Bleeding on Estradiol HRT | Dr. Valorie and Dr. Maki Explain

Introduction to spotting on estradiol HRT 0:00

even when you have them on lower doses, even when you have them on lower doses, they're still spotting. And we want to they're still spotting. And we want to they're still spotting. And we want to have good doses of estradiol, but if have good doses of estradiol, but if have good doses of estradiol, but if they're bleeding, we're kind of stuck in they're bleeding, we're kind of stuck in they're bleeding, we're kind of stuck in a catch a catch a catch Bleeding on estradiol HRT. Hi, I'm Dr.

Why spotting matters on HRT 0:13

Bleeding on estradiol HRT. Hi, I'm Dr. Bleeding on estradiol HRT. Hi, I'm Dr. Valerie Davidson from the Progressive Valerie Davidson from the Progressive Valerie Davidson from the Progressive Health Podcast. Health Podcast. Health Podcast. >> Dr. Mackey from the Progressive Health >> Dr. Mackey from the Progressive Health >> Dr. Mackey from the Progressive Health Podcast. Uh so, anytime a woman is Podcast. Uh so, anytime a woman is Podcast. Uh so, anytime a woman is starting HRT or, you know, you've even starting HRT or, you know, you've even starting HRT or, you know, you've even been on it for a while, dose change, been on it for a while, dose change, been on it for a while, dose change, something like that, you always have to something like that, you always have to something like that, you always have to be a little bit concerned about some be a little bit concerned about some be a little bit concerned about some spotting or bleeding.

Starting HRT and early spotting 0:29

spotting or bleeding. spotting or bleeding. >> Yeah, so when you're starting HRT, I >> Yeah, so when you're starting HRT, I >> Yeah, so when you're starting HRT, I mean, granted, if you're on static mean, granted, if you're on static mean, granted, if you're on static dosing where you're taking the same dosing where you're taking the same dosing where you're taking the same estradiol or bias dose every day, is you estradiol or bias dose every day, is you estradiol or bias dose every day, is you don't want to spot. We do not want that don't want to spot. We do not want that don't want to spot. We do not want that endometrial lining to get thick, but endometrial lining to get thick, but endometrial lining to get thick, but sometimes when you first start HRT, you sometimes when you first start HRT, you sometimes when you first start HRT, you can have a little bit of spotting or if can have a little bit of spotting or if can have a little bit of spotting or if you're changing your dose. Not all the you're changing your dose. Not all the you're changing your dose. Not all the time, but it can happen, but we want to time, but it can happen, but we want to time, but it can happen, but we want to be aware of that. So, that's why we

When to tell your practitioner 0:51

be aware of that. So, that's why we be aware of that. So, that's why we wanted to do this podcast so we can make wanted to do this podcast so we can make wanted to do this podcast so we can make you aware of, you know, we don't want to you aware of, you know, we don't want to you aware of, you know, we don't want to spot chronically, but if does happen, we spot chronically, but if does happen, we spot chronically, but if does happen, we want to make sure that you tell your want to make sure that you tell your want to make sure that you tell your practitioner so they can adjust the dose practitioner so they can adjust the dose practitioner so they can adjust the dose or monitor. So, again, this is we always or monitor. So, again, this is we always or monitor. So, again, this is we always have to say this, this is for have to say this, this is for have to say this, this is for educational purposes, not for medical educational purposes, not for medical educational purposes, not for medical advice.

advice. advice. >> Yeah, uh you know, it's it's just one of

Troubleshooting bleeding and dose balance 1:07

>> Yeah, uh you know, it's it's just one of >> Yeah, uh you know, it's it's just one of those things, it's kind of par for the those things, it's kind of par for the those things, it's kind of par for the course if you're on hormones and you course if you're on hormones and you course if you're on hormones and you start spotting or bleeding, it's sort of start spotting or bleeding, it's sort of start spotting or bleeding, it's sort of a wouldn't say normal, like we don't a wouldn't say normal, like we don't a wouldn't say normal, like we don't want that to happen, like I said, um but want that to happen, like I said, um but want that to happen, like I said, um but it, you know, it does happen and you it, you know, it does happen and you it, you know, it does happen and you have to know how to, you know, how to have to know how to, you know, how to have to know how to, you know, how to troubleshoot and to get it to resolve.

