0:00

you really, if you're gonna start it, you need to start it early.

0:02

We still recommend using the lowest effective

0:04

dose and tapering it off as soon as

0:06

your symptoms you know, begin to resolve.

0:09

Hi there. I'm Annemarie McQueen, a

0:11

menopause in midlife journalist. I have

0:13

25 years of experience covering

0:15

science health, and. And I

0:17

created hot flashing to inform, inspire,

0:20

and entertain people who go through pairing

0:22

menopause and menopause, and the people who care

0:24

about them. This podcast brings you

0:26

interviews with scientists, doctors,

0:29

practitioners, entrepreneurs, thought leaders,

0:31

and more. In the end, our menopause

0:33

experience is about so much more than ours. Symptoms.

0:36

I think it's a total and complete mind,

0:38

body, and soul shift. It's taking

0:40

radical responsibility for every single

0:42

part of our lives. It's becoming

0:44

who we were born to be. It's nothing

0:46

short of a hero's journey, and I am here walking

0:49

the path right beside you. We're

0:51

gonna have fun.

0:52

This is a topic I have to

0:55

admit that I shy away from because

0:57

it's so confusing and

0:59

the information is all over the place so

1:02

how are cardiologists feeling about this

1:04

and how did this paper come to be?

1:07

Well, I would say in general, Cardiologists

1:10

have generally shied away from the topic of h

1:12

r T as a whole because,

1:14

you know, obviously it's a little bit out of the wheelhouse

1:17

in general of the general cardiologist

1:19

and, the data,

1:21

suggesting that, hormone replacement

1:24

therapy could in increase cardiovascular risk.

1:26

I think just sort of, Put a level of

1:28

fear amongst cardiologists and

1:30

sort of the safe posture was to

1:32

say, just don't take hormone replacement therapy.

1:35

And so really what was driving

1:37

this manuscript is not that there's been

1:39

a plethora of new data that's come out,

1:41

but really we wanted to gather

1:44

together the data that's there and really

1:46

reframe. The approach

1:49

to the menopausal patient for the cardiologist

1:51

to sort of help guide the cardiologists through

1:54

how they should think about risk and

1:56

treatment for their patients who are

1:58

going through menopause.

2:01

And then is it intended also for the other

2:03

practitioners who are working with women? Because we know

2:05

menopause sort of falls into this gap, right?

2:07

Like there's the family practitioners and

2:10

then the OB GYNs, and then if you make it

2:12

to the card, Well, something's

2:14

probably going on already,

2:16

right? Yeah, absolutely It

2:18

is. I mean, I think intended to be a resource

2:20

for all of those people and really to kind

2:23

of specifically just think about

2:25

how can we, approach

2:28

hormone replacement therapy in

2:30

light of, cardiovascular disease

2:32

and cardiovascular risk.

2:36

Do I have this right? You have a sentence in there

2:38

saying it's appropriate that no medical societies

2:40

currently recommend HT for the primary

2:43

or secondary prevention of cardiovascular

2:45

disease. Can you explain that?

2:47

Yes. So, you know, when

2:49

hormone replacement therapy first came out,

2:52

the thought was that it was actually gonna be really

2:54

beneficial for reducing

2:56

cardiovascular events in women.

2:57

And really the, the theory behind

2:59

that made a lot of sense. We know that hormone replacement

3:02

therapy does have positive effects on,

3:04

cholesterol and weight, and

3:07

we know that women really do seem

3:09

to be protected against cardiovascular disease

3:11

until they go through menopause. So, you

3:13

know, of course it. therefore, seems

3:16

like it would make sense that if you gave patients

3:18

hormone replacement therapy, it would delay

3:20

or prevent cardiovascular disease, and

3:23

so it was just being used like crazy to help

3:25

prevent cardiovascular disease. Fortunately,

3:27

there have been several very large

3:29

well conducted studies that have shown that that is

3:31

not the case. There is actually

3:33

an increased risk of cardiovascular events

3:35

among patients who are taking hormone replacement

3:38

therapy. And so really

3:40

the way we need to think about approaching hormone

3:42

replacement therapy is not using

3:44

it to prevent long-term cardiovascular

3:46

events, but thinking about what

3:48

is that risk benefit ratio for the symptomatic

3:51

patient who really could have improvement in their

3:53

quality of life, by taking

3:55

hormone replacement therapy, and how do we

3:57

weigh that against. The potential

3:59

risk of cardiovascular events, which is

4:01

different, depending on who your patient

4:03

is.

