Hormonal shifts play a significant role in our moods and our mental health. This week, Niki Nephin, ND and Birth Doula joins us on Supplementing health to discuss the mental health impacts of pregnancy.
Episode 79: Mind, Body, Baby
The content of this podcast has not been evaluated by Health Canada or the FDA. It is educational in nature and should not be taken as medical advice. Always consult a qualified medical professional to see if a diet, lifestyle change, or supplement is right for you. Any supplements mentioned are not intended to diagnose, treat, cure or prevent any disease. Please note that the opinions of the guests or hosts are their own and may not reflect those of Advanced Orthomolecular Research, Inc.
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Welcome to Supplementing Health, a podcast presented by Advanced Orthomolecular Research. We are all about applying evidence based and effective dietary, lifestyle and natural health product strategies for your optimal health. In each episode, we will feature very engaging clinicians and experts from the world of functional and naturopathic medicine to help achieve our mission to empower people to lead their best lives naturally.
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[01:10] Cassy Price: Thanks for tuning into Supplementing Health. Today we are joined by Dr. Niki Nephin, naturopathic doctor and birth doula to discuss the impacts pregnancy and hormones can have on your mental health. Welcome Niki, thanks for joining me today.
[01:21] Dr. Niki Nephin: Thanks for having me.
[01:22] Cassy Price: So, I think we have all heard of postpartum depression or other changes like that happening after a child comes, especially with the stress of getting into your new routines and figuring out the whole being a parent thing. So, how common is it for women to experience mental health shifts due to pregnancy?
[01:44] Dr. Niki Nephin: So, I would say it is pretty common and we are seeing an increase in the PMADs which is perinatal mood and anxiety disorders. That is during pregnancy and also postpartum. So, previous to the pandemic, the statistics were about one in seven people in pregnancy would experience some sort of mood disorder, either anxiety or depression or a mixture of the two. Now we are seeing upwards of one in four. That is more recent research in the last year suggesting that one in four people are reporting symptoms consistent with a diagnosis of postpartum depression or anxiety or in pregnancy.
[02:29] Cassy Price: Wow that is almost double. That is crazy how much that has risen.
[02:33] Dr. Niki Nephin: Yeah. It really speaks to, we will get into this, but it really speaks to all of the environmental factors that influence our mental health. It is not just what is happening physiologically. I like to say it is not just serotonin. It is really underlining how much influence our environment, how much support we have, even things like access to being able to move our bodies. Certainly in areas like the GTA where recreational facilities are closed down. At one point parks were even not considered safe. That really impacts people in pregnancy and postpartum in terms of being able to get out and move their bodies, which is one of the things that we know really reduces symptoms.
[03:21] Cassy Price: Yeah. That totally makes sense. I am sure too that not having your support network around through all of those changes as well, like when we have been quarantined and not able to see even family members, let alone friends and all of that…
[03:33] Dr. Niki Nephin: Absolutely huge. The lack of support is one of the number one things that drives those mood changes. And certainly, I think especially for first time parents, they don’t know what to expect and they probably maybe assumed that they would be able to have their mom or their sister or somebody else come to help them in person. We know that people are having trouble accessing health care or they simply are not accessing healthcare because of fears of going into an office. So, going to midwife or obstetrician appointments or even following up with family doctors, there is definitely a concern that lots of people are remaining undiagnosed or untreated because of the lack of care as part of the pandemic as well.
[04:27] Cassy Price: So, do you usually see these mental health shifts starting in pregnancy? Or is more often postpartum? Or is there kind of an even mix across the board?
[04:36] Dr. Niki Nephin: Yeah, that is an interesting question because it is a bit of ‘is it the chicken or the egg that came first?’ We know that people who experience depression in pregnancy or anxiety in pregnancy are at higher risk of experiencing those same things postpartum. So, you know if we are seeing somebody who is struggling in pregnancy then definitely we are preparing to support them differently postpartum. Sometimes for people though it can come as a surprise postpartum and that is where the hormonal piece comes in as well, because we know that what happens after pregnancy we have those hormones after the baby and the placenta is delivered, we have the largest single drop in our hormones in our lives. It is actually akin to going into menopause. That is how much our sex hormones drop right after a baby is born. Then the other milk producing and bonding hormones come on board. That adjustment happens in the first 48 hours post birth and then we have got a few weeks where it sort of levels off. I think clinically I am seeing more in pregnancy now, more people identifying it in pregnancy. But traditionally, I think most of the time we are seeing more often postpartum disclosure, if that makes sense. People are realising it more in postpartum I think, than they do in pregnancy. The actual incidence is somewhat the same.
