MHT - Oestrogen, Progesterone, Testosterone — Which One Do You Actually Need?

 
 

Most women are handed a prescription without a proper explanation of what they're actually taking and why. This episode fixes that.

Three hormones. What each one does, what happens when you lose it, what the options are in Australia right now, and how to think about what you actually need. Plus how to have a better, more informed conversation with your GP.

This is information so you can advocate for yourself. Informed women get better outcomes.

In This Episode

  • What oestrogen actually does in your body beyond hot flushes

  • What happens to your bones, brain, heart and mood when oestrogen declines

  • Body-identical oestrogen vs synthetic and why it matters

  • Delivery methods available right now including gels as a patch alternative

  • Why progesterone drops first and what that does to your sleep and anxiety

  • Body-identical micronised progesterone vs synthetic progestins and why they are not the same thing

  • Testosterone for women, what it does, who needs it, and how it's prescribed in Australia

  • Who needs what at each stage from early perimenopause through to post-menopause

  • Women who thought they couldn't have MHT and why that conversation is worth having again

  • How to talk to your GP and what to specifically ask for

1. OESTROGEN   The one everyone knows about, but not as well as they think

What it does

  • Regulates the menstrual cycle

  • Protects bone density. Oestrogen loss is the primary driver of osteoporosis in women.

  • Supports brain function, memory, and mood. Oestrogen receptors are found throughout the brain.

  • Keeps skin, hair, and connective tissue healthy

  • Protects cardiovascular health over the long term

  • Keeps vaginal and urethral tissue healthy. See Episode 128 for the full conversation on this.

  • Influences sleep quality and body temperature regulation

When oestrogen declines, you are not just getting hot flushes. You are losing protection across almost every system in your body. That is why this matters.

What happens when it declines

  • Hot flushes and night sweats

  • Bone density loss and joint pain

  • Brain fog, memory changes, and mood shifts

  • Vaginal and urethral tissue changes

  • Skin changes and hair thinning

  • Sleep disruption

  • Cardiovascular risk increases over time

The forms of oestrogen available in Australia

Oestradiol (body-identical): The form your body actually makes. This is what we want.

Conjugated equine oestrogen (Premarin): The older synthetic version derived from horse urine. Not recommended as first choice.

Delivery methods:

  • Patches (transdermal): Bypasses the liver, lower clot risk. Currently in short supply in Australia.

  • Gels (Estrogel, Sandrena): Transdermal, applied to skin daily. An excellent alternative to patches right now.

  • Oral tablets: Goes through the liver, slightly higher clot risk than transdermal. Still used but not the first choice for most women.

  • Vaginal oestrogen: Local only, minimal systemic absorption. Covered in full in Episode 2.

Transdermal is generally preferred where possible because it bypasses the liver and has a better risk profile for clotting. Ask your doctor specifically about this.

Who typically needs oestrogen

  • Women in perimenopause with vasomotor symptoms including hot flushes and night sweats

  • Post-menopausal women

  • Women with early or surgical menopause

  • Important: oestrogen alone is only appropriate for women without a uterus. If you have a uterus, you need progesterone alongside it. See below.

2. PROGESTERONE   The underrated one, and the one most women are getting wrong

What it does

  • Balances and counteracts oestrogen, protecting the uterine lining

  • Anti-inflammatory and calming effect on the nervous system

  • Crucial for sleep. Progesterone acts on GABA receptors in the brain.

  • Supports mood and reduces anxiety

  • Natural diuretic effect, helps with bloating and fluid retention

Progesterone drops first, before oestrogen. When it does, women feel it in their sleep, their anxiety, and their ability to cope with stress. That is not a coincidence.

What happens when it declines

  • Poor sleep, frequent waking in the night

  • Anxiety and irritability, the wired but tired feeling

  • Heavy or irregular periods as oestrogen becomes dominant

  • Bloating and fluid retention

  • Mood instability

If you are still cycling but your sleep has gone to pieces and your anxiety is through the roof, this is often progesterone starting to drop. This is early perimenopause and a lot of GPs miss it.

The forms of progesterone

  • Micronised progesterone (Prometrium, Utrogestan): Body-identical. The gold standard. Taken orally at night, the sleep benefit is a bonus. Can also be used vaginally.

