Menopause Bloating: When SIBO Is Hiding Behind Your Hormone Symptoms

Awesome. And we're live. Welcome everyone to the Med Matrix Method podcast where we talk about health, wellness, functional medicine, how to just be a healthier, longer living person overall. We're joined by the wonderful Dr. Rose. Dr. Rose, thank you so much for joining in today. Happy to be here. Yeah, me too. Um, so real quick, none of what we're talking about today is medical advice. This is for educational purposes only. Um, if you've been listening to the podcast, thank you. We're so excited to have you. Um, we are starting to go live every so you may be watching this live right now actually. Um, pretty much it's going to be Tuesdays and Fridays um around four. So, if you're interested, want to join live, catch us then. Today, we're going to be talking about uh a couple fun things. Number one is going to be SIBO. Going in depth on what SIBO is, how to treat it, what we do, difference between functional and conventional medicine. Then we're going to be talking about menopause, which we see a lot of ladies for um at the practice. So, we're going to start off with SIBO. Um Dr. Rose, you're actually kind of a SIBO expert. Why don't you for those who don't know what SIBO is, give a definition of SIBO? Yeah, happy to. So it's um SIBO stands for small intestine bacterial overgrowth. Um there is uh there's also SEO which is small intestine fungal overgrowth but um for the purposes of this conversation we'll stick to to SIBO which is um probably more more common. Um SIBO presents like IBS or irritable bowel syndrome. So clinically people who have SIBO um may experience constipation, they may experience diarrhea, they may experience alternating constipation and diarrhea. Um almost in my clinical experience almost 100% of the time they have abdominal bloating. Um so they feel physically uncomfortable in the usually the mid or and or lower abdominal area. um usually doesn't matter what they eat. It's just kind of um physically uncomfortable. So the thing with SIBO is that because it pres it presents like irritable bowel syndrome. Historically, irritable bowel syndrome is like what they call a diagnosis of exclusion. So somebody goes to the gastronurologist or their primary care and they say, "I'm having these bowel issues. them really feel kind of gassy and bloated all the time. And if they go through the whole workup at at gastronurology and they get a colonoscopy and they see that they don't have anything more serious like Crohn's disease or colitis or cancer. Um, then they say, "Well, it's irritable bowel syndrome." And maybe they're given like Wellbutrin or an anti-depressant, or maybe they're told to take Mirax, um, which is an over-the-counter laxative. Um, but and then they're kind of sent on their way. And um again, irritable bowel syndrome might be a whole another conversation. But the issue is is that it because they present so similarly, some people might have IBS, but a lot of those people who are just given that IBS diagnosis actually have something functionally out of balance. Um and that's SIBO. So what it is is that in the small intestine we have um microbes, right? We have like the microbiome that we hear so much about. Those organisms are supposed to be there but only in certain levels only a certain amount and various things can trigger this but what happens is is that those organisms become too many in number. So the they're supposed to be there but not that many. And then when something triggers it there's this overgrowth. So you have this overgrowth of anorobic organisms that output hydrogen and or methane gas. That's what causes the issue. That's what causes gas, bloating, um excessive belching, um again the bloating, and then maybe constipation, maybe diarrhea depending on the type of organism. Um, so it really is a perfect example, I think, of like the need to dig deeper and not just throw a laxative at it, not just throw an anti-depressant at it, because you really need to see, is it IBS? Is it SIBO? Um, how do you test for SIBO? How do you know if you have SIBO? So, one way that is not ever really done and it's not really realistic for any for anybody is a small intestine biopsy. That doesn't happen. What is very easy to do is a breath test. Um, some hospitals will do this, although that's a little cumbersome to go through the hospital system to get it. It's a very easy atome test. It's a breath test. Um, and that what it does is it measures levels of hydrogen and methane gases. Um, so people receive the test kit at home. The instructions are very good. There's a whole day of prep for it. Um, and then they basically are exhaling into these vials and they mail that back to the lab. We we receive the results and then um, it tells us if those levels of hydrogen and or methane gas are over a certain level, telling us if it's a positive or negative for SIBO. Yeah, this might be a dumb question, but does your breath smell when you have SIBO? No. No, it doesn't. There's It's a good question. Um, no, it doesn't smell. There is a third gas that there's one lab that I know of that tests for hydrogen sulfate. Um, and that's kind of like a third type of SIBO. Um, and that is people who have that type of SIBO, like their their gas, their farts are like really like smell like eggs. It's sulfur. It's sulfuric. Um, but other than that, no, you don't you don't have it doesn't smell. Gotcha. How do you get SIBO? Right? Because we see so many patients who have GI issues. Um, how do you like how does one end up with SIBO? So, there's different triggers. Um, sometimes somebody had an episode of food poisoning, like they were maybe they were traveling internationally, maybe they just whenever for whatever reason they ate at a restaurant, they got food poisoning and so in their recollection they were really they had some GI bug for a while and they got over the GI bug but like ever basically that triggered this overgrowth of these microbes and probably for months or years they basically have had this overgrowth but it's been undiagnosed. More commonly it's at some point in childhood or adulthood they had a sugar basically a diet that was relatively high in sugar and processed carbs that can increase your risk. um being on proton pump inhibitors um medications like um azrazol formotedine um for years can also be incre make you know increase your risk. Sometimes it's actually anatomical. It's literally the way that the small intestine which is just a really really long tube lies on top of itself. If there's like kind of certain kinks it's just the way that you were made you're just more prone to it. Um, it's almost like these little pockets of microbes don't they don't circulate enough. They kind of f, you know, they're they're kind of stuck and they just produce gas and it can become problematic. Um, did I I don't know if I said antibiotic use. Did I say that? Um, yeah, high high sugar diet. Um, again, as a child and or adult, say somebody had a lot of ear infections as a child, they were given lots of um antibiotics. That's going to increase your risk, man. So, how I mean these are all common things a lot of people go through like how common is SIBO? How many people are walking around with an IBS diagnosis that actually have something like SIBO? Um, I don't have like an exact number, but I think a pretty a high percentage. So the re the the there's various studies that I have read in the past. It's maybe 60 to depending on the exact study that you look at 60 to 70% of people who think they have IBS were given a diagnosis of IBS. It's actually SIBO. Really? Wow. Because SIBO is treatable, right? It is treatable. Exactly. And that's why I mean IBS is too, but in actually a different way than SIBO. So SIBO is an infection. It's an overgrowth of these um organisms which are most of them are bacteria. So we really do um it does require an antimicrobial approach. Um and this may I don't know if you're this I don't know if you were going to go with this with your line of questioning but there is kind of like a conventional medical approach and then there's more of a functional medical approach. But yeah how like so I mean how do you treat SIBO? Is it