The unfair choice for elite female athletes with Janet Birkmyre
Janet Birkmyre began her career racing as a track cyclist in her mid-30s and won her first elite medal at the age of 40. She went on to win three elite National Championship titles and multiple masters World and European titles. Now at 55, Janet is continuing to improve her times and fitness, and she is a champion of women continuing to enjoy and excel at sport at any age.
In this episode, the conversation covers Janet’s experience of perimenopause and menopause and taking HRT. As an elite athlete however, there are sanctions for Janet if she takes testosterone replacement as there are currently no exemptions to the regulations for therapeutic use in women, only for men. Janet shares her frustration at the unfair choice imposed on her of continuing with the sport she loves and excels in or replacing her low testosterone levels to help with her ongoing menopausal symptoms.
Janet’s three positive steps to improve health through exercise:
- Enjoy being active – make it fun
- Exercise with a friend – you will motivate and encourage each other
- Don’t be self-conscious or compare yourself with others – we come in all wonderful shapes and sizes.
So whatever you look like, whatever you’re wearing, be active and enjoy it!
Follow Janet on Instagram @janbirkmyre_torq_track_cycling
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 evidenced based information and advice about both the perimenopause and the menopause.
Dr Louise Newson [00:00:46] So today on the podcast, I’ve got someone called Jan Birkmyre with me, who I’ve been frantically Googling and very, very impressed with the photos that I’ve seen of her amazing sport. And she’s come to talk today about sport and women, and very topical because the Commonwealth Games are just finishing in Birmingham near where I live. So there’s been a lot of spotlight on women actually and Sport, which is great. So thanks for coming today to talk about you and your experiences.
Jan Birkmyre [00:01:15] Thank you, my pleasure. I think it’s the first time in any sporting games where women have actually had more medals to go after than men, which has got to be a move in the right direction.
Dr Louise Newson [00:01:23] It’s so exciting, isn’t it? I went and watched some of, well I watched the table tennis live and I also watched netball and it was Uganda playing and they were just like the most amazing ballerinas. They were so fast. They were so brilliant. And I’m not someone that’s really… I like watching a bit of tennis, but I don’t really watch sport on television at all. But to go there live and to soak up this atmosphere and just to see people at their prime and amazing is incredible. So tell us a bit, if you don’t mind, about how you got into sport and cycling, what you do and how you’ve done it.
Jan Birkmyre [00:01:57] Sure. Well, it’s a long story, so I’ll keep it short and be honest. I mean, I had a very active childhood, but probably lost a lot of that when I left university – I became very focused on my career. So in fact I only got into cycling competitively in my mid-thirties. I got into it just for health and fitness, but I quite quickly found that the competitive spirit burned very strongly within me. Was encouraged to ride some time trials from there, had the road races. I met my husband through the Twickenham Cycle Club and he encouraged me to try track cycling and my physiology it would seem really suits track cycling. It’s suited to perhaps a more sprint physiology which would appear to be mine. And I very quickly enjoyed some success. So, my first elite national championships was 2005. I actually ended up riding with Victoria Pendleton at that point and was… narrowly missed out on a medal. I was just absolutely fired up to work hard and come back and win a medal, which I did the following year.
Dr Louise Newson [00:03:01] Gosh. So how old were you then?
Jan Birkmyre [00:03:03] So my first elite medal I would have been in 2006, so I would have been 40.
Dr Louise Newson [00:03:11] And is that – I’m not ageist but is that old, to have your…
Jan Birkmyre [00:03:16] It’s difficult to not sound ageist. Listen I’m so not sensitive. Yes, it is a significant age to win a medal, without a doubt. So I suppose in some ways it’s been easy for me because I wasn’t an athlete in my younger years. I haven’t seen that decline that many of my compatriots will have. If you were great in your twenties, then you’ll see a bit of a decline. Actually, I’m 55 now and I’m still aiming and working to go faster in my 55th year than I did in my 40th year. A lot of that’s training advantages, nutrition and some technical as well. But there’s no reason why women can’t work to improve their times and their physical fitness as they get older.
Dr Louise Newson [00:03:57] Which is really encouraging actually, because when we’re at university we’re quite different to how we are in our thirties and forties. And I think naively, or I certainly have done in the past, thinking well if you don’t get into sport when you’re young, it’s too late actually. And we’ve read some really awful statistics recently, haven’t we, that one in two women don’t do any exercise at all, which is really, really sad because I think no one’s too old to do any sport at all. And even if the sport just involves walking up the stairs instead of using the elevator, actually that’s still something, isn’t it? So I think people worry they have to do the best sport ever or nothing. There’s nothing in between. And everyone’s got to start somewhere, haven’t they?
