Brain fog in women – cognitive concerns in the menopause transition

Dr Marita Long: I’m a GP working in the northern suburbs. I do general practice. So again, for all of you out there doing general, general practise, I acknowledge how hard it is to keep on top of everything. I do have an interest in women’s health and cognitive health, so I do end up seeing a lot of midlife women who are menopausal, struggling with brain fog, and the odd person who lands because they’ve researched me and want to come and talk about their concerns about whether they do have a dementia or not. But I do still try and do general, general practise. And I work at Melbourne Uni one day a week and I do this sort of bits and pieces on and off for Wicking, but super excited to be able to start something in general practice in primary care, my real passion is really to embed dementia risk reduction in primary care.

And I think being able to have a clinic and a landing place for women at Jean Hailes, which has got a fantastic reputation, will be super exciting. And I think it’s the first women’s health brain clinic in Australia. I don’t think anyone is doing this. And it’s interesting that there’s so many women’s health clinics that pop up all over the place, but really it is just purely focused on sexual and reproductive health. So I think it’s going to be really exciting to have something that’s just that little bit different.

So we’re going to start by having a few sort of cases, and I’m hoping this will be interactive just to sort of work through what we do and we don’t know about brain fog. Let me just keep going for a bit. We’ve acknowledged the traditional custodians on the land of which we meet, but I’ll do that again, pay our respects to our Elders, past, present, and emerging, and also for any First Nations people with us here today.

Before I get going, I would like to acknowledge the work of Professor Aimee Spector and Associate Professor Caroline Gurvich, because they’re really the women who are doing a lot of work in this space who are incredibly passionate to try and understand what is happening for women during the menopausal transition in terms of their brains. We know that cognitive changes have been documented for decades now, but it’s really only been the last few years that we’re seeing people really come forward with brain fog. And a lot of that’s probably been post-COVID because brain fog really came into, sort of, ‘the being’ when people were experiencing this post-COVID. Before that, it’s kind of been, I suppose, in the setting of cancer treatments and chronic fatigue, people with celiac disease, they often talk about brain fog, but it has really taken off in the menopause space because it’s something that’s caused a lot of distress.

So Liz has developed the cases for us. The work in these slides is really drawn on my own clinical experience. Learning outcomes, I’m not going to read those all out. You can all read them at some point in time. Basically, it’s just to all get an understanding of what we mean by brain fog. So this is Kristen. She’s 48. She’s an IT executive. She presents with brain fog, irritability, some sleep disturbance, which is related to some hot flushes. She’s feeling incredibly overwhelmed, and she’s noted that she feels worse before she does get her period. She got her periods at age 12. She’s POG1 by choice. She’s got having regular periods until about 18 months ago. Now they’re every two or three months, sometimes lasting longer and sometimes heavier.

12 months ago, she really noticed brain fog and it was causing her some significant problems at work. And so that sort of has brought it to the forefront for her. She’s otherwise pretty healthy. She’s divorced. She’s close to her 18-year-old stepdaughter. She’s exercising. She lives alone with a cat. Very important when we’re thinking about her MHT these days, isn’t it? Mom’s 78, overweight, hypertensive, high cholesterol, all the bits. Dad had an MI and he’s starting to show some signs of cognitive decline. And I guess you would all see that too, that lots of people come in because they’ve got a parent and they think, “Oh, I’m sort of heading the same way.” Paternal grandparents also had dementia, so she’s had that experience as well. And she’s got a sister who’s got some epilepsy and hypertension.

So she’s here for help. Her main worry is about her memory and whether this could be a sign of dementia. She’s also had, as I said, these problems at work, and she’s actually been put on a work performance program. She read this article that came out on the conversation about brains shrinking in menopause, which has really added to her anxiety. And she’s really keen to know, she takes hormones now, can she prevent dementia? So is that something that you sort of, everyone’s shaking their head. It’s just so common now, which I think is a really great thing because at least it’s bringing brain health into the consult, which is fantastic. Even though the likelihood is none of these women are going to have dementia, it really is bringing it into the forefront.

So I’m just going to get you to put up your hands here about how common you think brain fog is in menopause. Does anyone think it’s uncommon? Less than 20%? 20 to 30%? 30 to 50? Getting there. 50 to 70? Yeah. Anyone over 70? Yep. Someone’s over 70 there. So interestingly, in Australia, it’s sort of documented about two thirds of women, but the UK did this massive survey of 1,500 women called the Menopause Mandate Survey. They actually found that brain fog was the most commonly reported symptom and the one that was causing distress. It was 86% of people are reporting that. And that was followed by weight gain, which again, we see so many women quite distressed about weight gain, and fatigue. So they sort of were ahead of vasomotor symptoms, interestingly. So it really has taken off.