  • Progestins and synthetic progestogens: The older synthetic versions found in many older HRT formulations and the Mirena IUD. Not the same as body-identical progesterone. Different molecular structure, different effect on the body.

  • Progesterone cream: Over the counter, low dose. Good for mild early perimenopausal symptoms. Not strong enough for everyone.

Progestins and progesterone are not the same thing. The 2002 WHI study that scared everyone away from HRT used a synthetic progestin. Body-identical micronised progesterone has a much better safety profile. If your doctor is offering an older combined formulation, it is worth asking specifically about body-identical progesterone.

Who typically needs progesterone

  • Any woman with a uterus who is taking systemic oestrogen. This is non-negotiable.

  • Women still cycling with perimenopause symptoms, especially sleep disruption and anxiety. Progesterone-only can be a great starting point.

  • Women with the Mirena IUD. Note: the Mirena contains a synthetic progestin, not body-identical progesterone. This is a different conversation worth having with your GP.

3. TESTOSTERONE   The one nobody talks about, and it is a game changer

What it does

  • Libido and sexual function. Yes, testosterone matters for women too.

  • Energy and motivation, the get up and go hormone

  • Muscle mass and strength maintenance

  • Bone density, working alongside oestrogen

  • Cognitive function, focus, and mental sharpness

  • Mood and overall sense of wellbeing

Testosterone is not just a male hormone. Women have it, we need it, and we lose it in our 40s and 50s. When it goes, women often describe feeling flat. Not depressed exactly, just flat. No drive, no spark. That is often testosterone.

What happens when it declines

  • Low libido, often the first thing women notice

  • Fatigue that sleep does not fix

  • Muscle loss despite regular exercise

  • Low motivation and flat mood

  • Brain fog and difficulty concentrating

Testosterone in Australia

Androfeme cream: An Australian compounded testosterone cream for women. Applied to the inner arm or thigh daily.

Important things to know:

  • Testosterone is not yet TGA-approved for women in Australia. It is prescribed off-label, which is perfectly legal and very common. Do not be alarmed if your doctor mentions this.

  • Doses for women are very low, a fraction of what men use. The goal is to restore normal female physiological levels, not to masculinise.

  • Side effects at appropriate doses are rare. If acne or increased hair growth occurs, the dose is likely too high and can be easily adjusted.

For a lot of women, testosterone is genuinely life-changing. The doses are tiny. We are just replacing what your body used to make.

Who typically needs testosterone

  • Women with persistent low libido despite oestrogen being optimised

  • Women with significant fatigue and flat mood that other hormones haven't resolved

  • Active women losing muscle despite exercise and good nutrition

  • Women with brain fog that hasn't improved with oestrogen

Putting It Together: Who Needs What at Each Stage

Still cycling, early perimenopause

  • Progesterone only is often the best starting point

  • Addresses sleep disruption, anxiety, heavy periods, and early mood changes

  • Oestrogen not usually needed yet unless vasomotor symptoms are significant

Perimenopause with more symptoms

  • Combination of body-identical oestrogen plus micronised progesterone

  • Transdermal oestrogen preferred where possible

  • Consider adding testosterone if libido, energy, or muscle are concerns

Post-menopause

  • Combination therapy for most women

  • Vaginal oestrogen for all women regardless of systemic MHT decision

  • Testosterone conversation if libido, energy, or cognition are still concerns

Women who thought they couldn't have MHT

  • Breast cancer history: Depends entirely on the type, receptor status, and individual risk profile. Not automatically a no. Worth a specialist conversation.

  • Clot risk: Transdermal oestrogen has a very different risk profile to oral. Patches and gels bypass the liver and do not increase clot risk in the same way.

  • High blood pressure: Transdermal is generally safer than oral for this too.

  • Early menopause under 45: MHT is generally strongly recommended at least until the average age of natural menopause. The risks of not replacing hormones in this group are significant.

If you were told no years ago, it is worth going back and having that conversation again with a doctor who is up to date. The guidance has changed significantly.

How to Talk to Your GP

  • Write down your symptoms before the appointment and rate them out of 10

  • Be specific: sleep, libido, energy, brain fog, mood, hot flushes, vaginal symptoms

  • Ask specifically about body-identical hormones and transdermal delivery

  • Ask about all three hormones, not just oestrogen

  • If your GP is dismissive or unfamiliar, ask for a referral

  • The Australasian Menopause Society has a find-a-doctor tool on their website

You deserve a doctor who takes this seriously. If yours doesn't, find one who does. This is your quality of life we are talking about.

