120: Dr Salome Masghati knows how complicated perimenopause is

Today Hotflash inc founder Ann Marie McQueen is speaking with a board-certified gynecologist whose surgical career was focused on fibroids and endometriosis before she discovered her love for functional medicine and holistic therapy and discovered what it could do for women struggling with menopause, hormones and wellness. Dr Masghati, who offers virtual consults worldwide in four languages, talks about treating patients from Lebanon to the Philippines, about the balance of estrogen and progesterone, the role of testosterone, the relevance of detoxification, ADHD in midlife, why some people want compounded hormones and why no matter what, we all need individualized treatments. The conversation also delves into the misconceptions about hormone therapies, such as pellets, and how to support women as they undergo psychological and physical changes. 

01:59 Dr Masghati’s journey to holistic medicine

03:35 Understanding hormonal imbalances (and estrogen dominance, even if you call it something else)

03:56 Global perspectives on women's health

06:02 Environmental factors affecting hormones

10:27 The importance of progesterone

17:58 Challenges in hormone treatment

20:02 The role of functional medicine

29:03 Liver health and hormone balance

34:11 Thyroid and insulin resistance

34:44 Liver detox and macronutrients

35:13 Hormones and sleep

36:12 Diet and exercise tips

38:28 ADHD and hormonal changes

41:19 Managing ADHD symptoms in perimenopause

47:29 Hormone therapy options

52:07 Risks and side effects of hormone therapy

57:55 Hormones and disease prevention

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Transcript

Salome: 0:00

if you're one of those people who does, you know, who just doesn't want hormones, don't let anybody guilt trip you either into not doing hormones. That's my mantra. If you want hormones, Super. I'll help you. I'll take away the fear. You don't want hormones? Super. I'll help you and tell you what you can do to be healthy.

0:17

I'm Anne Marie McQueen, journalist and proud 50 ish woman, and we are here looking for the true truth in perimenopause, menopause, midlife, and beyond. Opening our minds to other possibilities is not always easy. Hot flash ink. You're all woman to me. All right, Anne Marie. 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.

Ann Marie: 1:35

I'm so excited, I'm here with Dr. Salome Mizgati. And I thought I was going to call you Salome. So I'm really excited that you mentioned that at the last minute. I had to say it. You're one of the cool people that I've come across on social media. We've talked a little bit and you have a really neat take on, on the whole hormonal thing, but let's talk about how you got into it because you're an OBGYN and you focused on fibroids. and endometriosis and surgery and then shifted gears at the beginning of COVID. So how did that sort of happen?

Salome: 2:07

Yeah, I wanted to kind of go more towards, you know, the holistic and functional medicine aspect of medicine, because during COVID, I realized we need to do more to prevent disease, not just, you know, react to it. And I've always loved hormones. Even during my OBGYN residency was one of my favorite topics. When I was 17 in high school in Austria, you have to actually write a dissertation before you graduate high school. And my dissertation was on hormones. I mean, which 17 year old loves hormones and menopause? It was on menopause. And it was interesting that I love that back then already. So I think, um, that I can help a lot of women, in a more diverse way when I focus on their wellness on their, you know, hormones. And what I love about that is that I can also work really internationally with people versus when I do my surgeries, I'm bound to my location where I am and where I live and where I work. But with the hormones, I can really just. Um, I love it. I'm keep learning about it and it's all coming together more and more. Like for example, I'm now also including the thyroid and how important the thyroid is. A lot of people just focus on, you know, the typical hormones, estrogen, progesterone, testosterone. But I'm noticing that you've got to know. everything if you want to help women, during their transition. And so, yeah, I'm enjoying it very much.

Ann Marie: 3:35

That's one of the things I noticed about you, because one of my beefs is that it's still, it's 2024 and we're just estrogen, estrogen, estrogen. It reminds me of the Brady Bunch when they were always like, Marsha, Marsha, Marsha. It's like, we have all these different hormones. And what I like about you too is you're functional, but you talk about hormone therapy, but just in such a smart way. So let's just, you talk to people from all around the world. What are you hearing from women?

Salome: 4:02

I had this patient from Lebanon the other day and I loved hearing about her experiences, but I was very interested because I still got to diagnose her with estrogen dominance. And I was like, wow, I thought he would. I know. I thought I was like, I would just only find that in my American patients, but it's just so funny how Problems can be across the board, very similar for so many women. Uh, PCOS, for example, find it a lot in my Middle Eastern patients or Hispanic patients. So it's kind of like, you know, women across, you know, we're all from different places, have different environments, and it really matters, you know, how much sun we get, or, you know, what is our air quality like, what's the tap water quality, or what's the meat fed with, like, is it hormone pump? It does matter our environment and where we grew up and what our culture is like, what kind of foods we eat. It matters. Problems can be very similar in a way. And, and it is really great to have someone who has worked with women from different cultures, because she understands, like the other day I had someone who was a Filipino and I knew without her telling me that she was high in carbs in her diet. I said, I know Filipino food work with so many, I have so many Filipino friends went on a mission trip in the Philippines. Like, I know you guys, it's all about rice. It's all about this and that. And I'm like. Let's check your fasting insulin and your insulin, you know, markers and your glucose markers. And sure enough, should insulin resistance. But what I'm saying is it's so helpful to have someone who understands different, you know, people, because it makes me understand people and their diseases better. So yeah, um, it is fascinating having international patients. I love it. And I want even more of it. I want more people to know that I can help them because I might not be able to prescribe you medication in your country, but I can I can help you interpret labs, I can help put things together. There's some functional medicine labs we can actually ship internationally. Uh, so there, there are options for me to help people. So it's, it's pretty, pretty fascinating. I love that.

Ann Marie: 6:02

Can you just talk a little bit about, the environmental mismatch that possibly could be making our, uh, our perimenopause more difficult.

