Hi, I’m a 48 year old female who has struggled with PCOS my whole life. I’ve taken 200 milligrams of oral progesterone for several years now. I also take 45 milligrams of Armour Thyroid, and my TSH is 3.87, and my free T3 is 3.22. I’ve had symptoms of: hair loss, dry eyes, vaginal dryness, very low sex drive, and irritability. I just had a saliva test done which revealed very low estradiol levels, and low DHEA along with borderline low testosterone. The practitioner I have, put me on sublingual drops with a dosage of 80/20 ratio of biased being– which is interesting, .8 milligrams of an 80/20 bias, .8 milligrams of testosterone, 25 milligrams of oral DHEA and kept me on my 200 milligrams of oral progesterone. My question is, is this a safe way to administer my Biest and testosterone? Do you agree with the dosing amounts? Any advice would be appreciated. Thank you for your time, Heidi.
We do not like the idea of taking Biest and testosterone orally. Taking BHRT in a sublingual form is ok because the intention is to avoid the digestive tract and liver. However, for Estrogen and Testosterone, we prefer to use a transdermal cream instead. Also, in this case, the dosing is too low. Her Biest needs to be gradually increased, but with caution in order to prevent any bleeding or spotting.
PYHP 081 Full Transcript:
Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress your Health Podcast, I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson.
Dr. Maki: So, we’re going to dive right back in. We have another listener question. Actually, this is a reader question from a post on our website. What is bias? This is from Heidi. Dr. Davidson, why don’t you go ahead and give it a read.
Dr. Davidson: Oh, sure. Sure. So, this is from Heidi. “Hi, I’m a 48 year old female who has struggled with PCOS my whole life. I’ve taken 200 milligrams of oral progesterone for several years now. I also take 45 milligrams of Armour Thyroid, and my TSH is 3.87, and my free T3 is 3.22. I’ve had symptoms of: hair loss, dry eyes, vaginal dryness, very low sex drive and irritability. I just had a saliva test done which revealed very low estradiol levels, and low DHEA along with borderline low testosterone. The practitioner I have, put me on sublingual drops with a dosage of 80/20 ratio of biased being– which is interesting, .8 milligrams of an 80/20 bias, .8 milligrams of testosterone, 25 milligrams of oral DHEA and kept me on my 200 milligrams of oral progesterone. My question is, is this a safe way to administer my Biest and testosterone? Do you agree with the dosing amounts? Any advice would be appreciated. Thank you for your time, Heidi.”
Dr. Maki: So, yes, there’s a lot to dissect there. This is– and I actually responded to her on the website. I asked her a question, is her progesterone, is it Prometrium or is it bioidentical progesterone? She came back to say that it was actually 200 milligrams of Prometrium. She had asked why we don’t– because in my response to her, I said, we don’t typically prescribe or don’t really recommend Prometrium and she was wondering why. So, Dr. Davidson, why don’t you say why you don’t prefer Prometrium?
Dr. Davidson: Well, Prometrium is still technically progesterone, but it’s an instant release, and you can’t– it only comes in a couple of forms, 100 milligrams and 200 milligrams. Hence, she’s on the 200 milligrams. You can’t really move that around and when you’re working with hormones, especially bioidentical hormones, even though we’re all humans, we’re all still so incredibly unique, that it’s not one size fits all. So, that’s where with progesterone, I like to do a sustained release. What stays in your system a little longer, it definitely the sustained release helps with women staying asleep. So, she’s a 48-year old female. She’s maybe had struggled with PCOS. She’s definitely in some kind of perimenopause phase right now. So, she’s probably having trouble sleeping, even though it doesn’t have that on her symptom list but the sustained release helps stay in the system, it helps you stay asleep, and then you can– because I feel like 200 maybe a little high for her, because Heidi had also– because there’s a lot to this that we’re going to break it all down for you. But Heidi had also responded to Dr. Maki saying that she’s still cycling, meaning that she’s still getting her period, meaning that she still has a uterus. So, with that Prometrium being that high, it might be kind of throwing her cycles off a little bit, too.
Dr. Maki: Yes. Maybe either too frequent or too long or kind of increasing– it can do– we talked about on the last podcast and previous ones as well, that progesterone can– especially at 200 milligrams of Prometrium which we tend to find– maybe because of the instant release, we tend to find that it’s a little stronger, women have a harder time tolerating it than the bioidentical oral progesterone.
