115: The Musculoskeletal Syndrome of Menopause with Dr Vonda Wright

This week Florida orthopedic sports medicine surgeon Dr Vonda Wright published a review paper Climacteric, the journal of the International Menopause Society, introducing Musculoskeletal Syndrome of Menopause. The paper has been shared widely across social media, and this interview with Dr Wright is an edited version from last year diving into Dr Wright’s efforts to create awareness of this constellation of muscle and joint problems experienced during perimenopause. 

This is an issue close to Dr Wright’s heart: it was the first thing she went though in perimenopause. 

Listen in as she explains why MSM is her mission, just what happens to our bones and muscles as we get older, and delves into the need for proper diagnosis and preventive measures such as exercise and diet, and the importance of estrogen in maintaining bone health. 

1:33 Why she’s back

2:45 Musculoskeletal Syndrome of Menopause

3:46 Personal experiences and reflections

4:09 Understanding bone health

12:22 The importance of mobility

22:15 Diet and supplements for bone health

26:58 Hormone therapy and long-term health

31:05 Her words of hope 

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Transcript

0:00

It was perimenopause pain because my primary symptom, my first symptom, was I could no longer get out of bed every morning. And I, at 40, was in the best shape of my life. And then at 47, I thought I was going to die. Anyone who listens to the hot flashing podcast will know I've had a hard time finding help with my perimenopause and menopause symptoms, whether it was trouble sleeping or extreme anxiety or vagina stuff. I've encountered roadblock after roadblock in doctors who didn't know anything about taking care of women like me. It made everything harder than it had to be. That's why I'm so happy that there are companies like MidiHealth stepping into the gap and sponsoring podcasts like this one. Their supportive, comprehensive, and holistic approach to the menopause transition will provide you with what we all need most, a personalized care plan. Their virtual care clinic is easy to use and covered by most insurance plans. You can chat with your specialists during an appointment or message 24 seven. You don't have to deal with this alone. Any longer book your visit today at join midi. com. That's J O I N M I D I. com. This week I wanted to go back to an interview I did with Dr. Vonda Wright, an orthopedic surgeon in the US who I interviewed last year. And during the interview, which was one of the most popular episodes I've had, she talked all about how she wanted to create nomenclature for the constellation of muscle and joint problems that happened during perimenopause and call it muscular skeletal syndrome. of menopause, and I thought this was fascinating because I had this, and what I think is so interesting about this space is Dr. VonderRheid had it too. She's dedicated so much time. I mean, it's been 10 years since she had this and she could barely get out of bed, yet she's devoted to creating change. And I feel the same way, which is why I do hot flash ink. So I wanted to bring this to you this week because I love a person who does what they say they're going to do. Her study was published in Climacteric, the journal of the International Menopause Society. It's a review article, and it's published in the July 2024 issue of Climacteric, the journal of the International Menopause Society, and it was widely shared this week. Uh, Dr. Wright has a lot of colleagues who she works with on menopause awareness, so you probably have been hearing a lot about the paper called the Musculoskeletal Syndrome of Menopause, there's so many things that can come out of this. The paper itself talks about the need to have something to name it, so it increases awareness for the first line doctors that women see and for the women who go so that they're not just sloughed off. So that they are told, you know, this happens, this is something you can have. She compares, it to genitory syndrome of menopause, which, is a constellation of symptoms that can happen to the vaginal vulvic area. That only was approved by, certain guiding bodies in 2014. And once that happens, then there's like a focus and people can do more research. And so it's almost like you, you build it and they will come. So I wanted to bring this interview again this week just because this topic is hot right now. It's something that impacted me. It impacted her. It's impacted a lot of people. I just love you to listen to her talk about. pain in bones and muscles, what we can do about it. The fears of sarcopenia and osteoporosis and bone reabsorption and things that you hear tossed around all the time, but you don't really understand. She just wants to keep you healthy and out of a nursing home and out of being bedridden, due to frail bones because once you have that fall and you break a bone when you're older, a lot of people are dealing with this right now with their aging parents. It's. No good. No bueno from there on. The outcomes are not great. So I hope you enjoy this episode that I am posting again for you. And I will have another bone expert on the podcast, very short order, and I'm going to write in depth about this on my sub stack. And I'm going to publish it on Tuesday. So you can go over to my sub stack. That's hotflashinc. substack. com and sign up there. And I'm taking a deep dive into her report because I think this is really groundbreaking. Enjoy. And when you go and seek care from my amazing colleagues, 97 percent of whom are men. They may not recognize it. And if they do do tests for you, 41 percent of the time they will come back as normal. And you walk away thinking, I am falling apart, but he said nothing's wrong with me. Am I going crazy? Which just adds to the anxiety, Anne Marie. 80 percent of every woman that I know or don't know is suffering from this. It bears talking about.

