Making the Connection: Hashimoto's Thyroiditis & PCOS [Podcast] - PCOS Diva
Making the Connection: Hashimoto’s Thyroiditis & PCOS [Podcast]

PCOS Podcast #67 - Hashimoto's Thyroiditis & PCOSI receive questions almost every day about thyroid disease & PCOS. Hashimoto’s thyroiditis and other thyroid issues are very common in women with PCOS, and many of us don’t even know we have it because it can take years to show up on a blood test. Hashimoto’s expert Shannon Garrett, explains that Hashimoto’s is a 3-legged stool and how you must balance thyroid, adrenal glands, and sex hormones to truly begin healing. Do you have Hashimoto’s? Listen in as we discuss:

  • The connection of inflammation to Hashimoto’s and PCOS
  • Lesser recognized symptoms of low level chronic inflammation: acid reflux or heartburn, chronic acne, chronic dry eye, recurrent urinary tract infections, PCOS, dermatitis or periodontal disease.
  • Classic low thyroid symptoms like fatigue that worsens over time, weight loss resistance, brain fog, skin change conditions (like scaly skin), or losing hair.
  • What is the best kind of diet for Hashimoto’s (keto? AIP, PCOS Diva)?
  • Role of stress management & proven techniques
  • The 2-3 supplements you should be taking

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A full transcript follows.

Shannon Garrett, BS, RN, CNN is an Autoimmune Thyroid Wellness Nurse Expert & Certified Functional Nurse Nutritionist. She currently serves on the advisory board for HeyHashi.org and serves as a volunteer LDN nurse educator and is featured on LDN Research Trust.org. Shannon teaches women how to reverse the symptoms of Hashimoto’s thyroiditis by helping them discover underlying causes and by incorporating lifestyle changes and customized nutrition. She is the author of The Hashi’s Sister’s Guide to LDN, Hashimoto’s: Finding Joy in the Journey and the soon to be released book, Hashimoto’s R&R.

Shannon is the founder of HolisticThyroidCare.net. She received her degree in nursing from the prestigious Aquinas College School of Nursing, a degree in human development & psychology from Amridge University and certification as a nurse-nutritionist from the American Nurse-Nutritionist Certification Board. She was also one of the top graduates of the inaugural class of the Hashimoto’s Institute’s 12-week practitioner education program.

Full Transcript:

Amy Medling:                    Hello and welcome to the PCOS Diva podcast. My name is Amy Medling. I’m a certified health coach, and I’m the founder of PCOS Diva. My mission is to help women with PCOS find the tools and knowledge they need to take control of their PCOS so they can regain their fertility, femininity, health, and happiness. If you haven’t already, make sure you check out pcosdiva.com, because there I offer lots of great free information about PCOS and how to develop your PCOS diet and lifestyle plan so you can begin to thrive like a Diva.

Today, we are going to be talking about Hashimoto’s, inflammation, auto-immunity, and how that all could possibly be connected for women with PCOS. I know I hear from so many women with auto-immune issues and also hypothyroidism, and I think a lot of women don’t really make the connection that they could possibly have Hashimoto’s, which is an auto-immune thyroid condition if you are not already aware of that.

I wanted to bring on one of my favorite Hashimoto’s experts, and that’s Sharon Garrett, so Shannon, welcome to the podcast.

 

Shannon Garrett:             Thank you for having me, I’m so happy to come on the PCOS Diva podcast.

Amy Medling:                    Well, I want to just give my listeners a little info about your background, so Shannon teaches women how to reverse the symptoms of Hashimoto’s by helping them discover underlying causes by incorporating diet, lifestyle changes, and customized nutrition. She is an autoimmune thyroid wellness nurse expert, and certified functional nurse nutritionist. She’s the author of the Hashi’s Sister Guide to LDN, and Hashimoto’s: Finding Joy in the Journey, and the soon to be released book, Hashimoto’s R&R. She’s the founder of holisticthyroidcare.net, so again Shannon, thank you for joining us.

Shannon Garrett:             Thank you, I really truly am glad to be here. I admire your work so much, and our communities have a lot in common, so I’m really glad to be here.