troubleshoot and to get it to resolve. troubleshoot and to get it to resolve. >> So, to troubleshoot, usually the >> So, to troubleshoot, usually the >> So, to troubleshoot, usually the estrogen or the estradiol dose is too estrogen or the estradiol dose is too estrogen or the estradiol dose is too high or the progesterone dose is too low high or the progesterone dose is too low high or the progesterone dose is too low or the ratio between the two are or the ratio between the two are or the ratio between the two are imbalanced because and estradiol loves imbalanced because and estradiol loves imbalanced because and estradiol loves to cause that endometrial lining to to cause that endometrial lining to to cause that endometrial lining to thicken up, but the progesterone, you thicken up, but the progesterone, you thicken up, but the progesterone, you put that in there is supposed to keep put that in there is supposed to keep put that in there is supposed to keep that lining thin and keep that estradiol that lining thin and keep that estradiol that lining thin and keep that estradiol at bay. So, that that would be the first at bay. So, that that would be the first at bay. So, that that would be the first thing that you would do is readjust one thing that you would do is readjust one thing that you would do is readjust one or both of the doses of the estradiol or or both of the doses of the estradiol or or both of the doses of the estradiol or the progesterone. But most women say,

Using ultrasound to check the uterus 1:49

the progesterone. But most women say, the progesterone. But most women say, "Oh my gosh, I don't want to lower my "Oh my gosh, I don't want to lower my "Oh my gosh, I don't want to lower my estradiol. I feel so good. I love it, estradiol. I feel so good. I love it, estradiol. I feel so good. I love it, but I don't want to be spotting." So, but I don't want to be spotting." So, but I don't want to be spotting." So, then you may want to maybe do a then you may want to maybe do a then you may want to maybe do a transvaginal ultrasound cuz it might not transvaginal ultrasound cuz it might not transvaginal ultrasound cuz it might not even be that that endometrial lining is even be that that endometrial lining is even be that that endometrial lining is thick. It could be there's polyps.

thick. It could be there's polyps. thick. It could be there's polyps. Polyps are very common. They're Polyps are very common. They're Polyps are very common. They're non-cancerous. They're completely non-cancerous. They're completely non-cancerous. They're completely benign, but they're annoying. They cause benign, but they're annoying. They cause benign, but they're annoying. They cause spotting. There could be fibroids, which spotting. There could be fibroids, which spotting. There could be fibroids, which fibroids are pretty common as well. So fibroids are pretty common as well. So fibroids are pretty common as well. So doing a transvaginal ultrasound, I think doing a transvaginal ultrasound, I think doing a transvaginal ultrasound, I think is a really good idea to get an idea of is a really good idea to get an idea of is a really good idea to get an idea of what's going on with the inside of the what's going on with the inside of the what's going on with the inside of the uterus.

Risks of uterine cancer and ongoing monitoring 2:18

uterus. uterus. >> Yeah, cuz at the end of the day, you >> Yeah, cuz at the end of the day, you >> Yeah, cuz at the end of the day, you know, what we're um trying to make sure know, what we're um trying to make sure know, what we're um trying to make sure that we don't put a woman in a that we don't put a woman in a that we don't put a woman in a compromised situation. The main risk of compromised situation. The main risk of compromised situation. The main risk of HRT is uterine cancer. Uh you know, um HRT is uterine cancer. Uh you know, um HRT is uterine cancer. Uh you know, um so that's why you know, spotting is kind so that's why you know, spotting is kind so that's why you know, spotting is kind of like a little bit of a snapshot that of like a little bit of a snapshot that of like a little bit of a snapshot that isn't going to be immediate. You get isn't going to be immediate. You get isn't going to be immediate. You get some You start in some hormones, a month some You start in some hormones, a month some You start in some hormones, a month later you got some spotting or bleeding.

later you got some spotting or bleeding. later you got some spotting or bleeding. You don't have cancer. You don't have cancer. You don't have cancer. >> It doesn't happen overnight, but it's >> It doesn't happen overnight, but it's >> It doesn't happen overnight, but it's that long It's having it more frequently that long It's having it more frequently that long It's having it more frequently can increase up that risk. can increase up that risk. can increase up that risk. >> Sure. Sure. And uh you know, a a very >> Sure. Sure. And uh you know, a a very >> Sure. Sure. And uh you know, a a very simple way to sort of eliminate the risk simple way to sort of eliminate the risk simple way to sort of eliminate the risk is like you said, just to have a annual is like you said, just to have a annual is like you said, just to have a annual transvaginal ultrasound. In some ways, transvaginal ultrasound. In some ways, transvaginal ultrasound. In some ways, by not having any spotting or bleeding, by not having any spotting or bleeding, by not having any spotting or bleeding, that's the better situation to have the that's the better situation to have the that's the better situation to have the transvaginal ultrasound on an annual

