I was in my late forties, so I was perimenopausal. I’d started HRT, but it took me quite a long time to decide should I have my ovaries out or not? But I just thought, any hormones that they’re squirting out, I might as well keep them for as long as possible. And that’s a personal, individual choice. But actually, the work that you’ve done, looking at women who are under the age of 40, so who are young and they’re young to be menopausal. And it’s very interesting whether you call it a surgical menopause, you know, it’s a lot of women have their ovaries removed and not their womb. So are they menopausal because they’ve still got their womb? It doesn’t really matter. You’ve actually removed their ovarian function, haven’t you? And their hormones are very low. So looking at this accelerated ageing, this inflammation that occurs in the body, which we know occurs during the menopause, but it’s quite accelerated, isn’t it, in these young women who suddenly have their hormones withdrawn from their body?
Dr Walter Rocca [00:10:46] Yes. In my experience, at least in the data that we have collected here in the United States, the majority of women that have the ovaries removed, they also have the uterus removed either at the same time or they had the uterus removed before. So, the majority of women that come out of a surgery to remove the ovaries are also without the uterus. But of course, you could consider removing the ovaries and keeping the uterus. Absolutely, that would be completely possible. But it’s very uncommon historically. One problem that we are working on is my concern for women who have their uterus removed, even if the ovaries are conserved, is that sometimes these women then don’t have menses. And so it becomes very difficult to then decide precisely when they become menopausal. And so if they don’t take estrogen or treatment and they don’t know when they become menopausal, they may kind of fall through the cracks and be in the limbo because they are not having menses, but they may still be hormonally active, but at some point they will become hormonally silent and they may or may not realise it. If they have very major symptoms, they may then complain of the symptoms and that will maybe attract the attention of the physician and of the woman to do something about it. But sometimes they don’t. And so there may be women that have the uterus removed and they conserved the ovary, which is the correct thing to do if you really need to remove the uterus, if you have a strong indication, but these women, then we cannot really say when they became menopausal. And I’m actually just now writing a paper that should be coming out in Maturitas in the United Kingdom, where we actually argue that for these women it’s difficult because nobody wants to spend the money to do the testing of their blood every six month. I mean, you would have to test these women every six months, they come and we measure their hormones until one day we say, oh, your hormones are low, some hormones are low some hormones are high. And so you are menopausal. That doesn’t make any sense because it’s costly, it’s invasive. So these women may walk around without knowing when they became menopausal. They can tell you when they stop menstruating because that will be the day after their hysterectomy, but they cannot tell you when they became menopausal. So if they were naturally predisposed to be premature or early menopause, having removed the uterus before will conceal or will censor their menopause. So, they may not know that they are having a premature or early cessation of ovarian function. The doctor will not treat them and they may be at a disadvantage if they don’t get treated because nobody knows that there is a problem. So that is kind of an interesting group of women and they are not uncommon as you testify. It’s a good big group of women who are now walking around and they have undergone hysterectomy, they have the ovaries in place and they are in this limbo state. And some of them, they should be treated and they are not being treated.
Dr Louise Newson [00:14:03] Absolutely. And we see a lot of these women who are on antidepressants and they’re often on blood pressure lowering treatment. They’re sometimes on sleeping tablets, they’re often on cholesterol lowering treatment. And when you talk to them, they say, oh, I’ve been feeling so dreadful. I’ve given up my work, my partner has left me, my relationship has been really terrible, I’ve been diagnosed with osteopenia, osteoporosis, I’ve got arthritis of this. And then you say, well, when did your health start to deteriorate? Oh, it was about a year after I had my hysterectomy. But I don’t think that’s related because it was just my hysterectomy. And you can see it’s all happened. But even women who have had their ovaries removed at a young age, certainly in the UK, a lot of them are still not offered hormone replacement routinely. And so we tend to pick up the pieces further down the line. And we’ve seen quite a few women in my clinic recently have been told by the surgeon ‘just see how you get on. You don’t really want hormones to see how you get on and come back if there are any problems’. Well, a lot of women and then waiting for flushes and sweats because that’s all they read about with the menopause. A lot of young women, women in general often don’t get them, I never had a hot flush at all, so how would they know? But then they’re presenting with all these other symptoms. But I think what’s really interesting is your list of diseases that are associated with having their hormones removed or reduced at a young age, because even your list of all those conditions includes psychosis and kidney disease and Parkinson’s disease, your lovely paper that’s recently come out. So, there’s a lot of these inflammatory conditions, but conditions that you wouldn’t necessarily put together. And I don’t think anyone that goes to a renal clinic, renal physicians would even think about hormones.
