Ep. 28: Obstetrics, Gynecology, Heart HealthHeartBeats: Shipley Cardiothoracic Center Podcasts
Welcome, I'm Cathy Murtagh Schaefer. And I'm your host for this episode Heartbeats. This podcast is brought to you by Shipley Cardiothoracic Center and education series dedicated to providing our patients and Community with information and education about our cardiothoracic surgery program, Lee Health and matters affecting your Health. This is a third in a series of podcast dedicated to our female listeners and celebrating the women's cardiac Surgery Center here at the Shipley Center at HealthPark in Fort Myers. Today's podcast takes a little different. Look into women's cardiac health. And how obstetric issues can often tell the future of a woman's potential heart problems. Our Guest today is Dr. Sarah DiGiorgi who is a board-certified obstetrician and gynecologist and a The American College of Obstetricians and gynecologists. She's been practicing Women's Health here in Fort Myers since 2007. DiGiorgi is trained in the use of Robotics for minimally, invasive, surgeries, and is a specialist in uterine fibroids, endometriosis, and polycystic ovary syndrome, which we'll talk a little bit about today. And besides her outstanding medical credentials. We here at Shipley know her is our Dr. DiGiorgi's wife. Thank you. Dr. DiGiorgi for being here. Welcome. So happy, you're able to join us today. Would you like to begin by talking a little bit about your background and how you came to Fort Myers? Sure. Good morning, Cathy. Thank you so much for having me here today. I'm really honored to be a part of your podcast show and I have to say I'm a novice this is my first podcast ever. So I'm super excited Paul and I moved to Fort Myers in 2007, basically following the sunshine like many other new Floridians. We have three children. And really, the reason why I went into Obstetrics and Gynecology is I my medical training. I enjoyed surgery a lot, but I did not enjoy that. Once you took care of somebody, they kind of left and rode off into the sunset forever. And Obstetrics and Gynecology is one of those few specialties where you get to do a lot of procedures and surgeries, and you also get to continue to take care of your patients for a lifetime. So that's kind of what attracted me to OBGYN and it's been a really great fit and we are super happy here in Fort Myers. It's been a really long time since I worked in the obstetrics world, but my very first job was as a PA as a PA was with Toby gin and that was some 31 years ago and a lot has changed. I think one of the biggest changes we are seeing is the increase in maternal. Mortality a policy statement from the American Heart Association in October 2021 stated. We've gone from 7.2 maternal deaths per a 100,000 in 1987 to 17.4 per 100,000 live births in 2018 and the maternal mortality ratio in the United States is more than double the ratio of 10 other high-income countries. That's a horrible Trend. But what surprised me was that the leading cause of maternal death was cardiovascular disease. Is this? Your experience as well? Is there something in particular that's contributing to this cardiovascular risk profile. Yes, Cathy the stats that you report are, in fact, you know, their National and correct worldwide. Maternal mortality, has been declining, but in the United States, it has been rising. There's lots of different quality collaboratives that try to look at this problem and address some of those more common features that you would see. For maternal mortality. I think the risk factors that we see for Men are advancing maternal age, pre-existing medical conditions. We see that the General Health of the population is not as healthy even in younger people as it had been in the past and availability of prenatal. Care is still an issue when we look here in Southwest Florida, particularly within the Lee health system for mortality, are numbers are Better than the national average and it is, it is good. And I think that the thing to really think about is what can you modify from basically a patient standpoint from a practitioner standpoint and then eventually from a systems standpoint, but what we look at here is being careful with our Hemorrhage risks, and there's been a lot of work on that which has been remarkably transformational for our patients. In our experience here. So we're real proud of that Improvement. Regarding cardiovascular risk, blood pressure problems, preeclampsia in pregnancy. A lot of that is early recognition, understanding the risk factors, and making sure that patients are being closely followed up. So, the first thing that I would say to women who are of childbearing age is number one, have some control over your fertility. If you are not in a healthy state then you need to be taking measures to protect yourself from getting pregnant until you are healthier. So that's the first thing, like planned pregnancy. The second thing would be making sure that you do get in her early prenatal care. We want to see patients when the first trimester that helps us to assess what their risks are. To make sure that they have the appropriate Baseline laboratory work and work UPS to understand what any of those pre-existing conditions may be and then to be assigned to certain specialist if they're needed. The other thing is a lot of patient education and what are some of the modifiable things that patients can do when they're pregnant. Most of