Amy Medling:                    Yeah, and you know, I love your approach to, and just the title of your book, Finding Joy in the Journey, and I think that’s what I want to focus on with women with PCOS. We think about all of these negative things, but it really is a journey, when you’re dealing with a health issue or chronic health condition, to help you grow stronger, and I think to look at life from a different perspective. If you can kind of shift to joy and gratitude it really does help the journey for sure.

Shannon Garrett:             Oh, absolutely, and it’s really impossible for a body to heal, body, mind, and spirit, if you’re rooted like I was. I had a lot of issues with forgiveness and anger, frustration, irritation, because I went eight years undiagnosed and misdiagnosed by nine different doctors, so I ended up with really some hardening of heart, and I eventually realized, I’ve got to heal that and let that go if I’m going to get better. I can take all the supplements, follow the nutrition, do all these things, but until I can heal those areas, I’m not going to get better. So that’s where Hashimoto’s: Finding Joy in the Journey evolved from.

Amy Medling:                    Yeah, and I think we need to realize that it’s so much more than just … I say going on a low carb diet and killing yourself at the gym. I mean, it really takes this holistic mind, body, spirit approach to healing.

Shannon Garrett:             Absolutely, yes.

Amy Medling:                    So something that I think, I’ve talked about on the podcast, on my website, is the role that inflammation plays with PCOS, and I know that inflammation is something that is really at the root of Hashimoto’s as well, so I was hoping we could kind of start with explaining maybe what the connection is with inflammation and Hashimoto’s. Another question I wanted to ask you, too, is how does one go about figuring out if her hypothyroidism in fact is Hashimoto’s?

Shannon Garrett:             Okay, so the diagnosis of Hashimoto’s also includes a term called thyroiditis, and any medical diagnosis that ends with itis indicates inflammation, usually chronic, which means long term. So it can take many, many years for Hashimoto’s to manifest into what we perceive to be classic low thyroid symptoms, even though there are early red flags going on and an underlying chronic inflammation process. So when I’m working with women, what I like to explain is that when I think of chronic inflammation, I tend to think of a fire that’s burning out of control.

And like the type of inflammation you notice when, for example, you cut yourself or you have a bruise, and we have those wonderful white blood cells, fighters, that congregate to clean up the area, and we have a little swelling or whatever, chronic inflammation is not like that. It’s not visible to the naked eye, so what I’ll often ask women is, “Were you inflamed even before you knew you had Hashimoto’s, or before you knew you had low thyroid symptoms?”

There are a lot of conditions that indicate this low level chronic inflammation that people don’t necessarily associate with a compromised intestinal area that’s releasing inflammatory chemicals. Some conditions such as acid reflux or heartburn, chronic acne, chronic dry eye, recurrent urinary tract infections, PCOS, for example, dermatitis. One of the common ones that people won’t necessarily relate to an autoimmune disease possibly in the works is periodontal disease.

I think of the popular commercial, chronic dry eye, and they’re prescribing some type of drops for the chronic dry eye, but that’s just treating symptoms. There’s something going on in the body that’s releasing these inflammatory chemicals that’s driving the chronic inflammation. With Hashimoto’s, a woman may experience what we know to be classic low thyroid symptoms like fatigue that worsens over time, weight loss resistance, brain fog, skin change conditions where we have scaly skin, or losing our hair. All of these are driven by an underlying inflammatory process, but it can take several years for the thyroid antibodies to actually show up on a blood test.

What I do with clients and patients who actually were not seeing those antibodies manifested yet is that we just assume that we’re possibly headed towards thyroid autoimmunity, and we treat ourselves as such. We care for ourselves with the nutrition and the nutraceuticals and reducing inflammation the way we would if Hashimoto’s had already been diagnosed. Hashimoto’s and hypothyroidism are two different diseases, basically, even though hypothyroidism is the result of Hashimoto’s, so women are also often surprised to see that when I put care plans together for them, Hashimoto’s is one care plan, hypothyroidism is a second care plan.

It’s really to show them that we’re dealing with two separate processes. You can get into remission with Hashimoto’s and you can improve hypothyroidism, but the two issues are different. Does that make sense?

Amy Medling:                    Yeah, yeah. And so many of these health issues like PCOS and thyroid issues can be managed with lifestyle change, so what are you recommending to your clients? What is the best kind of diet for PCOS? I mean, for Hashimoto’s.