Dr Walter Rocca [00:15:50] Yes, indeed. When we published our paper showing that absence of adequate estrogen at the right age is linked to chronic kidney disease, which then would lead to dialysis to death due to kidney failure. It was somewhat official for us, it was a first. I mean, there was some data, but not very convincing on the estrogen effect, the menopause effect. But clearly nobody would have even expected these. The same with lungs. We found that there is an effect on chronic obstructive pulmonary disorder, which again was very clear. The situation is a bit more complicated with asthma. Okay, so the confusion with the lung is between asthma and chronic obstructive pulmonary disorder and chronic bronchitis bronchiectasis, because the estrogen is slightly different in the two conditions. Estrogen sometimes is worsening asthma symptoms but in the same time it’s protecting your lung tissue. So you have to be very careful not to lump everything into a single package. Otherwise you say, oh, yesterday’s not really important in the lung. Well, it’s important in different ways. So whether you protect the mucosa, you protect the alveoli or you have this constriction which is more acute. But very fascinating work on the lung we have done in collaboration with the group of experts on the lung here at the Mayo Clinic. So it’s fascinating what we are learning. And the way I see it is that of course, I’m taking a bit of a scientific perspective because for me the scope is to understand what’s going on. Of course, for other people to translate this understanding into improving the health of women. So I think I’m contributing to improving the health of women, but by understanding what’s happened in the background. And so from the background, we can consider the women that now are living in the UK or in the US or in any other country, these women that have had surgery, we should study them because they will teach us what to do for the next generation. So even though you can say, well, I’m very sad that they had the surgery, but they did have the surgery. So at this point it’s rather good pragmatism to study them and see what happened to them, understand them, and then we can tell their daughter or their sister or the new generation, you know, this is not a good idea. This is a good idea. And so, in a sense, what’s happened to women that the ovaries removed young becomes almost like a window to understanding ageing, to understanding menopause, and that it’s really revealing to us a lot of things that we didn’t know before of the effect of estrogen on organs like the kidney or the lung or the skin that you would not think about unless you start looking at big groups of women who had the ovaries removed.
Dr Louise Newson [00:18:40] And to me, I’ve got a pathology and immunology degree as well, and I’m very interested in basic science. Sometimes in medicine, if we can’t understand things or things sound conflicting, I always go back to basics because it’s just easier, actually. And I remember having a lot of lectures by a very eminent professor of biochemistry talking about our inflammatory cells, especially our macrophages, and if they’re not switched on properly, they become very pro-inflammatory. So they’re not good in the body. They turn on us almost. Whereas if we’ve got the right stimulation, they become very anti-inflammatory, which helps protect our body from inflammatory diseases, and that includes diseases such as heart disease, osteoporosis, Type 2 diabetes, dementia, all the diseases in fact, that are related to that list that you have seen and women that have their ovaries removed. So the lack of estrogen is switching those immune cells in a bad negative way. So, it actually makes sense. You know, your research is confirming some basic science that we’ve known for many, many years.
Dr Walter Rocca [00:19:42] Right now it has been shown that even the women that have a high-risk genetic marker. So even women that carry BRCA 1, BRCA 3, or Lynch syndrome, these women currently we believe, they should consider oophorectomy at the given age range because their risk is so high, 40, 50%, then it justifies at that level of risk the risk of having all of the other diseases. But, even if they have a high risk of cancer, ovarian and breast, it’s still indicated to give them estrogen because that’s been shown that estrogen in these women is not risky and does not worsen the cancer risk, but did benefit the dementia, the cardiovascular and the bones. So, I would say that we have now learned that even women who have high genetic risk, they should be comfortable in taking estrogen at the appropriate dosage.
Dr Louise Newson [00:20:47] Yeah, looking at young women, I sort of really think, why are we not giving hormones rather than should we be giving hormones? Because certainly up to the age of 51, we are really designed to have these hormones in our body. And so it really should be the minority of women following an oophorectomy or an early menopause should be not having HRT yet. We still know only the minority actually are given HRT. And it’s really difficult, as you say, we don’t have a diagnostic test. It’s easier if someone has their ovaries removed because then we know. But actually there are still so many women who are young without any contraindications, who have both ovaries removed, who are not routinely given HRT or even had the conversation. And that should be really the conversation should occur before the surgery, shouldn’t it as we know, because so many women don’t still know what the menopause means. And actually they think, Oh, if it’s a few hot flashes, I’ll get through them and then I’ll be okay. What people really need to do is to talk about, you know, your studies, your research showing these health risks if people don’t have hormones back when they’re young.