Jan Birkmyre [00:04:37] They certainly do. And that’s what’s so perfect about cycling. It genuinely is an all-life sport because of the low impact nature – that has some issues in terms of bone density that I’m sure we’ll touch on. But in respect of sport that you can do with the family, that you can do from any age, it’s a really, really perfect sport and there are opportunities to just ride on the canal path, to do mass participation rides or obviously to compete, which is my chosen route. There’s no judgement. Any exercise is good exercise.
Dr Louise Newson [00:05:08] Yeah. And I think there is something about being outside as well isn’t there. And certainly, where I live they do a fun cycle every year. They do different lengths. So the shortest length is always the people that have only been on their bike once a year and they’re wobbling around, but everyone’s happy. It’s very easy and you can get through a larger distance. I hate running and I’m very self-conscious of what people think about my running style and it’s very frustrating because I can’t run very fast and then I can’t run very far and then I have to…whereas cycling, you can cover some really good distances and there’s lots to distract you. And like you said, I think working and doing exercise with others is really important as well. So cycling definitely ticks a lot of boxes, doesn’t it? And I think just being able to do anything where your heart rate increases, you’re using your muscles. We know as we get older. Some of you who have listened to the podcast before know that our risk of heart disease increases as we age. Our risk of osteoporosis… about one in two women over the age of 50 develop osteoporosis. And as you rightly say, cycling isn’t that good weight bearing, but it still is using your muscles a lot and it will be helping your bones. And actually with osteoporosis, one of the things is keeping your strength as well. So if you did trip over the carpet, you’re less likely to fall. If you do fall, you’ve got the strength to put your arms down and reduce fracture. So everyone thinks it’s all about the bones with osteoporosis, but actually it’s the soft tissue and the muscles and everything else as well, which is so important. And women and men actually as they age, we develop something called sarcopenia, which is this loss of muscle mass. And it’s thought to be related with hormones as well – some of it is age related – but estrogen and testosterone, two quite important hormones in women, as they decline, this loss of muscle mass really does have an effect.
Jan Birkmyre [00:07:04] I mean, muscle mass is something I chase with a passion. It’s become slightly more difficult for me. So it’s probably worth saying that one of the routes to getting faster is by becoming stronger. So on the track where you have a single fixed gear, if you can push a bigger gear, then you can go greater distance with one pedal revolution. But you need to be strong enough to push that gear. That requires getting in the gym and that’s something I’ve done quite successfully. But really quite suddenly, I suppose when I felt the worst effects of menopause at the end of last year, I just suffered an awful lot of joint pain and I haven’t been able to get in the gym. That’s a big loss to me and something that I feel quite strongly.
Dr Louise Newson [00:07:48] So you’re 55. So the average, not that anyone’s average, but the average age of the menopause is 51 in the UK. So I presume again, I don’t want to presume, but I presume you’re menopausal age 55 because, I’ve had a few patients who have the odd period at 55, but 55 people will either definitely be menopausal or near enough. So your hormones, as I’m sure you know, so I’m not insulting you, will not be the same level as they were 20 years ago or even ten years ago. And you mentioned some symptoms, but when you started your cycling when you in your early forties, did you know much about the menopause at all?
Jan Birkmyre [00:08:24] Absolutely nothing. I mean I think it’s fantastic that we can have these conversations now, that it’s the topic du jour if you like, and that it’s being spoken about. I’ve probably been held back from talking about it; maybe I was embarrassed. Whereas now I think it’s something that we can all be very overt about. I think that’s important for later generations who follow us.
Dr Louise Newson [00:08:46] Absolutely. It’s really important. So but how is it affected you, your perimenopause or menopause?