[06:13] Cassy Price: That makes sense. Do you think some of why more people are able to identify it now is because there is a greater awareness around what the symptoms are and what to look for and even that it exists in the first place?
[06:29] Dr. Niki Nephin: Absolutely. Here is one of the saving graces of social media, it is one area where I think there is a lot more education around what mental health looks like in pregnancy, in postpartum, what those symptoms are and there is a lot more normalisation of that transition which they call matrescence from pre-pregnancy and to becoming a parent. We see it also in fathers by the way. We know that if one partner has a mental health disorder, a perinatal mental health disorder, that there is 50% chance that the other partner will as well. That also speaks back to what the environmental causes are, right? In terms of what are we looking at here for reasoning behind why people are struggling. I was just going to say also, that with the pandemic we can actually see in that newer research there is actually a map showing Canada, we can see it by region that it varies slightly by region. We are seeing it higher in the Maritimes and lower in the Prairies. I think that is really interesting research to dig into as well, right? Those new statistics show 23%, is what they are showing, in terms of how many people are reporting those symptoms right now, previously again it was about one in seven. For fathers one in 10.
[08:13] Cassy Price: Interesting. I wonder too if there are any, maybe you actually know this, are there any stats as to if the season of birth plays into that? Like, if it is winter and it is dark and grey? Would that bring an increase versus in summer when people have more sun and vitamin D and things like that?
[08:35] Dr. Niki Nephin: Yeah. You know what? I don’t know if there has actually been any formal research done of that. That would be fascinating. Certainly, from my own personal experience, winter babies are tougher because you are bundling them up and getting them outside if you are in Canadian winters, that can be really tricky. Also, just with the lack of sunlight it is harder to get to those social baby and mum or baby and dad music classes, and all of those things. I would assume that that’s impacted by season, but I don’t know if there has been any formal research on that yet.
[09:11] Cassy Price: So, have you noticed if people that have had depression or anxiety or other mental health conditions prior to pregnancy, has being pregnant helped rebalance those things ever for them? Can the hormones help improve those situations?
[09:29] Dr. Niki Nephin: Right. So, some people feel really great in pregnancy and we don’t fully understand why that is. There is certainly, we know that estrogen in particular estradiol, can affect depression. So sometimes people feel better in pregnancy because both progesterone and estrogen are higher but we also know that some people who would come in with a higher base level of estrogen feel worse because of that amount. So, it sort of depends where somebody is in their own unique hormone picture coming in. The same is true of progesterone. Progesterone tends to be our smoothing over hormone. Lots of people in pregnancy will feel a little more calm or less reactive because progesterone actually affects us on our GABA receptors which is the neurotransmitter that calms everything down. It really does depend on the person. Again, if someone is coming in and their estrogen is high that extra estrogen can make them feel worst. In terms of progesterone, there are also some people who are really sensitive, not to the amount of the progesterone, but simply to that fluctuation. You might see that also in people who struggle with other hormone changes like, you might see it for instance in perimenopause or they might see that similar struggle happen in weaning if they have been breastfeeding or even near ovulation in their regular cycle. It sort of depends on what that person’s specific hormonal picture is. It is really unique to that person.
[11:12] Cassy Price: So, then beside our regular sex hormones like our progesterone and our estrogen that are coursing through our bodies our whole lives, there is also other hormones that come out specifically for pregnancy like HCG. Do those hormones ever play into that mental health picture?
[11:30] Dr. Niki Nephin: HCG; there has not been a lot of research done on the impacts specifically to pregnancy, depression or postpartum depression. What happens is that that hormone signals the body to release more of our sex hormones. I don’t think HCG plays a huge picture, at least we don’t know that yet, but we do see other hormones. You imagine that there is like a triad of hormones and the sex hormones are on one point, and then we have our adrenal hormones, and then we have our thyroid hormones. Those all create a complex web of how they interact. So, during pregnancy all of those hormones are still on board, right? Some of them are up regulated and some of them are down regulated. So, we more often see things like thyroid hormones can really impact mood, they can impact mood outside of pregnancy and postpartum, but certainly that is exaggerated in pregnancy and postpartum. Specifically in the first four months before the foetus starts to produce its own thyroid hormone. So, that is sort of one area where you might see extra changes happening or extra influence outside of specifically the sex hormones. The other is cortisol, which is our stress hormone or adrenal hormone. That changes throughout pregnancy as well. It is not really well understood actually about what those changes are about, but we know that in the third trimester cortisol actually goes up naturally and we want it to be up naturally because it can help speed up the lung maturation of the baby. We would also feel that shift in that third trimester towards maybe more stress like responses from that cortisol. That can aggravate mood disorders or mimic them.