those are going to resolve around nutrition exercise. The use of aspirin actually has been remarkably beneficial to decrease the risk for preeclampsia later in pregnancy. And so, even though there are certain things that one can't change. There's a lot that you can Can be on the lookout for and that you can as a coordinated team, help to reduce the risk. For maternal mortality. We mentioned that we're not as healthy as we used to be. Do you attribute that to different issues or does have a lot of that, surround the issue of obesity? I think that's a super complex question and I would say In general, obesity is a concern diabetes is a concern and elevated stress levels, even in this day and age right now. Everybody's kind of on pins and needles and a lot of that is hard to measure in a like you can't take your blood pressure for stress. And so I think that those are things that holistically people can try to improve and the good. News with that, is that, that is all modifiable 100%. It does take Financial Resources to be able to eat healthier. It takes mental, commitment, to kind of stay on a program and it takes time with in your life, to organize, to be able to go out and have a walk or make time to talk with friends to kind of decompress and de-stress. And I think, when I think of my patients in myself included, the demands on women's lives is significant. And the pandemic has really exposed that there is not a lot of wiggle room there. And so that would be probably the biggest change that would have an effect on long-term diseases like cardiovascular disease. I remember working at the been table at Baylor College of Medicine in Houston, which had a charity clinic. And so often, women usually very young women presented for the first time in their pregnancy between six and eight months often coming in with what we now call, Poor social determinants of Health. Poor, young lacking Insurance, single mothers, housing insecurity, undocumented, immigrants, Financial strain, lack of social support, Etc. These are the things that I think you're referring to when you talk about support, how important is it that a woman? Begin prenatal care? As soon as the pregnancy is identified and how does presenting late in pregnancy for prenatal care, affect maternal and baby outcomes, prenatal care is really truly very important and never one to understand those risk factors that women may have. But also, there are a lot of programs within the United States, that can help women, especially with their first baby, that are free services, and a lot of women, just don't know about them, and they can't really get tapped into them in the right way. And so, I do think that, once you start with prenatal care, then you can get access to those Services, you get more education, the more education that women can get the more prepared, they can be for what's coming to follow. Certainly decreasing the risk of preterm birth preterm delivery with prenatal care has been well established. But I also think it really sets women up for Success. Particularly when you talk about people, who have a lot of challenges in their life and bringing a new baby into that only makes it more complicated. So, there are lots of opportunities for access to care and it's just finding out in your particular neighborhood. Like, where's your OBGYN? How do you get? Set up for Medicaid if you don't have insurance, how are you going to support that transportation in order to get looked after? But it's certainly important to do that. I think your point is very well taken. If you can access prenatal care, that's the beginning of the journey so that you can access other resources within the community. Because you're right. Most people don't know what's out there. But why would they write? I can actually we Working with our high-risk maternal clinic across the street, trying to engage our opioid-dependent, pregnant patients. And that's been a really successful effort in getting people connected to our addiction medicine clinic and getting them started on the appropriate medication, so they can get off their opioids and also engage with social social services. So, that when the baby is born, that way, they already know what's going to happen and how it's going to happen. And it doesn't come as a big shock when Social Services steps in and DCF is called etc. Etc. So, I think there have been and that we already issue with in Southwest Florida. Has been a great example where there's also been a lot of education and fundamental cultural shifts within the medical community to address that as a problem and try to be more. Thoughtful, in addition to aware of what it's like for that moment and that new baby together. And so, we've had women who have delivered, maybe eight years ago and, and had a harder experience and then gotten pregnant again, then already connected with services and say that, they felt so much more empowered in their second pregnancy because they were brought along the whole throughout their entire prenatal care of what. Expectations would be and they just felt more valued as a mother where they could have a voice in that whole care team and understanding that, that baby is going to go to NICU and has special needs and special concerns, but that she's not devalued as a mother, and has a voice and all that. So I think it is important for prenatal care to allow people to be part of that conversation early because let's face it, that