4:05

Okay. So if

4:07

we're talking about someone who doesn't

4:09

have any cardiovascular issues right now,

4:12

and they're thinking, well,

4:15

I think I should go on hormone therapy for other

4:17

reasons, but I think it will also help

4:20

protect me from cardiovascular

4:22

issues.

4:24

What is your advice to.

4:26

There's not good data to suggest that it will

4:28

prevent cardiovascular disease. However,

4:31

I think we can safely say that if

4:34

you are a low

4:36

to moderate risk patient and

4:39

you have recently gone through menopause,

4:41

then it, the absolute risk

4:43

to the patient is quite low.

4:45

So it is not zero, but it's quite

4:48

low. And so if you're having. A

4:50

lot of symptoms related to menopause,

4:52

then it would be reasonable for

4:55

you to be treated with hormone replacement therapy

4:57

because, you know, as I always tell my patients,

4:59

both quantity of life and quality of life

5:01

are really important. And so

5:04

it probably is worth taking a very small,

5:06

absolute increased risk, if it's

5:08

gonna dramatically improve your quality of life.

5:11

I keep going over this because what you're hearing,

5:13

what you're saying to me and what I read in the paper

5:16

is so different from what I'm hearing.

5:18

When I look at social media and

5:20

from practitioners on social media,

5:23

you are talking about, Hey, it's probably worth

5:25

going on it for your symptoms and any risk

5:27

you might face will be minimal, and it's offset

5:30

by the fact that it's helping your symptom.

5:32

I'm hearing over and over and over

5:34

again that it's gonna help prevent cardiovascular

5:37

disease that it's gonna, what did someone just

5:39

say right today? The onset of menopause

5:41

coincides with accelerated vascular aging.

5:44

The endothelium plays a pivotal role. It's

5:46

saying that progressive dysfunction of the endothelial

5:49

cell layer of the vascular wall

5:51

and estrogen can offset this.

5:53

This is the kind of. That we're seeing

5:55

all the time. And again, it's why you wrote

5:57

the paper, but what, what do you make

5:59

of that?

6:00

So most of that is accurate.

6:02

We do know that, those

6:05

changes do occur when patients go through menopause.

6:07

And that's exactly why we thought hormone replacement

6:09

therapy would delay or prevent, cardiovascular

6:12

disease. And I mean, the medical community was shocked

6:14

when we did not see that, when we in fact saw

6:16

the opposite. So, That

6:18

thinking is exactly in line with what all

6:21

of the experts in medicine were

6:23

thinking when these big hormone replacement

6:25

trials were initiated. Unfortunately,

6:27

you know, hormone replacement therapy does have

6:30

some potential, drawbacks to

6:32

it, you know. Primarily related

6:35

to increased risk of, blood

6:37

clotting. And that is really part, a

6:39

major part of the driver that

6:41

contributes to heart attacks and strokes.

6:43

And so, you know, if you're a low risk

6:46

patient, you know that that overall

6:48

risk is probably low. But if you already have

6:50

a lot of other problems, like you already

6:52

have atherosclerosis, you know,

6:54

calcium and cholesterol plaques in your brain

6:57

or your heart, then

6:59

that risk, you know, risk changes

7:02

a little bit. If you increase

7:04

your risk of, of forming blood clots and you already

7:06

have sort of unstable plaques there. Or

7:09

if you have a lot of risk factors for it, like high

7:11

blood pressure and diabetes and high cholesterol,

7:14

and then you add this additional risk factor

7:16

in. It's just these things all sort of are additive

7:19

to one another. Now it is absolutely

7:21

true that it does positively reflect

7:23

on some of the risk factor profiles.

7:26

You know, it does help with weight. It

7:28

does, make your cholesterol look better. So

7:30

again, it's a little paradoxical that we

7:32

see this, increased

7:35

risk, but it's primarily,

7:37

Probably driven by that increased

7:39

risk for clotting, which we also see with

7:41

birth control pills. But again,

7:43

you know, even with birth control pills, that risk is

7:46

small. So for most patients, we say the benefit

7:48

is greater than the risk. But there are some patients

7:50

who have particularly high risk and we say,

7:52

yeah, in your case, the

7:55

risk is too high, and we would recommend an alternative

7:57

me method of contraception.