[13:33] Cassy Price: That is interesting. Does that also play into what we would deem ‘baby brain’ then, when women have a harder time focusing or remembering things, especially later on in pregnancy?
[13:47] Dr. Niki Nephin: Interesting. You know what, maybe it does. I am not sure if cortisol is what is behind that. Certainly, when we talk about actual baby brain, the studies that have been done on it so far show that there are actually physical changes happening in the brain likely mediated by hormones. I don’t know if it is just cortisol or if it’s really that unique cocktail at the end of pregnancy that shift us towards being able to be more receptive and to take in information. Essentially, preparing us to be thrown into the classroom of parenting. When you have your baby, of course, especially our first baby but even subsequent ones, we are learning, and we become super sensitive to the cues of that baby. It is the reason why when people say that the new born baby is crying and even if you talk to other mothers whose kids might even be older, hearing a new born baby cry elicits a very strong response in the birthing parent. That is because of those brain changes that make us super sensitive to them increasing their chance of survival essentially. Whether or not we don’t really quite understand how that is modulated in the brain, they are just starting to study that now, but we do see that the brain actually changes, we have more growth in our learning centres for instance during late pregnancy and early postpartum that last beyond that period.
[15:18] Cassy Price: That is so fascinating how the body can do all of these things completely outside of our awareness and control, I think.
[15:27] Dr. Niki Nephin: Totally. I like to say it is like the most normal/common thing but it is also a miracle. The whole thing is so wild. The experience is wild for people too. I think that is one of those things that we grossly underestimate. Moving through that transition even though it is very ‘normal.’ It is a huge transition. Not only physiologically in your body, your blood volume doubles and then it drops, your hormones are two hundred times the normal rate and then they literally plummet. Also from an emotional and mental perspective, being responsible for another human being and then bringing that experience into our specific culture around parenting, which right now is ‘impossible.’ Not only in the pandemic but I think even before that. There is a lot of stress on parents to parent a very specific way, to sort of ‘get it right’ and that is a huge influence on the mental health of parents, particularly primary parents who are usually the mother. You not only are adjusting to what is happening in your body, but you are also adjusting to this new role and responsibility and your identity. That is what the matrescence means, right? It is that identity, the word comes from maternal but also adolescence. It is like a second puberty almost into becoming a parent and what that means. Sandwiched in between those two things is this massive experience of having given birth, which really in terms of perinatal mental health is huge. That impact can’t be underestimated. What the birth experience was like and the early days of postpartum are like can influence postpartum depression and anxiety risk a lot.
[17:45] Cassy Price: What role does our societal changes that our ancestors didn’t have like social media, play into that? I think even aside from parenting and being a new mother and like you said shifting into that role, there are a lot of pressures that come from this curated image of people that they create online that you compare yourself to.
[18:15] Dr. Niki Nephin: Yeah, it is a double-edged sword. I see a lot of stuff on social media that is very normalising of the struggles of parenthood and postpartum, body image, changes in the body, everything. But on the other hand there is also yes, I love the word curation, because it really is curated. These accounts of parents and families that make it really difficult, even though we know cognitively that it is a curation, separating that and having that input constantly I think it really impacts our ability to be present in our own experience and hold strong to our own values and even just the realism of what is possible. I use the term ‘impossible parenting’ which is from a book by Olivia Scobie who is a Toronto perinatal therapist social worker. She really speaks to this awareness of this child centric culture and the concept of the ‘good mother.’ You can really dig into that research. When you start to see how that structure is set up in terms of our culture and what we expect of mothers, and what it means to be a good mother or a good father. I think social media really drives that conversation. It can really impact people seeing it. Maybe you are feeding your baby and you are checking your phone at the same time, you’re getting constant feedback about whether you are doing a good job, right? It is really hard not to compare yourself. That I think, layered onto some of the other things that happen in postpartum plus, for most people right now, the level of uncertainty and stress that there is around the pandemic, is like a perfect storm.