Dr. Davidson: So, just to kind of back up a little bit. So, Heidi is cycling. So, that means she’s getting a period every– with PCOS, it could be every 28 days, or it could be over 288 days, PCOS, Polycystic Ovarian Syndrome can throw the periods off. But she does say she’s cycling, and she did a saliva test which tested her hormones. Then her estradiol was very low and her DHA was low, and her testosterone was borderline low. Now the DHEA and the testosterone throughout, let’s say, aside from Heidi on a perfect 28-day cycle on a cycling female, DHA and testosterone pretty much stay the same the whole 28 days. Round ovulation that testosterone comes up and that DHEA. But pretty much whatever day you test those hormones, the DHA and the testosterone in that 28-day cycle are going to be relatively pretty consistent. Where the estrogen changes.
When you’re on your period, day one to five, you basically have no estradiol, no estrogen in your system, no progesterone either, because that’s what causes the lining of the uterus to slop off, hence, a period and then the estrogen comes up, estrogen spikes on day 12, in a perfect 28-day cycle, and then comes down slowly until the next period. Progesterone really doesn’t come up in levels in the bloodstream until you hit ovulation. So, typically, you’re going to see levels of progesterone at a good level between day 14 and day 28. So, that’s where her very low level of estradiol, it really depends on when she had her saliva test done, if she did it, because there’s a couple of different saliva tests. You can do an instant saliva test, where I test, one, my saliva all day long, a morning saliva sample, at noon, and afternoon and evening time and then just send it in. Or there’s some saliva tests that you can do that are 28 days that you can follow the pattern of someone’s cycle. It looks like on hers that she just did just a one time saliva test, like a one day test. So, it just really depends on where she is in her cycle to really determine if she has low levels of estradiol.
Dr. Maki: Yes, right. When the history of PCOS too, it’s a little strange or a little bit interesting that her DHA and testosterone are both low on the saliva test. I said back in my comment that I would be interested to see what the– not so much the estradiol level because we could assume at 48 that are estradiol level was probably tapering off, just anyways, even though the fact that she’s still cycling, it’s going to be high enough because she’s still cycling. So, there– she’s still meeting that estrogen threshold. But the fact that her DHA and testosterone are both low on the saliva test, I want to see a blood test just to confirm or double check to see if that’s actually true because giving our 25 milligrams of oral DHEA with a little bit of testosterone, if she got a history of PCOS, I don’t really think those two things are really necessary for her.
Dr. Davidson: Exactly. So, just to back up, she said– Heidi has been struggling with PCOS her whole life. That’s Polycystic Ovarian Syndrome and we have some blog posts. We actually have some podcasts on PCOS if you want to learn a little bit more about it. But one of the hallmarks of PCOS, it’s a huge spectrum of hormones going this way and that way, but one of the main hallmarks is having higher levels of DHEA and testosterone. So, if Heidi is struggling with PCOS, just like Dr. Maki said is, why would her DHEA and testosterone be low or borderline low? So, it makes you think maybe she doesn’t need that because just on a side note, is, DHEA is available over the counter. It’s a dietary supplement. You can go down to GMC, you can go to Whole Foods and you can buy DHEA.
So, one thing that I find with females is 25 milligrams of oral DHEA is a lot of DHEA. But you’re only going to find 25 milligrams pretty much over the counter. There’s 5 and 10 milligrams, sometimes 50 milligram, 15 milligrams, those are a little bit harder to find just running down to Target or running over to Whole Foods to buy it. But I will tell you, 25 milligrams of oral DHEA is high.
Dr. Maki: Yes. Especially for a woman that has a history of PCOS, and one of her symptoms is hair loss. All right, so that’s another reason even besides the PCOS, giving her testosterone and DHEA could be compounding the fact that she’s losing hair, and we don’t really know what her stress level is. Stress level is going to exacerbate that hair loss as well. So, like you, we both– for women, most of the time prescribed usually 5 to 10 milligrams of DHEA, 25 is getting up there. Almost every woman that you give 25 milligrams to, they’re going to have symptoms. Either they’re going to– skin is going break out. They’re going to start growing hair on their chin, around the areola or on the abdomen, or they’re going to start having hair loss issues, almost invariably. It happens more often than it doesn’t.