And then it’s not surprising because the James Lind Alliance, which is a global, I guess, community that comes together to identify what the main research priorities are for different areas. When they did this for menopause, out of the top 10, two were related to cognition. So does the perimenopause menopause lead to cognition problems? So brain fog, memory loss. If yes, why? And how does it happen? How are these problems best detected and managed and can they be prevented or reversed? So that’s number three. That’s what women are thinking. Interesting, number one, I was really fascinated by this, is non-hormonal treatments, which I thought was quite interesting. Number nine was, does hormone therapy change the risk of dementia? And I think from what research we’ve done, we sort of can answer that for most women now, that MHT should be prescribed on the benefits and risks not for dementia prevention, nor should it be withheld from women because of the fear of increasing the risk of dementia. So that’s at least something we can say with confidence to women based on the data we have.

And so this was the article that has caused a lot of stir in terms of shrinking brains. And I don’t know if any of you follow Fiona Clark. Do any of you follow Fiona Clark? So she’s quite interesting. She’s a UK woman and she did a really good debunk of this with Pauline Maki, who, really, the outcome of that was: all our brains shrink, men and women’s brains shrink. There are some areas that shrink a little bit more, potentially, but recover. So I guess it’s that thing of just being aware of what’s out there. And of course the media, as we know and we’ve talked about, they grab onto the things that are going to get the most clicks. And so for a menopause woman who’s thinking her brain is shrinking and that’s why she’s going to end up with dementia, that gets a lot of clicks.

So what do we mean when we think about brain fog? What are sort of the common things that you hear women say? And for women who are in senior roles who are sort of having to get up and perform, and you can’t remember the next word that’s got to come out, you can see how that’s quite distressing. I also have women who aren’t working who say their kids give them a hard time. And kids can be really nasty about that stuff. And I do have women who say it’s horrible. And sometimes for the women who haven’t had a role outside of work, it can actually be a lot worse because it’s, their whole kind of role is being, coming under attack. So yep, the word finding is classic. But all of a sudden you can’t multitask like you used to. I find that all the time now when I’m trying to do things at work, I have to say to my patients, “Shh. I can’t multitask anymore. Just let me do this.”

But yeah, it becomes a real problem. It’s scary, isn’t it? Because you’ve been so used to being able to do everything, starting to have to sort of heavily use your reminder systems and just that constant mental load, particularly for women who are working and trying to keep track, not only their own appointments, but all their kids’ appointments and all the functions that have got to be done, all the birthday presence that have got to be bought and it becomes incredibly overwhelming. So there’s some of the words, I guess, that people talk about.

So in the, I think it was 2022 when the white paper came out from the IMS, Maki and Jaff, they actually defined the brain fog as being ‘a constellation of cognitive symptoms experienced by women around the time of menopause, which most frequently manifest in memory and attention and involve such symptoms as difficulty encoding and recalling’ so that’s that word finding, ‘names, stories or numbers, difficulty maintaining that train of thought’, that sentence getting lost, ‘distractibility, forgetting intentions’, going into the room, opening up the fridge and going, “What the hell am I here for?” Closing it, going back, doing something, going, “Oh, I was taking stuff out of the freezer for dinner.” And ‘difficulty with tasks switching’, having to really pay attention to the task that you’re doing.

So then Caroline and Aimee, I guess have looked a little bit closer into how they think we could provide a definition. And they’ve really said it’s a self-reported impairment across one or more cognitive areas in the absence of any objective cognitive decline or impairment. It can fluctuate, which is sort of a little bit different to probably standard subjective cognitive decline, and does cause mild to significant distress for women. Some women, they’re just like, “Oh yeah, whatever.” It doesn’t worry them. For some women it is incredibly distressing. But it doesn’t result in any sustained change in function. And that’s again, a really important distinction.

So I guess then we sort of start to think about, well, what is influencing brain fog of menopause? And there’s several things. But I think the first thing to talk about is normal ageing, because I think we have to remember at this time of our lives, we are also going through normal ageing changes. So we know from the third or fourth decades of life, our processing speeds start to slow down and we do start to have those memory lapses. So we do occasionally forget names, misplace items or struggle with that tip-of-the-tongue sort of phenomena. That’s all very normal, as disconcerting as it is.