[20:25] Cassy Price: Now previously you had mentioned that the plummet in hormones that women experience in post pregnancy is almost akin to a second puberty if you will. How long after pregnancy does it usually take for the body to find its new normal or return to its previous normal?
[20:46] Dr. Niki Nephin: Right. So, you know most people don’t return to their previous normal to be honest in terms of hormones, in the sense that often what will happen is that we will see changes in the menstrual cycle. Sometimes these are really positive changes. For instance, someone who might have had really heavy painful periods might have lighter more manageable periods. In terms of how long it takes for hormones to readjust? Approximately two years is the baseline. That is what we use in terms of telling people about the recovery period before you should have another pregnancy in terms of the physiology. It really does depend on so many factors. It depends on whether someone breast feeds or not. That would delay the return of the menstrual cycle. Once the menstrual cycle comes back then we start producing progesterone again because we produce progesterone when we ovulate. Estrogen is suppressed until breastfeeding is ceased so that would remain low in lots of people. If we kind of zoom out from that, when do you fully recover from those events? Some people would say maybe ten years, if you have got a couple of kids and they are back-to-back. It also depends on how old you were and what kind of health you were in before you had a pregnancy. I notice that for instance that people who have their kids later in their 30s, which is really common in the city, might have their kids closer together if they are having more than one child. So, the impact in terms of hormonal recovery would be different than someone who was having their kids a little farther spaced out or earlier in their reproductive life.
[22:35] Cassy Price: That is interesting. Are there lifestyle factors that would also play into that? For example, we know that B vitamins are very important to the production of hormones and the methylation of the hormones and all of that. So, if you are getting a diet that is super rich in B vitamins for example, or omegas, or things like that that play a role in that hormone production, will that also influence at what point or how quickly you return to a balanced state, if you will?
[23:04] Dr. Niki Nephin: Yeah, I think that if you consider it like, are the building blocks for those hormones (if we are looking at hormonal health) are the building blocks there? Are you getting enough protein for instance to make those amino acids which are really important for building the neurotransmitters like serotonin, etc? Are you getting enough fat in your diet to build the hormones? Because the hormones like estrogen and progesterone are on a backbone of cholesterol which is fat. Certainly, diet plays into it. If the pregnancy itself and then if there is breastfeeding on top of that, can be very depleting in terms of nutrients. It definitely speaks to, how well you can take care of yourself in terms of diet and supplementation during pregnancy and postpartum can influence that balance for sure.
[23:56] Cassy Price: So, then for people that are suffering with postpartum depression, are there different signs that you look for from the standard list of indications? For example, I know changes in hygiene can be listed as something to indicate depression however, when you are a brand-new mom sometimes it can be a lot more challenging to get in that shower in the morning, right? Things like that. So, are there different signs that you look for?
[24:25] Dr. Niki Nephin: Yeah, with the screening for postpartum depression or anxiety there are standardised lists that a doctor or a naturopathic doctor would use, a scale, right? We would be looking at that. You are right, they really overlap with the normal experience of postpartum. For instance, sleep changes, insomnia or sleeping too much is a good example. I think that what differentiates that is first of all, the timing and the length of time that that person has been experiencing it. After you’ve had the baby there is often an initial euphoria for the first 48 hours, you just brought a human into the world, you are a warrior and then those hormones start to drop around day three or four, that is when there is that really big drop, changes and the milk hormones really come in. There is lots of crying and big feelings around those days and oftentimes increased need for support. After that, we have the first three or four weeks while you are adjusting where lots of people, up to 80%, actually experience what we call the baby blues. That is when people might be alternating between feeling really happy and feeling really sad. There is some grief about their previous life. There is happiness and excitement about their new life. There are changes in sleep because you have got a newborn. There are all of the physical changes like sweating and hot flashes, etc. After that initial period of time, if you have persistent feeling that is when we start to look at is there postpartum depression or anxiety risk here. The differentiation would be in terms of functioning and how severe those symptoms are.