just more antibiotics like how it is? It is antibiotics but um the way that I talk to my patients about it is that we have to approach it or I like to approach it with phase one and phase two of treatment. And so phase one is antimicrobial but you have options. You have options of doing um kind of the pharmaceutical antibiotics um which can be quite effective or you can do like a botanical. They're pretty potent antimicrobial herbs. So things like um oil of oregano, um uh bourberine, garlic, those are all botanical and and but they're not wimpy. They are pretty potent. So I usually I just give people the options, the pros and cons. Um and that that has to happen before we then move to phase two. And phase two is I think where conventional medicine falls short because if if somebody is treated again in the conventional medical model, they are probably they're given a pharmaceutical antibiotic, but then that's it. Then they're just kind of there's there's no follow-up support. There's no phase two. Phase two is making sure that you prevent a recurrence, you maintain kind of that new healthy microbiome. Um, and it's individualized, right? So depending on if the person tends towards diarrhea, we're going to use certain tools. If it's more constipation, we're going to use different tools. Um some of that might be nutrition. You know, kind of avoiding certain foods at least in the short term. Um across the board, you don't want a high sugar diet. That's just going to kind of increase your risk of having a recurrence. And then different neutrautical med you know some medications that can kind of again start to heal the gut, lower inflammation, improve the absorption of nutrients, all these things that um are basically squella of having SIBO and usually having had SIBO for years. So we do all of this work so that we can heal the gut and prevent a recurrence. And that's what I don't see happening um from the few conventional medical people who are actually treating SIBO. Gotcha. Okay. Um when but it sounds like you go to conventional medicine, they're very rarely finding it. Is that right? some gastro I mean I'm happy when somebody comes back and they say that their gastronurologist actually is recognizing it, treating it, doing anything with it. Um it um some only a small percentage I would say of primary care providers have been trained in it to even know what it is, recognize it. Um, you know, it's a I guess you could say relatively new discovery within gastronenterology like within the last 15 years. Um, so people who were trained prior to that probably didn't get it in medical school. I don't know currently to be honest if it's now being taught to you know people going through training now. Okay. Gotcha. All right. So obviously in functional medicine, you know, you see a much lower volume of patients than like a primary care would. Like on a busy day, you're probably seeing seven patients. Um what when when so when was the last time you actually like full saw a patient who had who's dealing with SIBO? Oh, yesterday. Okay. So [laughter] what Okay. So by the way, by the way, I by the way, I saw 15 people yesterday, not seven, but Okay. Okay. You probably had a lot of follow-ups then. I did. That's a busy That's a busy day. Yeah. Yeah. That's crazy. Um what Okay. Can you walk me through like um you don't have to do the last patient, but just a memorable SIBO patient and like the care plan they did and like Yeah. the what they had gone through and the results they got through functional. Yeah. Yep. So, this one always stands out to me. This was um a woman who is um early 60s and she had been dealing with chronic constipation for literally decades. Um and her she was married to a physician, not a gastronurologist. I don't remember his specialty, but I know it wasn't gastro. Um and had been put on laxatives for decades. So, um that was the only way she could have a bowel movement. She was bloated, but that she had just come to think of that as just that was just how it was. That was her normal, you know, didn't really know any other way. Um, it had gotten to the point I think basically I saw her shortly after she retired while she was working as a bookkeeper. It her health that aspect of her health was just back burner. She just kind of dealt with it. She took her laxative, whatever. She retires. she decides it's time to kind of focus on her physical health a little bit. So, she comes to me and had never heard of SIBO. Um, and we ran a breath test and her, again, standard test will breath test will look for elevated hydrogen, elevated methane. Her methane levels were really high. So, methane usually, including in this case, correlates with constipation. Um, so her methane was really high. What happens with that is that the methane slows down the motility of the intestines. When this motility slows down, you can't poop. And then when you can't poop, those microbes build up even more, producing more methane. So, it's this vicious cycle. Um, I put her on two antibiotics. Uh, the the standard one is raffaxamon. um it just targets the small intestine. It doesn't disrupt the the microbiome in the in the colon or the large intestine. And then I also because she had elevated methane, I added a second more old school antibiotic which is neomy. Two week course. Um she had improvement almost immediately and that varies. Some people it's immediate, some people it takes a week, some people it takes longer. So basically it was like the first time and I'm not making this up. The first time in decades that she was having bowel movements I think maybe for her ended she was going from really not being able to go at all on her own to not being on the laxative but having um a relatively healthy bowel movement every other day. Wow. That must have been huge for her. It was it was Yeah, it was huge. Um yeah. And so I think what I did, what I usually do if somebody had been deal has been dealing with it for that long, I repeated the another, we did another two-eek course um just to kind of really make sure that the infection was gone, the overgrowth was diminished. And um then we moved into phase two, right? So for her, the goal is let's maintain the motility. Like we just need to get her and when somebody is on a laxative chronically like that, the intestines forget how to move themselves. they lose that their own knowledge basically of muscular contraction because they're just it's they don't need to use it anymore. The laxative's doing the work. So we have to kind of retrain it sounds a little funny but almost like retrain the muscle memory for those for her intestines. Um and so again some neutrauticals um I don't remember the exact details of what was involved with plan two but um fiber magnesium like just kind of keep things going and really reserving the mirillax for just as needed. Um so that was that was a success case. That's a good one. That's a good story. Just curious, was her because her husband Did you say her husband was a physician? I think he I mean I don't I never met him but um I I mean obviously he was really happy for his wife and happy to have her feeling better and um I think pleasantly surprised. I don't Yeah. Yeah, that's really interesting. So what um I guess how like how often are you seeing SIBO with IBS patients that is it the is that the 40 or no you said 60% right 60 to so this is not in my own practice but just what the research shows that 60 to 70% of people who have been given that IBS diagnosis it actually is SIBO so everyone who comes into the practice who has IB s are you wanting are you doing a breath test? No, because again this is such a personalized medicine. I definitely will, you know, offer it. But most, you know, most people that come in have like multiple things going on. If gut health is their priority or that's kind of the biggest issue for them and I strongly suspect that it's SIBO, I will order a breath test. Um, the other gut test that I order probably more frequently because it covers more bases, not just SIBO, is the GI map with zulin. And that is not a breath test. It's a stool test, but it does show if the if there's um certain bacteria are elevated, including some bacteria that are