Shannon Garrett:             Well, and this would go for PCOS as well. An anti-inflammatory diet that’s unique to a particular woman. There are many prescribed diets across social media and across the masses of information that we hear about, but not every Hashimoto’s patient needs to be following, for example, the AIP diet. It really depends on where a woman is coming from. Is she coming from eating a lot of processed and packaged food every day and maybe eating fast food on the run because she’s busy in her career and whatnot, and this is eating real food and cooking 90% of your meals at home is going to be a big change? Then moving a woman towards AIP is going to be an improvement.

However, long-term, what I have seen clinically is that AIP can result in significant nutrient deficiencies, and the deficiency that tends to deplete over time are those that are necessary for cellular energy, thiamine being one of them, vitamin B1 is one of the most important ones, and CoQ10 and there are others.

So what I say is that, let’s do a food sensitivity test to see what foods your unique body happens to be reacting to, and we’ll eliminate those, and then of course we’ll avoid the foods that play a role in molecular mimicry and trigger inflammation, like gluten, dairy, corn, and soy protein. But to say that we all need to eliminate certain groups of highly nutrient-dense foods that we may not be reacting to is not something that I generally recommend. So I think nutrition these days is highly individual. We’re all starting at a different place, we all have different triggers, and we’re just on a unique journey, that basically overall anti-inflammatory customized for each woman.

Amy Medling:                    Yeah, and I love that you brought up food sensitivity testing. That was something that I just had done for myself, gosh, maybe about nine months ago, and I had my naturopath, Dr. Margaret Mikulis, so if anybody’s interested in that you can listen to that podcast with Dr. Mikulis. I found out that I was highly, highly allergic to eggs, or insensitive to eggs, and so since I’ve taken the eggs out, you know it’s funny because if I would have like a gluten-free muffin or something like that with eggs in it, I always thought that it was the grains that were bothering me.

Shannon Garrett:             Oh yeah?

Amy Medling:                    Yeah, and so now that I can make a vegan muffin or whatever, I don’t really have a problem with it. It was more like that fatigue, brain foggy kind of inflammatory feeling. So removing the eggs from my diet the last nine months has made a huge difference in the way that I feel.

Shannon Garrett:             That’s awesome.

Amy Medling:                    Yeah, I’m glad that you mentioned that, and it is. There’s something that I’ve been hearing about a lot lately is the ketogenic diet, and everybody says if you have PCOS, you have to be on the ketogenic diet. You know, I don’t think that there’s any one size fits all approach, the same as your philosophy, but it still has to be based in an anti-inflammatory diet, lots of plant-based foods.

Shannon Garrett:             Yes.

Amy Medling:                    But if you’re intolerant to something, like another one on my list was pineapple, and I was eating a lot of pineapple because of the bromalin is a good enzyme that helps digest after meals. But that was something that was causing inflammation for me, so it could be something that’s actually a really good food.

Shannon Garrett:             Oh, true. I’ll have women, when they complete their health history, and they’ll always state that they eat a really healthy diet, and I’m always like, “Let’s break that down. What is your healthy diet?” Because for me, I thought I was eating a healthy diet, too, and then my test results came back that I was sensitive to broccoli and cauliflower.

Amy Medling:                    Oh, wow.

Shannon Garrett:             So what we perceive as a healthy food, we’re just living in a crazy era where the environment has changed, and the soil has changed, and there are a lot of variables that can influence why we may react to a food that we perceive as healthy because it is healthy, but it may not be for each person. Especially, we’re talking about people who have an autoimmune condition, and PCOS, so obviously our systems may be reacting to foods that, for the broad masses of people who don’t have an autoimmune condition, is a healthy food.

Amy Medling:                    So besides food, what other ways do you like to help your clients reduce inflammation?

Shannon Garrett:             Okay, so definitely proactively engaging in stress management on a daily basis to help the body cope with not only emotional and mental stress, but also this physiological stress that’s going on inside the body. That’s not the type of stress you necessarily are aware of, but I can tell you for sure that your cells are. So proactively engaging stress reduction techniques on a daily basis is huge. Of course, I mentioned nutrition.

Selenium, we need to increase glutathione production in the body, so I said that chronic inflammation is sort of like a fire that’s burning out of control. Antioxidants, glutathione being the master antioxidant is sort of like, think of the firemen that put out the fire. So selenium is excellent for increasing glutathione production in the body, and so is acetylcysteine, NAC. Those combined are very powerful nutrients for increasing glutathione.