8:00

When you read this paper, do you get media

8:02

coverage on it?

8:03

Have you had a lot of media coverage on it? I've had

8:05

some. Yeah, there has been some. You know,

8:08

I think we're hopeful that it'll be really

8:10

be a resource for the medical

8:12

community to turn to, to really think about

8:14

how can we incorporate all this really conflicting

8:17

data about who should and shouldn't

8:19

get hormone replacement therapy.

8:22

And I think, you know, honestly, one really important

8:24

takeaway from. Is that essentially

8:26

everybody can get vaginal estrogen.

8:29

The dose of that is so low,

8:31

it does not have a substantial systemic

8:34

effect. But, you know, many

8:36

people just think you're high

8:38

risk estrogen. That seems like a bad

8:40

idea. We would not recommend it.

8:42

But even for our higher risk patients, really

8:45

they can get substantial quality of life benefit

8:48

from that without having, really

8:50

a significant increase in their cardiovascular.

8:53

Everyone focuses on the, the

8:56

results of the Women's Health Initiative study

8:58

and then the book Estrogen Matters. That came

9:00

out a couple of years ago and we know that there

9:02

were problems with that study and women were perhaps

9:05

started on hormone therapy too

9:07

late.

9:07

And you talk about that risk, how

9:10

those risks increase and the window of opportunity,

9:12

it's best to go on it ear earliest to menopause

9:14

and all that. But there are other

9:16

studies like this, the women's health in.

9:19

Portion of that study that was not the only one

9:21

that found this increased risk. Right? Like this

9:23

is what you're saying you've looked at.

9:24

It was a very complete review

9:27

of the literature and, You

9:29

know, and, and, and in addition to

9:31

that complete review of the literature really,

9:33

also took in the

9:36

expertise of advice in,

9:38

experts in menopausal, Medicine

9:41

and OB, G Y N and cardiology.

9:43

So I think it's a really nice,

9:45

summary of bringing together not only like what

9:48

is the literature today, but also

9:50

what are the experts in all of the relevant

9:52

fields. Yeah. Like what has been their experience

9:55

and their guidance.

9:56

It's sometimes just portrayed as, that was the study

9:59

that made it seem like there was a cardiovascular

10:01

risk and that study been, has been debunked,

10:04

and we just need to get to a place where

10:06

we can get some new research that will show

10:08

a different finding.

10:10

But what I like about what you guys did

10:12

is you looked at, you've looked at everything and

10:14

it's like, it's not just that study guys

10:15

absolutely it is. You know, it, it's not

10:17

just that study, but you're absolutely

10:20

right. There were some flaws with that,

10:22

you know, which definitely have been incorporated

10:24

into the way we think about this.

10:25

You know, we can't be starting. You know,

10:27

75 year old women on hormone replacement

10:29

therapy who went through menopause at 50. You know,

10:31

you really, if you're gonna start it, you need to start it early.

10:34

You know, we still recommend using the lowest effective

10:36

dose and tapering it off as soon as

10:38

your symptoms be, you know, begin to resolve.

10:41

So, you know, I think it just really takes a

10:43

thoughtful approach to sort of picking

10:46

the right patient for it and, using.

10:48

Sort of safe methods of it. But you

10:50

know, what we wanna kind of get across is that hormone

10:53

replacement therapy. Doesn't need to be a no

10:55

for everybody. It's, we

10:57

don't believe it's gonna help protect you.

10:59

But you know, for most people,

11:01

if you're having really severe symptom,

11:04

a very small, absolute risk

11:06

increase is something that most people

11:09

are willing to take

11:11

in order to feel dramatically better.

11:14

Do you, do you think that we'll get

11:16

new research at any point? Because you,

11:18

you said there's not a lot of new research.

11:20

Do we need new research? Do we need

11:22

some of those studies were done in men?

11:24

I do think that there's value of, ongoing

11:26

research in this area and really in.

11:28

You know, women in general and in the

11:30

intersection of reproductive health and cardiovascular

11:33

disease. In general, these are

11:35

topics that are, grossly understudied.