methanogenic, the ones that the organisms that produce um methane. And so I can kind of infer from that test if somebody probably has SIBO matched with their their symptoms, their clinical presentation. Um, and that one again that because that one will tell me if somebody has a parasite, a fungal overgrowth. It just kind of does more. But if and then once in a while I will order both, you know, both the GI map and the breath test. Gotcha. So, how does something like SIBO or IBS, which we know is more or less a cover up diagnosis, play a role in the gut brain access? Yeah. I mean, [sighs] a fair amount. There's the um there's the leaky gut theory. So, that is leaky gut. We we'll try to be brief in that description of that, but that is um quite frequently goes along with SIBO. The idea sometimes that SIBO causes leaky gut. So if you have this bacterial overgrowth, there's a lot of kind of imbalance in the gut level, including uh higher levels of inflammation. When there's inflammation at the gut level, the um cells that make make up the lining of the intestine, again, they become inflamed and they kind of pull apart. And what we're talking about is tight junctions. So tight junctions are like gates between two cells in the intestine. If those get inflamed that we lose the tight junction, things can get into the bloodstream that aren't supposed to get into the bloodstream, triggering an inflammatory response anywhere and throughout the body. And that often is um in the nervous system. So it can affect the brain and it can affect mood and it can affect everything. So brain fog, anxiety, like anything having to do with the nervous system if you're kind of your inflammation level has gone up. Um all of that can be involved. Gotcha. What and what can happen when the gut brain access is messed up? Um well lots of things. I mean you then then you get um well when the gut brain access is messed you mean when that happens when there's like a leaky gut process or just when what do you mean when it's messed up? When well like when the gut brain access So is when we talk about like the gut brain access is that just effectively leaky gut? It's often leaky gut. it. Um I think the way that I think of it, we do we do throw that term around and I think I think of it a little bit more that we have um part of our brain is actually in the intestine. It's called the entic brain, which I think we've talked about before, but it um so we think of the brain as being up in the skull, but actually a good chunk of a lot of the brain is actually literally in the gut. And so it's almost like they're so interwoven. So, you know, the obvious connection is when for some people when they're anxious, like there's performance anxiety, there's like you're about to public speaking, you're going on a first date. Um you your stomach starts to, you know, you start to get butterflies, you start to clench, some people actually have to run to the bathroom. That's like your classic example of how emo how emotions or the nervous system is literally affecting your gut. Um, that's really interesting. Weird question again. So, if I get punched a If I get punched in the gut, could I get a concussion or like a brain damage brain? [laughter] Not in the classic That's a good question. Not Not in the classic definition of traumatic brain injury or concussion, but um, yes, definitely affect the nervous. Yes, they're going to affect you neurologically. Gotcha. So, people who are eating, I'll just say it, shitty foods, putting bad things in their body, um not getting normal bowel movements in, they're going to be cognitively affected by that. Oh, yeah. Wow. Brain brain fog if at minimum. Mhm. Really? Okay. Um how often with patients who are dealing with like cognitive issues is it relate also related to the gut? probably a high percentage of the time. Um, again, I can't speak to actual like I don't have any studies right here, but just in my own practice, um, I always say that, you know, it's a cliche that like everything starts with the gut, but it's actually a cliche that I believe. Um because I think that you know if you're if things are out of balance, if you're not eliminating properly, you're constipated or bloated all the time or on the other hand you are one of my patients who can't leave the house till 12:00 noon because you're you have to be right next to your toilet like all of those things like that's going to affect everything else all other systems. Um okay can SIBO relate to diarrhea? Yeah. So, just like with IBS, we talk about IBSD, diarrhea, IBS C, constipation, um, and mixed. We have the exact same thing with SIBO. We have D, C, and mixed. Um, yeah, it really kind of depends on which organism, the overgrowth of which organism. Um, and because certain organisms put out hydrogen, certain ones put out methane, and depending on, and again, if you have mixed, you probably have elevated levels of both. Gotcha. what what um subsequent problems are related to diarrhea and what subsequent problems are related to constipation? So diarrhea, you're often going to be losing a lot of beneficial um microbes, right? A lot of beneficial bacteria um and and some level, I would say, of um kind of malabsorption. um you're just not getting um things are just kind of moving through you too quickly. Um and all the again systemically all the results of not having a healthy microbiome and that's going to affect you know we're just learning more and more everything from again nervous system to even hormonal implications of when your microbiome is off um and immunity immune immune um strength as well. Um, and then, uh, and I guess if it's really diarrhea, you're you're probably going to be relatively dehydrated. Um, constipation, which is probably more common in at least this patient population. Um, you know, you're not fully um, detoxing. You're not really able to, you know, your liver isn't able to, your liver does its job, but then things get stuck. So including even like estrogen metabolism um and all the other sex hormones like you know there's certain pathways that where things are supposed to kind of get processed through the liver. So this is any medication that you take but also your own sex hormones. If those can't be bound appropriately and then eliminated through the stool they end up kind of recirculating. And so in again in the case of estrogen, you get estrogen dominance symptoms because it's estrogen that was supposed to be bound up and pooped out and it's not. And so you kind of get too much estrogenic effect. Um, and I see it with, you know, as we've talked about on this podcast before with micotoxin or mold exposure and toxicity, um, with parasites, like all of that. If if somebody is not able to eliminate through the bowels, which is our most efficient mode of detoxification, then um they're not going to be able to handle exposure to mold the way that somebody who's having regular bowel movements is. If somebody does have a parasite, you can't put them on a parasitic cleanse uh until you get their bowels moving, or else it's just going to backfire. Gotcha. Okay. Um, [sighs] man. So, it's a problem when you because diarrhea and constipation, these are symptoms, right? So, when you give someone a laxative Exactly. Right. They're That's so common. I can't tell you the number of people that say whatever they went to their doctor for gut related, they were or gastronurologist, they were put on a laxative. Jeez. Um when when you're being told by your doctor to take a laxative, how often is that just the best solution for you versus there's actually a better there's a root cause reason to why you're constipated? I think there's almost always a root cause and even if it's um so if it's lack of motility if your bowels are and if when as people age they often kind of lose some of that natural motility gut-wise. um there's still kind of better ways to optimize that and manage that rather than in my opinion than a daily laxative. There's ways to kind of promote your body's own motility essentially. Um you know, if somebody if we're trying to figure out we're still doing kind of root cause medicine, we're doing the testing. We're kind of trying to figure out what's going on