Resources and Next Steps

Missed Episode 128 on vaginal oestrogen? Listen here:

Episode 128: Every Woman Should Be On Vaginal Oestrogen

Struggling to sleep through the night? Waking at 3am wide-eyed with your mind racing?That's not a sleep hygiene problem. It's a hormone problem — and there's a fix.

Grab the 3am Sleep Fix for just $37: HERE

Have questions after listening? Hit reply on any of Kylie's emails. Every single one gets read.

Please Share This Episode

If this episode helped you understand your options more clearly, share it with a woman who needs the same clarity. Send it to your best friend, your sister, or a woman in your life who has been told no and accepted it without question.

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Kylie x

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Transcript

I get asked about HRT constantly. And the most common question these days isn't, "Should I take it?" Which was the conversation a few years ago, but now it's, "Which one should I take? What does each one do? How do I know what I need?" And the problem is a lot of women are handed a prescription without a proper explanation of what they're taking and why.

So today, we're gonna fix that. We're gonna look at three hormones, what each one does, what happens when you lose it, and what the options are like, and how to think about what you might need and what might be right for you. Now, this is not medical [00:01:00] advice, this is information, so you can go and have a better conversation with your doctor.

So 100% every time informed women get better outcomes. Now, first up, let's have a look at the terminology. We wanna move away from HRT. So HRT, hormone replacement therapy, we're not replacing those hormones, where the current terminology MHT is menopause hormone therapy. So if you kind of get your head around the new terminology, we're never replacing those lost hormones.

So our body, once our hormone production starts to recline, we're never replacing those back to our, you know, fertile times. What we're doing is we're, you know, we're topping up. So we're keeping a baseline.

We're not replacing the levels of hormones that we had like back to when we were having children and having regular periods. So yeah, MHT. So it can be used interchangeably, but I really wanna move away from [00:02:00] HRT as a term.

Okay. So first up, let's talk about estrogen. So this is the hormone that we all know about, but not as well as we think.

So what it does is estrogen's responsible for regulating our menstrual cycle. It protects our bone density. So when we lose estrogen post-menopause, this is the primary driver of osteoporosis in women. Estrogen also supports our brain function, our memory, our mood. We have estrogen receptors throughout our whole brain.

Estrogen also keeps our skin, our hair, our connective tissue healthy. It protects our cardiovascular health. It keeps our vaginal and our urethral tissue healthy. So if you listened to our previous episode, you'll know why I'm recommending or suggest that everyone looks into vaginal estrogen.

Estrogen also influences our sleep quality and our body temperature [00:03:00] regulation. So when estrogen declines, we're not just getting hot flushes, we're losing protection across almost every single system in your body, and that's why this matters. Also helps with our insulin regulation as well.

So, you know, this is where the weight gain in menopause comes into play as well. So when our estrogen declines, yeah, hot flushes kick in, night sweats kick in, we are at risk of bone density loss, more joint pain, brain fog, memory changes, mood shifts. So you don't necessarily have dementia, but 100% those estrogen changes to your brain impacts us.

Vaginal and urethral tissue changes. So as we talked about just previously, that those genital urinary symptoms of menopause. Skin changes, hair thinning, broken sleep, [00:04:00] and an increased cardiovascular risk over time. So, you know, losing estrogen isn't just a vanity issue, it's a whole body health issue. So we do really need to pay attention.

So what's available to us in terms of estrogen in MHT? So estradiol, so that's what we wanna look at. That's our body-identical form of estrogen. So it's the form our body actually makes, and this is what we want to, you know, use in this hormone therapy.

So previously, there, and it still is available, it's not what we're recommending in 2025, was a conjugated equine estrogen. So basically concentrated pregnant mare urine, for want of a better term. So, you know, brands like Premarin is derived from horse urine, so it's synthetic. This is the old-school version of HRT and [00:05:00] definitely not what we want now.

So in terms of how we get estrogen delivered to our body where it needs and done in a safe way, we can look at patches. So these are transdermal, so that means through the skin. This bypasses the liver, so there's a lower blood clot risk. Currently the patches are in short supply globally, so it's an issue here in Australia.