11:38

But you know, I think. The

11:40

landscape is really different now. We

11:43

have, you know, different recommendations

11:45

at this time for point for

11:47

cholesterol management, blood pressure

11:49

management. You know, we have new strategies

11:51

for weight reduction. So

11:53

I think that really the primary prevention

11:56

landscape has changed a lot, as

11:58

has the, you know, the availability

12:01

of different, formulations of

12:03

hormone replacement therapy. And so,

12:06

you know, I think certainly, there would be

12:08

value in reassessing

12:10

risk in the modern era. Much

12:14

is

12:14

made of the fact. And as I understand

12:16

it, basically what happens in menopause as

12:19

our estrogen depletes is that we are

12:21

catching up to men in risk. Yes.

12:23

And that's sometimes portrayed as we are

12:25

having a huge surge in our risk.

12:28

And I think as you point out in your paper,

12:31

the more, conditions that you have

12:33

that go along with if you're diabetic,

12:35

metabolics, and all this thing complicates

12:37

it. But for the average

12:39

woman, who is worried about this?

12:41

What is your advice for her, whether

12:44

she's on hormone therapy or not?

12:46

I mean, I would say a few things.

12:47

Number one, you know, talk to your

12:49

physicians or or care team members

12:52

even before you

12:54

go through menopause and start thinking about how you

12:56

might wanna approach it. And certainly as you be,

12:58

begin to develop symptoms. You know, I think really

13:00

the goal of our, you know, what

13:02

our job is as. As healthcare providers

13:05

is to help our patients make informed decisions not to

13:07

tell them what they need to do. And

13:09

so we wanna make our sure our patients have all the information

13:12

that they, they need in order to make a good

13:14

decision. Number two, it is

13:16

absolutely true that all those cardiovascular

13:18

risk factors start to increase, definitely

13:20

during menopause, but even as patients begin

13:23

to approach menopause. So

13:25

I think that's really a good time to engage

13:28

not only with your ob gyn, but with your primary

13:30

care provider or your cardiologist

13:33

to start really monitoring your weight,

13:35

monitoring your blood pressure, monitoring your

13:37

cholesterol, monitoring your blood sugars, and

13:39

if you start to see negative changes

13:41

on those things, there are a lot of things that we can

13:44

do to sort of, you know, temper

13:46

those changes and keep. Cardiovascular

13:49

risk, kind of healthy trajectory. And obviously

13:52

that includes dietary changes

13:54

and exercise, but of course there are also

13:56

lots of, medication options that are available

13:58

as well. So we really wanna be proactive,

14:01

particularly around that time of

14:03

life when we see a lot of changes in that metabolic

14:05

risk.

14:06

And maybe this is going a little bit too far away from

14:09

your area of expertise, but you

14:11

mentioned, feminine forever and,

14:13

and the whole, you know, estrogen deficiency

14:16

narrative in your paper. And I do feel

14:18

we're returning to that in a strange way, it

14:20

seems in the culture. I

14:23

sort of wondered what you thought of that from

14:25

your area of expertise and

14:27

if this sort of deficiency narrative

14:29

exists in cardiology.

14:31

As a field of cardiology, again,

14:33

sort of the whole intersection

14:35

of reproductive hormones and,

14:37

and cardiovascular disease has been grossly

14:40

understudied and, undervalued.

14:42

So I think it's actually an area right now that

14:45

has a huge amount of interest, which

14:47

I think is very exciting for women

14:49

because, Pregnancy hormones, reproductive

14:51

hormones around the time of menopause very strongly

14:54

interact with both short and long-term cardiovascular

14:56

risk.

14:57

So, I hope to see increased

14:59

funding through the, you know, n i h

15:01

and other institutes to help us better understand

15:03

this. And definitely the conversation

15:05

is picking up within cardiology to.

15:09

Really trying to better understand how

15:11

these things interact with your long-term risk

15:13

and you know how we need to be thinking about them

15:16

and, and incorporating them into our

15:18

care of patients.

15:20

And one thing I'm seeing a lot more lately is

15:22

they're talking about hot flashes as

15:25

if you have really bad hot flashes and night sweats

15:27

as that being sort of a biomarker

15:29

for future cardiovascular problems.

15:31

And if that is really bad, I mean it always used to be

15:34

like, haha, I have hot flashes and you know,

15:36

it takes some hormone therapy. But it seems like

15:38

there's a, a link there. So can you sort

15:40

of explain where, where that, your understanding

15:42

of that is?