with this person. Why are they chronically constipated? And in the meantime, if left, if not given any support, this person is going to have a bowel movement maybe once a week. That's time where in the short term, take the laxative, right? Like just to get get us through till we know more, till we can kind of get get the answer. Um, you know, otherwise they're going to become impacted. They're going to go to the emergency room and that's not fun. Yeah, totally. Um what okay what happens when like something like SIBO goes unadressed for like 10 years 20 years like this patient you saw you do start to get the systemic things you do start to get um and there's all sorts of theories kind of but um you know what there there is inflammation essentially and that you know we see inflammation show up all over the body for different people in different ways. But um often times the the digestive symptoms are going to get worse. You're going to get some of these squella from having chronic constipation, having chronic diarrhea, um malabsorption of nutrients, etc. But then you're also going to get, you know, whether it's inflammation that's affecting the nervous system, the muscularkeeletal system, all of that's just going to kind of continue to get worse. So, um, [snorts] yeah, I think that's Are there any, um, symptoms that are hard fast? Like, I'm 99% certain this person has SIBO, chronic bloating, chronic bloating. They're like, okay, this person has SIBO. Yeah. And what I will honestly what I will do is if um if I am not totally sure I will put them on what's called a low FODMAP diet as an experiment, not as a long-term treatment. What are you looking for? So you put them all you think someone has SIBO, you put them on a low FODMAP diet. What are the outcomes that give you kind of insights to what's going on with the bloating goes down? So they so you know the classic foods that are highest in these difficult to digest starches which is what FODMAPs are. Um basically they go on a trial of eliminating those high FODMAP foods. If they come back to me and they say wow I am like 85 90% better. I haven't changed anything. I've just eliminated garlic, onion, apples, pears, these other you know whatever else is on the list. Um, that tells you they have SIBO. That tells me they No, that tells me that they might just have a real they some people, again, this is that entic brain that where it's all tied together. They're that entic brain those they're highly sensitive essentially. They're highly sensitive to those high FODMAP foods. That doesn't necessarily equal SIBO. Gotcha. Okay. So, for someone at home, if they're like having bloating, go on a low. They could try they could try a low FODMAP. Yep. The app that I tell people to go to is put out by um ME O N University. Um I think they are in Australia and they kind of came up with the low FODMAP diet and they have an app that is really helpful. So um if somebody's wondering and they want to just try that first, eliminate those foods and then see. Um it's not a diet that's meant to be forever. it usually the way again it's like a trial if it seems like it's effective most people are able to end up with a modified version so you don't have to continue on this restricted diet forever I really don't like recommend I don't like recommending restricted diets as a forever thing but it can be a tool and then they you people usually end up where they can they can just there's a few foods they might rarely want to eat in excess but otherwise they can kind of figure out what works for Gotcha. So, correct me if I'm wrong, but didn't you say um garlic was a natural remedy for Yes, it is. Yes, it is a it's an antimicrobial plant. Um and so what I'll do is when I if somebody says I want to treat SIBO with the you know botanically um I will ask somebody how do you tolerate dietary garlic like can you cook with can you eat garlic and do you feel fine and if they say yes it doesn't bother me as far as I can tell then excuse me it can be included in that protocol if somebody says no I really I really don't I either get heartburn I get bloated then I just won't include it in that protocol. Gotcha. All right, I'm bouncing around a little bit here, but um let's wrap up this question. So, someone is low, they have bloating, they do a low FODMAP diet, which they can do through that app you just mentioned. They're still bloated. Now, you're like, okay, this person probably has SIBO. Most likely has SIBO. Yeah. Okay. [clears throat] Then you do a breath test or then do you go right to like a Yeah. So, I think of it as like a flowchart. So, I give people the option. It technically can be a clinical or like a presumptive diagnosis. So we don't need and this is true like within any any field of medicine, gastronurology, functional medicine, we don't need that breath test result to make the diagnosis. I can clinically make the diagnosis, but I offer the breath I offer it to people. So the first decision is breath test or no test. Breath test, we come back, we see if it's positive or not, we proceed. If they say, you know what, I've just been feeling miserable for so long. I don't want to take the time to do the test. Just let's just start. Then the decision is uh ant herbal antimicrobials or pharmaceutical antimicrobials. Anti. How do you help patients decide? How do you help patients decide? Okay, am I going the like, you know, pharmaceutical route with this or am I going the more natural route with this? Um, I have seen after probably treating hundreds of people in this exact scenario, um, I've seen both work. I think for the majority of people, either option would be effective. Some people really just don't want to do conventional antibiotics no matter what, and they and they just want to go natural whenever possible. Great. We'll do we'll start we'll start with the with the botanical ones. Other people say, um, I just haven't had good luck in general with with herbs, with plants. So, um, I just want to go with the pharmaceutical. Great. Um, sometimes it's a matter like the botanical or the herbal protocol lasts four weeks. The pharmaceutical is two. So, sometimes, I don't know, somebody's going to be leaving the country in two weeks and they don't they don't want to deal with taking things with them on their on the flight. So, it's again, it's customized. Um, yeah. How effective is the botanical versus the pharmaceutical approach for CB? There's I mean it's been studied and it's quite and and again in my practice um it's usually just as effective. I have seen it go both ways. I've seen we've tried the botanicals doesn't really work. We go to the pharmaceutical it works. I've also seen the reverse. I've seen that people don't really respond well for whatever reason. They either have really they have side effects with like cramping or they don't find that the pharmaceuticals are effective. the botanicals work. So that's why I feel fortunate to have a large toolbox because everybody's different. Everybody's um digestive systems are different and it's really nice to have to not be limited to just one tool. Yeah, it's pretty scary to think of like how different every day I just learn more about the medical system and medicine like going to your doctor with bloating and gut issues and then they either refer you out to a gastro which is then you know another 3 six months to get in if that then it's like okay they just diagnose you with IBS then give you a laxative opposed to actually trying to figure out what's going on like using the low FODMAP diet and then reasoning from there and then giving them options to to treat the root cause of these issues. So really interesting. Last question to wrap up the gut health, SIBO, IBS talk before we move on to menopause. What um what is your opinion on antibiotics because I, you know, I was raised by a mom who was kind of always more natural, say granola mom. Um so I was always thought like antibiotics are bad, but sometimes they aren't necessary. you know, you got strep throat, you got to take antibiotics. What's your opinion on that? Like, when are antibiotics actually a good thing and when are they um when are they not why are they bad? Well, I think well, they're