Dr. Davidson: So, but now, for Heidi’s question, she is doing sublingual drops, that means she’s putting it under her tongue. She’s not taking an oral capsule of estrogen and testosterone combined together. So, with estrogen and testosterone on a female, you never really truly want to take an oral version. There’s a few exceptions with an estrogen with a bias taking it orally as a capsule. But truly, you don’t want to do too– you really don’t want to do oral forms of estrogen and oral forms of testosterone. One, because it’s very difficult to absorb it digestively anyway and two, because it’s very hard on the liver because a liver has to process that. So, definitely doing in a way that you bypass the digestion is the best way to absorb estrogen and testosterone bioidentically. So, doing a sublingual, sublingual is one way. I do find that the sublingual especially the drops and really the troches because you can put these little troches in. You have to let them sit there for like 15 minutes to dissolve, they taste pretty awful. A lot of people get a little hurried with that and end up just swallowing it. So then it becomes, a sublingual turning into an oral. So, you have to be careful with that or we do a transdermal cream.
Dr. Maki: Yes, yes. We prefer to do for both the estrogen and the testosterone but again, the other question that I have, too, is if she’s cycling and what is she taking estrogen for? Now, granted, the dose is less than a milligram, .8 milligrams, that’s fine. But if she’s still cycling, she’s not really a candidate. Maybe she’s having– she didn’t say in her question about having any hot flashes of any sort. So, if she’s not, then that’s a really tough position for woman. If she’s still cycling but having lots of hot flashes, then they’re kind of a candidate because that means her estrogen level is going down. But two things, the DHEA testosterone because of the PCOS, the oral testosterone and the estrogen. Estrogen is not really necessary because she’s still cycling. Of course, the Prometrium, we’re not a fan of that. So, in some ways, if she came to see you and I, we would kind of scrap all of it. We would just kind of start over from scratch.
Dr. Davidson: I would definitely kind of– there’s too many variables going on in here especially with Heidi’s question is I would– and I do consider when you’re working with a female’s hormones is the DHEA and the testosterone are like the frosting. You never start with that first. You got to make the cake first and then you add the little details on top. So, I would definitely keep some of these variables. Because I always– I love math, which is why I love the numbers on this, is you think of things like an equation. If you have all these different variables in Heidi’s equation, you won’t know what the reaction is coming from. So, if you keep the variables very tight, then you know what positive or negative reaction she’s getting from it. So, just like Dr. Maki said is I would take out the bias, I would take out the testosterone, I would take out the DHEA, for now, that’ll be like the frosting on our cake. Probably go back to that progesterone, take into account what was the PCOS, what was the issues with the PCOS she had had her whole life. Was she missing periods? Was she having high androgens? Was she having weight gain? What is the issue with the– was she having a lot of cysts? Hence, the PCOS diagnosis. Then, one thing that we really probably would come back to it the very beginning is looking at that thyroid dose.
Dr. Maki: Yes, absolutely. That’s one of the things I responded back to her, too, that the TSH is 3.87. Now, her free T3 is decent at 3.22. But that TSH, she might– and 45 milligrams of Armour, she might on as not been taking it. We would probably– more than likely would switch it to a compounded thyroid but if we kept her on Armour or some kind of NDT, Natural Desiccated Thyroid. NDT is– there’s a few different kinds. There’s Armour, there’s Westhroid, there’s Nature Thyroid, there’s NP Thyroid, those are all kind of collectively the same type of thing. We probably triple that dose, if not quadruple that dose.
So, she’s on three quarters of a grain, a grain is 60 milligrams. So, she’s on three quarters of a grain. If she came to see me, I probably increased her to two grains with a TSH of 3.87. Now, we don’t necessarily pay attention to the TSH as a standalone test. But when she’s on medication and she– you have a TSH at 3.87, her dose needs to go up. Okay, that number should be closer to one. The reference range that I gave her that we like to go by for the TSH is, let’s say, .7 to 1.3, so it’s either slightly below one or slightly above one. It’s almost at four and she’s actually on medication.
Dr. Davidson: Exactly. I know that Dr. Maki just said a whole bunch of things about her thyroid just now. So, just to break it down. The TSH is the Thyroid-Stimulating Hormone, and there’s a huge reference range on Labcorp Quest, any lab you go to, there’s a huge reference range, it’s like .45 to four and a half for TSH. So, you look at Heidi’s and she’s at 3.87. Her doctor might say, “Hey, your TSH is a normal range. You’re fine, you’re fine, you’re fine,” but she doesn’t feel fine. Because honestly her symptoms: hair loss, dry eyes, irritability, low sex drive, she’s probably having fatigue is could be coming from her thyroid and thyroid is upstream from the female reproductive system.