Salome: 6:11

Absolutely. We have to ask ourselves, why is it that so many women feel like they're suffering more than ever from certain symptoms? And we do know that things have changed. We know that our food has changed. We know that we're more exposed to so called, you know, endocrine disruptors and xenoestrogens. I don't know if you're familiar with the studies, but you know, when, when they checked. a baby's umbilical cord. They found over 140 toxins. I mean, that's something that I believe maybe 150 years ago, we were not exposed before the Industrial Revolution and all this, um, changes in the way we process food and, um, and our soil and our water and our air. So the way that impacts us is on multiple levels. Um, we are exposed to more chlorine and fluoride and bromide, you know, and those are, um, those are substances that can completely disrupt our thyroid and our thyroid can very, very important for our perimenopausal transition too. Because what happens is over time, the dose makes the disease and the toxins. And so if you're exposed to something over time, as you're in your third, fourth, fifth decade of life, obviously you've accumulated more of that. And if you're, capacity to detox and get rid of things over time slows down or is not being dealt with then you obviously just things go overboard and now your cup is filling over and everything comes together and then you already have certain Biologic changes that just happen anyways like in, you know, our ovarian function changes throughout life. We have a certain age where we are over productive age and obviously there's a transition initially when we go into puberty and then when we go into menopause. So if you add to that all the environmental factors. It can become a lot for a woman and let's not forget that it's often in her third and fourth and fifth decade of life where she has the biggest stressors because now she has built, she has created a family, she has the responsibility for her kids, for her job, and then sometimes taking care of elderly parents because now as you're getting older, your parents are getting older, your kids are getting older, you have all these responsibilities and if you have a career in addition to that. everything comes together. I want to mention that because my approach is different than other people who just focus on hormones. I go as deep as a patient wants me to, and I actually love going deep and we cannot, we cannot, um, we cannot, uh, ignore that. We have more, EMF radiation exposed to that disrupts our sleep. We have more circadian rhythm disruption because of blue light exposure because of the, electronics that we're exposed to. We cannot ignore that our lifestyle of the way we eat or drink, because now we work late and we eat later and all of that plays an other role in our hormone health. So yes. There is absolutely environmental factors, just another example, had another patient, Italian, and without her telling me, I said, I know your dinner is not before 9pm. I know it. I've been to Italy. People don't even go out for dinner before 10pm, right? So I said, listen, if we want to work on your, um, Cortisol and your sleep, we gotta have, I understand the cultural context, but there's, there's certain things that are universally true for our health, and we gotta work on that. So yes, how we eat, what we eat, how we sleep, what air we breathe, how much sunlight we get, all those things matter for our hormone health. And so we do not exist in a vacuum. Our health is not a vacuum. Our body doesn't work without context to our environment. Even how much social contact we have with people, what our social life looks like, how much we laugh, how much joy we have, how much we enjoy our job. Those things are important. I cannot ignore those factors and talk to you about your perimenopause and menopause and ignore everything else. If I did that, and if I just gave you a prescription for hormones, then I'm still not a good doctor, you know? And so, um, that's what I strive to do.

Ann Marie: 10:17

Wow. That is a wow. Okay, uh, you mentioned in the Filipino woman. No, you mentioned someone who is an estrogen dominance, the lady from Lebanon, I think. Was that right? Yes. Yes. So that term is very loaded. Like there's people who hate it and say, you see this on social media all the time. Like estrogen, no estrogen dominance isn't a thing. But can you describe for us what you're talking about in perimenopause as I understand estrogen rises and falls and having, having it high can cause. Particularly, I want progesterone is low. So can you just address that?

Salome: 10:49

There's different ways there is, uh, to talk about this. I see dominance because it's easy to understand. I might not agree with the term, but I think it's very easy to understand. It's an imbalance between estrogen and progesterone. In the second half of our cycle, progesterone should actually be higher. quantity wise than estrogen, but it's not just about the absolute quantity. It's about a ratio that they should have with each other. So as long as that ratio is, is, is good, women feel less, um, of those toxic estrogen effects. Estrogen is extremely important for our health, but if we have too little or too much of it, we don't feel good. And how would it present itself when we have too much of it, or the, the ratio between progesterone and estrogen is off. Breast tenderness. moodiness, um, bloated water retention. So there's just all this, all the symptoms, so for me, the estrogen dominance, the most important thing is just to understand there's a ratio between estrogen progesterone. If that balance is off, which often happens when we stop ovulating regularly, we don't produce enough progesterone. Even if you ovulate, If our egg quality isn't good enough or if our eggs aren't healthy enough due to stress and lack of sleep or lack of protein or, over exercising or just overall aging too, I, I, I hate saying that because I don't want to make women feel bad about aging, but it is that there are changes to the quality of our eggs as we age, obviously is normal because there is more, um, DNA damage to the eggs and the mitochondria become weaker anyways, as we produce fewer, less progesterone over time, which often happens late thirties, forties. We feel more of that toxic estrogen effect, but that's not for everybody. Some people can undergo many perimenopause. and be actually estrogen deficient already. And those are the women who often, before they completely, go for menopause already have hot flashes, night swabs, vaginal dryness, pain with intercourse. There's other things that happen for them and the periods get lighter and lighter. They barely spot. So Everybody's different. But the woman who says, I have super tender breasts. My breasts are huge. My periods are super heavy. My flow is so painful. That's more the person who is having too much estrogen. And the person who says, my periods are lighter. They're barely coming, they're spotting, have vaginal dryness. That's more the woman who is estrogen deficient already. And that's before she even completely undergoes menopause. So that's what I understand under estrogen dominance. And the reason I brought this up is because you could have not even too much estrogen in your body that your eggs produce, but your ability to get rid of it. And recycle it is not good. Your liver doesn't work as well. Your gut is now impacted. And now you are having estrogen excess symptoms without having so much estrogen that your body is producing, if that makes sense. So yeah, intricacies to that.

Ann Marie: 14:01

So this excess estrogen and the recycling issue is also controversial, but it's, it does happen that you're not excreting your ex estrogen. And it's circulating in your body and estrogen makes things grow. So it might make good things grow, but it can also make bad things grow. Like, is that why we have fibroids is that, and what does that mean? If you're having, what does that mean for breast cancer? What does that mean for other forms of, of female? uh, anatomy cancer. What, what's going on there?