Managing spotting in new HRT users 3:03

transvaginal ultrasound on an annual transvaginal ultrasound on an annual basis because that way you if you if basis because that way you if you if basis because that way you if you if there is no spotting or bleeding, which there is no spotting or bleeding, which there is no spotting or bleeding, which we don't want with static dosing, you're we don't want with static dosing, you're we don't want with static dosing, you're sort of flying blind a little bit. Uh sort of flying blind a little bit. Uh sort of flying blind a little bit. Uh now, what do you do with a woman that is now, what do you do with a woman that is now, what do you do with a woman that is new to HRT new to HRT new to HRT and she's just having a little bit of and she's just having a little bit of and she's just having a little bit of trouble and she's uh she starts bleeding trouble and she's uh she starts bleeding trouble and she's uh she starts bleeding sort of not continuously like a period, sort of not continuously like a period, sort of not continuously like a period, but spotting here or there?

but spotting here or there? but spotting here or there? >> Well, then you would, like I said, raise >> Well, then you would, like I said, raise >> Well, then you would, like I said, raise up that progesterone. Maybe they're on up that progesterone. Maybe they're on up that progesterone. Maybe they're on an oral progesterone, so you could raise an oral progesterone, so you could raise an oral progesterone, so you could raise up that dose. You can also uh do the up that dose. You can also uh do the up that dose. You can also uh do the progesterone transvaginally. So if you progesterone transvaginally. So if you progesterone transvaginally. So if you insert your progesterone capsule or insert your progesterone capsule or insert your progesterone capsule or oral, you know, oral tablet, whatnot, is oral, you know, oral tablet, whatnot, is oral, you know, oral tablet, whatnot, is you can insert it vaginally and it's you can insert it vaginally and it's you can insert it vaginally and it's very close to the uterus when you do very close to the uterus when you do very close to the uterus when you do that. So that can also help protect that that. So that can also help protect that that. So that can also help protect that lining or help thin that lining. Usually lining or help thin that lining. Usually lining or help thin that lining. Usually in the beginning, if they say, "Hey, I'm in the beginning, if they say, "Hey, I'm in the beginning, if they say, "Hey, I'm having some spotting." Actually, have having some spotting." Actually, have having some spotting." Actually, have them stop their hormones for a couple of them stop their hormones for a couple of them stop their hormones for a couple of days, so that they can slough off that days, so that they can slough off that days, so that they can slough off that entire endometrial lining and then entire endometrial lining and then entire endometrial lining and then restart. Now,

Adjusting progesterone and pausing hormones 3:57

restart. Now, restart. Now, some women their their uterus is inside some women their their uterus is inside some women their their uterus is inside of their uterus is just really sensitive of their uterus is just really sensitive of their uterus is just really sensitive to estradiol, and even when you have to estradiol, and even when you have to estradiol, and even when you have them on lower doses, they're still them on lower doses, they're still them on lower doses, they're still spotting, and we want to have good doses spotting, and we want to have good doses spotting, and we want to have good doses of estradiol, cuz that's good for our of estradiol, cuz that's good for our of estradiol, cuz that's good for our brain, our bones, our heart. That's good brain, our bones, our heart. That's good brain, our bones, our heart. That's good for our sleeping, it's good for the for our sleeping, it's good for the for our sleeping, it's good for the libido, it's So, we want to be able to libido, it's So, we want to be able to libido, it's So, we want to be able to have the therapeutic levels, but if have the therapeutic levels, but if have the therapeutic levels, but if they're bleeding, we're kind of stuck in they're bleeding, we're kind of stuck in they're bleeding, we're kind of stuck in a catch-22. So, at that point, you can a catch-22. So, at that point, you can a catch-22. So, at that point, you can cycle the progesterone to try to get cycle the progesterone to try to get cycle the progesterone to try to get them to have a monthly bleed, or what I them to have a monthly bleed, or what I them to have a monthly bleed, or what I find is kind of like the top shelf is find is kind of like the top shelf is find is kind of like the top shelf is you can do rhythmic dosing, which is you can do rhythmic dosing, which is you can do rhythmic dosing, which is encourages a monthly bleed, so that you encourages a monthly bleed, so that you encourages a monthly bleed, so that you can So, you're building up that lining, can So, you're building up that lining, can So, you're building up that lining, and then you slough off that lining at and then you slough off that lining at and then you slough off that lining at the end of the month, so that reduces the end of the month, so that reduces the end of the month, so that reduces that risk.