Dr Walter Rocca [00:21:59] Yes, absolutely. The hot flushes may be quite invasive and quite challenging on the life of women. I’m not saying that I’m not diminishing, but certainly those are not the kind of problem we are concerned about. We are concerned about cardiovascular, neurological, you know, major functionality of kidney, lung. So those are big issues.
Dr Louise Newson [00:22:21] I see some people who say, no, I have no symptoms at all. And then you start to talk to them and you say, well, what’s your sleep like? Oh, it’s terrible. I don’t sleep very well. Do you have any muscle or joint pains? Oh, yes. I spoke to a patient today, actually, and she tells me that she’s waking every night with awful muscle and joint pain. And it started when her periods stopped. And then you say, well, some people have got dry eyes. They can’t wear contact lenses or they’ve got urinary symptoms or they’ve got headaches or tinnitus. But they won’t say that’s related to their menopause because they don’t realise these symptoms. And it’s often when you give HRT, they say, goodness me, I can think clearly, I’m sleeping better, I’ve got no muscle pain, I’ve got more energy. And it’s these sort of subtle symptoms that make it quite difficult. And even certainly when I was perimenopausal, I didn’t know whether my symptoms were just because I was working too hard or whether I, you know, was in the wrong job or just because of having children and everything else. And then I thought, no, I’m just not coping. Maybe I’m just failing as a person and then it’s only having hormones back. You think, goodness, while the lights are on, I can think and colour again. Everything’s come back. But we’ve talked a lot about estrogen. But testosterone is also another important hormone that a lot of women find that they miss, especially when they’re young and have their ovaries removed, isn’t it?
Dr Walter Rocca [00:23:37] Yeah, unfortunately we know so much less about the dosage and possible toxicity, which then makes it difficult to really use it, which is probably it should be used more, but we should have then, you know, good data to support because again, there is fear. I mean, the problem, the enemy is always the fear. Oh, I take this medication and it will cause something bad to me. And yes, it could cause something better. You could also add to you a great deal. It could make your life much less miserable. So it’s always a matter of knowing precisely the correct dosage, the correct amount and all of that in that, you know, for example, in the United States, we don’t have a good product of testosterone for women in other countries like Australia. I think UK, you have some.
Dr Louise Newson [00:24:20] Well no, Australia is licensed for women in the UK, we don’t have a licensed product. We often use the Australian cream that we can use or we use a male licensed testosterone in lower doses, but we’ve been doing a lot of analysis of our patients actually of how their symptoms improve when they’re already on estrogen and we add in testosterone and we find that libido can improve unsurprisingly, and then we give it for reduced libido. But we’re monitoring all the other symptoms and we’ve found that actually mental health symptoms, so mood, anxiety actually improved significantly more than the reduced libido improves, and also muscle and joint pains improve. So we’ve got quite a lot of numbers and we are going to publish it soon. But that’s really interesting actually. And we find clinically women say my mood my energy, my concentration, my stamina improve. And we know from some of the preclinical studies looking at testosterone in mice, it’s exactly the same this anhedonia this can’t be bothered to do anything that creeps in when testosterone’s low. And it makes it very hard because a lot of women they’re not either listened to or no one thinks about testosterone or they’re sort of scared about it. But if you give it as a physiological dose and assess and I feel very strongly that women can be in control of this actually, and a lot of women, myself included, I wouldn’t be able to function without testosterone. But I mean, my level is still very, very low, but it was incredibly low. So it’s just still low, normal. But it’s fine. I can function. I haven’t got a beard, I don’t have any hair anywhere. I don’t have any side effects. So it’s my decision that I want to carry on knowing that I’m monitored carefully. And actually I just think of it as replacing a hormone like I would if I had low thyroxine. It’s very unusual, I think, to have a long-term problem, but we need more data. And this is where it’s so frustrating. The lack of science and good quality research in menopausal women. It’s just been neglected for so long, hasn’t it?