14:34

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Salome: 15:27

And I was going to say that too. I think there's, there is the total estrogen that's circulating in our body and there's the localized estrogen effect. And that has more to do with how much, um, we have certain enzyme activity in that tissue. So in breast tissue, for example, if we have increased aromatase, which is a protein, an enzyme is a protein that just converts things. It's like a, busy worker, and, it's a protein and it converts, you know, testosterone to estrogen, and you can have that localized effect. And you can make that or, um, upregulate that from fat tissue itself. So if someone has, is more prone to being overweight, or they have more inflammation in their body, they have more of that activity in their breast tissue. So they're going to be prone to dense breasts, fibrocystic breasts, And all of those conditions are associated with increased breast cancer, because to me, And I have to be very careful how I word it. It's not because they have so much estrogen, but it's because they have overactive estrogen activity in that localized tissue, together with that inflammation. I think the inflammation is the missing factor there. And then, it's the lack of balance with progesterone. We know that if those women have adequate progesterone, we can improve those conditions for them. Estrogen and progesterone work in harmony. They're in symphony together. This is why I love giving even women who had a hysterectomy progesterone, because they still benefit from progesterone. This is not just to protect the endometrial lining. It really can do so much more on different areas in the body, wherever estrogen works, progesterone can help, especially in the breast tissue. And so if that explains it a little bit, we're not as good as knowing the tissue activity. I would have to biopsy someone's breast to know exactly what's going on, but I can use surrogate markers like their symptoms. I can, I can, and we could do imaging, we could do a thermography and look at the inflammation. We could do MRIs and look how dense their breast is. Do you see what I'm saying? So we can, we can use surrogate markers and I can listen to the woman. I mean, a woman usually patients are really good at describing. You just have to listen. I mean, honestly, I could probably diagnose people just by listening to them and just not even doing any tests. I love doing tests because it shows them what's going on and it makes them understand, but I could probably just treat them without. without testing them.

Ann Marie: 17:56

Well, it's interesting that you say that. I saw a very popular doctor and someone asked on social media and someone said, I'm on estrogen, but I still have very sore breasts and I'm moody. And her answer was sort of, um, well, you might not be absorbing the estrogen or maybe you should take more estrogen. And I'm like, I'm a journalist and I think this woman has too much estrogen just to myself. I would be so careful with who are the very popular people on Instagram. And this is not because I'm jealous or whatever. This is because

Salome: 18:25

from a doctor's perspective, there's so much wrong information on Instagram. And it hurts me because I'm just not as good as, um, making it sound like easy. It's because in my brain, I know it's never easy. And so I can never present it like it's simple. But let's be honest. So many people and I see the big picture. Big people there, big players, they don't understand that if you start someone on estrogen, for example, and they're on menopause, and they have breast tenderness, That's not a sign of too little estrogen. That's too much estrogen in the tissue localized. So on the serum levels, they might not show up as high enough because they might be monitoring their levels. But on a tissue level, that's too much. And you gotta understand, that's why I think if you go to someone and they understand functional medicine, or at least a holistic perspective of how the liver works. The brain and the gut are really important for that because now when you heal their gut and when you help their gut and you help their liver, that improves. Or if you understand how progesterone is important and what form of progesterone would help that particular person, it's so much more helpful than just, I'm a menopause expert, I prescribe hormones. That's not all it is because I can train someone that in three days. Honestly, it's not difficult. Like you already, you figured it out by just following people. It's not difficult to just start someone. What is much more difficult is to understand the individual response to something. How are you different than everybody else that I'm giving that estrogen? How's your body reacting? How's your body detoxing it? What's your individual terrain? And that I think. There is a lot of subtlety that gets lost when people just listen to someone on social media. But I understand the despair of women because they go to their OBGYN and they don't know anything about hormones. So they're going to go and try to find someone on TikTok and Instagram and, and, and those people have to make it sound very simple because they can't treat you individually. They're just. Bringing out messages for the masses and, and those messages are just reduced to sim, for simplicity purposes. So just take it with a grain of salt, take away what you can, but if you really want to be treated on an individual level, find yourself someone who actually follows you, who you build a relationship with, who knows you. I can't help someone after one visit, but I love working with women that I've already met and known over months because We get to learn from each other. Find yourself someone that you can trust like that because that's going to make such a big difference for your outcomes. You want to be safe. Hormones are powerful, powerful messengers. You can, you can, you can go overboard with that. You can do too much, you can do too little. You want someone who understands the safety, who is not scared to give you hormones, but who is not too cowboy and misses the cues that you're giving them, that your body is feeling overwhelmed with the amount of estrogen you're giving them. You don't want someone who misses that. You were spot on by saying, that's a sign of too much localized estrogen, not too little. So kudos to you for informing yourself so much and being so, so well educated.

Ann Marie: 21:34

Well, I don't think there's many people who talking, you know, I've talked, I've have over a hundred episodes of this podcast and dozens of dozens of doctors. And early on, I started to realize like most people don't even track progesterone. It's just something that you have to give and I just started to think, how is it possible that these doctors who speak so confidently don't even seem to know that and I don't think estrogen can be the answer to every question. It just doesn't make sense. And so that's just something I started to learn with all the questions I'm asking, but it's crazy making a little bit to look at. Yeah. People who are very, very popular who are saying estrogen is always the answer to every question and all you can do is sort of, I always say, follow a lot of people like no one is your guru because. No one's watching social media, doctors on social media and saying, I mean, all the medical boards have so many restrictions on you guys, but completely social media is just a wild West. You can just sort of say anything. And there's like a big, um, chorus that everyone's joined in. So that's just me on my soapbox. But it's very interesting to hear you say it because it's like these people, smart people on the fringes that are like, it's not always estrogen. And yeah,