Jan Birkmyre [00:08:52] So early I would say the effects were very minor. Now, this is slightly controversial, I don’t know. I was in a situation where my sister had had breast cancer. So when I went to my GP with perimenopausal symptoms which were hot flashes, hot flushes and night sweats and difficulty sleeping, I was offered citalopram which I really didn’t want to take, but I’ll be honest with you, I wanted to sleep more than anything. And so I took it for a while and very quickly realised that it was not a drug that I wanted to stay on. And actually my experience coming off it underlined that. It’s really not a nice drug. I then did a lot of reading around HRT and realised that a lot of the information that my GP had and that I had been fed was incorrect and out-of-date and that it was entirely safe for me to take hormone replacement therapy. And that’s been a huge revelation to me. So I take estrogen and progesterone and that has had a significant positive effect on some of my symptoms. So I’m certainly… haven’t ticked them all off, let’s say. But in terms of the hot flashes, hot flushes, those are a thing of the past, that’s completely controlled by the estrogen, progesterone. But I have very quickly gained three kilograms at the end of this year out of nowhere. Bear in mind, I’m exercising six days a week. I’m very conscious of what I eat, very strict and disciplined with my nutrition. It was not through eating. I am having difficulty sleeping and I have joint pain which make it very difficult for me to do what I want to do to support my cycling. So the HRT that I can take legally without being sanctioned for my sport is definitely making a positive improvement, but I believe my health is still compromised. I would like to do more.
Dr Louise Newson [00:10:51] And this is where we started conversations together, didn’t we? Because it’s looking at the other hormone that I’m sure a lot of you listening have heard me talk about before is testosterone. And there’s a few things here, really. First thing is the testosterone is produced by our ovaries. It declines as we get older and at different rates for different people. The other thing is, is that testosterone hasn’t been well researched in women and most of the studies have looked at libido. And libido is very, very important, of course, for a lot of women. But actually, it’s not the only thing that testosterone works on. And we know we have testosterone receptors all over our bodies and it’s a very biologically active hormone. If we’ve got receptors on our cells, it means that our cells become activated by a hormone. And this is what hormones do all round our body, like cortisol, adrenaline, thyroxine, insulin, estrogen, progesterone, as you mentioned. And testosterone as well. We have a lot of testosterone receptors in our brains, but also in our muscles and joints and our cardiovascular system. And there’s a study out today that’s come out recently showing that women who have low testosterone levels have an increased risk of heart disease. And a lot of people commenting on the study are saying, of course, that doesn’t mean testosterone will reduce risk of heart disease, but actually it needs further research. Of course, how can we just say that without saying… but is an urgent need for more research in this hormone. We notice because we’ve got a lot of people who use testosterone, including myself, but one of one is not enough for a study. But we see a lot of women and because we collect symptoms all the time on patients that come, we are noticing that women find that their mood, energy, concentration, stamina improve but also a lot of muscle, joint and stiffness and pain can improve as well. What’s very frustrating is because we haven’t got the evidence, there are quite a few experts that say, ‘well, we haven’t got any evidence, therefore we shouldn’t be using testosterone’. And actually all we’re doing is replacing what’s missing. And hormone blood tests can be basically unreliable. A low level doesn’t mean that that woman’s symptoms are all due to her testosterone deficiency. But we measure testosterone levels when we give people testosterone to make sure they’re still in the female physiological range, so they’re ‘normal’. And actually I’ve been pulling off our results for my last four years of testosterone and the vast majority – so 99% – are within normal female range. Occasionally, we get a high one, and that’s often actually people that have come from other clinics that are on a different preparations than we would use. And occasionally you get the odd spurious result which you can do with anything, and you realise that someone’s rubbed the cream on over their arm and then they’ve had the blood taken through the testosterone cream. The levels are ridiculously high, and you repeat it and it’s normal. So it’s very reassuring that our results show that women on testosterone still have physiological levels and a lot of the levels are on the low side, actually, my level is actually really quite low. But I know that testosterone makes a difference because if I don’t use it for a couple of days, my joints become very stiff, my brain becomes just slower down and I don’t sleep as well. And it’s not a placebo because I’m not expecting all these symptoms to occur. So we got into conversation because we know that the regulations are for professional athletes, that you’re not allowed to use testosterone of any form are you?
Jan Birkmyre [00:14:23] Yes. And this is really where I guess we both feel quite strongly, there is a system called a TUE or Therapeutic Use Exemption. The purpose of this piece of paper or exemption that is generated by medical professionals is to allow athletes to be treated for medical conditions with treatments that would otherwise involve a substance that is prohibited, but to protect them from being sanctioned. And testosterone is allowable for men with a TUE under some circumstances, but not allowed for women under any circumstances. And that clearly is not an equal treating, treatment.