But as Sarah McKay points out, we do have crystallised sort of knowledge. As we get older, we can still trade off our knowledge and our experience. So that sort of keeps us or gives us the ability to keep up with all those cool young kids. And we’re flexible. So we are able to adapt. We’re much more able to work around some changes and adapt to the change. And I think that’s really important too, in that women know that this is also part of normal ageing. It is not just menopause, this is happening to men as well, but we should also acknowledge that we are incredibly knowledgeable, experienced, skilled women who will be able to adapt. And to reassure women that the brain will adapt for most women as well.

And so then we’ve also got what’s going on in the actual menopause. And we do know that low or changing or fluctuating levels of oestradiol do, of course, impact our brain. We know that menopause is a neurological transition, as you all know, as well as sexual and reproductive. The vasomotor symptoms, of course, that impacts our sleep, that impacts our ability to concentrate, to stay focused if we’re having hot flushes, not sleeping well, and that’s going to impact on memory. We also know that it can be a time when women really experience a change in mood. And if you’ve got a low mood, that also affects your ability to concentrate, and your cognition.

And of course, all of this is impacting on poor sleep. And everyone knows how worse we perform after a bad night’s sleep. So there are so many things that are contributing to cognition. Again, I think that’s incredibly reassuring for women when you can put all this together for them to show them what else is going on. And then there’s other factors that predict the severity of your perimenopausal symptoms, including cognition, and that is low parity. There’s life stressors. We all know that. We all know that woman who sits in and just offloads everything that’s going on in her life, which is why I think the work that we all do in this menopause space is incredibly hard at times.

Okay. So if we move into, I guess, what’s happening in the trajectory of cognitive decline. And when I first started teaching in dementia education space, and that wasn’t something I ever had a strong desire to do, that was being in the wrong place at the wrong time. I got roped into it. And back in that 10, 12 years ago, there was no subjective cognitive decline. In fact, there wasn’t even mild cognitive impairment. You would attest to this. There was a lot of debate. Was mild cognitive impairment even a thing? But now we’re hearing all these terms, so I think it’s important we know what they are.

So subjective cognitive decline, which is kind of this new group that they’ve identified, is the people who are coming and reporting persistent change. So not necessarily during menopause, but when you do your assessment, you can’t find anything. Everything seems fine, but they are worried enough about it to come and talk to you. Certainly there’s no functional impact for these people, when you do the history, you won’t find that. They’re functioning, they’re working, they’re playing, they’re socialising and doing everything quite well.

But I do think people who present like this, even if they are young, because remember people do get dementia under the age of 65, and for them to get a diagnosis, it often takes about eight years. So I think these are a group we should pay attention to. We should not say, “Yeah, I forget that. I forget stuff all the time. Don’t worry about it.” We should have a think about it and just keep them on our radar.

So I like this term CFM, cognition for monitoring. If someone’s got a slightly elevated blood sugar, we don’t just forget about them. We follow them up, we monitor them. And I think this is a group that we should be paying attention to. And just, if it’s every 12 months, just checking in and seeing how they’re going in terms of their cognition, unless things change in the interim.

So then we’ve got mild cognitive impairment, which is a very hot diagnosis at the moment. You’ll see lots and lots of people coming out and talking about this now. So this is where we’ve got a subjective report of persistent cognitive decline. So people are coming and saying they’re noticing something, but when we do assessment, we do find that there is some impairment there. These people will still be working and playing okay. It won’t be impacting their ability to function, but they might be more fatigued or they might be the people who are saying, “I am having to rely a lot more on calendars and lists. And some things I am finding, I am finding harder.”

Important group, important to talk about. 60% of people with MCI, they say, won’t progress. They’ll stay the same. It might be something’s happened and it’s their new norm. Or they’ll improve, there’ll be some kind of reversible or contributing factors. So I think that takes away some of the fear that people say, “I don’t want to go and tell anyone because someone might take my licence off me or I might not be able to work anymore.” But we talk about this as something that doesn’t necessarily have a terrible trajectory. But if someone has got symptoms that are across multiple domains, particularly where memory is impacted, they might be at more risk. So they might be, again, a group that you really want to concentrate in on.