So, instead of chasing your tale trying to treat these female hormones, go upstream, treat the thyroid first and then go downstream and treat the remaining hormones that need to be balanced. So, just like Dr. Maki said, a TSH of 3.87 we do believe is too high, and the way the TSH works, it works in a negative feedback loop. So if a TSH, thyroid stimulating hormone, which comes from the brain is elevated, that means the thyroid function is low. Hence, if you see a TSH at like, .02 because it’s very, very low, that means someone’s thyroid function is possibly too high. Just like Dr. Maki said is I never rely on a dose of thyroid based on a TSH level. But just to kind of give you a little background, seeing her TSH level at 3.87 being technically what we would consider high, that means her thyroid function is low.
Dr. Maki: Yes, right. So, there’s– what that means is there’s basically a lot of room for improvement to kind of modify and tweak her dose. When it comes to thyroid, you don’t want to do too much too quickly. But I would definitely give her kind of a quick– a fairly initial increase and then probably retest in somewhere between a month to two months, see how she feels and really try to get that TSH down, like you said, down closer to one. The free T3, ironically enough, the free T3 is actually pretty decent at 3.22. What we like to see is a low normal TSH, so again, something around one and a high normal free T3. Her free T3 isn’t bad, but her TSH is high normal and those things need to go in opposite directions.
Dr. Davidson: So, like Dr. Maki said, and of course, I love the numbers. She’s on .75 or 3/4 grain of Armour thyroid, which is 45 milligrams. The thing with Armour thyroid is it’s a desiccated thyroid, it’s natural, it’s from porcine or a pig’s thyroid. It does have the T4 and the T3 component into it. So, that’s what differentiates it from Synthroid or levothyroxine, which is just a T4 only medication. But a, Armour thyroid or any kind of porcine thyroid has a, basically a 4 to 1 ratio of T4 to T3 in it. So it basically 45 milligrams, which is .75 grains that equals 28.5 micrograms of T4, with 6.75 micrograms of T3 in that 45 milligrams.
So, that sounds all in good. But just like Dr. Maki was saying has her free T3 really isn’t too bad? 3.2, I’d love to see it at 3.8. But that’s not– it’s not too bad. It’s not down there at 2.2 or 1.7 where I see them all the time. We don’t know what her free T4 is. So, let’s say we did raise up her Armour thyroid from 45 milligrams to 120 milligrams. Let’s say we raise it up. The unfortunate thing with porcine thyroid, now again, I love porcine thyroid, but the unfortunate thing is when you raise it up, when you raise up the dose, you’re raising up the T4 and the T3 and you can’t balance that because I have some people, they absorb their T4 so great, but it doesn’t convert to T3, so I have to add T3 into their mix. So, that would be one thing I would be concerned about is, “Hey, what’s your free T4 level?” As we’re raising it up, if her free T3 goes up too high, then you have a little disproportionate ratio between the T4 and the T3, if that makes sense.
Dr. Maki: Yes, right. Yes. So, we know that NDT is popular. We do use it all the time. In this case, what would be really simple for– and we’re not giving any medical advice. So, disclaimer there. This is just for educational purposes, so everybody can learn and understand how we– not necessarily how we do it, but just a different perspective. A very simple thing for Heidi to do would be, for her to just add a second pill. So, she goes from 45 to 90. Then in another amount of time, she could add a third pill in the morning. Then she collectively has tripled her dose in the matter of a few weeks to a couple of months based on how she feels, and then we do lab testing on the back end of that. So, she’ll know– the patient always knows when they’re under medicated or over medicated. Okay. The patient always knows at least when they’re over medicated, they know before the doctor does. They know in a lot of cases, they know even regardless of what the lab test show. Okay. If you’re taking medication, you’re tight treating a dose up like that, you start getting anxious, you start getting jittery, you start getting all the symptoms of hyper thyroid, then you know that whenever you’re taking and as long as those symptoms are kind of prolonged, meaning they’re happening on a daily basis, then you know the thyroid dose is too high, and then you have to go back down a little bit. Now granted, that’s a very kind of on the fly kind of way to achieve a thyroid dose, but it’s something that we do quite often and the patient knows when they start to feel better, they actually have the subjective feeling, say, “You know what, my energy is better, my mood is better, my cycle is better. My digestion is better.” All those things because as we know, the thyroid controls literally everything in your body. When the thyroid is functioning properly, then everything else will function at least a little bit better as well.