I often get asked from patients, “Can’t I just go take an IV glutathione therapy, because those are available?” But at least from my own research and what I know clinically about glutathione as an IV therapy, it’s too large of a molecule to cross the cell membrane. It’s really better if we can optimize glutathione by giving our liver what it needs to make its own. That’s one of the great gifts we have been given as a human by our maker is that our body can produce its own glutathione. So also omega 3 essential fatty acids, I like to use complexes that are derived from fish, flax, and borage seed oils. I’ve found those to be very effective, and then as we said earlier, just eliminating gluten, dairy, corn, and soy protein and then any foods that we know are triggering inflammation in the body.

This is the initial starting point for women. You never want to just throw the whole box of supplements at someone, because that can be overwhelming, but these two or three nutrients are pretty basic and can really move you forward to decreasing inflammation.

Amy Medling:                    Yeah, and N-Acetyl Cysteine (NAC) is something that I write about extensively on pcosdiva.com, and it not only helps with inflammation and the production of glutathione, but just a couple other things that it can help with. It’s one of those supplements that I think gives you a good bang for your buck. It improves insulin sensitivity, lowers testosterone, improves menstrual regularity and frequency of ovulation and supports egg quality for fertility, and it’s very safe, too.

Shannon Garrett:             And do you want to know something else about it?

Amy Medling:                    Yeah.

Shannon Garrett:             As a nurse, I used to work in a pulmonary setting before I became a cardiac nurse, and so you see a lot of patients with COPD or different lung diseases, and they have a lot of mucous production, and this is when respiratory therapists come in and give nebulizing treatments in the clinical setting to help them break up the mucous in their lungs. Well, in all of those medications, N-Acetyl Cysteine is the base ingredient in those types of medications, and it’s the one that … sometimes you’ll notice when you open a bottle of it, it sometimes has the tendency to smell like eggs?

Amy Medling:                    Yeah, sulfur-ish.

Shannon Garrett:             Sulfur. So now what we see is many pulmonologists will recommend the acetylcysteine supplement to their patients who have COPD or patients who have bronchitis issues, or even allergy issues in the spring, to help with mucous production.

Amy Medling:                    Oh, that’s interesting. Yeah, my 16-year-old’s having tough spring allergies, so maybe I need to give him some.

Shannon Garrett:             Give him some N-Acetyl Cysteine.

Amy Medling:                    Yeah. Yeah, he’ll roll his eyes, though, it’s just something else mom wants him to take. I did want to ask you, because you mentioned the stress reduction, which I do think is so key. What are your favorite ways to reduce stress?

Shannon Garrett:             I have several, but one of my best tips is journaling and deep breathing. But with journaling there’s a specific process I use for journaling. I used to teach this in the clinical setting. I’ve taught it to practitioners in the clinical setting and fellow nurses who were really faced with … You see a lot of conditions and situations, clinically, that you feel helpless, and when this is a daily basis, practitioners are extremely stressed. It’s called compassion fatigue, but with journaling, what I like to do is, before you go to bed at night, you take a loose sheet of paper and you jot down everything you’re worried about for the day. Everything, what’s keeping up awake, what’s bothering you, what’s nagging at you, and just write those things down. When you’re done, tell yourself, “I’ll worry about these tomorrow,” and literally wad it up and throw it away.

Then you take out your journal, you know, this is going to be the stuff that you keep. You’re not keeping your worries, you’re throwing them in the trash. But you take out your journal and you write down at least 20 things that you’re grateful for from that day. That’s what you’re going to keep. We all have 20 things we can be grateful for, but people who are beginning journaling often don’t know what they’re grateful for, so I could be things like, “I’m grateful I can breathe, I’m grateful I can see, I’m grateful I can walk.” Then you just start there, “I’m grateful for the person who smiled at me at the post office,” or it could be anything, but you do this over time, and the results are just phenomenal. You don’t worry about the things the next day that you wrote about the night before. Those tend to go away.

Along with that, reminding yourself to deep breathe every day. Just take five to 10 minutes a few times a day that you can, and focus on deep breathing, taking a nice salt bath. Yeah, we need to get into not focusing on stress and reducing stress when we’re having life stressful events. We need to be focusing on these every day, when we have any type of chronic health issue, because it helps the body copy with inflammation, not just our brain, our mind. Even though negative thinking, negative thoughts, a lot of people really aren’t fully aware of what a negative thought is, but we have thousands of them per day, and negative thinking is signaling inflammation in the body.