life-saving. So, I don't I mean, they've really they've kind of radicalized our I mean, people are living longer and, you know, surviving childhood diseases now in a way that they weren't 100 years ago. So I don't think we can overstate kind of public healthwise the importance of what antibiotics have done. Um they have you [clears throat] know been overprescribed and so we have res you know one's you know um some antibiotic resistance etc. I think it's I think it again it depends on the situation. I think that what's been done is it's been the go-to. People are just you know they were just put on antibiotics for everything. didn't even see if it was a viral infection or bacterial. It was just here's your antibiotic. And that's kind of how we ended up in this situation. I do like using them when um in the right circumstances. So when, for example, we've we know if somebody has or we suspect somebody has SIBO, I like having that pharmaceutical option of um a pharmaceutical antibiotic. or if there's a different type of intestinal infection um H pylori for example I like having the option of using shortterm antibiotics um if somebody has acute lime or an acute another acute tickborne um infection doxycyc is appropriate so there are definitely times but again large toolbox there's some really great botanical and you know or yeah, botanical um antimicrobials that are very potent and and and actually quite effective. So, um I don't know if that answers your question, but I guess used judiciously, I do think that they're they have they serve a role. Okay. Yeah, thanks for clarifying. That's um it's good advice. And that's the thing, you go to a conventional doctor, you might never even be told of another option, you know, right? Um, so appreciate you kind of sharing some insight there. So, all right, that concludes the um, you know, talk about SIBO, IBS. Uh, if you're live with us right now, you're listening to the podcast, you want to work with us as a patient, check out, go to medmatrixusa.com, send us a DM on social media, um, and click get started if you're on the website and you can book a call with a patient coordinator. Uh, with that said, thank you guys for joining. We're going to be moving into talking about menopause. So, if you're just joining us now, this is the MedMatrix Method podcast. We're live currently. If you're watching to recording of this, you can catch us live Tuesdays and Thursdays uh after 4. So, to kick us off, and by the way, everything we're talking about, none of this is medical advice, simply for educational purposes only. So, Dr. O, why don't you give us some context on what is menopause? What is it really? Um, so yeah, let's go. Okay. Um well, it is an area of um I guess medicine that has been sadly kind of ignored, dismissed, passed along um uh by medical providers in general. Um hopefully that is changing. I think we're having a little bit of a moment um with some you know social awareness um around the stage of a woman's life. Perry menopause are the years leading up to menopause. So pmenopause can last 10 to 20 years. It can start as early as age 35 for some women. Um and pmenopause is um when our hor our sex hormones are basically fluctuating. It can be it can vary for every woman, but it can be one, you know, one day, one week, one month, you know, estrogen is really high and then maybe the next it's really low. And it's it can it it's kind of all over the map. And a woman's going to feel that. She's going to feel those fluctuations. Menopause is actually an event. Menopause is is technically 12 months since you've had a period. And at that point, your body, the ovaries are no longer making estrogen and really no longer making progesterone. Um, and that's kind of like a hard stop. So, as some people describe it, it's a little bit like falling off a cliff. Um, yeah. So, those are kind of the technical definitions. Gotcha. Why does menopause just hit some women so hard? Just completely change their life. Yeah. I mean the the that is a true statement. I think some people um some of my patients um you know even speaking to them kind of retrospectively like a woman who's say 70 and I ask well what was menopause like for you? Some women will say that it was miserable. They stopped being able to sleep. They the hot flashes were awful. Um and they were depressed. They gained weight. And then some women are like, it just kind of my period stopped and it was just uneventful and nothing really changed. Um, you know, I think there's a lot of things that go into it. Some of it might be somewhat genetic. Um, in terms of, you know, we always like to ask like, do you know what it was like for your mother, for your sisters when they went through the change? Um, and other times I think it does tie into things like um your ability to to eliminate to detoxify. So what's happening with kind of estrogen [clears throat] metabolism at the level of the liver and um you know somebody chronically constipated they're going to probably have more estrogen dominant symptoms. So more PMS, more heavy bleeding, you know maybe all of that. Um so other aspects of a woman's health play a role um in how kind of what that transition is like. Um but I think a lot of it is just we are all such unique beings. We have different hormonal makeup and um it's not necessarily I mean we always say pmenopause menopause it's not a pathology right it's like a it's like a normal part of it's a normal stage. It doesn't mean that we can't support the woman's endocrine system and and you know kind of make some adjustments, but there's not there's not really a disease here. Gotcha. I guess why before we get into like best practices, what you can do on your own, how we help patients or how functional medicine helps women with menopause. Um why do so many because we have a lot of ladies with menopause. Yep. Almost all of them going through menopause. Yeah. Almost all of them come to us after being really frustrated with not getting the help they wanted from conventional medicine. Why is that? So um in the late 90s there was this huge um study the women's health initiative and up until that point like in the 60s in the 70s a lot of women were put on estrogen somewhat routinely um and what happened with this women's health initiative it was kind of a retrospective study looking at um older women women I think over 65 five. And what the conclusion was was that women on HRT had a higher risk of breast cancer and a higher risk of um getting a blood clot, therefore increasing risk of cardiovascular disease. And so pretty much overnight, thousands of women were taken off HRT. And that's what we were taught in medical school was it's not safe for most it just wasn't prescribed. We just you just don't do it. And that is so um basically that's still that has been the mentality up until quite recently and still is I think for a lot of a lot of people especially maybe people who were again went through medical school years and years ago like myself. Um but um so what happened for a lot of us is that we did our we had to do most of our training after medical school, right? Like we had to do kind of a lot of the continuing education around hormone replacement therapy after because it really wasn't baked into the to the curriculum. Um so so women will go to their primary care doctors um sometimes even to their OB um to their gynecologists and the they these doctors are either a they've it's just been they they're scared. There's fear. They've just been told you do not put women on hormone replacement therapy and or they were just never taught how to prescribe it. They just it's just not in their wheelhouse. And so they don't offer it. And um you know I think uh the the right thing to do is to just own that and just to say I just this is not my specialty. I don't know how to do this and maybe help refer that woman on to somebody who does. Um B actually learn how to do it, do the training, do put in the work. Um, but what I hear more often is that the woman just feels dismissed and that the provider rather than kind of owning that they don't know something, um, will just make this put the woman on an anti-depressant, tell her to lose weight, change her