Salome: 22:45

And it's not just doctors. I mean, I have every type of person speaking up on hormones. And if you say something with authority, people will think you're an expert, but I think you, you have to prove yourself in actually how you treat someone. That's how you become an expert and not just by speaking. And often people who are really good speakers and who, who they're, they don't actually really treat people one to one anymore because they're so busy with things like that, that they want to go out and speak. and write books and all of that, and that's wonderful because you do bring a lot of information to the masses. I'm happy that there is a destigmatization of estrogen in our society now because we have to, we have to correct a lot of things that the Women's Health Initiative did. to, to our beliefs about hormones. And we still, you know, the books like Estrogen Matters and every doctor, every blooming and all these people, they are important because there, there is a lot of misconception about estrogen, but to just say that it's all about estrogen. Estrogen is not the only thing that matters, but it gets a lot of hype right now because you obviously have some neuroscientists like Dr. Moscone talking about estrogen and Alzheimer. Then you have, people who talk about how, there's certain breast cancer specialists who say estrogen doesn't cause breast cancer. So estrogen is all we talk about, but there is progesterone and there is testosterone and there is pregnenolone and there is DHEA and there's the thyroid and there's cortisol and there's insulin and, and our body is a symphony of all those things. And it's not even just hormones, it's minerals and vitamins and, you know, proteins and carbs and fats. It's all those things, the building blocks of the hormones and what makes our body. And so, and how our liver works and how our gut works. I mean, I've talked to conventional doctor who calls themselves a hormone specialist. If I talk to them, how their gut health, a patient's gut health is important for their hormones. They don't even listen. They don't even know what I'm talking about. But there is certain enzymes that you have in your stool. And if you, if your gut bacteria is out of it. balance and you have overgrowth of certain bad bacteria, we call it. You can have too much activity of that enzyme, and what it does, it helps the estrogen recirculate back in your system. Not just estrogen, it actually helps certain toxins go back into your system too. So we're learning about it, but we know that we can down regulate it by working on the gut dysbiosis. It's a really important thing! It's not just something I'm saying, there's research on it, but people don't know about it. Or we know that the liver has certain phases of estrogen detoxification. How can you give someone hormones and not even know about that? You know what I mean? So it's, it's difficult because we regulate so many things and we don't regulate the important things in medicine. And I just, um, believe me and Mary, I believe I don't know enough. I have to constantly teach myself things. I will never be happy. I constantly learn because every time a patient asks me a question I don't know about. I don't want to let them down. I have to go and educate myself. Um, so it's never ends. If you think, you know, enough. You're wrong. And as a doctor, you have to constantly educate yourself and these topics are evolving. Um, so yeah, I don't want to ramble on, but I think you get the point that I'm making.

Ann Marie: 26:06

Well, there's a, another controversial thing that people speak very confidently about is that you don't need these functional tests and that they're just a waste of money if you're in perimenopause. And I feel like that conversation gets hijacked because they'll say, you don't need them to diagnose perimenopause. And I'm always feeling like. No, they're not diagnosing perimenopause. They're looking at the range of things that could be going on here. And that thyroid, liver, gut access, axis, I've started saying access, access instead of axis, but that, I mean, that was where my health fell down is I had all of the problems with that. And so is that what the testing is to sort of give you an idea of what's the hormones, but then what else is going on? Can you talk about that testing a little bit?

Salome: 26:50

Yeah. So definitely thyroid directly, you can measure that as you know, and there's different markers and often in conventional medicine, by the way, we only check TSH and 3T4 as a reflex, but that's not enough. You have more markers, like the thyroid globulin binding, you know, you can, you can measure the protein that binds the thyroid. You can. measure the free T3, the reverse T3, all of that. You can check the antibodies to make sure they don't have autoimmune thyroid disease like Hashimoto's or, um, Graves disease. For the liver, you can, measure the liver detoxification of estrogen, you cannot measure directly liver markers for that, uh, or the liver markers you can measure don't tell you much about the hormone detoxification, but you can check the estrogen metabolites. And you can do that in the urine. And so there's the Dutch test or other tests similarly, where you can check the metabolites that will give you indication on how you're metabolizing estrogen. And from that, you deduct that's how your liver is doing. Now, generally, when I talk to someone, uh, and I diagnosed them just clinically without even testing, I do make certain recommendations how to improve the liver detox just anyways without even measuring certain metabolites because that's never a bad thing. When you're giving someone hormones or they are suffering from hormone issues, it's never a bad thing to work on detoxification anyways, okay? But the conventional doctors don't even like the word detoxification or they don't like even talking about it. They don't acknowledge that and that's okay. I think it's great to have diversity of thought and opinions and Different type of doctors work for different type of patients. The type of patients that come to me or drawn to me, they are the ones that already have the awareness that there could be more to things than just giving you hormones. But to answer your question, can you measure liver detoxification directly? Not really, but you can check metabolites and you can check the liver function and from that you can deduct things.

Ann Marie: 28:48

What about fatty liver? We're hearing that maybe a third of Americans have fatty liver. I had a fatty liver. It doesn't, I certainly, when I reversed that, everything got better. So I just don't know if anyone's paying it. Not very many people.

Salome: 29:02

Yeah, absolutely. Fatty liver is not actually just that you're having fat accumulated in your liver because you're adding eating fatty foods. It's actually oxidative stress and damage to liver cells. And that can happen from, environmental toxins that can happen from, inflammation inside the liver. And yes, it can happen from excess sugar or excess fat, but, but the result is that the liver cells change from oxidative damage. Every disease in the body is from oxidative stress or oxidative damage. And so that inflammation changes the liver cells. Um, Really important to understand how hormones can play a role in that and how it impacts the hormones as well. So, so estrogen, for example, is super important for our bile flow and our liver activity. If, um, because estrogen can activate certain molecules in the liver to be produced and synthesized more. And it's important because in certain, phases in our life, when we have more estrogen, we need more of those things. But if you have excess, then we have, for example, excess clotting factors or excess, the bowel becomes super, super slow, sluggish. And, we develop bile sludge, and then we're more prone to gallbladder stones and biliary, you know, um, uh, basically I want to use words that are not medical. So basically things get stuck more. So the ducts in the liver and the ducts in the gallbladder can get more stuck and you can create more problems with the liver and the gallbladder. So too much estrogen can cause that. Vice versa. If your gallbladder doesn't work well, Then now you're not detoxing enough estrogen because the bile binds the estrogen and gets rid of it in the stool. So if your gallbladder or your liver don't work well, you're more prone to having too much estrogen again, or recycling it back. Whether while your body wanted to actually get rid of it, you know, so, so that's super important to know. You can, you can stimulate the bile flow and the liver health for different things, herbs. foods, the way you digest food, what type of foods you eat, and you can help the oxidative damage on the liver for certain things that help the cell membranes. and detoxification from the cells from inside the cells. So one good thing would be like phosphatidylcholine or alpha lipoic acid. These are substances that in our clinic we can even do as IV therapies and that can help reverse fatty liver. For the bile, that digestive herbs like bitters, you know, in France, You always have an aperitif and a digestive, so you have, you have bitters that you, that you help stimulate your digestion and you take that with your food. I, I encourage women to use bitter herbs in their, in their diet or use them as drops. To help stimulate their gallbladder flow. So it depends on the person and it depends on their context, but if I see there are symptoms of a sluggish gallbladder, for example, there are certain things I recommend. If someone had a gallbladder removal, they're going to be more prone to problems with their hormones because they're not detoxing the estrogen as well.