[26:11] Dr. Niki Nephin: So, depression would tend to be more like low mood, so a lack of interest or joy, the inability to see the good side of things, lots of sadness and crying, lots of guilt or shame, or anger, that is another thing that comes up in new parents as well. Then for anxiety, you might see unwanted flashbacks to the birth experience or something about the experience. Intrusive thoughts are really common and can be really disturbing which would be standing at the top of the stairs and holding your baby and thinking “oh my god, I am going to fall down the stairs” or even imagining falling down the stairs. It is when those symptoms are there and they persist, so it is more than two weeks past that first month, that is where we start to clinically based on those scales we would say “hey, maybe you are experiencing something beyond that normal shift?” It is also going to really depend on the person in terms of how they are experiencing it. It is hard to differentiate between those normal changes postpartum and needing support. If there is not support then obviously you are going to be struggling more, right? If you had a birth experience that was traumatic, you are going to struggle more. I think that is where it can be tricky for practitioners in the conventional medical model, they want to put people in a box like “you’re suffering from postpartum depression” or “you’re having trouble adjusting.” They actually call it adjustment disorder. Whereas in some other more holistic paths, we are looking at it as a whole picture which is of course somebody is going to be struggling when they are adjusting into a role like this. Of course, everything from a lack of sleep, postpartum depression and anxiety mimics sleep deprivation which is really common in the first few months of new parenthood. So, in terms of signs we’d be looking for those signs of depression or anxiety in general but them persisting, beyond two weeks, and starting to interfere with the ability to function, in particular, to be able to take care of the baby.
[28:39] Cassy Price: So, then if someone is suffering from one of those conditions, whether it be postpartum depression or anxiety or any of those, what are some of the treatment options that they can safely take when they are still planning to breastfeed and want to take those steps in their parenting journey?
[28:59] Dr. Niki Nephin: Right, so I think starting off by saying that a lot of people are really resistant to medication in pregnancy and breastfeeding even though there is some good research to suggest that lots of the medications that they use are actually fairly safe. There are a lot of people who don’t want to take that. That is another reason why we see people being underdiagnosed because they don’t want to go to the doctor to talk about their symptoms because they are worried that all they will be offered is medication. That is where in naturopathic medicine we really have a huge role here because it is not just serotonin. We can safely use, for instance, St. John’s Wort in pregnancy and in breastfeeding to help support the serotonin pathways. That works best with people who have mild to moderate depression. It doesn’t work as well in people who have really severe depression. I like to say that we have a greater toolbox, in the sense that our best approach is coming from more than one angle. So we can influence not only the neurotransmitters like serotonin and GABA, and we actually have natural health supplements, for instance, we know that St. John’s Wort works on serotonin but lavender works on the GABA receptors and valerian works on the adrenaline, if the adrenaline is too high. So, we can have a layered effect on the neurotransmitters which is a bonus, but we can also work from things like what is happening in the hormonal picture. Sometimes we get clues from that based on the symptoms and how they are presenting now or from the person’s previous history in terms of their menstrual cycle. We can also work on inflammation. In depression, now we see it that it is partially mediated by actual inflammation on the brain and we know that pregnancy, especially late pregnancy and labour is an inflammatory event. You need inflammation at your cervix in order for labour to initiate. So, in the postpartum period there is a massive amount of inflammation that we can work on. We can also work on the HPA access and the stressed physiology. There are different supplements we can use for all of those, lots of which are safe in breastfeeding and studied in breastfeeding. Some of which is really common, for instance, Vitamin D there is quite a bit of research around Vitamin D so not only depression but also sleep, in terms of how it affects our sleep which can of course affect our mood as well.
[31:40] Cassy Price: Interesting. Earlier you had mentioned how quickly you have your children, if you have multiple children, and how close they are and things like that, play into that hormone balance and how quickly you recover. Does your overall age at which you start or when you are having your children play a role in your risk for these kinds of conditions?