Ann Marie: 5:37

Well, when I saw you for when I first came across you, whenever that was, I was like, Oh my gosh, I wish I saw her before because I'm 53 and I just went through menopause and I had a whole bunch of health issues that I've healed up.

5:50

But in my forties, I was in tremendous pain. And my friend Ferris would just. You were always saying to me, you were always asking me, are you in pain? Are you in pain? I said, it hurts to roll over in bed. And I was still working out and I was still walking and I ate healthy, but I was just riddled by this intense body pain I understand being devastated by it because you're always thinking. Often in perimenopause, if you're having a hard time, you're thinking, am I dying? Am I dying? Am I dying? Am I dying? Like, this is crazy. Yeah. And my mom had fibromyalgia, and I often wonder, like, did she have fibromyalgia?

Dr Vonda Wright: 6:21

Oh, Anne Marie, there are actual studies, because Mary Claire Haver and I were talking about this when we were together recently, and I said, Mary Claire.

6:30

Do you think fibromyalgia may be misdiagnosed pain of perimenopause due to musculoskeletal and we're like being so she looked it up and there are actual papers from decades ago asking that question. And postulating that for some women, it's not fibro, fibromyalgia at all, because that is the diagnosis of exclusion. Don't know what it is. Let's call it something. Let's give women pain medicine. Let's put them on antidepressants. When, as we know more, don't get me started on the need for research funding. The problem is funding. So to answer your question, your mother went through terrible pain. Maybe it was like you. It was perimenopause pain because my primary symptom, my first symptom, and then came all the things like heart palpitations. I had a cardiac exam. All the things was I could no longer get out of bed every morning. And I, at 40, was in the best shape of my life. And then at 47, I thought I was going to die.

Ann Marie: 7:35

Wow, you have just blown my mind, but because that's just something I've quietly thought to myself for like, ever since I had that, ever since I figured out what was going on, and she had it, and we're not going to talk about my mom all day, but she died at 53, but.

7:48

She had a hysterectomy and I'm certain didn't go on any hormone therapy at all. So it's not out of the realm of possibility at all that that happened. And this is so crazy in this conversation because to be the first people asking questions is weird,

Dr Vonda Wright: 8:04

but time let's just ask, you know what? The beautiful thing about my age,

8:09

I don't care. I talk about everything. I name body parts. I have accomplished what I need to in my career. So there's none of that like, oh, don't want to offend the mainstay, right? Let's just talk about it. I'm so glad you're on the boat with me.

Ann Marie: 8:24

Okay, so you, you have actually, just like we have genitourary syndrome of menopause, and that affects about 80 percent of women, you're developing your own thesis about muscular skeletal syndrome of menopause.

8:40

And you're doing research on that because you actually feel that this constellation of symptoms deserves to be called a syndrome. Can you explain how and where and when you came to that?

Dr Vonda Wright: 8:51

Well, I came to it as, uh, I experienced it myself and I didn't know what it was. And then I figured it out.