Dr. Davidson: Exactly. I know a lot of doctors are a little hesitant to do that with thyroid, like, “Hey, let’s raise it up. Let’s increase it up.” Because they’re afraid of putting their patient into “hyperthyroid.” But all of our patients and all of you listeners, you’re very well educated. You know what you’re doing, you know how you feel. Just like with our patients, if they ever felt hyperthyroid, they can get a hold of us in an instant. They don’t– we’re not on– they can get ahold of our assistant, they can get ahold of us. It can be 10 o’clock on a Thursday. So that if we needed to readjust that dose, we can do that very quickly. I think sometimes, it’s a little harder for doc’s when there’s– maybe they have– don’t have the right staff or they’re super busy, and they’re– I hear from patients all the time, they’ll say, “My other doctor, I couldn’t get ahold of him for three weeks, and I was bleeding or I was having these symptoms.” That might be something more about their system. But I definitely– we’re not hesitant, but we definitely work very, very closely with our patients in terms of raising up their thyroid.
Dr. Maki: Yes. Because we focus so much on those types of things, the things that we prioritize are bleeding. If woman is on hormones and she’s bleeding, which is normal, it happens all the time. If a woman has her uterus, bleeding is kind of when you’re taking hormone therapy is kind of par for the course, but we want to know about it. So, we want to give specific instructions if that does happen. Then of course, any type of potential thyroid related symptoms: heart palpitations, the anxious, the jittery, insomnia. Now, when we do a compounded thyroid, this would– she would be definitely a candidate, what we typically like to do is compounded sustained release thyroid. Those types of symptoms don’t happen very often. Our job as the practitioners to get the dosing right. Usually, we’re pretty good about that so, we keep them out of that– the hyper thyroid symptoms. But again, as we titrate over the period of a couple of weeks to a couple of months, their subjective response does improve. They will– they tell us that. They say, “Yes, you know what I feel better. I have–” maybe they don’t feel stimulated, like they just drink a big cup of coffee and they’re like buzzing around. But they have a nice level of sustain energy, and they do– subjectively, they do feel kind of better overall.
Dr. Davidson: Exactly. So, hopefully, we’re not beating a dead horse here, but we would definitely first, scale back, kind of reduce down some of the variables in Heidi’s equation. Then look at the thyroid, readjust the thyroid, try to readjust that T4 and that T3 and get that TSH down to basically low normal. Then we kind of go into those hormones. I would probably still keep her on some form of progesterone because if she’s had some type of PCOS her entire life, progesterone is amazing for PCOS. So, we would definitely probably just keep her with that. Maybe readjust the dose, do it is a sustained release. With compound, you can do any milligram you could possibly want. I would say, being a 48-year old female, I mean, I’m going to be 47 pretty soon, so I know what it’s like to be in your late 40’s and [crosstalk] we work with–
Dr. Maki: Did you take your progesterone today?
Dr. Davidson: I don’t take it in the morning. You know that.
Dr. Maki: Yes, of course. You take it at night, of course. I’m teasing you.
Dr. Davidson: But know that you know we’ve also worked with a lot of women of all ages, perimenopause, menopause, PMS, PCOS, so I– if she’s having the vaginal dryness, we want to– we– and the low sex drive, we want to address that the low sex drive can sometimes be about energy, because sometimes when a female is tired, the last thing you want to do is go have sex because you’re tired. So, the thyroid might help a little bit with that. But the vaginal dryness is probably truly hormonal. So, then instead of giving her as a sublingual bias, where that’s just going– where the sublingual goes more into the bloodstream, rather than acutely focusing on the vaginal tissues, we might actually do more of an estriol or an E3 vaginal application to help with that vaginal dryness, and that works so easy.
Dr. Maki: Yes, right. Either a cream or a suppository works very well.
Dr. Davidson: Safe and fast.
Dr. Maki: Yes, yes. So again, we would kind of scrap pretty much the entire thing. So, just to kind of rehash that, okay, so we would do, we would increase her nature thy—excuse me, her Armour–
Dr. Davidson: Or switch it to a compound.
Dr. Maki: Or switch it. But she already has the nature thy– the Armour. So, the easiest thing would be to start with that and to increase. If she was open to switching, then that’s great. Get rid of the bias and the testosterone sublingual, get rid of the 25 milligrams of DHEA. Switch from 200 milligrams of Prometrium to probably 100 milligrams of bioidentical oral progesterone, sustained release progesterone.
Dr. Davidson: Or maybe even 125 or 150.