Dr Louise Newson [00:15:03] It’s very much not an equal treating. There’s a lot, isn’t there in society, in medicine, where there’s a lot of sexism. And I’m reading the book and the minute ‘Unwell Women’, which is a phenomenal read actually and even starts talking about when they discovered the uterus. And it’s been described as a cauldron, which when you look back about witches and witchcraft and people were scared of women, they were scared about how their moods were changing throughout the cycle and worried what was going on with this cauldron inside them and all sorts of treatments, including removing it to see how that would improve. But obviously then they become menopausal and far worse. And you look at the word hysterectomy and hysteria that are similar words. And so people are scared of women, they’re scared of hormones. But actually the more work I do in this space, the more I realise people are scared of women feeling good actually. There’s a lot of misogyny. There’s a lot of suppression of women. I’ve heard so many times how horrendous it is that women are now asking for HRT and it’s because they see it as a like a lifestyle drug… that they want to be looking like Davina. And of course Davina’s lovely, but none of us aspire to look like Davina. We aspire to be the best version of ourselves and the healthiest version of ourselves as well. And just because we don’t have all the research in testosterone, we can’t ignore it as it being a female hormone. And there are different reasons why people have low testosterone as women. And, you know, for you, it’s an age-related menopause that you’ve experienced, but a lot of women have, what’s called iatrogenic menopause. So it means we’ve caused it as doctors. And so there are quite a few people who have their ovaries removed, say, for example, if they’ve got ovarian cysts or if they’ve had a cancer or some people, if they’ve had really bad endometriosis, they might have their ovaries removed. And some of these women or a lot of women actually, have them removed at a young age. So I could have been a 25 year old athlete and had endometriosis, had my ovaries removed that would have removed the majority of my estrogen and testosterone in my body. I would be allowed by the regulatory authorities to have estrogen. But from what you’re saying, I would never be allowed to have testosterone. But if I was a 25-year-old man that had a problem with my scrotum and had to have both my scrotum removed, which would again stop me from any testosterone or most of my testosterone in my body, I would have one of these exemption certificates and I would be allowed to replace myself with testosterone, wouldn’t I?
Jan Birkmyre [00:17:50] Yeah, that’s absolutely correct.
Dr Louise Newson [00:17:51] So it doesn’t make sense to me. And we know that there is always risk of abuse, isn’t there, with anything really. And we know – I don’t want to talk out of turn – with sports people, but there has always been those who push boundaries and they have to be really strict with regulation. You don’t want to be competing against someone that’s taking medication or hormones that is enhancing them beyond what they should be normally.
Jan Birkmyre [00:18:18] Absolutely. I mean, the point of the TUE is to bring you to a healthy level when other medications can’t do that. So, if you take something like hayfever, for example, an athlete would be expected to treat that with antihistamines. In very extreme cases, something like triamcinolone might be prescribed – that is clearly banned. It’s a steroid with very clear performance enhancing properties. And to your point, I want sport to be clean. I feel passionately that it should be fair. I’ve stood on the podium with people who’ve cheated. I’ve judge them very harshly. It’s clearly wrong. But it’s also wrong to ask women to choose between their optimum health, the best version of themselves, and their ability to compete in their sport.
Dr Louise Newson [00:19:04] And that’s what it’s coming down to actually. The more I read about it and the more I speak to people like yourself and others, is that you’re making this choice. And there are two things that sort of concern me about this. One is that testosterone is likely to have some health benefits. We don’t know that it reduces risk of heart disease. We’ve got some small studies showing that it might do in younger people. It might reduce dementia, we don’t know. We’ve got to do more studies in it. We’ve got some studies that even were done in the eighties showing it reduces osteoporosis. So it has some health benefits, which we need more research for. It has day to day benefits for improving, you know, function and reducing symptoms. We know that even just looking at our data, but speaking to other people as well who are noticing this as well. But then the other thing is, is that you are unable to probably perform the way that you would do because you’re missing a hormone. It’s like trying to say, well, if you’ve got an underactive thyroid gland, see how you are without thyroxine. There’s nothing about it that you want to abuse or use to higher levels. You just want to get back to the levels that you were before. So you either, in my mind, you should be not allowed estrogen at all, or you should be allowed estrogen and testosterone, because what’s the difference? You know, you could still function. And a lot of… we know the majority of women don’t take HRT and often that’s due to these unfounded fears about safety of HRT, but that’s up to them if they choose. But women who often choose to take HRT – and increasingly I speak to women who are taking HRT, as in oestrogen and progesterone, to improve symptoms but also they know that taking HRT reduces their risk of heart disease, osteoporosis and other conditions. So they’re making an informed choice to try and improve their health. And of course, we need to improve our health with diet and exercise and wellbeing and everything else. But actually, we know that HRT can improve that. So you’ve made the choice, as you say you’re taking estrogen and progesterone, but you’re not allowed another hormone. And to make this choice between something that you adore and are actually really good at, I mean, you know, the achievements that you’ve had are astounding, it just seems so cruel.