Dr Walter Rocca [00:26:22] And that’s why in 2005, 2006, we were doing massive gynaecological surgeries. Assuming that was good, there was no problem. And, you know, like nobody thought that there would be any consequences because if you follow women for six months or a year or two or three years, you don’t see anything. You have to follow women for 15, 20, 25, 30 years to see the long-term sequelae of this derailing of the endocrine system. You know, short term, you can see effects on sleep, on mood and anxiety, on feelings, quality of life, but you don’t see the damage to the kidney, to the long, to the arteries or to the brain. This takes 20, 30 years. We could only show these effects because we were able to follow women historically for a very long period of time. And that’s what we did. What the registries in Europe, like in Denmark or in Finland. Other studies where there were very good registries. They could then follow women with data for a very long period of time. If you only follow women shortly, it’s a short-term effect it’s a completely different question.
Dr Louise Newson [00:27:37] But now we’ve got this data I feel really strongly to improve the global health of women. To prevent disease, we have to act on, you know, your data, your results. And we certainly, even if we did start looking at young women, they really shouldn’t be neglected from hormones, especially, you know, if there’s no contraindication because of the health benefits in their health, preventative benefits that you’ve clearly shown.
Dr Walter Rocca [00:28:01] Absolutely.
Dr Louise Newson [00:28:02] So we need to change the tide. We need to move the needle. We need to, you know, allow women to have what they can have with their hormones back to not just improve symptoms but to reduce disease. So I’m very grateful for you to talk to me, Walter and I’m very grateful for the research you’ve done actually. And I just hope we can shout about it more and more. But before we finish, I know you’re so diligent that you’ve already done your three take home tips. Do you mind sharing them with us, please?
Dr Walter Rocca [00:28:31] Well, yes, I thought because I wanted to make sure that they would say something that is really useful to the people that are listening to us to be as beneficial as we can in terms of sharing our experience. These 15 years that I’ve spent looking at these issues and reading the literature and listening to my colleagues and debating with my colleagues have really put me in this position to have some opinion. So, the first message is that I would really like to impress on the listeners that the ovaries are a tremendously important organ and they are not only a reproductive organ, but as we said at the beginning, they are glands like the thyroid. So these are the adrenal gland, they are vital. They are needed to function normally and so they have influence on outside of the reproductive system, especially on the heart, the brain, the bone, the kidney and the lung. This is the most important. Of course, they have effect on the cartilage, the skin, the eyes. But I would say these are a little bit less vital than the others.
The second message is that I would really like if this reaches anybody who is in practice, in gynaecology or in internal medicine, to be very careful about suggesting the removal of ovaries or uterus in women unless there is a clear, clear documented indication. These are not surgeries that should be done light-heartedly they are not nonconsequential. And because we have now shown that the harmful effects are way, way greater than the immediate apparent benefit of having less bleeding or less abdominal pain or things of that sort. So don’t remove the genitalia light-heartedly because it may be a dangerous idea.
If a woman, finally, the third message really is the minority of women that have a genetic high risk. And these women, of course, exist and they have a serious problem, women that carry a BRCA1, BRCA2, or they are affected by Lynch syndrome and a few other rare conditions you probably don’t know the name of these women, that they are a risk of ovarian cancer. And I really mean 40, 50, 60%. Okay. Those are the ones that should be serious about using the removal of their organ as a preventive technique, not the women that are at 2%, 3%. That is a crazy idea. But if they are at high genetic risk, they should then consider removing the ovaries at the proper time window, which varies depending on whether you have BRCA1 or BRCA2. But even if you remove the ovaries, these women should be prescribed estrogen replacement therapy because they are going to be deprived of estrogen in a period of life in which they are supposed to have the estrogen. So you remove the organ which you think is where the cancer may develop, but you give the hormone that the organ would have produced to protect the remaining organs of the body, such as the brain, the bone and the heart. So the indication today and I would say there is consensus on this, is that these women should receive estrogen. Similarly, for women who naturally, without any medical intervention, experience premature meaning below 40 or early between 40 and 45 years menopause also, these women should be treated as if they had had the surgery because they were having premature or early menopause and they are having unusually low levels of circulating hormones that are supposed to be there. And so these women might actually benefit from being treated properly through the age of 50, 51 at least.
Dr Louise Newson [00:32:43] So very good advice. Thank you so much for your time and I look forward to reading even more papers as you publish them Walter, so thanks very much for your time today.
Dr Walter Rocca [00:32:53] Thank you very much. And thank you for the invitation. And I hope this is useful to the listeners.
Dr Louise Newson [00:32:58] Absolutely. Thank you. For more information about the perimenopause and menopause, please visit my website, www.balance-menopause.com. Or you can download the free balance app, which is available to download from the App Store or from Google Play.