So if we go back to Aimee and Caroline’s definition of brain fog, where does it fit? Well, I sort of feel like it’s almost normal ageing on steroids or something. It’s not quite subjective concern, because it’s fluctuating, and we know for most people it’s going to resolve, but it’s somewhere in there. And again, I think that it is really important when we’re talking to women that we reassure them the likelihood is it is just brain fog, but that we should also somehow remember to come back to that group once menopause is sort of passed through and they’ve sort of settled, just to check that their cognition is in fact back on track.

Okay. So we do know from most of the studies that brain fog does resolve post-menopause. So the SWAN study showed that, that it was limited to perimenopause, which I think is a really interesting point as well, because in perimenopause, we still do have oestrogen. So post-menopause, when it’s resolved, the oestrogen, it’s lower. So it’s got to be more than just, it shows that just giving oestrogen is not necessarily going to fix that. There was some verbal learning difficulties that did persist, but mostly things resolve. There was one study that showed low income women of colour, that this might be the heralding of a new cognitive change that will persist post-menopause, but overall, we don’t really know what factors make women more vulnerable.

But we do know, and I think this is, again, such a fantastic message, we do know there are 14 modifiable risk factors for dementia, and we know that a lot of those relate to midlife. And so really, when we’re seeing women in midlife, it is the perfect opportunity to address dementia risk reduction. And I don’t know about you, but a lot of the women I see in this phase are carrying excess weight, their blood sugar’s just tipped over, their blood pressure’s just creeping up a little bit. So there’s a lot that we can actually do to intervene there and really reduce their risk of dementia. At least we can delay it from coming on at 80 to maybe 90.

So when we think about dementia, what’s that? How does that syndrome kind of present? Well, that’s the gradual onset of persistent cognitive impairment. So this is there all the time and it has to be getting worse. There has to be some ability to demonstrate that two years ago this person was better than what they are now. There has to be some failure of function. You have to be able to identify that person’s not working and playing as they were before. It can’t be due to any other reversible cause. And I think one of the things I’ve noticed, when people come into my room and they’re reporting these problems, usually they don’t have dementia, but it’s when other people, and you would all have that, when the email comes before, the person comes in with mum or dad, brother, sister, “I’m really worried.” It’s often someone else who’s reporting that. Not always, but often.

And so this was a slide that does show that sort of trajectory and where you see this group of subjective cognitive decline, and you’ll see most are going to just go on that normal ageing curve, but there might be some who do then develop mild cognitive impairment. And so I think for some people in that, that’s where I would have that group where I might want to keep a little bit of a closer eye, and they can self-monitor. So there are apps now, as we know, there’s apps for everything, but Dementia Australia have produced what’s called a BrainTracker that’s had probably over 130,000 downloads now. Interestingly, mostly people over the age of 70, which I think wouldn’t be downloading apps, but they are. That can track people’s cognition. If someone was really worried and you thought, well, you can hop on, you can track your own cognition. That can be quite reassuring when people actually realise, oh, actually I’m not doing too bad and it’s not changing.

There’s also one from Canada, which is the XpressO MoCa. If you tell anyone to do this brain track app, make sure you tell them to read the instructions. Unlike me, I did not. I thought I don’t have any dementia. I’m just going to do this. It wasn’t a good outcome. You do actually have to read what you’re supposed to be doing for the activities. They’re not that easy and they’re definitely not fun. They say they’re fun, they’re not.

So we come back to Kir, oh, Kristen, I’ve changed it to Kirsten now, with all of her symptoms. Yeah. So what are we going to do with Kristen? What are you going to do with a patient like this that you see in clinic when they come and say, “This is a thing that’s worrying me most.” What would be your sort of general approach?

Yeah. So the first thing I think it is about that validation, because of course people are very heightened, aren’t they? When they’re sort of worried and thinking, “What’s a doctor going to tell me?” So Ruth, what would your first thing be if someone’s going, “I’m really worried I’ve got dementia.” How would you validate that menopausal woman? And that you’re going to be able to try and work out as best you can what’s going on to help them. So I guess it is trying to think about the onset nature and impact of symptoms. So again, Aimee Spector and Caroline Gurvich have sort of come up with some questions to have just as a bit of a checklist if you sort of think, “Oh god, where do I start with this?”

So, have you experienced any difficulties? When did you first notice them? Have you noticed any fluctuation in your cycle? Are they impacting on your ability to function? How is that happening? What else is going on? And what’s going on with sleep? So there’s sort of just some baseline questions that you could sort of start the conversation off. So it is sort of showing that you really are paying attention to the fact that this person’s worried about their cognitive change.