Ann Marie: 32:20

Okay. And there's a lot of gallbladder removals in the States in particular.

Salome: 32:24

Yes. Thanks. Because of the same issue is that if you have excess off the estrogen can cause more sluggish gallbladder and we also know that xenoestrogens can be related. We know that parasites can be related to and and then we know that excess fatty intake, we know we have a lot of, you know, processed foods in our diet. Um, we always poo poo seed oils, but yes, excess seed oils, not just seed oils, but excess seed oils, excess sugar, all of that contributes to the gallbladder. Um, epidemic that we have.

Ann Marie: 32:56

So a lot of times a huge complaint is weight, is weight gain. And how much of weight gain is tied to the hormones and how much can it be tied to all this other stuff?

Salome: 33:08

Still learning about that, but I find it hard to always, um, find answers right away. I, I, I found there are different types of people that have experienced weight gain. What is the type that has that excess stress, excess cortisol, um, disrupted sleep, just under eating, not eating enough protein. It's just, That kind of context. And then I have the person who does everything right, exercises all the time. It's super healthy, lots of protein, and it's just nothing is moving. And it's almost like the cells are overfilled with toxins and they're just not reacting to anything. Like the cell membranes don't let anything through, nothing communicates with each other. And I found that with those people, like focusing on more detoxification can be very helpful. And then there are the people whose metabolism is just slowed down because, you know, As we age, our growth hormone goes down and that can impact how our metabolism and our metabolic rate works. Our thyroid is super important and often very underdiagnosed, um, low thyroid function, especially the T3 being low. And then there's the people who have insulin resistance because as estrogen fluctuates, our insulin resistance can get worse. And insulin resistance is a big factor for some women. and weight gain. But I do believe me that one person with midsection fat doesn't always have just insulin resistance. There are just so many different causes. So I, I have found that helping the liver detoxification, the fatty liver, the, the, the, just the cellular detox has been very helpful for women. If it's an undereating problem, definitely working on the macronutrients. If it's an overeating problem, but overeating of the wrong things, like they don't even know they're overeating, but they're snacking constantly or they're stressed and then they overeat at the wrong times of the day. I found that to be helpful. Working on sleep. This is why when you ask, are hormones a problem for weight gain? Yes. Just the fact that if your estrogen, uh, your progesterone is low and your sleep is disrupted, it's And the sleep disruption causes weight gain. That's a hormone issue by giving them progesterone, making them sleep better in their perimenopause. It allows them to have more energy to work out and actually have better cortisol and better, you know, fasting glucose because now their sleep is not disrupted. So many factors. I wish the weight gain question was an easy one, but is there absolutely weight gain overall in perimenopause and menopause? 100%. It's a very common problem. And, um, it's not an easy answer. I have to test you individually. I have to see what your individual body is doing. Um, I wish I could just say there's that one diet you have to do and that will help everyone. But overall, there's some basic principles. Make sure you eat enough protein because the digestion of protein itself uses energy. So it's a very great nutrient in terms of gives you lots of energy, but then you use up energy to digest it versus carbs. You know, the digestion is easier. And so you, you get more calories easy. That's, there's a reason why people who want to bulk up for bodybuilding competitions, eat lots of carbs because it's easy to bulk up. It's the type of carbs you eat. It's type of protein you eat. It's the type of fat you eat. We talk about all of that. It's the time of the day you eat. It's the consistency and the schedule at which you eat. If you're eating at different times all the time, your body never knows when the next meal is going to come. It's going to be stressed and you, you're going to retain more, more, um, weight. Um, so it's the time is the consistency is the amount of macronutrients of protein. And then it's also how much you, you, you move your body. You don't, you know, you, you got to move your body so that your body feels, you know, That something is going on, so I don't have to, you know, just hold on to everything. I can, I can spend it, you know, so it's, it's very interesting. It's type of exercise is the time of the day you do certain exercises. It's how things work on your insulin and your cortisol. If people want to really deep dive with me, the ones who are really interested, I love working with heart rate variability, monitoring things. looking at their sleep quality, get an aura ring. Let's look at your sleep. Let's look at your heart rate velvety. Let's find out what type of exercise works at what time of your cycle. If you're in your luteal phase, Right now, the last week, I'm very, I've been in my, you know, PMS phase, I didn't feel like lifting heavy. I didn't feel like doing crazy stuff because I know my blood sugar dysregulates much easier. I'm more prone to stress, more adrenaline excess. I already have more disrupted sleep. So I'm going to do things that calm my nervous system down. I don't overdo my cardio or my weightlifting. It's different than when I'm ovulating or in my first half of my cycle in my follicular phase. I work out differently. I eat a little bit differently. So all those things I can talk to about women, you know,

Ann Marie: 38:28

what about we talked a little bit more before we started recording. We talked a little bit about ADHD and how it's so underdiagnosed in women and what, whatever it is, whether it's this, you know, a sort of a trauma informed neurological change or it's actually ADHD. I mean, I don't know, but I know that something happened to me and what's sort of going on in perimenopause. Do you think with this, these brain changes where women are experiencing just a complete I would describe a complete inability to organize myself.

Salome: 39:02

Well, you know, estrogen and progesterone and testosterone are neurosteroids, and we know that they have an effect on our brain and our neurotransmitters. So the simple answer is absolutely any time your life, be it in pregnancy, postpartum, uh, PMS, uh, menopause, perimenopause, when there is changes to these hormones, you're going to feel changes to your brain and your behavior.