diet. Um, she's just she feels dismissed. Yeah. Like I hear you. And then a lot of them too are put on things like anti-depressants, lack, right? Exactly. Meds they don't need. Yeah. And the interesting the interesting thing is is that younger women and even women into their 40s are routinely put on birth control, oral birth control. And that hormones in um birth control is so much higher levels of of hormone replacement than what we put on women going through pmenopause and menopause. Oh, okay. Gotcha. Yeah. What else is the difference? Right. Because it's those are synthetic hormones, right? What do you think? Those are synthetic and we prefer bio identical. Bio identical meaning that it's that it's chemically identical to what our own hormones look like as opposed to synthetic which are um similar but not uh identical. And the safety profile of bioididentical is better is higher. Um. Yeah. Okay, real quick. Sorry. So, I'm gonna ask a question. It's going to sidetrack us for just a second. How bad is birth control? Like, if you were um you know, for moms out there with daughters, right? Tw 16, 22, whatever. Um what are the long-term side effects of something like being on a super high dose of synthetic estrogen as a young girl for a long time? Um, [sighs and gasps] you know, I I think again, everybody's different. I think um sometimes it does feel like a necessary evil if a girl woman is having really severe menstrual pain, heavy bleeding, um really irregular periods and that um andor if that's the only form of contraception that really makes sense, then it's the right thing to do. Um, we also now have I um IUDs, intrauterine devices, the hormonal versions and then the non hormonal versions. And those can sometimes be a good option as well. It's a lower and localized dose of um uh progesterine or progesterone um synthetic progesterone. But long term, I think one thing is that we you kind of um I think for some women it can affect fertility in the long term. Not not all and probably not the majority, but I think it can impact fertility down the road if somebody's been on it for, you know, 10 to 20 years. Um I also just think that in some way I think, you know, girls and women are meant to cycle. And so if you're taking um a synthetic form of hormone that is making you not cycle at all, I do think that that um I think again if when that is going on for 10 to 20 years, you're going to the body's can sometimes it can just kind of forget how to cycle on its own. It can take a while. For example, if a woman has been on oral birth control, it can take her a while to conceive because the body it it she doesn't really remember how to do that normal monthly cycle. Fair enough. Okay. Gotcha. All right. Back to Yeah. And and I mean, you know, birth control does increase your risk of blood clots. So, for example, if you smoke, do not be on a you should not be on birth control. Okay. Gotcha. Smoke anything. Uh nicotine. Okay. Nicotine. Cigarette. Yeah. because both increase your risk of blood clots. So, um the synthetic um estrogen increases your risk of blood clots and smoking increases your risk of blood clots. So, um neither neither [clears throat] one is great, but you definitely don't want to do both. So, what about all the like girls in college who are on birth control and vaping? Are they like screwed? Not great. I would say I mean I guess again I would say so that's or this is oral estrogen and that's one of the negatives that's why an IUD is a better option for a lot of young women. Okay, back to menopause. Um okay, what are some of the Well, I guess let's we kind of already asked that about the we all asked this like what are some of the biggest myths or misconceptions about menopause that you hear from patients where they have limiting beliefs? um that H well it's what we've all been you know what was kind of put out which is that it's not safe and that it's going to increase risk of breast cancer which it is not um the you know transermal or topical estrogen um which is bio identical is actually in studies recent studies shows that it lowers your risk of breast cancer as well as colorectyl and lung um or and or increases your risk of cardiovascular disease because of the risk of blood clots. What happened with that women's health initiative is that the we we now know that those um results were misinterpreted um and that so basically there's just been misinformation out there for decades. So um actually maintaining a serum level a blood level of estrogen um for a certain number of years reduces your risk of cardiovascular disease. Um, and so there's again there's a big difference in terms of the amount of estrogen and whether it's transdermal, meaning topical versus oral. Gotcha. Is there ever a scenario in menopause where you don't recommend bio identical hormone replacement therapy for ladies? Um it technically if a woman has had a personal history of breast cancer we would not recommend um estrogen. Now vaginal estrogen is safe for literally any woman or any person with a vagina. Um but um uh if somebody again family history of breast cancer it's fine. Um if woman has a personal history of breast cancer, you know, all it just needs to be she needs to be provided with a lot of information and understand the risks and if there's you know really clear reasons why this person um you know she's having really debilitating hot flashes, other vasom motor symptoms like night sweats um then it needs to be it can be a you know a personal decision between her and her doctor. Um, progesterone, oral progesterone, totally safe. Um, topical testosterone, totally safe. It's really the So, that's that's one person that um or and or um a you know, a clotting disorder. If she has a tendency for um DBTs, deep vein thrombosis, uh other another clotting disorder, we might be a little bit hesitant to put her on um a form [clears throat] of estrogen or estradile other than vaginal. Gotcha. Okay. Um [clears throat] let's talk a little bit about hormone testing because a lot of ladies are told that doesn't exist or it's not important. Why is can you kind of break the myths or give some truth to blood testing for estrogen, progesterone, testosterone, you know, your sex hormones? Yeah. Yeah. So, um I do we do, you know, it's part of our initial panel. Um and we do like to monitor um blood levels of those hormones if somebody is on um bioididentical HRT. Um what we see is that somebody's experiencing pmenopausal symptoms. Um again it could be the vasom motor, it could be brain fog, it could be just poor sleep, it could be um weight gain, could be low libido. Um we're not going to see that in the pmenopausal time frame. We're not going to see that directly reflected in the blood work usually, right? If a woman is still cycling, that's what we're going to see on the blood work. We're not going to see usually blatant um imbalance in the blood work, but it does give us a baseline for when we do start to give her potentially hormone replacement therapy. Now, if a woman is postmenopausal, I can tell right away based on this on the blood work, right? I can tell she's not making progesterone, she's not making estrogen, her follical stimulating hormone is high. Um, and um, so again, it's a baseline and it can be used as a way to monitor or manage treatment, but um, so that's why it's good to test. Um, it's certainly not imperative because really what we're doing is we're adjusting doses. We're finding the right forms for that woman based on clinical symptoms. Gotcha. Clinical symptoms being what are the main respond. So a woman for example the the simplest is maybe oral progesterone. Um wakes up between 2 and 4 a.m. is you know tired um has brain fog largely because of the poor sleep. Um, we put her on progesterone, oral progesterone, which is really the relaxation hormone. Um, and she's able to sleep more. She therefore feels better. That's so that that's more important to me than getting a certain lab value on her follow-up labs. I want to see what the lab what what we're, you know, I want to see it, but more important to me is how she's what she reports. Gotcha. Is there a connection between cortisol, so that stress hormone, and menopause? Um, yes. [sighs