Does anyone use the Meno-D? Yeah, I really like it. And I really like it because it sort of asks around a whole lot of different areas. And it actually does have some questions in about memory and concentration. So it’s kind of also a nice sort of starting point to get a sense of what’s going on for people. So that’s quite a good, not intended for that, of course. It’s not intended to be any kind of cognitive assessment, but it is just quite interesting that it does give quite a rounded picture of what’s going on for women and gives them that chance to sort of think about it.

You know when women come in, and you would find this all the time, I know, they come and they sort of say, “Oh, I’m having some hot flushes. Yeah, my sleep’s not great.” And that’s about it. And when you give them the symptom scorer and they go through one of those and they go, “Oh gee, oh, is that to do with menopause?” And how many times when they get to brain fog say, “Oh, can I put 10 for brain fog?” And I’m like, “No, 3 is maximum.” But a lot of them really want to put that as the heightened one. So I find that a quite useful tool as well, as a way of getting a bit of a baseline.

Of course, after we do history, we always follow that with examination, and fairly base examination in terms of this, but just checking things like blood pressure, looking for any sort of neuroabnormalities and BMI and checking on all those other things which you would all do.

So if we get to the point where we are thinking that there might be a cognitive concern, and with the patient presented today, I wouldn’t have a high volition to do a cognitive assessment tool because I think it sort of is pretty clear usually that it is going to be brain fog. But if I did, I’d probably then, as part of my examination, want to administer a cognitive assessment tool. And there’s loads of these. My favourite is GPCOG. Does anyone else use GPCOG? Yeah, it’s quick, it’s easy, it’s developed for general practice. It gives you an idea. It tells you about what you’ve got to ask someone else. It tells you about what investigations to do. So that’s quite a good one.

If I was a little bit more worried, if I thought, oh, it’s a little bit more than meets the eye here, I’d probably want to do a MoCa, because a MoCa is much more sensitive for early cognitive change. Once you become familiar with it, it doesn’t take too long. They do recommend that you should do training to do it, but I think most of us can probably manage to do it. Just a link there to a podcast on cognitive assessment tools, remembering these are not diagnostic tools. So you can have someone who has normal cognition and has a terrible score, or someone who is cognitively impaired and they can score quite well. They’re just sort of to add to your examination. But if you’ve got that niggly feeling and they’re still doing well, make sure you follow up. Don’t just think, “Oh yeah, they’re fine.”

Yeah. So it’s just the MoCa is a little bit more sensitive because it does … Actually, you can see that compared to the MMSE for cognitive impairment. And I had a woman I sent to memory clinic not long ago, came back with a MMSE of 29 on 30 and a MoCa of like 22 on 40. So there is quite a difference there. Very easy to do. If they get a score under 25 on 30, it does indicate there is some cognitive impairment.

So investigations, you would all do all the routine investigations for a menopausal woman who you’re seeing, particularly one who has got some heavy bleeding. And then I would also try and sneak in the CogDrisk at this point, because I feel like if someone’s worried enough to present brain fog, they’re going to be curious enough or interested enough to know about their dementia risk. So the CogDrisk is a validated dementia risk assessment tool. It’s not a diagnostic tool for dementia. It’s validated for anyone over the age of 18. If you’re over the age of 40, it will give you a score. So the higher the score, the higher your risk. But basically I say anything that’s over zero needs attention. It’s not as simple as the cardiovascular risk that can put you into a sort of high/moderate and it’s not as, I guess, specific to that person.

But it’s a really good tool, because if you think back to medical school or general practice training, we’re all about the motivational interviewing, It’s actually a perfect motivational interviewing tool. And we know whatever we’re going to do for the brain is going to be good for their heart. It’s going to be good for their bones. It’s going to be good for their overall health and wellbeing. So I find it a really good tool. The report that’s developed is a really strengths-based report as well. So it gives you the number. It has all the things the person is doing well. So you focus on that straightaway and say, “Gosh, you’re doing so well. There are so many things here that you’re doing to look after your brain.” And then the things to improve on, that’s what it is. It’s things you could improve on. It’s sort of not things you must do.