I know it's an issue in the US. So alternatives to the patches could be a gel. So something like Estrogel or Sandrena. Again, it's transdermal, so we apply it to our skin daily. A great alternative to patches if they're not available to you. We can get estradiol in an oral tablet, but this does go through the liver, so it is slightly higher blood clot risk than a transdermal method.

So it's, it's still used, [00:06:00] but it's probably not the first choice for most people. You can get estradiol implants. These, these are less common, but longer-acting. And then, of course, there's vaginal estrogen. So it's locally applied to the vagina, labia, you know, that whole area, and we covered this in episode 128.

So, you know, if you are suffering UTIs, dryness, just feeling uncomfortable, painful sex, definitely go back and listen to the episode on vaginal estrogen. But yeah, so if we think about estrogen transdermal, so through the skin, is definitely preferred because it bypasses the liver and a better risk profile for clotting.

So this is definitely worth discussing with your doctor, if you have high blood pressure or you've been marked at high risk of, and it's- you've been told no.

So typically who needs estrogen? [00:07:00] Women who are going through perimenopause with particularly if you've got hot flushes and night sweats, if you're suffering with those.

But you don't need those as a prerequisite for estrogen. 100% post-menopausal women, women who've gone through early surgical menopause, that puts you into, for a lot of women, instant menopause, so definitely supplementing with estrogen can help. And then estrogen by itself, this is sort of something that's important.

So estrogen by itself is only appropriate for women who still have a uterus. If you have a uterus, you also need to kind of like balance that out with progesterone, and, you know, I'll just- I'll cover that in the next section. So it's kind of non-negotiable actually. So estrogen without progesterone, if you still have your uterus intact, increases the endometrial cancer risk.

So your doctor should know that, but I want you to know as well. So it [00:08:00] doesn't matter pre-menopause, post menopause, you want to have that estrogen balanced with progesterone. Okay. So while we're on progesterone, this is I think one of the underrated hormone therapies, and it's the one most women are getting wrong.

So what progesterone does is it balances and counteracts estrogen, so it protects that uterine lining as we just talked about. Progesterone is our happy, calming hormone, so it's anti-inflammatory and it has a calming effect on that nervous system. Progesterone is crucial for sleep. It acts on our GABA receptors in the brain.

It supports our mood. It reduces anxiety. It has a natural diuretic effect, so it can help with bloating. And I think progesterone is often the one I think that gets the least airtime, and it really shouldn't because when our progesterone drops, and it drops first in early perimenopause before estrogen, women feel it in their [00:09:00] sleep, their anxiety levels, their ability to cope with stress and, you know, like this isn't a coincidence.

So a lot of women are often prescribed or should be prescribed progesterone first. When our progesterone is low, this is when we have poor sleep, we're waking up in the night, we can feel anxious and irritable, you know, and get that sort of like wired and tired feeling. So we can be exhausted, but our brain's going a million miles. We can't come down.

Bloating, fluid retention, and mood instability. So if you are still having a menstrual cycle but your sleep has gone to pieces and your anxiety is through the roof, this is often a sign that our progesterone levels are declining. So this is early peri- menopause, and a lot of GPs miss this.

A lot of women are just told to knuckle it out, or they're put on an anti-anxiety [00:10:00] medication. Definitely this is a good place to start. You can always layer in something over the top if you need it. So forms of progesterone. So we've got micronized progesterone, so this is the preferred form.

So this is our body identical, oral micronized progesterone. So this is Prometrium here in Australia, Utrogestan in New Zealand. And this is the gold standard. So it's generally taken orally, generally taken at nighttime. So the sleep benefits are 100% a bonus. It can also be used vaginally, so for women who, again, don't want that risk of it passing through the liver.

Then we've got our, what we call our synthetic progestins. So progestins, so this is the older synthetic version of progesterone. So this is found in a lot of older HRT. It's found in a lot of combination [00:11:00] HRT formulations, and this is what you get in your Mirena. So it's not the same as body identical progesterone.