and gasps] The, um, I think you've heard me say this before. Um, there is that triangular relationship, um, between the ovaries. So, the sex hormones come from the ovaries, the adrenals, cortisol comes from the adrenal glands, and the thyroid. Um, and they're all interrelated. They're all part of the endocrine, the hormonal system. It's not a linear relationship. If there's, um, high stress, uh, which will disregulate cortisol, it doesn't necessarily mean somebody has high cortisol. It could be high, it could be chronically low, it could just be kind of out of whack. That is going to most likely um, or can impact both the thyroid um, and or the sex hormones. So um it can it's a little kind of complicated in exactly in how it does that but um in the same way say a woman's progesterone is you know she's in parmenopause she kind of you know her progesterone is a little bit low given what her needs are at that time she's not sleeping well she's not handling the stress in her life very well that is going to therefore impact cortisol. So again, it's it's kind of everything's interrelated. Um, yeah, including including the thyroid, including overall metabolism. Gotcha. With that said, everything being in related when a patient comes in with menopause or is postmenopause or pmenopause? Um, how often are you look, you know, obviously you're looking at everything, but how often are you actually creating a plan that also supports their thyroid and their gut health and their sex hormones? Is it always you're looking at all three? I'm always looking at I'm always looking at all of that. I'm always asking I'm looking. So again, our initial panel includes cortisol, includes a full thyroid panel, includes a full sex hormone panel. So in one glance I am able to kind of get at least an initial look at the status of those and then by extensive questioning I can find out the gut health. Is she constipated? Is she bloated? Etc. So in my head at least I'm always looking at all of it. I ask about sleep. I ask about life stressors. I've asked somebody how do you handle not just what are the stressors in your life but how do what's your stress resilience like? How do you handle stress? Um, so I'm at least starting to form an idea and depending on the person, we might kind of attack all of that at once. We might bring in things to help with constipation. We might bring in things, you know, some hormone replacement therapy, including maybe some thyroid replacement or some other nutritional things to help support the thyroid. Um it's personalized in a lot of ways including someone's um acknowledging or recognizing someone's bandwidth. Some people come in and they are gung-ho and they are ready to do all of that. A lot of people are really overwhelmed as it is and we just we need to take things kind of step by step. So that's part of the conversation. It's a really crucial part of that first visit of like where do where what's what's the best way in here? what's what's going to give this person relief the soonest and let's where can we just at least start to move the needle and we will get to these other things. But I I always say to people, I don't want you to leave feeling like your head is spinning. Like I could recommend a hundred things. They're all appropriate. It's just going to probably be too much for you. We just need to start somewhere. Gotcha. It's a good approach. Um, what can women do prior to menopause to make it easier for when that does happen where it's they're not as affected if anything at all? Prior to pmenopause or met menopause? Well, it goes parmenopause. Metopause, right? Yeah. Yeah. [clears throat] Just all of it. Um, [sighs] well, circling back to the gut, I mean, I think, you know, having regular healthy bowel movements is crucial. Um, and um, having working on ways to maintain a low level of inflammation systemwide is also going to be beneficial. So if inflammation is high going into pmenopause that added inflammation goes up uh for a lot of women in permenopause. So if your baseline is already really high and again you're not detoxing well, you're not kind of processing everything through the liver, including sex hormones well, then you kind of it's like then pmenopause happens. It's like adding more fuel to that fire. So, if you're if you can optimize your baseline before perry menopause, um, and it's all this, it's kind of boring, but it's still true. Nutrition, like optimal nutrition, you know, relatively low sugar diet, um, lots of fruits and vegetables, high protein, and moving your body regularly, sweating regularly, all of the things that we know we should do. Well, it's still true. Lifestyle choices do really matter. then when you kind of get this added uh piece of pmenopause, you're going to probably be able to handle it better. It's almost like it's like the load, right? It's like what's the um the load. And so if you're if you're kind of like your cup is already kind of full with these physiologic stressors, it's not it's it's going to be much harder when you add that that pmenopausal piece. Heard. Okay. Um so talk a little bit about weight loss and menopause. How come so many women hit you know 40 50 60 probably more 50 40s and like weight starts coming on it's so hard to lose weight is that menopause and then then if so how does menopause directly you know make it hard to lose weight? Yeah it's a big part of it. I mean it's the drop in estrogen um is a big part of it. Um I was reading an article about this yesterday or the day before and it was they were also saying that we we now know that like um even some of those hormones like gerolin and um leptin those kind of those hormones more on the gut level those are impacted by a drop in estrogen and women are often hungrier than they used to be and so that satiety level of how quickly you are full that shifts. So a woman might not even she may or may not realize that she's actually eating more. Um so you both have kind of a um a downregulation in metabolism. So oftentimes thyroid hypothyroidism kicks in. So your metabolism is lower, your estrogen is lower and you might be eating more. Um we talked a little bit about cortisol. you know, if cortisol is disregulated, there's emotional eating. So, there's all different things that can kind of play into it. Um, but it's super common for because of all those things for women to gain weight often in the midsection. Gotcha. How often are you like putting women on estrogen and then all of a sudden they lose weight, they start losing weight again for like the first time? Yeah, it definitely it's it commonly, you know, it's not um if a woman needs to lose 100 pounds, she's going to need some things in addition to estrogen replacement. Um but it definitely can be an important part of the plan. Gotcha. Okay. Um let's see here. going over. Those were all my questions. Um any what else would be important for you know a woman to know about going through menopause and making sure that they have the best health possible. Um, I think just to kind of reiterate that even though it's like a normal stage of life, pmenopause, pmenopause is actually often harder for a woman than menopause. um because there's these fluctuations, it's unpredictable. Um and for a lot of women after menopause actually hits and you kind of fall off the cliff um kind of emotionally and sometimes it's actually easier than than the the volatility of pmenopause. Um, but I guess I would say that even though it's there's not it's not a medical pathology that um it can be life-changing to be on hormone replacement therapy and it doesn't mean that it's a it's not a failure. like you can still do all the work, like you can still work on your nutrition and your exercise and do all the things that you've been doing and it's like can sometimes be just a really great support and a tool. Um, and what I like to tell women is you're doing it for your current self, your current body, but as I listed earlier, there's these really incredible statistics about um what it prevents. And so there's there's I say you're gifting your 63 year old self, your 73y old self, your 83 year old self. If you the earlier you are like late 40s, early 50s, if you give