that risk. that risk. >> Yeah. Uh you know, women seem to always >> Yeah. Uh you know, women seem to always >> Yeah. Uh you know, women seem to always want more estro- estrogen. want more estro- estrogen. want more estro- estrogen. And uh well, of course, it makes them, And uh well, of course, it makes them, And uh well, of course, it makes them, you know, women uh you know, feel the you know, women uh you know, feel the you know, women uh you know, feel the way they want to feel, but that comes to way they want to feel, but that comes to way they want to feel, but that comes to a potentially a point um where you can't a potentially a point um where you can't a potentially a point um where you can't really cross that dosing level, uh and

Rhythmic dosing and monthly bleeding 4:57

really cross that dosing level, uh and really cross that dosing level, uh and sometimes the best option would be to sometimes the best option would be to sometimes the best option would be to switch them to rhythmic dosing, because switch them to rhythmic dosing, because switch them to rhythmic dosing, because now you're controlling the bleeding, now you're controlling the bleeding, now you're controlling the bleeding, okay? You're creating a typical uh okay? You're creating a typical uh okay? You're creating a typical uh 28-day cycle, or you know, whatever 28-day cycle, or you know, whatever 28-day cycle, or you know, whatever someone's normal is, and now you're someone's normal is, and now you're someone's normal is, and now you're eliminating a lot of that risk.

eliminating a lot of that risk. eliminating a lot of that risk. >> And I know a lot of women say, "Oh my >> And I know a lot of women say, "Oh my >> And I know a lot of women say, "Oh my gosh, I do not want to have a period." gosh, I do not want to have a period." gosh, I do not want to have a period." >> Yeah, yeah. >> Yeah, yeah. >> Yeah, yeah. >> But when you're doing the rhythmic >> But when you're doing the rhythmic >> But when you're doing the rhythmic dosing, the periods are not supposed to dosing, the periods are not supposed to dosing, the periods are not supposed to be horrendous, they're not supposed to be horrendous, they're not supposed to be horrendous, they're not supposed to be painful, they're not supposed to be be painful, they're not supposed to be be painful, they're not supposed to be heavy. It's just a way a result of heavy. It's just a way a result of heavy. It's just a way a result of getting that endometrial lining that's getting that endometrial lining that's getting that endometrial lining that's thickened up out of the body, so it thickened up out of the body, so it thickened up out of the body, so it doesn't create that risk. Cuz that's doesn't create that risk. Cuz that's doesn't create that risk. Cuz that's where women do want to have that extra where women do want to have that extra where women do want to have that extra estradiol, so we're kind of finding that estradiol, so we're kind of finding that estradiol, so we're kind of finding that balance of, "Okay, you're going to have balance of, "Okay, you're going to have balance of, "Okay, you're going to have a, you know, easy-peasy period, but that a, you know, easy-peasy period, but that a, you know, easy-peasy period, but that way we can really get those estradiol way we can really get those estradiol way we can really get those estradiol levels up." Now, some women don't have

Finding the right estrogen balance 5:39

levels up." Now, some women don't have levels up." Now, some women don't have They can take really good estradiol They can take really good estradiol They can take really good estradiol levels and never spot, like they levels and never spot, like they levels and never spot, like they never spot, you know? That's perfect. never spot, you know? That's perfect. never spot, you know? That's perfect. Just some people are more sensitive than Just some people are more sensitive than Just some people are more sensitive than others.