Jan Birkmyre [00:21:21] I have to say, it makes me very angry that I am not allowed to make that decision for myself. I think I’ve already made some sound decisions about my health. I’ve invested in my health and my wellbeing, and for this decision to be taken for women, which is allowable for men, is so wrong on so many levels. I don’t even know whether it will help me, but I’d like the opportunity to find out for myself.
Dr Louise Newson [00:21:46] Yeah, and I think this is the whole thing. When I prescribe testosterone as a doctor, I’m never going to give anyone false hope. I’m never going to say, of course it will improve your stamina or make you feel the woman that you haven’t been for 20 years. And it’s going to do all these things. I have no idea. But what I do know is that when we give it as a cream or gel, it’s completely reversible. The women are in control. I often say try it for 3 to 6 months, see how you feel. And then you know you’re making those choices. And everything I do in medicine is about shared decision making. I am not here as a paternalistic doctor saying, ‘Come on, you have to have this’. Of course I’m not. But it’s about, well, you could try it and see. And then we can have a discussion and see and then often do a blood test, because if someone comes back after six months and says ‘I don’t feel any better’, then I’ll often say, ‘Well, how much have you used?’ And everyone under uses testosterone because they think they’re going to turn into bearded monsters. And they say, ‘Oh, well I’ve used a really small amount of the tube’. And then I do their blood test and the levels are really low. So then I try and increase and then sometimes quite often they do feel better. But the risk of side effects of testosterone are very, very low. The only women I’ve seen actually with sort of systemic hair are – hair on their arms or on their face – are women who have actually… I’ve got a few patients who have lied and said they’re men and then ordered it online ‘for their husband’ but taken it themselves, and they’ve guessed the dose, or women that have gone to compounded bioidentical clinics where the products are not licensed or regulated, and I’ve done their blood tests and they’re very high. When it’s prescribed in a controlled way with a regulated product, and we do blood tests regularly, we know that we’re keeping them within a female physiological range, that they’re not having systemic side effects and they’re getting benefit from it. So my sort of pushback to the regulatory authorities for sport is why can we not do that with women? With men who have testosterone replacement, have this exemption certificate, they should still have their blood tests to make sure they’re not abusing it. And for men, obviously, the range is a lot higher. They’re allowed a lot more because they’re men. But you still have to make sure, because even men who have testosterone replacement, there is an ability to abuse it, isn’t there? And they could go over.
Jan Birkmyre [00:24:03] It is a substance that’s abused and therefore does need to be controlled. I’m not suggesting we turn this into a free for all. I think it’s really important as you said, you know, when we’re talking about supplementing, we’re only bringing women back to their premenopausal levels, whereas when it’s being abused, it’s usually being used at a level for sports advantage or athletic advantage that is way above that. So when you look at the levels, I understand that menopausal women will see they’re so, so low, just to bring them back to that premenopausal level. And I think the stress here is we’ve got three hormones that decline in menopause. It’s as much about balance as it is about levels. So keeping the balance between the three, allowing us to supplement with only two is curtailing our opportunity to enjoy great health.
Dr Louise Newson [00:24:55] Yeah, I mean it is very cruel and I think there are quite a few people out there, including some medics who are very, very anti-testosterone and I’m not really sure why. And then you when you do ask it, saying, ‘well, there isn’t the evidence’, but we need to urgently do more research into testosterone, but also we need to allow choice as well. Like you say, there’s a reason that we have it. And one of the problems is that blood tests are not always reliable, and it depends on the laboratories and everything else. But, you know, they’re better than nothing. And so we can see that women, when they have very low levels and we’re increasing, that they still are low, you know, and that’s where I think the authority should be looking at monitoring very carefully. And, you know, you wouldn’t mind having a blood test every day if it meant that you could try some testosterone and see if it’d help your symptoms. But to be denied something that is a treatment that is mentioned on NICE guidance as well, to say that women are allowed testosterone if they’ve got reduced sexual desire despite being on HRT, then you’re not allowed it because of your sport. It just seems completely wrong on that level and even more wrong that men are allowed it too. It’s this gender inequality that really drives me mad. That’s what makes me so cross about all of this.