Ann Marie: 39:26

That's just, it's just a time where those hormones are receding or fluctuating and you're going to be exposed to,

Salome: 39:35

just a quick example. Serotonin, for example, is maintained by estrogen levels. The higher estrogen, the more serotonin, um, or dopamine, how it's metabolized, it's impacted. Obviously, it's not just hormones, by the way. Vitamins, B vitamins, cofactors, you know, we have minerals. Very, very important. Absolutely. I would argue more important than hormones, but do hormones have an effect on the neurotransmitters? Absolutely. So, for example, dopamine and serotonin and estrogen, there is a correlation. So I like to say The PMS, the window before your period is, um, is the days before your period, how you feel then is kind of a little bit in the window into how you're going to feel in menopause, because that's when you're both estrogen and progesterone fall. They're steep declining. And so if you're prone to migraines or if you're prone to mood symptoms or depression or, um, anxiety, some of those things will get worse in perimenopause and menopause, because it means that the way you maintain your neurotransmitters, you're very sensitive to the hormone fluctuations. And so that's going to come back and even be worse in those periods of time. You can help that. You can do something about that.

Ann Marie: 40:52

Well, yeah. And then this is so interesting because if women are in their thirties and they have this, then they can tackle it in their thirties and not have to hit a wall in perimenopause. Like so many of us did.

Salome: 41:02

Yes. My goodness. I wish someone had told me all the things I tell my young patients. Like I have, you know, young, very young people and they don't want to be on birth control and they want to do things naturally. I wish someone had told me all that when I was younger, which I knew all the things myself when I was in my twenties, but yeah. It's never too late, but yes, um, definitely ADHD can get worse because ADHD, I do believe there's a trauma component to that. I do believe there's a nervous system overactivity. I do believe also that there are certain genetic SNPs and enzyme changes we are born with. And that's okay. Uh, again, genetics only makes a certain percentage of what we, what, what, you know, things end up being a behavior, but there are going to be certain things that someone with ADHD is going to have a harder time maintaining stable dopamine levels because they kind of like metabolize it faster, or there could be certain changes with how they metabolize adrenaline. There could be certain changes with serotonin. So there are going to be more. more susceptible or more sensitive to hormone changes or PMS. or menopause. So things could get worse before it gets better. That's very important for those, for those kind of people. It's important to regulate their hormones very, very well and make sure that their vitamins and minerals are perfected. Like the B vitamins are very important for ADHD people. I know that in my, um, PMS, phase, I definitely need more GABA support. I definitely need more serotonin support, more dopamines. And so I work on that through certain supplements, my B vitamins, my 5 HTP, things like that. It's just really different, uh, things you can do. I stay off, um, social media more. I do more calming exercise. I try to read positive books and watch positive videos. I can't do politics in my luteal phase. I just can't. I want to cry about the whole world, but I've also noticed that I become more introspective and I can use that time to be more wise about the decisions I make. Because when I'm in my being ADHD, we're just more up, there's more ups and downs and there's just more emotional volatility for sure. But I've noticed that as much as I can compensate for that, for the way I eat and the way I exercise and the way I focus on my supplements, there's just certain things that are a little bit different. I use that time. To be more reflective and, you know, make more wise decisions for myself and kind of be more in touch with myself. I don't know. I'm trying to make something positive out of that time that I feel like I, yes, I want less contact. I want to go, go out less, hang out less, but. I can use that for me time. And when I allow myself that, and when I allow myself to really deeply go down into the depths of how sad I can feel about certain things, it allows me to be very truthful and authentic with myself. And. It allows me to make decisions that are more in line with what my values are versus if I'm ovulating and I'm just generally happy and excited about everything, those decisions might not be always the best decisions because they're over optimistic decisions. And it's, it's interesting. Anyways, I love that. Yeah, I'm trying to make the best out of that PMS and, um, yeah, so definitely ADHD, more, more struggle during menopause and PMS, for sure, but it can be helped.

Ann Marie: 44:47

What would you suggest to help people?

Salome: 44:49

I think. understanding what are exactly the changes that happen for you. Are you more anxious or you're more depressed? Are you more, um, restless from that? I can deduct what it is that we can work on. And then it could be, I would definitely recommend checking minerals, vitamins. Let's look at your, your diet. Let's look at your exercise pattern. Let's look at how we can improve your sleep. Dan. And then can we work on breathing? Can we work on mindfulness? Can we work on strategies that help you organize better? Let's simplify your life in your PMS or in your menopause. Let's simplify things from too many things to fewer things, but let's do them well. Um, less social media, less distraction, less tech, fewer tasks. Let's just focus on a few things and get them done. Okay. Because you're going to be less capable of doing that. organ managing your time, you're going to be less capable of multitasking. You're going to feel overwhelmed much easier. You're going to have less patience with yourself and other people. You're going to be more irritable. But when I, when we, when we work on, do I really need all this? What is really essential? And let's focus first on me feeling okay. What can I cut down on? What really needs to be done? Let's create checklists and simplify. Just simplify. Because you're going to feel overwhelmed much easier. We can't have the same expectations of ourselves all the time. And why do we think we have to be perfect all the time? And why is it never enough? ADHD people are more prone to wanting a lot and too much of themselves. It's going to be a challenge for them to calm that side of them and just simplify. I think that's going to be the challenge and I'm going through that myself. So we're in it together Ann Marie, I will, I will help you help me, but I can tell you one thing. It really helps during that time to make sure I don't skip breakfast. Because I'm going to be more irritable. I don't drink coffee. I drink my matcha because my L theanine helps me calm me down. I make sure I don't skip my B vitamin supplements and there are specific ones because I can actually check specifically which ones you need, just not at B complex. I focus on the supplements. I focus on sleep I focus on regular meals and I focus on Positive people and positive thoughts during that time. These are the time I can't be really available for other people too much or I can't be around negative thoughts too much. And then And I focus more on the relaxation techniques during that time. Definitely, that's where the yoga comes in, the breathing comes in. Yeah.

Ann Marie: 47:29

So we hear a lot about hormones, bioidentical, synthetic, compounded. Do you just have a little primer for people when they are navigating this with their, uh, provider?