yourself this kind of gift, you're going to reap the benefits in, you know, you're going to have a lower risk of um fracturing your bones because your bone mineral density is going to be higher. you if you go on vaginal estrogen, you're going to lower your risk of UTI, which basically puts people in the emergency room all every day. Um uh you're going to decrease your risk of cardiovascular disease, like all these things, even reduce your risk of dementia. And so I think it's a conversation and it's information I like any woman between the ages of 35 and honestly 75 to have. Doesn't mean every woman should be on hormone replacement therapy, but every woman should have the education around it and have the information and make the informed decision herself. It should be on the menu. Gotcha. Let's talk about some of the the older ladies out there, you know, um way after menopause. What um what are the best options for them? Are you how often are you putting um so traditional? Yeah. Um the up until recently and still kind of the old school of thought was if a woman was 10 years postmenopausal and or over 65 that because of this idea that we were increasing the risk of um blood clots that we were therefore increasing her risk of having a cardiovascular event like a stroke um or a heart attack that you would not put a woman on hormone replacement therapy. You would not put her on estrogen um because of that. And that has recently been refuted. Um again using topical what we call transdermal estrogen. Um the the risks are so low of um a blood clot and therefore increasing cardiovascular disease or an event that um often times the benefits out ray outweigh the risks. The benefits of you can still improve bone mineral density, you can still you know decrease risk of dementia. um even if a woman is in her 60s and and 70s. And just to be a broken record, vaginal estradile is safe for everybody. And often it's that population that is dealing with vaginal dryness um uh pain pain with intercourse um and really kind of maintaining the health of that vaginal tissue. um is pretty significant and again safe for every anybody any female. Gotcha. Um so what are the options out there going through you know you're noticing some hormonal changes you're going to your primary they're referring you out they're not helping. What is a patient's options? Um well ideally you come to a practice like this where this is what we do you know day in and day out and we have you know you kind of we have the right testing we have um options and um can kind of provide education. Um there's there is you know you have to be a little careful going online but there you know there are people kind of providing good information around women's health around menopause medicine um and doing kind of your own research. Um but ideally you do find a provider that can work with you and your specific history, your goals. Um, I mean that's again I like to use the term personalized medicine, customized medicine because um what might work be working for your girlfriend or your sister might not work for you. Um, and that's that's again why we do testing and why we spend so much time with our patients so that we can come up with an individualized plan. Gotcha. Cool. Uh, last thing is I always like to ask this question. How many women with I mean you probably see multiple women every day dealing with hormonal imbalances, right? Yeah. Yeah. Okay. Can you give uh one of your favorite patient case studies of a lady who came in dealing with hormonal changes and u maybe had been dealing with them with for a while and then with you know kind of like what type of plan got her back to feeling like herself again? Um yeah. So um let's see. I saw a woman yesterday um who pretty common scenario. I think this was the um [sighs] this was the third visit that I'd had with her. Um and I usually meet with people every 3 months. So when she first came um she had been kind of trying again had done her own research, felt like she would she had some hormonal imbalances, was kind of looking for someone to help her with um potential hormone replacement therapy, had tried primary care. um had again been dismissed, told um that she just needed to lose some weight and and she would be, you know, that was kind of all she was told. Um didn't have much luck either with her gynecologist, did some research, found us, and um still cycling. So 45 year old woman still cycling um and had actually had actually missed a period for like nine months um but then had had one. So definitely permenopausal, right? You have to be tw have technically 12 months without a period to be menopausal. Um and I could also tell from her initial blood work that she was still her ovaries were still producing some estrogen and progesterone. Mhm. [clears throat] So, um, again, this was six months ago. We started her on, um, oral progesterone, a estrogen cream that's called Bias. It's a combination of estradiol and estriol, two two different type of two different forms of estrogen. Um, so it's a cream she applies every day. And um when I saw her 3 months ago, she had had some improvement. So she was feeling um some improvement with sleep. Wasn't 100% um and had um was having was had not noticed a change in her hot flashes or night sweats. So three months ago, I increased the dose of the pro oral progesterone and I increased the do. We always we tend to like to start low and slow, right? Like lowest amount possible um of hormone and see how somebody responds. Everybody has different levels of sensitivity. I bumped up I basically bumped up the dose of both and um so increased uh with the creams it's really easy um with comp because we use compoundingies to to be really specific and the concentration of estrogens um so I increased those three months ago increased the oral progesterone saw her yesterday um and her sleep she hasn't slept as well in years she's sleeping quite well sleeping through that 2 to 4:00 a.m. time, which is oftentimes when women in pmenopause are going to be waking up. Um, and her um, hot flashes are few and far between. She's still having them, but again, it was like when she came it was probably multiple times a day, and now it's maybe once a week she'll have a hot flash. Um, and her, you know, we're doing blood work throughout and everything looks totally normal on blood work. Um, so it's really safe. It's not that complicated. And this woman just feels so much better. It's great, man. What a good story. I mean, it's really scary actually to think about like what if she hadn't done anything and she just kind of was, you know, said, "All right, this is how it is." Um, when the reality is she actually could feel a lot better again with some more functional help. Um, yeah. So, it's pretty exciting. We get to do that every single day. Yeah. So, um, yeah, if you're watching this or if you're watching recording of this and you're interested in becoming a patient, you can go to medmatrixusa.com. Uh, you can click get started and book a time with a patient coordinator and we would absolutely love to talk to you and see if we can help you reach your health goals. Um, but with that, that's time for today's episode. Dr. Rose, thank you so much for joining and educating us all. Always so much fun. And uh yeah, we'll see you in the next one. Thanks. Oh, real quick before everyone who's live goes, just so you know, it is next Thursday at um 4:30. We're going live with Dr. Anod and Dr. Rose, and we're going to be talking about functional medicine. We're going to be talking about long haul COVID. Um so, two really exciting hot topics, as well as doing some Q&A. um hoping to do some more kind of panels with Dr. Oz and Dr. Nod as the future goes on. Uh things like POTS and all these other various issues that patients come to us with. Um really exciting one. So I would actually put this on your calendar. We're going to be sending out some emails. Um and yeah, Dr. Rose, anything to add before we hop off? I don't think so. I thought it was this Thursday. Is it this Thursday or next Thursday? This Thursday. Yep. 4:30. It's this Thursday. Okay. Okay, great. Cool. No, great. Thank you. Awesome. All right, everyone. Thank you so much.