Jan Birkmyre [00:26:15] If you have a conversation about testosterone in men and it’s about strength and power and it’s all positive things, when you talk about women’s hormones, it suddenly gets very complicated, very frightening and people back away from the conversation. I’m quite certain that a large proportion of the decision making authority at WAD, the World Antidoping Association, I would guess, and it is only a guess, but it’s a largely male panel and that conversations around menopausal women specifically have simply not been had.
Dr Louise Newson [00:26:45] No. And I understand that. You know, I couldn’t have had this level of conversation three or four years ago before I’d seen as many patients and learnt as much as I have and like I say, monitored symptoms and monitored blood results as well. But it’s time that we move the conversation forward and I know that you are working behind the scenes. I’m doing a bit of work, it has to be a group collaborative effort. And I hope we can report, you know, progress that’s been made, because I think that the authorities are listening and learning. But it’s not enough to just say we’re going to review it and we’ll come back in however many months or years’ time, because it’s crucial for the future generation of sportswomen, you know, we’ve seen the amazing, what the lionesses have done. But they’re all going to become menopausal. Every single female sports person is going to become menopausal. So this needs to be addressed doesn’t it?
Jan Birkmyre [00:27:34] We need to allow women to enjoy good health in latter years. The issues around weight gain generally, obesity generally, lack of exercise, I’m not saying that testosterone is the magic wand, but at least if we allow women to enjoy their best health by balancing hormones, we’re potentially encouraging them to be more active. And if women are active, the family’s active, it goes way beyond just sports.
Dr Louise Newson [00:28:01] Yeah, I totally agree. I mean, we’re doing a lot of work behind the scenes with areas of social inequality, and we know that certain women in low socioeconomic classes are more likely to be obese, less likely to exercise. And if you’re not feeling great as a woman, you’re less likely to feed your children well, you’re less likely to go to the park just stick the telly on. And it has this slippery slope that is so crucial. And I feel it’s so important when we’re looking at the future health of the nation, actually. And like it or not, most women are what pulls the families together and gets everything done. And it’s a generalisation, but it’s true in a lot of households and so we owe it to society to improve and looking at sport, not at your level of sport but you know, even my level is really, really crucial when we’re looking at preventative care, we’re trying to stop people going to see their GPs, going into hospital, reduce diseases. We’ve got to start looking at what’s enabling us to help exercise because exercise is so crucial for everyone isn’t it.
Jan Birkmyre [00:29:05] Yes it is, it’s something I feel passionately about and cycling in particular is a fabulous family sport, an all-life sport. It’s got so much to offer and it’s certainly been a good sport to me.
Dr Louise Newson [00:29:15] Yeah, so what a great way to end in a positive way, but there’s a lot we need to do. So I’m very grateful, Jan, for your time today. There’s three take home tips, but I want to end and keep continuing in a positive way. So three positive things that people can do if they’re listening to this podcast, feeling a bit guilty that they haven’t done quite the exercise they should have done over the last few weeks. So what are three easy things for people to enjoy exercise by doing?
Jan Birkmyre [00:29:39] I suppose the number one tip would be to exercise with someone, with a friend, and that could just be a brisk walk. I mean, what’s more fabulous in this weather, than you can get out, spend some time talking, walking. That would be number one for me. The second would be just to not be self-conscious. Just because you’re not doing as much as fast, as heavy as the next man doesn’t make it great for you. And I think women do struggle a little bit sometimes in competitive environments. They feel very self-conscious. And the third one would be about being self-conscious. We come in all sorts of beautiful shapes and sizes and there is no perfect. So whatever you look like, whatever you’re wearing, just enjoy it, be active, you will feel the benefits quickly.
Dr Louise Newson [00:30:22] Lovely, great way to end. And I really appreciate your time today and so thanks so much for joining me.
Jan Birkmyre [00:30:27] It’s been my pleasure. Thank you for having me.
Dr Louise Newson [00:30:32] For more information about the perimenopause and menopause, please visit my website balance-menopause.com. Or you can download the free balance app which is available to download from the App Store or from Google Play.