baby coming out. Better to understand what that might look like. So that you can be emotionally financially in Every Which Way medically better prepared. I know you and I briefly talked a little bit about the risk of preeclampsia, gestational diabetes, and gestational hypertension. Can you please briefly discuss the implications of those problems in pregnancy and then tell us how those diseases can foreshadow? The future. One of the things that is really fabulous about pregnancy is that it really does act like a crystal ball for the future of some of you are risk factors. Or weaknesses, perhaps that would show as medical problems later in life. So we'll start with gestational diabetes and then work into that, the heart related stuff. So, just a tional diabetes. We know that pregnant people through the placenta make something called human placental, active gin, and it affects how your body's insulin works and putting sugar into your tissue versus having it be free floating within your within your bloodstream. And so pregnant. Women have more bloodshed. Sugar floating around and who knows why Mother Nature made it that way. Maybe when there was less food available. You wanted to make it available to your to your growing fetus in American nutritional world. That's not really necessary. Like we don't want as much around and so it doesn't necessarily have to be more overweight women that you can have super thin people that just guess what they have just a tional diabetes. So everybody gets screened for that in a pregnancy. If you happen to have that then they're managed with diet sometimes with insulin metformin different medications and their pregnancies are followed differently because they do have additional risk factors. It does let you know, though, that those women after they've delivered, have an increased lifetime risk of developing type 2 diabetes. So we know that if your insulin dependent, when you're pregnant, that you should have your blood sugar tested. Every three years when that baby turns 3, 6, 9 12, you should be like, it's my blood sugar time. It's my blood. Your time, if your diet controlled, it's every five years and so it's in my education to women because it's really a pain in the neck to have gestational diabetes. You have to check your sugar's, you have to think about something else, but it is worth making those nutritional changes those Lifestyle Changes because you have this insight to what your future could look like if you do not make those changes. And so you have to learn to live with the genes that you've been given. And those are risk factors that you Modify. If you can learn to love spinach. Well, guess what? You're going to cook spinach, your baby's going to eat spinach, and your kids are going to grow up having a love of eating plants as well. And in that turn will help to improve their long-term nutritional choices. And so I do think pregnancy is a beautiful time where you can identify some of those challenges and then say you have the opportunity to make a change and how all that you found that out when you were 25 and not when you were 55 because you just were given 30 years to fix or to not waste time and keeping your body as healthy as possible. For pre-existing high blood pressure or people who develop hypertension in pregnancy, which is kind of the new term. It replaces, just a tional hypertension and preeclampsia, sort of little bit more inclusive, pre-existing high blood pressure. Those patients need to get managed in a separate way because we know that they Are more at risk for developing preeclampsia, severe preeclampsia help later in pregnancy. For people who are normal tensive, have normal blood pressure within the first up until 20 weeks. And then later on develop elevated, blood pressure and pregnancy, that kind of dovetails into those two diagnoses of the old-fashioned either. Just a tional hypertension or preeclampsia, which is now all wrapped up in that hip hypertension in pregnancy. And so, oh, those women. We know also similar to gestational diabetes are at an increased lifetime risk of having cardiovascular disease and stroke. And so it is very much the same conversation where you say while you're pregnant. Okay. These are the things that we're going to do to kind of keep your blood pressure normal, help to protect you from developing that severe preeclampsia that's going to result in potentially an earlier delivery or more maternal complication and make sure that those patients are aware of what the signs. Symptoms are if they're getting sicker, how they get into the Health Care system if they're feeling any of those signs and symptoms. And then after they deliver to really say, okay. Listen, we need to continue to get you hooked up with your primary care. Maybe you need a cardiologist, many woman's blood pressure will go back to normal within that first. Six week, postpartum period And there's a fraction of women who never really get their blood pressure back, normotensive and they stay on antihypertensive medication from that point. Forward. The truth is to make sure they're aware. We have diagnosed and underlying weakness and underlying condition. That even if you do, go back to normal, your blood pressure is normal, you know that this exists now and your medical history and you need to be a nonsmoker for forever. If you quit for your pregnancy, you need to think about exercise. You need to think about your nutrition. You