others. others. >> Yeah, and there's really no way to >> Yeah, and there's really no way to >> Yeah, and there's really no way to predict that. Like there's no way to, predict that. Like there's no way to, predict that. Like there's no way to, you know, even with the good health you know, even with the good health you know, even with the good health history necessary. Now, granted, that history necessary. Now, granted, that history necessary. Now, granted, that does help. You know, what was their does help. You know, what was their does help. You know, what was their periods like when they were younger, you periods like when they were younger, you periods like when they were younger, you know, children, all those things. Those know, children, all those things. Those know, children, all those things. Those things definitely, at least a start of things definitely, at least a start of things definitely, at least a start of finding a starting point, finding a starting point, finding a starting point, um, gives you an idea of the likelihood um, gives you an idea of the likelihood um, gives you an idea of the likelihood whether they're going to turn up. That's whether they're going to turn up. That's whether they're going to turn up. That's also why, uh, we said in the last also why, uh, we said in the last also why, uh, we said in the last podcast, why you always start low and podcast, why you always start low and podcast, why you always start low and sort of gradually work your way up sort of gradually work your way up sort of gradually work your way up because, um, you know, if you start too because, um, you know, if you start too because, um, you know, if you start too high and you're bleeding, well, you now high and you're bleeding, well, you now high and you're bleeding, well, you now you don't know. You still got to go down you don't know. You still got to go down you don't know. You still got to go down anyways. So, it's better to start low so anyways. So, it's better to start low so anyways. So, it's better to start low so you don't create any spotting or you don't create any spotting or you don't create any spotting or bleeding and then over time, as the body bleeding and then over time, as the body bleeding and then over time, as the body acclimates and sort of gets used to

Individual sensitivity and starting low 6:29

acclimates and sort of gets used to acclimates and sort of gets used to having that hormone around again, you having that hormone around again, you having that hormone around again, you know, then now the frequency or the, uh, know, then now the frequency or the, uh, know, then now the frequency or the, uh, the chance that there might be some the chance that there might be some the chance that there might be some spotting or bleeding tends to go down spotting or bleeding tends to go down spotting or bleeding tends to go down over time.

over time. over time. >> Absolutely. >> Absolutely. >> Absolutely. >> Yeah, so. >> Yeah, so. >> Yeah, so. Uh, anything else, uh, that you want to Uh, anything else, uh, that you want to Uh, anything else, uh, that you want to add about about that situation? add about about that situation? add about about that situation? >> So, if you are spotting and you're on >> So, if you are spotting and you're on >> So, if you are spotting and you're on HRT, don't ignore it. Go and find your HRT, don't ignore it. Go and find your HRT, don't ignore it. Go and find your practitioner, have a trans vaginal practitioner, have a trans vaginal practitioner, have a trans vaginal vaginal ultrasound and assess is this vaginal ultrasound and assess is this vaginal ultrasound and assess is this because I have endometrial hyperplasia, because I have endometrial hyperplasia, because I have endometrial hyperplasia, thickening of the lining of the uterus?

thickening of the lining of the uterus? thickening of the lining of the uterus? Do I have a polyp, couple of polyps? Do I have a polyp, couple of polyps? Do I have a polyp, couple of polyps? Those are easy, they're really common. Those are easy, they're really common. Those are easy, they're really common. You just take them out with a D&C. Or You just take them out with a D&C. Or You just take them out with a D&C. Or are my fibroids activated? Cuz that can are my fibroids activated? Cuz that can are my fibroids activated? Cuz that can happen, too. I haven't seen it that happen, too. I haven't seen it that happen, too. I haven't seen it that often, but sometimes women's fibroids

When spotting happens, get evaluated 7:07

often, but sometimes women's fibroids often, but sometimes women's fibroids can be activated by doing the HRT. So, can be activated by doing the HRT. So, can be activated by doing the HRT. So, you just want to make sure you talk to you just want to make sure you talk to you just want to make sure you talk to your practitioner. I do think if you're your practitioner. I do think if you're your practitioner. I do think if you're on HRT, having a trans vaginal on HRT, having a trans vaginal on HRT, having a trans vaginal ultrasound, even if you aren't spotting, ultrasound, even if you aren't spotting, ultrasound, even if you aren't spotting, is probably a good idea annually. So, is probably a good idea annually. So, is probably a good idea annually. So, that's one option there. And then if you that's one option there. And then if you that's one option there. And then if you are, like I said, if you're spotting, are, like I said, if you're spotting, are, like I said, if you're spotting, talk to your practitioner. They'll talk to your practitioner. They'll talk to your practitioner. They'll probably readjust your estradiol and probably readjust your estradiol and probably readjust your estradiol and your progesterone.