And I find with women, I just say, “Look down that list, is there anything you can do easily?” And they’ll say, “Oh, I could easily eat fish. I don’t even think about having fish. I could easily eat a bit more fish or a few more veggies.” “Yes, I know I shouldn’t be drinking that much. I reckon I can cut back my alcohol.” And then I might say, “What could I help you with? Is there anything there I could help you with?” Usually that’s with, “I’ve done everything to lose weight. I cannot lose weight. It doesn’t matter what I do. I cannot lose weight.” And so that can be a really good way to say, “Well, maybe I can help you with that.” And then I might say after that, “Look, there’s a few things I’d like to look at. Your blood pressure is a little bit up.”

And I mean, I think we’ve been very tolerant of blood pressures under 140 or 90 for women. And I think we really have to start thinking we should be really getting that blood pressure lower for women. We really want a blood pressure under 130 on 80. And now you don’t have to do six weeks of lifestyle, blah, blah, blah. You can actually get into treating women quickly. And I think women need that information. They need to know that this is a risk factor and what they want to do about it.

We’ve come back to Kristen. She’s now gone from Kirsten back to Kristen. So she had a Meno-D of 26. So there is some evidence there that she does have some mood or some psychological issues going on. Her GPCOG was totally normal. Ferritin 23, surprise, surprise. LDL is creeping up. She does have a CogDrisk of 7, and she feels reassured that there’s no objective change there. But she still is left with her symptoms. She’s still got brain fog. So I’d be very happy. I’m like, “You’re fine,” blah, blah, but she’s got to go away and figure out how she’s going to manage her symptoms.

So you’re going to do all the right things, and come back to that basic boring lifestyle interventions. And I know, again, everyone’s incredibly tuned in to working with women. I really think it’s important we don’t talk to women about lifestyle choices, because I think a lot of the time there’s not a lot of choice. So we should be talking about lifestyle factors, lifestyle interventions and not putting the personal responsibility on the person for making those changes.

So what about the brain fog? So we’ve done her iron and we’ve sort of corrected everything. She is sleeping a lot better. She’s a little bit better, but she still is, and she’s still got this work performance thing hanging over her head. She’s still really finding that she’s just not operating at that level that she was before she hit perimenopause. I think all the lifestyle things are going to improve brain fog. Everyone feels better if they’re exercising. In Australia, the most significant risk factors for women are obesity, physical inactivity, and depression.

Again, this comes from Aimee Spector and Caroline Gurvich. They’ve tried to think about how they can help women with this, what sort of things might work. And one is education. So talking to them about the link. The CBT, really good. Actually, a lot of good evidence for hot flushes and those issues when you feel panicked because you can’t remember someone’s name or you can’t remember your sentence. So there is some good evidence for cognitive behavioural therapy. And then, thinking about just those simple strategies. So giving women permission to think about where do they perform best. So if you work best in the morning, do all those high cognitive tasks in the morning if you can.

Try just to concentrate on one thing at one time. So if you need to concentrate, tell everyone else to bugger off and just let you concentrate on what you’ve got to do. Set time aside. Using memory aids, giving in, you need a diary, you need a electronic diary, lists, whatever it might be. Pass off whatever you can cognitively to other people, start delegating. And there is some role, I guess, for cognitive training, which I’ll just talk about in a minute. And then again, as you said, all the lifestyle modifications are incredibly important. I do find a lot of women in midlife are also drinking a lot more. And we know that women in their midlife are the only demographic where we’re seeing an increase in alcohol consumption.

There are people developing these cognitive stimulation courses. There’s a lot we see that now for dementia. Caroline Gurvich has a program she’s developed and is running out of Monash. It’s 10 weeks. It’s for women, anyone who’s got brain fog. It’s not just necessarily people who are menopausal. It’s facilitated by two neuropsychs. Unfortunately, again, always the problem that people have to have money to be able to do these. So they need to have private health insurance. But if you had a woman who was really, really worried and had the capacity, it would be something I would probably, again, let them know that these are there and offer that.

There are good fact sheets. So Caroline Gurvich has developed quite a good fact sheet that sits on the Monash site. The AMS fact sheet, I think, again, really good. It is about to be updated. It’s a great podcast with Sarah and myself that you can listen to or you can get your women to listen to.

And also, this is a really fantastic episode if I do say so myself. Not for my knowledge, for Caroline Gurvitch’s, but it’s just a quick, I think it’s 28 minutes and it’s, oh no, 19 minutes even. And it’s quite a good little tool, bit of information. And on a high note, there was a recent study that came out. There was a prospective cohort study that does say that coffee is great.

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