8:58

And, you know, we can talk about how I feel like I've kind of, and I don't say this glibly, but I needed to label this too. I kind of mastered this phase because I've done the hard work, right? I've researched it. I became a student of this and I lived through it. So through that process, you're a journalist and curious. I'm a surgeon and curious. I read enough papers where, and I'm going to be honest with you, not many of them are from the United States. Asia is studying this, India is studying this. They're very small studies. There are only two produced by orthopedic surgeons in this country. Uh, one on frozen shoulder, um, and one on, uh, treatment of frozen shoulder, right? So we have a lot to do, but as I was reading and putting the body of knowledge together, there are six or seven things, and I'll just. Do it on my hands, right? Arthralgia, which is total body pain, usually associated with the joints. There is, inflammation, estrogen. It serves an anti inflammatory role, not only the shoulder, but of the hips of the knees. So body wide inflammation, there is loss of lean muscle mass. We can talk all day about loss of lean muscle mass and sarcopenia, loss of bone density, another subject, whole conferences on that, right? Here's the deal. Listen to this. Uh, estrogen, uh, has a lot of receptors. The main ones are alpha and beta. Alpha and beta receptors are ubiquitous in every tissue of the body. Everything has it. So why wouldn't when estrogen uncouples or there's no more estrogen to fill the baskets, why wouldn't the downstream tissues, muscle, tendon, cartilage, tendon, cartilage? Uh, fat bone no longer have the stimuli to do what keeps them healthy, right? So it's not a mystery to me now that I've spent a little time with it. But here's the thing I wanted to say about cartilage before 50. Men have more osteoarthritis than women after 50 women have a precipitous increase in the severity of arthritis. Why is that? Well, for the little research that done and we're that's part of this paper that we've just submitted the arthritis of menopause it's described because people were postulating well estrogens not there what's happening to the cartilage matrix. is less hardy, is less stable, so you can't protect the cartilage anymore, which protects the bones, loss of cartilage is arthritis, so when I talk about the musculoskeletal syndrome of menopause, I say things like, it is silent, you don't know your bones are dying away, you don't know your muscles going away, you don't know your cartilage is going away, silent, devastating, and listen, if we don't get in front of it, it's permanent, silent. Silent. Hot flashes can go away. Night sweats can go away. We will figure out a way to sleep. Anxiety decreases. Thank God we could talk about my rage when I was going through perimenopause. But

Dr Vonda Wright: 12:10

if we do not get in front of our cartilage, our bone and our muscle, we will end up frail. Disabled old women and we cannot have that because we didn't pay attention.

Ann Marie: 12:22

Mobility is a word that gets tossed around, but what does mobility mean to you when you're speaking about it

Dr Vonda Wright: 12:27

Yeah, you know what? I'm glad you asked that question because when I got out of my residency in 2004, I said, exercise, we're going to exercise and I'm not really kidding you. People's faces glossed over. They're like all excited and I say the word exercise. They're like, you know, they're looking at the ceiling.

12:44

So I stopped using it because of the very word turns people off. So I adopted the word mobility because yeah. Every movement matters, whether it's fidgeting at the office, whether it's standing desk, whether it's going back and forth to the copier 97 times, whether it's, uh, I encourage a lot of people to, to do baseline aerobics as zone to base training with sprints on top. That's mobility. I count the lifting heavy that I encourage as mobility. It's anytime we move our bodies, because listen, we're designed for mobility. If I get on another tangent, we're designed, the biggest muscles, I'm going to tell you as an orthopedic surgeon, the biggest muscles in our bodies are below our belly buttons. If that, if we, in nature, form follows function. If we were not designed to use mobility as our primary tool of health, we would be formed, nature's not stupid, we would be formed like Jabba the Hutt, with a big sessile base. Right? We're not. It's all muscle. Oh, so anyway,

Ann Marie: 13:50

Walk me through. What we need to know at that outset, lean muscle mass, bone mineral density through to osteopenia and osteoporosis,

Dr Vonda Wright: 13:59

so I brought this prop just so you, I sometimes ask women to stand in front of the mirror and notice their bones because most people don't even think about their bones until you break one.