It's got a different molecular structure, a different effect on the body. So your Mirena acts locally within your uterus to stop that kind of implantation. It's not enough to counter the progesterone loss in perimenopause. Okay, so you can have a Mirena and take micronized oral progesterone

So progesterone cream is another one. It's over-the-counter. It's low dose. This is really good for early, mild, early perimenopausal symptoms. It's not strong enough for everyone. So like your Anna's Wild Yam cream is great here. It's low dose if that works better for you. So this is where just on progesterone where I get fired up a bit [00:12:00] because progesterones and progestins are not the same thing.

So definitely that Women's Health Initiative study back in 2002 that scared everyone away from HRT is a synthetic progestin. Okay, your body identical micronized progesterone has much better safety profile. And if your doctor's offer- offering you an older combined pill or an older HRT formulation, it's worth specifically asking about body identical progesterone.

Okay, so who needs it? So any woman who has a uterus who is taking estrogen, it's non-negotiable. Perimenopause, post-menopause, doesn't matter. Women who are still cycling with perimenopause symptoms, especially sleep and anxiety, progesterone only can be a great starting point on your MHT journey. Women who've got a Mirena, which like I said, [00:13:00] just contains a progestin, not a body identical progesterone can take progesterone as well as have the Mirena.

So if you're in early perimenopause, still having periods, still struggling with sleep and anxiety, talk to your GP about progesterone only. You might not need estrogen yet, but often starting with progesterone can make a really meaningful difference for you.

Okie dokes. Now, the next one. This is the one no one's talking about, and this can be life-changing for a lot of women.

It's testosterone. So testosterone is all about libido and sexual function. And testosterone 100% matters for women too. So we have natural levels of testosterone, and they do decline during menopause. It's our energy and our motivation. It's like our get-up-and-go hormone. It helps maintain our muscle mass and our strength [00:14:00] maintenance as well.

It works alongside estrogen for bone density. Testosterone can help with our cognitive function, that focus and mental sharpness. It can support our mood and our sense of wellbeing. So testosterone, like I said, it's not just a male hormone. Women naturally make testosterone. We need it, and we lose it in our 40s and 50s.

And when it goes, women often describe feeling flat. So not depressed exactly, but just flat. No kind of drive, no spark, and often that's testosterone So what happens when testosterone levels drop? Often the first thing we- women notice is low libido, fatigue that doesn't fix, that doesn't get better with a good night's sleep.

Muscle loss despite exercise, so this can be really frustrating for active women. Less motivation, flat mood, brain fog, difficulty [00:15:00] concentrating. So I often have women who come to me who are on estrogen and progesterone and still feel like something's missing, and often it's testosterone. So it's 100% worth asking your doctor about.

So different forms of testosterone. So there's a compounded testosterone cream for women called Androfemme. So this is applied, again, through the skin, so transdermally, so often on the inner arm or thigh. Now testosterone is not yet TGA-approved for women in Australia, which is mad. It is prescribed off-label, which is perfectly legal and quite common, and it's worth knowing.

So don't be alarmed if your doctor mentions it or if you ask for it and your doctor gives it to you. It's totally... It is approved. Sorry, it is not approved by the TGA, but it is quite legal and quite common. Now bear in mind that testosterone [00:16:00] doses for women are very low, so it's a fraction of what men would use, and the goal is to restore normal female physiological levels of testosterone.

We're not looking at creating a masculine kind of environment. So just low dose can be enough to make a difference Now some of the side effects which can happen at... and side effects are rare, but it's, it's good to be aware of at the appropriate doses could be acne and increased hair growth if the dose is too high.

So generally it's hair growth where we don't want it. So not on your head, but you might notice it on your chin or perhaps on your chest or, or somewhere like that. And this is easily adjusted, you just drop the dose. So testosterone's got this reputation for being a male thing, and women are sometimes nervous about it.

But the doses we're talking about here are [00:17:00] tiny. We're just supporting what your body used to make, and for a lot of women, generally it can make the difference just in motivation, drive, libido, mental clarity. It can be quite significant change. So who would benefit from testosterone? So generally women who have persistent low libido despite, you know, having your estrogen being optimized.

Women who have significant fatigue and flat mood. Active women who are losing muscle despite exercise, good nutrition. Women with brain fog that hasn't resolved with estrogen. So testosterone's often the last thing that's sort of layered in. So once estrogen and progesterone have been sorted, but if you feel like something's still missing, it's a good thing to have that conversation with your doctor, bring it up and ask the question.[00:18:00] 

Okay, so if we pull this all together, who needs what and at which stage? So let's break it down. So if you are still having a cycle, you're early perimenopause, progesterone only is often the best starting point.