[32:08] Dr. Niki Nephin: It is interesting. It is sort of debatable. Some more recent pandemic research I was speaking to was pointing towards younger mothers being at the most risk for PPDA which is postpartum depression anxiety. I wonder if that means less access to social support. It doesn’t actually say in the research why that is, but other research has shown that older parents at higher risk. I think it is probably somewhere in between that the risk is approximately the same or that it is hard to really differentiate based solely on age. I know that for instance in older parents and kids closer together, there is this concept of postnatal depletion. It takes a lot for us to grow an entire human from two cells and then to give birth to it and then potentially to feed it from our bodies. Lots of people again, if you are having your children a little closer together maybe you are nursing still while you are in pregnancy, it can be hard to keep up with the level of nutrients. The other thing that impacts that is and particularly for pregnancy in the thirties, is that perimenopause which is that period before menopause, can start up to ten years before your cycle actually ends. So, we know that menopause in most women starts between 45 to 55. So, that means that for some people who would have a naturally earlier menopause, their perimenopause can start around even 35 which isn’t an uncommon time for someone to have a first or a second or a third baby. So, those hormone levels in perimenopause are fluctuating greatly as your body is adjusting preparing for your cycle to end a decade later. That will impact things as well in terms of age. So, I guess in short, I don’t know if the younger mothers in that study, if it was I would assume maybe more social support, whereas the risk in older parents might be more physiologically or hormonally driven.
[34:19] Cassy Price: That study about the Covid is interesting. It made me think that maybe it has something to do with financial stability as well, right? Usually when you are mature you are a little bit more stable whereas the younger you are still figuring things out, obviously generalising here but…
[34:35] Dr. Niki Nephin: No, but we know that the risk factors for PPD for instance financial stress, marital stress, is it a wanted or planned pregnancy, do you have support? Yes. How much of that is going to change your life, which might be more common in younger parents. Certainly, that could be true. I don’t know. They didn’t specifically list it, but I would imagine that that’s true.
[35:04] Cassy Price: So then, for pre-existing hormonal conditions, you mentioned that thyroid plays into the whole picture, or PCOS, or endometriosis that specifically influence women’s hormonal pictures. Does that play into a woman’s risk of a hormonally driven mental health condition during or after pregnancy?
[35:28] Dr. Niki Nephin: Yes. Certainly, anything that is going to interact with the endocrine system for hormones is going to influence that risk. The endometriosis is an interesting one because we use to think that endometriosis was caused by estrogen dominance so high estrogen but now we know that it is not necessarily caused by that. It is influenced by estrogen but that is more of an inflammatory or immune related disease but in terms of thyroid there is some pretty good associations between what is happening with the thyroid pre-pregnancy or during pregnancy and the risk afterwards. That is being studied more now than it was before as well. Even diabetes can influence the risk because of how those hormones all interact. It is an area where naturopathic medicine really shines because it is hard to say in terms of that research, as a large umbrella, that everyone with a thyroid TSH number of this is going to be at risk. It has not been studied to that level of accuracy yet, but when we look at someone’s individual risk factors for sure we want to take into account what is happening with anything that is hormonally related and all of those hormones, like I said, are kind of like a complex web. Then we layer on the social, mental, environmental stuff that is happening too in terms of support and what is the context of that pregnancy as well as nutrients. What is their vitamin D like? What are their B vitamins like? What is their iron like? Those things will all impact our mental health as well. It is almost like everything postpartum in particular but pregnancy as well it is just exaggerated, right, because of the sheer need for the amount of hormones or the amount of nutrients to sustain the pregnancy or choose to feed the child after it has been born.
[37:47] Cassy Price: Yeah, that makes sense. This is a fascinating topic and I am sure we could probably talk about it for hours, but we have actually reached the end of our time. So, for listeners who wanted to work with you, what would be the best way for them to get a hold of you?
[38:02] Dr. Niki Nephin: They can go to my website with is www.nikithenaturopath.com. That is my website. I am also on Instagram @nikithenaturopath. I have lots of resources there including a postpartum support plan which is one of the biggest things that I talk about with people in pregnancy, is preparing for the postpartum period in terms of what kind of support is out there. One of the things that I am super passionate about is helping people understand that there are so many different ways that we can approach mental health in pregnancy and postpartum. That concept that it is not just serotonin. In particular, destigmatising people who choose to take medication as well and letting people know that if you are struggling with your mental health then getting help in any way that feels right to you is actually really important and it doesn’t preclude having care in naturopathic medicine. A lot of what we do we can work alongside medication, or we can work on completely separate systems in the body that don’t affect it too. So, they can find my on my website or Instagram or I am also on Facebook. I am Dr. Niki Nephin.
[39:22] Cassy Price: Fantastic. Well, thank you so much for taking the time to chat with me. I think there is lots here for our listeners to take away and learn more about.
[39:31] Dr. Niki Nephin: Great. Thank you so much for having me.
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