Dr. Maki: Yes, right. Because 200 milligrams of Prometrium compared to 200 milligrams of– that’s actually a good point, 200 milligrams of oral bioidentical progesterone it’s not the same thing. I’m surprised that she can even tolerate the 200 milligrams of Prometrium. That’s a dose that most women really can– they can barely handle the hundred, let alone the 200. Her irritability, so the DHEA, the Prometrium and the testosterone. Now, granted, the irritability part is something that we see all the time. That could be based on those three things. It could have kind of exacerbate some of that irritability and she’s mad at her husband all the time.
Dr. Davidson: Well, maybe he deserves it. Just kidding. But no, exactly. Excuse me. Maybe you could explain a little bit about that, the having high levels of progesterone or Prometrium, taking such a high dose, what kind of symptoms, like why she wouldn’t tolerate it?
Dr. Maki: Yes, right. So, what we hear most often is that’s where the– and she doesn’t claim of any of that. So, maybe she’s not having any of those symptoms. It says she’s been on it for years. So, she’s obviously tolerating it fine. But usually right away, they can’t sleep, they’re anxious, they’re jittery, they’re bloated.
Dr. Davidson: They’re depressed. Having high levels of progesterone can make you really lethargic.
Dr. Maki: Yes. Lethargic and kind of very melancholy, very– kind of go to a little bit of a dark place. We do see that quite often with the Prometrium, which is why we’re just not really fans of it. We just seem–
Dr. Davidson: I see weight gain. Women don’t want to gain weight. We work really hard not to. But definitely with a higher doses, bloating and weight gain.
Dr. Maki: Sure. Yes, yes, yes. So, I hope that is helpful for Heidi, for everyone else, there’s a lot going on there. To be honest, I think there some decent things but, we would kind of scrap– the way that we approach it, we would scrap all of it and start over from scratch. This is where less is more in this case, right, kind of simplifying a couple things, very specifically targeting a couple of key areas. The only thing that we probably not address right off the bat, like you said, is libido. I would imagine there’s probably a stress level component to that. So, as she sleeps better, as the other things kind of take effect, then gradually her sex drive should probably just come back on its own, which you should see. Because if you’re really stressed, let’s say your job is really stressful, your family is stressful, you’re exercising a lot, you got all this stress all the time, you’re not sleeping, your libido is going to disappear. So, if some of that stuff calms down and you’re getting rest, and you’re not over exercising, then the libido will come back naturally, and it won’t be so low on a regular basis.
Dr. Davidson: Exactly. You do have to admit, I’m glad that her practitioner wants to do oral– I’m sorry, wants to do bioidentical hormones. We meet so many doctors that are like, think hormones are horrible or they group them all into Premarin and Prometri– or what does that– pro– the other one they used to use all the time?
Dr. Maki: Prempro?
Dr. Davidson: Prempro. Yes, all that old school stuff. So, it is really nice that there is a practitioner out there that is open to doing bioidentical hormones and the fact, the sublingual, because sometimes they see doctors do oral estrogen and oral testosterone and we get worried about that. So, at least they’re trying to do it by bypassing the digestion, working on– and they’re not afraid of the progesterone, which is great. Hey, hey– and also doing Armour thyroid, so many doctors only want to do Synthroid or they look at you cross-eyed when you want to do something else. So, definitely this practitioner is open to all that. It’s just, like I said, it’s very individualized. We’re all so unique. What might work for one person, might not work for Heidi.
Dr. Maki: Yes. So hopefully, we didn’t talk too fast. Hopefully, you’re writing notes down or– because this one, we did talk a lot of numbers, and it’s kind of hard to keep track of. But hopefully, this gives some insight and we plan on doing more of this kind of questions are– they’re relatively easy for us to talk about. Now, we just been going on for almost a half an hour. It’s easy for us to explain, that way, the person that sends us the question, or the ones that we actually read, they get a very specific answer. But now, everyone else gets to benefit from that answer at the same time, which is why we decided to do these in the first place. So one, it makes it easy for a preparation perspective on our part. We don’t have to prepare a lot because these are the situations we deal with all the time. Now that answer can be shared with, hopefully, hopefully, tens of thousands if not hundreds of thousands of people depending on our download.
Dr. Davidson: Let’s do it.
Dr. Maki: Yes, yes, yes. So, Dr. Davidson, I think we beat this one– we did– we answered this one in every which way we could. Do you have anything else to add?
Dr. Davidson: No, no. Thank you Heidi, for all your information and for your question and for reading and listening, and to all you listeners, thank you so much.
Dr. Maki: All right. Until next time, I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson.
Dr. Maki: Take care. Bye-bye.