15:43

Yeah, I mean there does seem to be some,

15:46

length area that may be some,

15:48

physiological marker

15:50

of, you know, the hormone changes and,

15:52

associated

15:53

risk. So I think it's, it's

15:55

not well, uh, studied

15:58

and well understood, but certainly there

16:00

does seem to be a relationship

16:02

there.

16:02

And so, you know, I definitely think that's an area.

16:06

Ongoing evaluation. You know, we

16:09

honestly, when we do our cardiovascular studies, oftentimes,

16:11

you know, we don't even ask about these reproductive

16:14

factors better yet, severity

16:16

of them. And so it's a real missed opportunity

16:19

to, you know, when we, we take patients

16:21

with premature, you know, cardiovascular events.

16:23

We don't even ask them when they went through menopause

16:25

or if they had, you know, pre-eclampsia during pregnancy.

16:28

So it's a real opportunity for us to start

16:30

gather that information where we're doing these many

16:32

thousands of people trials to start to tease

16:35

out how those symptoms,

16:37

how those risk factors really relate to

16:39

the long-term events.

16:41

Do you have any advice for people who are

16:44

going through this who may read medical studies

16:47

in the paper? Because I know the media are notorious

16:49

for getting this stuff wrong. Yeah. I mean, that's what

16:51

happened with the Women's Health Initiative and It's

16:55

happened over and over and over. But do you have any advice

16:57

for people when they're reading stories about

16:59

it,

17:00

how it's portrayed how to, how to. Read

17:02

it with a certain amount of skepticism.

17:05

I think it's very valuable

17:07

to, you know, be invested

17:10

in understanding the issue,

17:12

particularly when, you know, when it, it, you know, personally

17:15

pertains to you and to

17:17

obtain the information you can so that you have

17:19

kind of a framework for having the discussion

17:22

with your healthcare team.

17:23

I think it's really important to remember though, that,

17:26

you know, Things that are published in the lay

17:28

media can have extreme amounts

17:30

of bias or, or bent

17:32

just depending on what the source is of

17:34

the publication. Can definitely,

17:37

you know, bend not, not bend

17:39

the truth, but sort of, portray, data

17:42

in, in different lights, just sort of

17:44

depending on what the

17:46

bias of the writer is. So

17:48

I think it's important to gather that information

17:50

to kind of build your framework and then have

17:53

an honest conversation with a healthcare provider

17:55

that you trust, because they're

17:57

going to have the experience. Really

17:59

reading all of the medical literature and

18:01

knowing how to sort of incorporate

18:04

that in hopefully a less biased

18:06

manner and be able to kind of help distill

18:09

that down, that you can

18:11

use that information to build off of the framework

18:13

that you have.

18:14

And since I have you on a call, I'm

18:16

52, turning 53.

18:19

I'm pretty healthy. Got a few little things

18:21

that I'm working out, but what's your best advice

18:23

and not on hormone therapy? What's your best advice

18:25

for me to keep my heart going?

18:28

Absolutely. So, you

18:30

know, obviously if you smoke,

18:32

stop smoking and if you don't smoke, don't start.

18:35

That's the most important thing you can do.

18:36

What about vaping? What about vaping?

18:38

No, we would definitely recommend staying away from

18:40

vaping as well. There's a lot of people who think

18:42

vaping is, is fine.

18:44

We were real, I think we're really hopeful that it would

18:46

be a much safer alternative

18:48

to smoking, but it doesn't really seem to be the case.

18:50

And then, you know, right around this time you are. Tend

18:53

to see your metabolism slow down, your weights

18:55

start to go up. That can be really frustrating for

18:57

patients who have never had a problem

18:59

with their weight and all of a sudden it's really hard.