Amy Medling:                    Oh, I so believe that, and I-

Shannon Garrett:             So a negative thought could be something like, for a woman you pass the mirror, you know, you pass by the mirror and you say to yourself, “Oh, I look awful today,” or “Oh, I’m so tired today.” You’re feeding yourself these thoughts, and over time those compounded are negative thoughts.

Amy Medling:                    Yeah, and you know what I think is probably one of the most stressful things that you sort of encounter during your day on this low level stress, is scrolling through Facebook or Instagram, or social media. Not only all of the political stuff, but just, everybody’s putting out there their best versions of themselves. You don’t see all of the other stuff.

Shannon Garrett:             Yes.

Amy Medling:                    And you start comparing yourself with everybody’s highlight reel, and I think you start thinking that you’re less than, that you’re not enough, and that comparison … I don’t know who I can attribute the quote to, but the comparison is the thief of joy. I’m not sure who said that, but it’s so true, and I think that comparison brings a lot of kind of chronic stress as well.

Shannon Garrett:             Oh, I totally agree. I don’t remember who said this either, but our brains can be hardwired towards negativity, and that’s what mainstream news knows about how the human brain works, and that’s why it’s so addictive, it seems, for a lot of people. But really it’s true. We have to tune those things out, we have to tune out the media, we have to shut Facebook off because it can be overwhelming.

Amy Medling:                    Yeah, so we-

Shannon Garrett:             When we get into the comparison and feeling not good enough, those are just additional examples of negative thoughts.

Amy Medling:                    So put down the cell phone at night and pick up the journal.

Shannon Garrett:             Pick up the journal, write down your worries on a loose sheet of paper and throw those away, say you’ll worry about those tomorrow, and then focus on the good stuff, 20 things you’re grateful for, at least.

Amy Medling:                    So that’s a challenge for everyone listening. I’m going to do that tonight, thanks. I usually do three, like in my head, but I’m going to try writing them down on a piece of paper.

Shannon Garrett:             You’ll be amazed over time. I can’t wait to hear back from you, you’ll have to report back how that went. I had a patient years ago in the psychiatric setting. I taught her how to do this, and when she saw me like two weeks later she was just in tears because she said, “You know, no one’s ever taught me … I didn’t know I could cope and feel better.” And she said, “I do this every night.” She showed me her 14 days’ worth of her journal. It was beautiful.

Amy Medling:                    Oh, it does lift … we were talking about the joy in the journey. I think that definitely does help us find joy in the journey, and we don’t sweat the small stuff as much.

Shannon Garrett:             Yes.

Amy Medling:                    And I think that kind of brings us to the subject of adrenal fatigue, that constant overwhelm and exhaustion that I know a lot of women with PCOS are dealing with, myself included. I have to be very careful of nourishing my adrenals with supplements and acupuncture and salt baths, and all of the stress reduction techniques that we just talked about. But how is adrenal fatigue connected with Hashimoto’s?

Shannon Garrett:             Yeah, so it’s that chronic inflammation, that physiological stress, the oxidative stress that’s really causing the adrenals to react in a way that, for example, they want to release more cortisol because they’re in this fight or flight mode for a while. Cortisol is the body’s natural anti-inflammatory, but over time, with most autoimmune conditions, or any long-term chronic health issue, they’re going to become depleted and can’t produce the level of cortisol that they once did. So we need to support the adrenals, obviously some of the nutrients we can use, vitamin C is huge.

Even though vitamin C is a water-soluble vitamin, what research has shown is that while it is in the body, the greatest concentrations are found in the adrenal cortex. That’s like the heart of the adrenals, so B vitamins, pantothenic acid is a great one, and it can depend on what phase of adrenal fatigue you’re it, phase 1, phase 2, or phase 3, dosages of nutrients, but you definitely want to be solid in your anti-inflammatory diet, reducing stress as much as possible. Some patients, if they’re in phase 3, have to actually opt for a prescription for hydrocortisone. I don’t like that, but it just depends on the extent to which their adrenals are fatigued.

Amy Medling:                    And how do you like to test for that?