14:10

You just know your arm moves, right? So this is a, this is a femur. When you break your hip, that's where you break it right here, right? So if you've never seen a femur, this is a saw bone of a femur. Cool. Really cool. It sits in the cup. So I encourage you if you've never taken the time to notice. Your bones. Just stand there and look at the amazing architecture of everything you have. We are born with 300 soft bones that fuse into about 206 hard bones as an adult. Through a process of building through a cell called an osteoblast. And resorbing through a cell called an osteoclast. And it's the balance of those two processes. There's a cell in the middle. Blast is the builder. Uh, Osteocyte is the healthy adult cell, keeping your bones good. And Clast is the breaker downer. And then it's a cycle of build the breaker downer. Building and resorbing. Building and resorbing. We are best at building until we're in our mid 20s, early 30s at the latest. So for our younger sisters or our children, I have children this age, you got to build some bone people because it's, it's all you're ever going to get right. So get out there. Eat healthy bash. I call it bashing your bones. It's not a good now. It's not a good thought most of the time, but it's just let's impact and put some mineral down. Okay, because what happens as time progresses, and especially in perimenopause when our estrogen begins to fluctuate wildly. We still build bone. This is, this is the caveat. People don't know. We build bone. We resort bone, but there becomes a mismatch. Okay. We resorb much faster than we build and so we start demineralizing our bones. So what happens? a solid hard bone that's harder than wood. I can't drill through it with my, without a drill, smoking becomes soft like butter because you have the mesh structure, but you don't have the minerals that, that keep it strong. Estrogen has a huge role in the regulation of these two processes. And when we lose our estrogen, Resorption becomes higher and there's a gap. So how do we know and what do we do about it? Well, sometimes the first time we're ever aware of our bones is when we break one. And starting about age 40, the incidence of fracture increases. We break our wrists. We, uh, we fall down and break our kneecaps. We'll break our ankle, but. When you fall and break your hip, which happens to a huge percentage of men and women by the time we're 70, here's this shattering data. And sometimes we can't think about what it's like to be 70 when we're in our 50s, certainly not when our 30s, but here's the thing. We all have a grandmother or you've all heard of the lady down the street who was just standing in her kitchen and she toppled over. And she broke her hip. When you break your hip, 50 percent of us will not return to pre fall function. What does that mean? Well, you can't stay in the house where you've raised your children. You can't just get in your car and be independent anymore. 50%, it's not small. And one third of us? will die. So when we say that bones are silenced until they're screaming at you and we need to pay attention, I'm not really kidding. And I'm not trying to be dramatic. It's the truth that the hard data is the hard data. So what do we do about it? Well, the first minute we're aware that we have bones, we need to be Interested in them. And that even happens for our daughters. Like I was an athlete growing up a dancer and I wouldn't have periods for six months, right? So we're not laying down enough bone at that point. I have a 28 year old. I'm currently taking care of. She broke her hip. She broke this bone, right? So it doesn't matter your age. It's worse when you get older and estrogen walks out, but it can happen at every age. So what do we do about it? You know that your mother is shrinking or shrank, right? She used to be your, my mother used to be my height. Now she's about down to here. Well, that happens because the vertebrae collapse due to osteoporosis. If your mother is shrinking, if you're female, if you smoked, if you have been little your whole life, if you did not have regular periods. because you were so thin or didn't have enough body fat. Those are all risk factors for osteopenia and osteoporosis. If that is you, please get a DEXA scan. It's an imperfect test, but it gives you an idea. So what does the DEXA scan tell you? It doesn't tell you the elasticity, you can't tell bone elasticity without putting a bone on a, robot and breaking it. So that's not feasible. So all we're left with, It's to get a density scan. So you go lay there. It's like 10 minutes. I have them all the time. Uh, an x ray is taken and it tells you the density of your bone compared to a 30 year old woman. So that's, it's like a bell curve, like we were graded on, right? So that the top is zero. Anything Positive number is amazing, right? You go, you've got good bone density between zero and minus one is okay, but at minus one, you become osteopenic, meaning your bone density is lighter than it should be, right? It's, it's less than it should be. And let's pay attention when you get a DEXA scan, and you are two and a half standard deviations from, from a 30 year old minus 2. 5. Okay. And we're looking at T scores. You're frankly osteoporotic. It can happen at any age. It happened to my 28 year old. It happened to a 57 year old who was working out and she just, her bones couldn't take the load. So if you have those risk factors. Ask for a DEXA scan. And if your doctor will not give you one, at least in the United States, you can really buy one for, I found it around my neighborhood, for 99 to 250. So, so it's not overwhelming. It's like one month's of Starbucks coffee, right? Just skip the coffee, go get a DEXA scan. So that we know how to diagnose our bones. But what do we do about trying to maintain our bones? So get a DEXA because when I tell people to go lift heavy, It's only what your bones can bear. And if you're osteopenic or osteoporotic, we need to treat you more gingerly. Impact exercise. Now that does not mean you have to go run a marathon. Listen, there is data that shows that jumping up and down 20 times is enough, right? You can do it in place just, and I've got videos of I'm jumping up and down. It's silly behind your desk, jump up and down. Number one. Number two, if that hurts, NASA has amazing data that when astronauts come back from space, they put them on trampolines and use a rebounding technique to stimulate bone and muscle. Who would have thought? I was really skeptical of that. So, impact exercise, rebounding. If you need to do this stuff in the pool because you really do hurt that bad, that's better than nothing, right? So that's all number one. Number two is let's build some lean muscle mass. muscle pulls on the bone and causes bone to lay down mineral, right? So it's, it's multifaceted. It's an electrical, it's via our electrical system. It's kind of, our bodies are so cool. Number three, let's focus on what we eat. Women in general. And I know you're a journalist. You would never write this, but There are many magazines that tell women that they have to survive on less than a thousand calories a day, you know, let's, women have gotten that somewhere, I don't know, but.