19:02

So I think watching your diet can be really

19:04

helpful for that. I usually recommend

19:06

a Mediterranean diet with lots of fruits

19:08

and vegetables, whole grains, lean meats

19:11

like fish and chicken. And you really have

19:13

to think about portion control because unfortunately

19:15

it's really hard to exercise off weight. It

19:17

really comes down to portion control. And

19:21

I also usually recommend to really pay attention

19:23

to what, what calories you're drinking. So it's

19:25

really easy to drink a lot of calories through soda,

19:28

sweet tea, Gatorade, sweetened

19:30

coffees, things like that. And you don't really

19:32

calculate those in your brain when you're thinking about

19:34

what you ate for the day. but those are calories

19:37

that can really sneak in. Definitely

19:39

stay active with exercise. If you can

19:42

exercise most days of the week that you

19:44

know, not only helps prevent weight gain, but

19:46

it also helps your blood pressure, helps your cholesterol,

19:49

it helps your blood sugars, it helps your

19:51

overall cardiovascular risk. And

19:53

then I would say, you should definitely be speaking

19:55

with your healthcare provider, really on an annual

19:58

basis. Really around the time of

20:00

menopause, I tend to do a little more,

20:02

intensive screening for diabetes

20:05

and cholesterol. And blood

20:07

pressure because those are times when those risk factors

20:09

start to go up and we

20:12

can, you know, really assess your long-term

20:14

risk of cardiovascular events and kind of determine

20:17

whether or not there's any indications we're starting

20:19

cholesterol medicines or if we just need to keep working

20:21

on diet and exercise. And,

20:23

you know, even if patients begin to develop pre-diabetes,

20:26

there are some interventions we have that can help, prevent

20:29

or delay the onset of diabetes. So

20:31

I think it's a time to really engage

20:33

with your healthcare provider, stay

20:36

active, and really be

20:38

proactive about treating all those risk factors

20:40

as they may begin to accumulate. I

20:43

was talking to my friend who's

20:44

the same age as me. She said, I think this

20:46

is a time where everything is in flux

20:48

and your body's kind of like really

20:50

trying to balance, right? And

20:52

so this is the time

20:54

when things can. And

20:56

get worse. Yeah, but they don't Maybe,

20:59

maybe they can start and you can nip it.

21:01

Is that, is that, am I reading?

21:02

Is that, that's how we feel?

21:04

I think that's absolutely true. I mean, you know, as

21:06

you go through menopause, you can start to develop high blood

21:08

pressure or high cholesterol, and you feel fine

21:10

with those things. You have no idea that those issues

21:12

are even going on. And it's important to recognize

21:15

and treat them early.

21:16

because if we treat them, it's really gonna help keep your

21:18

heart and your brain healthy over the long term. If

21:21

they go unchecked for a long time, that's

21:23

where you're really gonna start to get into trouble. So,

21:26

you know, we wanna identify those right away and

21:28

so we can really kind of keep you on

21:30

a healthy trajectory over the long term.

21:32

So menopause isn't a direct line to heart

21:35

disease and hormone

21:37

therapy isn't the cure

21:39

I think that is a good summary.

21:42

Thank you. I'm really glad I talked to

21:44

you today. That's great. Is there anything that I, I'm,

21:46

I mean your whole career and everything you've ever done, but

21:48

is there anything in this part that you think I should

21:51

have asked or you'd like to say?

21:53

No, I think that that was great. It really summarized

21:55

our work really well.

21:56

Thank you so much for joining me. If

21:58

you like this conversation, I hope you'll check

22:00

out some of my other interviews on the Hot

22:03

Flashing Podcast, subscribe,

22:06

give a rating, maybe a review, and

22:08

come back for more next week. Hot

22:13

Flash Inc. Was created and is hosted by Annemarie

22:15

McQueen, produced and edited by Sonya Mac.

22:17

The information contained in this podcast is

22:20

intended for informational purposes only, and is not

22:22

intended for the purpose of diagnosing, treating, curing,

22:24

or preventing any disease. Before using

22:27

any products referenced on the podcast, consult

22:29

with your healthcare provider, read all labels, and

22:31

he all directions and cautions that accompany the products.

22:34

Information received through the podcast should not be

22:36

used in place of a consultation or advice. Care

22:38

provider. If you suspect you have a medical

22:40

problem, ie. Menopause or anything else or

22:42

any healthcare questions, please promptly

22:44

see your healthcare provider. This podcast,

22:46

including Annemarie McQueen and any producers

22:49

or editors disclaim any responsibility from

22:51

any possible adverse effects from the use of any

22:53

information. Contains herein opinions

22:55

of guests on this podcast. Are their own, and the

22:57

podcast does not endorse or accept responsibility

22:59

for statements made by guests. This podcast

23:02

does not make any representations or warranties

23:04

about a guest's qualifications or credibility.

23:06

This podcast may contain paid endorsements

23:08

and advertisements for products or services. Individuals

23:11

on this podcast may have direct or indirect financial

23:13

interest in products or services. Referred to here

23:16

in this podcast is owned by Hot Flash,

23:18

Inc. Media.