Salome: 47:42

Yeah, listen, I would say do whatever works for you within your budget, but just understand when you go for a regular pharmacy, there is inactive ingredients and fillers in those medications. You can still have a bio identical progesterone, but if you're going through the regular pharmacy and it's a prometrium, called in the U. S. prometrium, that has inactive ingredients and food dyes in it. If you wanted none of that, then you can go for a compounding pharmacy where they mix it up fresh for you. It has a, you know, shorter shelf life, but it doesn't have the inactive ingredients. Both are bioidentical. Then you have synthetic, so you have synthetic progestins. Those would be different names that, that, uh, wouldn't be really a progesterone, it's a progestin. So you have like, you know, Noone or um, Provera or. Livonorgestrel. These are American names, by the way, in Europe they're called differently, in Middle East are differently, but usually if you tell me the name of what you're taking, I can tell you what type of progesterone it is. For estrogen, you can use bioidentical creams, tablets, trochees, injections, or, patches, but it all depends on whether you want to use your insurance or not, either you want to go for the compounding pharmacy or not. In the end, do what works for you and just stick with it and consistency. Really don't feel that you're missing out if you're not doing everything else that someone else is talking about. If something works for you, stick with that. It really depends on the person. Whether cream or tablets or patch works better for someone really depends on the person, on their uptake, on their absorption. And on their individual risk factors, some people might not be good, good person to do the tablets for because the tablets can have increased risk of blood clotting, a little bit minor increase. But for some people, the patch and the cream don't work. They just don't absorb it well enough. And then you have to switch to oral. I'm never going to be an absolutist about anything. anything because what works for you might not work for the next person. And I'm not going to judge too many people.

Ann Marie: 49:52

What about pellets?

Salome: 49:53

Believe it or not, I love them. I didn't know about them until four months ago. And then I started working in this clinic and I don't love them because the person who taught me told me to love them. I'm loving them because the patients love them that come to the clinic and I am a patient advocate. I will buy whatever the patients tell me works for them. I will become a believer. The patients who use the pellets love it. And so if a woman tells me she's back, I'm back. I'm the one who I was. What am I to judge just because in residency and fellowship and on social media, everybody's telling me pellets are bad. I'm not going to judge a woman who loves her pellets. I'm going to help her get them. And it's just so fun to be that kind of doctor who is absolutely open to anything. It's the biggest adventure in life because honestly, if you had asked me two years ago, I was like, I don't know. I was told they're not good and now I love them for patients. So it works for certain patients. And the reason it works for certain patients is, and not for everyone, is because we're all different, but for the ones it works, it works because they're getting the absorption, they're bypassing everything, they're bypassing the mouth, the liver, you know, it's just by direct absorption. for the subcutaneous tissue. It's a basically it's an implant that you insert into the, into the buttocks or into the flank area and you absorb the hormones from the fatty tissue, right? And you absorb it over a period of three to four months. So you don't have to take something every day and You have kind of like around seven to ten days, you kind of feel it and then you have a peak about six to eight weeks and then you kind of come down right when your next pallet is due and, and so you have kind of more of a steady instead of something that you have to take every day where you go up and down. But having said that doesn't work for everybody, and not everybody loves it. But for the ones it works, I'll do it. I have to say it's specifically very effective for testosterone, for libido and energy. I have to say that's where I have seen the best results for it.

Ann Marie: 52:07

And what about, you know, the risks and the side effects, everyone's worried about that. It's hard to get at the truth from where you're sitting. What do you think we need to be careful of if we're going on therapy?

Salome: 52:19

I think when people just talk about risk, they, they, they don't go into detail of why, and I think that can be scary for women. It's important to understand everything I give you has a risk, has a potential risk. Even the best bioidentical estrogen or the bioidentical progesterone. Because what is the risk? For example, progesterone, I could slow down your digestive system. You could have candida overgrowth. You could have, you know, bloating. That's a risk. I have to understand what it is and then we can help you. You know, uh, remedy that. So with the risks of testosterone, and that can be in injection form, or, uh, palate form, or it can be in tablet form, or in cream form, it doesn't matter. There's a subset of women That are sensitive to converting testosterone to dihydrotestosterone locally, meaning on their skull, on their face, or wherever they have hair follicles like chest, back, they're more prone to growing hair in the wrong places and more prone to losing hair. I'm prone to that. I have like, like endogenic alopecia. And so if I were to take testosterone at some point in my life, I would probably experiencing some of those effects. We can work on lowering inflammation and the local effect of testosterone. We can work on that. If someone tells me I had a history of acne, I'm going to be more sensitive to how much testosterone I gave her because she's going to be more prone to breaking out. So you have to understand the patient and then you can start them slow. You could say, if someone tells me, I want to try pellets, but I've never had testosterone and I'm scared of how I'm going to react, I'm going to say, let's try a pill or a cream first. If you do well with that, let's try the pallet. So you, you kind of work with people. Let's say someone has a pellet and starts developing those symptoms. You can help them. You can give them certain herbs or certain medications to mitigate some of the side effects. You can lower the dose. You can hold off on it. You can stop using it. There's multitude of things. From my experience, our pellet patients, the way they love. Their sex life and their energy, dear, they are not willing to give this testosterone up for anything. I have to find other ways to help them with the side effects. So, so it's just. It's just a way to say it's never easy to give someone hormones without having any side effects. It's a matter of helping them mitigate them.

Ann Marie: 54:56

And what about estrogen and breast cancer? I mean, it's very hard to get at this.

Salome: 55:00

Yes. Yeah, I do believe it's more, uh, almost like an intrinsic estrogen production and the inflammation that plays a role for breast cancer more than anything. But, you know, we use in breast cancer patients, we use estrogen receptor blockers as a therapy. So to say estrogen doesn't play a role at all. is simplifying it, but does it, does it cause the cancer? I believe we can say from the studies we know most likely it's not the cause of the cancer. It can potentially grow tissue. So if you are on estrogen and you develop breast cancer, please don't let your cancer doctor tell you it was your fault because you took the hormones. Please don't let anybody guilt trip you into anything. If anything, we should spend more time talking to women about how A disrupted circadian rhythm has been shown to be a much higher risk factor for breast cancer than hormones ever were, or how alcohol consumption is a rigorous factor for breast cancer or how, you know, being overweight or having inflammation or having radiation to your chest, all those things. We don't talk about it. We don't talk about, Hey, are you putting your cell phone in your bra? A much bigger risk than any hormone ever could. So what I'm saying is take your hormones. Do your breast cancer screening, do your breast self breast exams, work on your lymphatic drainage, work on your breast health, eat healthy, eat your fiber, work on your liver detox, work on your gut health. If God forbid you develop breast cancer, don't blame the hormones. The hormones didn't cause the cancer. The cancer was caused by DNA damage, a multitude of different factors we don't all completely understand, but The hormones were not the cause of it. If you now have to stop the hormones because they're using the hormone receptors to attack the cancer, that's another thing, but once your therapy is completed. You can start hormones again. The reason I love the pallets so much Ann Marie is because we have a lot of breast cancer patients who are not allowed to be on estrogen, but we can give them testosterone and it's not FDA approved for that and it's definitely off label, but the patients understand that and we can control a lot of their menopausal symptoms from testosterone. And then we give them something that blocks that testosterone to estrogen conversion. So it's really. Yeah, it's really exciting. The person I work with, she's a physician. She herself had breast cancer and she's on testosterone pellets. Kind of pretty amazing. So yeah, so don't blame the hormones for the cancer, but once you have cancer and they are hormone receptor positive, you will have to stop them because of them using the estrogen receptor as a treatment. target.