your progesterone. your progesterone. >> Yeah, so either the progesterone dose >> Yeah, so either the progesterone dose >> Yeah, so either the progesterone dose goes up and the estrogen estrogen dose goes up and the estrogen estrogen dose goes up and the estrogen estrogen dose goes down. Either one or both of those goes down. Either one or both of those goes down. Either one or both of those things would need to happen for most things would need to happen for most things would need to happen for most people. Uh, so, uh, if you have any people. Uh, so, uh, if you have any people. Uh, so, uh, if you have any comments or questions, you can write comments or questions, you can write comments or questions, you can write them in the, uh, comment section down them in the, uh, comment section down them in the, uh, comment section down below. Uh, again, uh, we do have a below. Uh, again, uh, we do have a below. Uh, again, uh, we do have a community Progressive Hormones community Progressive Hormones community Progressive Hormones community. We answer all these types of community. We answer all these types of community. We answer all these types of questions for people

Ultrasound, fibroids, and dose readjustment 7:47

questions for people questions for people because, you know, it's complicated. because, you know, it's complicated. because, you know, it's complicated. Every woman's going to respond a little Every woman's going to respond a little Every woman's going to respond a little differently. There's not a differently. There's not a differently. There's not a one-size-fits-all. one-size-fits-all. one-size-fits-all. If you've If you've If you've learned anything from our podcast, it's learned anything from our podcast, it's learned anything from our podcast, it's that there's not a one-size-fits-all.

that there's not a one-size-fits-all. that there's not a one-size-fits-all. And when it comes to bleeding, there's And when it comes to bleeding, there's And when it comes to bleeding, there's no way to really good way to predict no way to really good way to predict no way to really good way to predict who's going to and who's not. And if it who's going to and who's not. And if it who's going to and who's not. And if it does happen, how do we how to resolve does happen, how do we how to resolve does happen, how do we how to resolve that issue?

that issue? that issue? >> Yeah, exactly. That's why I love the >> Yeah, exactly. That's why I love the >> Yeah, exactly. That's why I love the community is community is community is sometimes it's hard to get a hold of sometimes it's hard to get a hold of sometimes it's hard to get a hold of your practitioner or maybe your your practitioner or maybe your your practitioner or maybe your practitioner may not know you know, may practitioner may not know you know, may practitioner may not know you know, may not know the studies or know exactly not know the studies or know exactly not know the studies or know exactly what to do. And then of course, you what to do. And then of course, you what to do. And then of course, you don't want to trust too much stuff on don't want to trust too much stuff on don't want to trust too much stuff on the internet. So it's a nice way the internet. So it's a nice way the internet. So it's a nice way you know, to be able to get your you know, to be able to get your you know, to be able to get your questions answered and we kind of go questions answered and we kind of go questions answered and we kind of go into a little bit more detail.

Community support and closing remarks 8:27

into a little bit more detail. into a little bit more detail. >> Yeah. And a lot of that stuff when it >> Yeah. And a lot of that stuff when it >> Yeah. And a lot of that stuff when it comes to HRT too is from practice comes to HRT too is from practice comes to HRT too is from practice as opposed to research. as opposed to research. as opposed to research. Research, you know, clinical practice Research, you know, clinical practice Research, you know, clinical practice versus research is two fundamentally versus research is two fundamentally versus research is two fundamentally different things. Sometimes sometimes different things. Sometimes sometimes different things. Sometimes sometimes they don't translate very well. And what they don't translate very well. And what they don't translate very well. And what you read in the research is not really you read in the research is not really you read in the research is not really what happens in clinical practice. So if what happens in clinical practice. So if what happens in clinical practice. So if you're interested, it's you're interested, it's you're interested, it's progressivehormones.com.

progressivehormones.com. progressivehormones.com. You know, we're we do live events You know, we're we do live events You know, we're we do live events office hours on a weekly basis. office hours on a weekly basis. office hours on a weekly basis. It's really really fun and exciting. It's really really fun and exciting. It's really really fun and exciting. >> All right. >> All right. >> All right. >> All right. >> All right. >> All right. Anything else to add? Anything else to add? Anything else to add? >> Nope. Thank you. This is great.

>> Nope. Thank you. This is great. >> Nope. Thank you. This is great. >> Okay. Until next time. I'm Dr. Mackey. >> Okay. Until next time. I'm Dr. Mackey. >> Okay. Until next time. I'm Dr. Mackey. >> And I'm Dr. Valerie. >> And I'm Dr. Valerie. >> And I'm Dr. Valerie. >> Take care. Bye-bye.