Shannon Garrett:             I do a saliva test in conjunction with a urine neurotransmitter test, because I have found that neurotransmitters are uniquely related to hormone balance and adrenal function, so addressing all of those areas is usually helpful for a woman. What I have found is that there’s this thing called the three-legged stool of thyroid disease. So you’ve got your thyroid, your adrenal glands, and your sex hormones, and those are all related, so when one area is out of balance, you have to address all three, because likely they’re all out of balance. You can’t really address one without the other.

For example, for women, when cortisol production is insufficient, the body will usually steal from their progesterone, because cortisol is vital for so many life-sustaining functions. We can’t live without cortisol, and this will result in depleted progesterone, which is also estrogen dominance. In addition, imbalanced testosterone or hot flashes prior to menopause can also be a signal that there’s an adrenal problem going on. So like to test with Labrix labs. I do the neurohormone panel, which assesses all three of those areas plus neurotransmitters.

Amy Medling:                    The other thing that I wanted to ask you is regarding Hashimoto’s and remission. I know that there really is no cure for PCOS. I mean, you can certainly kind of keep symptoms at bay through lifestyle, but what about Hashimoto’s? Is it sort of a similar paradigm?

Shannon Garrett:             Well, what I will discuss with women is that when we hear the term Hashimoto’s, we assume it’s a thyroid disease, right? When we hear the terms lupus, MS, rheumatoid arthritis in community circles, it’s perceived that those autoimmune conditions are much, much worse, and although they may be, Hashimoto’s can’t be discounted to just a thyroid disease. It is an autoimmune condition where the body has lost self-tolerance for itself, and it’s attacking the thyroid. Just like with MS, or lupus, or any other autoimmune condition, really, you can get into remission.

Now, with Hashimoto’s, I have not seen it with diet alone. I’ve heard about it, however I see a lot of labs on a daily basis, and I have not seen that. I have seen people get into remission, just as myself, with correction of some nutrition, correction of any nutrient deficiencies, positive daily coping mechanisms for stress that we talked about, in addition to immune system modulators, like Low Dose Naltrexone or Moducare, for example. And then there’s a lot of research for Myo-inositol, which I’m sure you know quite a bit about as well as being beneficial for PCOS.

So I have seen people get into remission, but that doesn’t mean that we can eliminate thyroid medication. That’s sort of a perception I see people have, is oh, you’re in remission, you must not need your thyroid medication anymore. And that’s not true. It can really depend on the extent to which the damage occurred, like how long was this attack on your thyroid going on? For me it was eight years undiagnosed, so obviously I was not able to go off of thyroid medication.

Amy Medling:                    So for women that are listening today, the inflammation markers that you were talking about earlier in the podcast, and they may have had some low thyroid tests done, and they want to dig deeper and they want to learn more about your work and your programs, how can they find out more?

Shannon Garrett:             Oh great. So they can go to holisticthyroidcare.net. They can follow me on the Holistic Thyroid Care page on Facebook. I post a lot of positive and helpful information there. And on Instagram @thyroidnurse.

Amy Medling:                    And your books are available on your website?

Shannon Garrett:             Yes, they’re on the website and Hashimoto’s: Finding Joy on the Journey is on Amazon. Hashimoto’s R&R hopefully will be released end of 2018.

Amy Medling:                    Awesome. Well, it was so nice talking to you today, Shannon, and thank you for sharing all of your wonderful information. I’d love to have you come back, and we could talk more about sort of the emotional side of dealing with chronic disease and chronic health conditions. It seems like something that you’re really dialed in and I’d love to pick your brain more about.

Shannon Garrett:             Oh, I would love to. That’s one of my favorite areas.

Amy Medling:                    Thank you so much for coming and sharing your knowledge, and thank you everyone for joining us today. I hope that you enjoyed the podcast, and if you liked the episode please don’t forget to subscribe to PCOS Diva on iTunes or wherever else you might be listening to the show. If you have a minute, please leave me a quick review on iTunes, because I love to hear from you. If you think somebody else might benefit from this podcast, please take a minute to share it with a family member or friend so she can benefit from it, too. Don’t forget to sign up for my free newsletter. I send it out every Thursday. Actually, now that we’re getting into the summer it’s going to be every other Thursday, but just enter your email on pcosdiva.com to get instant access and make sure you never miss a future podcast. This is Amy Medling wishing you good health. Goodbye.

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