Ann Marie: 22:33

Well, our age, we grew up reading those kinds of articles, right? That old habits really die hard on that low calorie stuff, and the cardio Stairmaster for 90 minutes, you know, yeah, we had, it's nine, like, our Gen X. We had a hard time letting that go. I did anyway.

Dr Vonda Wright: 22:52

Yeah, it's what I did. I mean, I did. I did high cardio until like two years ago.

22:57

So let's eat something ladies. If you, you know, if you're X, if you're moving enough, your body will adjust to the more calories, but what are we going to eat? We're going to eat lots of green leafy. Anything green nature in general, besides a Kiwi does not make for fluorescent food. So whole green leafy. We need protein. I get mine from a variety of sources, whether it's beans or lean. Meat. If you're not a meat person, just get it from somewhere, right? We need enough protein. Um, basically, and then what's up and what minerals? Well, we need a really healthy diet full of minerals. If we're talking to one specifically for bone, and this is a little controversial. Um, calcium is a little controversial, although most of us can you talk about calcium because I'm very, I know, and I'm, you know, and the research is this way in that way, right? People, the data cannot agree whether we should be taking 800, 1800 milligrams of calcium or not. So unless, so my advice to people, um, is unless you have a kidney problem or are prone to calcium kidney stones, there are data that say, uh, once you're. menopausal 1800 milligrams of calcium. Vitamin D is a must. We can, there is no controversy about vitamin D. Um, so a good way to know how much to take is to have your vitamin D level measured. Your, your doctor can do that for us because we wear so much sunscreen these days. And I even live in Florida, which I don't really go out in the sun unless. You know, so hot here. I know you live in a hot place, but we don't get enough vitamin D. So have it measured and supplement.

Ann Marie: 24:48

Can I just ask you about vitamin D and we'll continue. You hear a lot about you need to take vitamin D with fat or with K2. Do you know a little bit about that?

24:58

Is there a proper way to take it?

Dr Vonda Wright: 25:00

Yeah, it's usually recommended you take vitamin D with. A meal, not just a Novo, uh, with it helps absorption, uh, the There's several kinds of K, K2 versus K1, um, you know, and I'm not an expert on this. I also believe it helps absorption. So often D is paired with K2.

25:24

However, if we're, it's more important to me that you have vitamin D. And many of us, if our vitamin D is low, we need as much as, 5, 000 international units to come back up. Mine was really low. Like I've never seen the sun in my life. So I take 10, 000 every day, but it really get it get it measured. There's almost no system that doesn't need vitamin D and and bones are certainly a benefactor of that. But then things like magnesium. I recommend my patients take magnesium for a lot of reasons. Just Glycinate, threonine, right? Not citrate. Magnesium citrate is how we do enemas in the hospital. So don't do that one because there's lots of forms of magnesium. Um, but then other remote supplements, which I don't take like boron and zinc, they're all part of the mineralization. I'd rather, before you get marred down at how many pills you have to take a day, Are you impacting? Are you lifting? Are you eating green leafy and enough protein?

Ann Marie: 26:29

One thing I get confused about all the time, because I live in Abu Dhabi and I can't, haven't been able to get hormone therapy. I asked about it at 47.

26:37

I had a French doctor. She was like, no, it's a long saga. My doctor now wouldn't give it to me. I've now gone through menopause. I'm going to go back and ask her, but there's also a supply problem. So I, and I actually feel pretty good. You know what I mean? Like that pain is gone. I've, I've fixed a lot of things. I feel pretty good. And I'm always asking people, do I need to go on hormone therapy in your opinion? And do women like me, uh, to protect our bones? We have recommendations from the North American menopause society that this is a good idea. And I'm just wondering what. You have to say about that. If you're doing everything else right, What is the added, you know, what's it add on top?