This addresses your sleep, anxiety, heavy periods, early mood changes. And estrogen's generally not usually needed unless you have those significant vasomotor symptoms, so your hot flushes, your night sweats. So once perimenopause starts ramping up, with more symptoms, you can look at a combination of estrogen plus progesterone.

So we're looking at specifically body-identical transdermal estrogen plus a micronized oral progesterone. So a patch, a gel, a cream in your estrogen plus a tablet for your progesterone. And then consider adding [00:19:00] testosterone in if your libido is tanked or you have energy or losing muscle are concerns of yours.

And then for all of my post-menopause friends, definitely a combination therapy is appropriate for most women. Vaginal estrogen, just to circle back to episode 128 is great for all women regardless of what you decide with estrogen, progesterone, and testosterone. All women, vaginal estrogen start it in your early 40s.

Honestly, the earlier you get onto that, the more effective it's gonna be and the less sort of long-term impacts you're gonna have. And then testosterone, have the conversation if you feel it's relevant.

Okay. So what about... I know there's sort of got a element of women who have been told they can't have MHT, it's not recommended for them. [00:20:00] So if you have had breast cancer or have breast cancer or have a family history of breast cancer, it really depends whether or not MHT is suitable for you, really depends on the type of breast cancer you had, the receptor status, and your individual risk. So these days, MHT isn't automatically a no if you've, you've got risk factors for breast cancer, and it's definitely worth...

I can't say yes or no or anything like that. It's a conversation, and it's a decision to be had between your specialist and your oncologist and yourself, okay? So you've also got to do what you feel comfortable with. If you are at clot risk, transderm-transdermal estrogen has a very different risk profile to an oral estrogen.

So patches and gels bypass the liver, and they don't increase [00:21:00] clot risk in the same way. If you've had high blood pressure, transdermal estrogen is generally safer than oral for this as well. So similar to the clot risk. Early menopause under, say, 40 or under 45, MHT is generally strongly recommended, at least until the average age of natural menopause.

So this is, you know, early 50s. And the risks of not replacing hormones in that sort of younger age group are quite significant. So I want to just make this really clear. Like, if you were told no years ago, like two years ago, five years ago, ten years ago, it's worth going back and having that conversation again with a doctor who's up to date, because the guidelines and the recommendations have changed significantly.

So you want to be talking to a doctor who's up to date with all of this. So how do you [00:22:00] have the conversation with your GP? So go in, like, create a list of symptoms, okay? And write them down and rate them out of ten. And be specific, sleep, libido, energy, brain fog, mood, hot flushes, vaginal symptoms.

Be very specific about all of those. Ask about, specifically about body identical hormones and transdermal delivery. Ask about all three hormones, so progesterone, estrogen, and testosterone, not just estrogen. If your GP is dismissive or unfamiliar, ask for a referral to a gynecologist or ask for a referral to a GP who has a menopause interest.

In Australia we've got the Australasian Menopause Society. So they've got a website where you can look up different doctors. I think all women deserve a doctor who takes this seriously. If your doctor doesn't take this seriously, [00:23:00] find one who does. And, at the end of the day, this is your quality of life that we're talking about.

Okay. So this is information that is gonna help you have a better conversation. It's not a prescription. Regardless, MHT is still a tool in your kit. So those lifestyle foundation really matters regardless of your ultimate decision about hormones.

We want to look at how is your quality of sleep? How are you coping with stress? Is your nutrition supporting how you want to feel? Is your lifestyle choices supporting how you want to feel? If you are looking for extra support, we have the Hormone Reset, we have the Hormone Code program.

All of these are designed to help you so you can work independently with the information that I've got in the Hormone Reset, or we can look at working one-on-one together if you would [00:24:00] like my support, my guidelines. So all of the links are in the show notes. So if this episode helped you, please share it.

If you have questions, hit reply on any of my emails. I read them all. And yeah, share it with your friends, share it with your work colleagues, share it with your book club, your pickleball team, everyone who needs to hear it. Big love, and I will see you in the next episode.

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Every Woman Should Be On Vaginal Oestrogen