Ann Marie: 57:55

And the big question everyone's asking that is also very confusing is this, if you don't feel like you need or want hormones to deal with your symptoms, the prevention. Everyone's saying that it, they prevent dementia and they prevent cardiovascular disease. If you aren't on hormones, I'm not on hormones yet. I have trouble getting them. And I did a whole bunch of things to sort of, to sort of heal myself and all my perimenopause and menopause symptoms went away, including brain fog. So now it's just a matter of, okay, am I going to try to optimize my health, taking them. What's your, what's your take on the prevention?

Salome: 58:33

We have to distinguish between what studies are showing as association and what's causation and what are the multitude of other factors that play a role. So while we know that estrogen and progesterone can be neuroprotective, even testosterone, I have patients with just testosterone palates. The brain fog goes away. There is a sharpness of the mind that comes back. So we cannot deny that these are neurosteroids. All three of them have effects on the brain. Absolutely. And in different ways, in different ways, for example, progesterone can be used after brain trauma. Like if you have a car accident. And yet a brain trauma, pregnenolone and progesterone have been shown to be neuroprotective for the myelin sheath, the little cover of a nerve that covers and protects the nerves. So it helps regenerate that estrogen and Alzheimer. So, Just because estrogen can help decrease your risk doesn't mean that you need estrogen to not develop Alzheimer's. It's very important to understand just because it's the same thing if in a negative way just because people who had higher estrogen levels had breast cancer doesn't mean estrogen caused it but so we have to be very very careful with association versus causation. So this is what I would tell someone. If your brain fog Is gone if you're if your fatigue is gone if your mental sharpness is back without hormones That's a sign that your brain is getting what it needs Okay If you have brain fog if you have fatigue mental fatigue memory loss then do things to mitigate that. If you can't be in hormones, there is a multitude of other things that protect your brain. So eating healthy exercise, social contact, meaning and purpose in life, keeping your mind active. When we look at the blue zones or people like in Japan or Sicily, and they live up to be 90, a hundred. And even though there might be some critics of those studies that meet people might have exaggerated the results of people might not even be that helpful. Whatever you, however you take it. If you look at cultures where people are older, but their minds are working sharp, they were never on estrogen. It's not that you need estrogen to have a sharp mind is that it can be one of the tools for someone who has brain fog and is not getting their symptoms under control. And maybe that's because for that person that estrogen works, but that's not the only thing that works. And estrogen does not replace a healthy lifestyle. If you're sedentary, if you're not using your brain, if you're not exercising, if you're not eating healthy, just taking estrogen is not going to replace all of that. It can be one tool in your toolbox. It's not the one determining factor, but can it be helpful? Yes.

Ann Marie: 1:01:27

Would the same thing apply for heart disease?

Salome: 1:01:30

I mean, we do know that it really works on the cell, um, on the, on the vessel walls. It works on the flexibility of the vessel walls. It can help lower, um, oxidizing, oxidization of lipids so that you have less inflammatory like plaques built. Um, it can work, it can help improve insulin metabolism so that you have less, uh, hyperinsulinemia, which is a risk factor for cardiovascular disease. Yes, we know all of that. But what I'm seeing is. Do you, do you need estrogen to have all that? No, you can also do things in a healthy way and make sure that you, you do everything else right. And if you're one of those people who does, you know, who just doesn't want hormones, don't let anybody guilt trip you either into not doing hormones. That's my mantra. If you want hormones, Super. I'll help you. I'll take away the fear. You don't want hormones? Super. I'll help you and tell you what you can do to be healthy. It's not black and white. Now everybody's on the hormone train. Doesn't mean you have to be, you know, it doesn't mean this works for you. As long as you live your life without fear, everything will be okay. And if, if we develop cancer or heart attacks, things happen. We can only try to achieve to like, understand. And try to do better and to, you know, heal from it. But can we do everything to prevent it? Yes. There's no guarantee in life for anything anyways, I can give you the best hormones and tomorrow you go and you have a car accident. I mean, there is no way of preventing death. Just live your life fearlessly. Know that there are doctors out there that listen to you, that help you as an individual. And they understand you're not one in a million, uh, like other million people. You are one in one in a, you know, what your own kind and their solution to everything's. I have so many different types of patients. I love them all. Some of them tell me they don't want hormones. That's totally fine with me. That's awesome. I'm a hormone doctor that will work with people who don't want hormones. Absolutely. I'll still help you work on your, you know, imbalances and your gut and your liver and your breast health and your cardiovascular health. And there's so much more I could say. Anne Marie, we're discovering so much in terms of longevity and anti aging and it's. fascinating. There are ways we can screen someone for cardiovascular disease. You know, there are ways we can, you know, use AI to predict in models what the heart attack risk is, the stroke risk is. So as we get better in that, We can individualize people even better. We can be very precise so that you can say, okay, I don't want you an oestrogen, but what's my risk for stroke or what heart attacks. And we can help you. You know, that's not the only marker. That's not the only tool in the toolbox. Do whatever works for you and what makes you happy. Okay. That's amazing. Thank you so much. I loved talking to you. Welcome. I was, it was a pleasure talking with you and we can definitely do a part two if you want me back.

Ann Marie: 1:04:32

Yeah, for sure.

1:04:34

Hot Flash Inc. was created and is hosted by Anne Marie McQueen, produced and edited by Sonia 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 healthcare 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 healthcare 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.