Dr Vonda Wright: 27:17

What's the icing effect? Okay, so, uh, It is hard for women to get estrogen. Your experience? happens not only where you live, but in this country. Women write me all the time. No one will give it to me. They say it's poison, right?

27:31

All the things. Well, I don't know if they deliver outside the United States and Canada, but there are many platforms right now where you can have a telemedicine visit with a real menopause doctor and get, uh, delivered to you. But why would I Take estrogen now, even if I don't have all those symptoms anymore. Here's why. Remember those estrogen receptors that are everywhere? We know that Taking hormone therapy can get rid of the symptoms that you're talking about. So when we think about if our symptoms are better, which, you know, that's a really hopeful thing for many of us when we get, I am, I am mid fifties now and it's gotten better too. Um, what would be reasons to consider Mm hmm. Still seeking hormone therapy. Well, we know that that estrogen is critical for the bones and even the menopause society talks about that as a recommendation and for prevention of osteoporosis. It's FDA approved here. So number two, we know there is a connection between preventing heart disease and estrogen and dementia and estrogen and the permanent treatment. Sequela of not having it is why I would consider it. In fact, I think the true icing on the cake is that it gets rid of the perimenopausal symptoms. I think the true cake is the long term effects on aging well that supplementing with estrogen can give a woman. Because when I talk to groups of women, I, because my research is all in aging and longevity, I ask them to build a strategic plan on how they want to live and be like, just like a business, like you would run your business. What do you want to be in five years? What do I want to be at 97 I'm about to turn 57 at 97 which is how long minimum I want to live because I'm going to bug these children that I have my whole their whole lives. You know, what do I want to be doing well if I use my own parents as an example who are 84. My dad still walks six miles most days. My mom is frail but she takes her two pound weight and she walks around the pool every day. I, I want to be able to go out to Bible study like they do and go to their friend groups and that takes preparation and strategic planning. So to get back to your question, why should people consider estrogen even if their symptoms are gone? It's, it may not be for today. But it's how do you want to live in the future? And frailty and weakness is the quickest way to disability and aging. So you just think it is like, you can do everything right, but you still need it. That is my decision, right? And you know what, even though I'm a surgeon and a doctor and I direct care, I think the stance that most of us take is. The doctors who talk a lot about this, a lot is it is every woman's body. It is every woman's decision, educate yourself, be surrounded by science, do not be surrounded by fear. It is okay to decide not to do it, but not due to some knee jerk reaction and fear mongering that, Oh my God, Oh my God, it's going to give you cancer because the data does not bear that.

Ann Marie: 31:05

So what's your words of, hope and inspiration for women going through perimenopause who are like, I'm falling apart.

Dr Vonda Wright: 31:12

We're so nice to have me. This is based on my 20 years of research. Living through it and knowing lots of women who have arrived on the other side of this transition, happy, vital, active, joyful, that there is never an age or skill level when your body will not respond to what you ask it to do.

31:32

You're asking it to move. You're asking it to do resistance training. You're asking it to eat green leafy and lean protein. You may not feel like it, but there's never an age or skill level when you can not make profound changes. So be hopeful. Number one, number two, it's hard, but I want you to know, and until we get over this. This little hump, nothing will change because I've been in practice more than 20 years, and I've heard every excuse. You can't out excuse me, but here is what I know. I know that you are worth. The daily investment in your health. And when you decide that you are worth the daily investment in your health, you can change anything. Hot Flash Inc. was created and is hosted by Anne Marie McQueen, produced and edited by Sonya Mack. The information contained in this podcast is intended for informational purposes only and is not intended for the purpose of diagnosing, treating, curing, or preventing any disease. Before using any products referenced on the podcast, consult with your health care provider, read all labels, and heed all directions and cautions that accompany the products. Information podcast should not be used in place of a consultation or advice from a health care provider. If you suspect you have a medical problem, i. e. menopause or anything else, or any healthcare questions, please promptly see your healthcare provider. This podcast, including Anne Marie McQueen and any producers or editors, disclaim any responsibility from any possible adverse effects from the use of any information contained herein. Opinions of guests on this podcast are their own and the podcast does not endorse or accept responsibility for statements made by guests. This podcast does not make any representations or warranties about a guest's qualifications or credibility. This podcast may contain paid endorsements and advertisements for products or services. Individuals on this podcast may have direct or indirect financial interest in products or services referred to herein. This podcast is owned by Hot Flash, Inc. Media.