need to be aware of your stress level, and how to dial it back in the right ways. So, That 30 years from now, you're not being told that oh look you have heart disease. You just had a heart attack you're at risk for stroke and it's a really kind of see that through for a lifetime. So it's kind of a gift in pregnancy to be given one of those diagnoses. It's not the gift that everybody wants. You want like the A-Plus clear sailing, but it is a gift that you know it because it gives you the power to make those changes before. For the permanent damage is done to your body. I like your point about leaving a legacy. You're giving women an opportunity to leave a legacy train, your kids, teach their kids. This is how we need to eat. This is how we need to exercise, and if they get brought up in that fashion, they'll continue that on and then their children will continue and it's a lifelong Legacy that women can potentially leave their mark on society. Yeah, and I will tell you I have patients in my practice that are so good at that. Yeah, really, and they may have struggled themselves whether it was obesity or medical problems and they have been able to find the way for that healthier path and they do live that for their kids. It's impressive. What risk factors, do you look for in women? That would make you think they are more likely to have preeclampsia desk gestational diabetes. So there's a bunch of different things that the easy ones are if you have already high blood pressure. If you already have diabetes, like those things are going to potentially become worse and pregnancy, extremes of age and pregnancy can put you at increased risk for for preeclampsia. So the super young or the advanced maternal age, the Other risk factors are going to be people who are smokers, people who are overweight primarily. Those are the populations that we reach out to the other would be if you have underlying conditions, some people who have in this is much less common, but people who have kidney disease that's going to put you in increased risk for some women who know that they have antiphospholipid antibody syndrome. And so there's kind of smaller and smaller. Groups of folks where you say? Okay. Well you have Lupus. This is a risk factor. And so anyone who has an underlying medical problem. Those folks, really do want to get into prenatal care and it's primarily to get a baseline for some of these other risk factors. In the introduction, I mentioned polycystic ovary syndrome. Can you tell us what that is? And why it puts a woman at cardiovascular risk. So polycystic ovarian syndrome or PCOS come sort of in two different flavors and it really is a metabolic disorder that is hasn't Hallmark of either hyperinsulinism or hyper and unit Androgen ISM or a swirl of both and Those people who have hyperinsulinism just have more insulin insensitivity. And so they create more insulin in their body in order to keep their blood sugar normal. And over time, that's going to increase your risk for diabetes. For women who have PCOS. It doesn't mean that you have need to have giant ovaries or anything like that. It's more. So the Hallmark is that you get the term on ultrasound is String of Pearls. So if you're looking with an ultrasound at an ovary, And an overreach should normally kind of look like a chocolate chip cookie where there's little follicles, like chocolate chips within the structure of ovary for women with PCOS. It's called String of Pearls. And so those follicles all line up on the edge of the ovary. So it looks like a pearl necklace. They're small like little pearls. They're not Mama Jama water balloons. So that's the clinical look, when you were making the diagnosis. What's physiologically happening? Is those women? Have challenges ovulating where they will not have a regular period, because they do not ovulate in a regular predictable way. In those follicles, those eggs within the ovary, when they are being stimulated to try to come to the surface, interrupt out as an egg and ovulate, they get held up. And so they all line up at the service at the surface of the ovary. Like they're ready to launch but they just can't hit burst out. And so that's why it has that appearance under ultrasound. And that's why women who have PCOS tend to have irregular cycles have difficulty, sometimes getting pregnant because they're not releasing eggs, that then can get fertilized and the hyperinsulinism puts it in an increase risk, for diabetes, the hyperandrogenism, for those patients. They may see unwanted hair growth, increased acne, other challenges like that. And in that, in addition causes fertility, related issues. So with PCOS as a group, Those women do have an increased risk for cardiovascular disease because of the comorbidities of obesity diabetes or associated with that condition. Then the metabolic issues that go along with diet, insulin, absolute and or Judaism. Yeah. There's also I think in this honestly, I'll tell you Kathy. I just looked up last night. But what I did know was that for women with PCOS when you Hear them to match controls of a similar body mass index that they also have worsening lipid profiles. And so they have more of that disc Le Petit Nia or abnormal cholesterol levels, that are not appreciated just for weight or diabetes alone. So there are other factors that are happening with PCOS that are either not well understood or certainly not well understood by me for why it would cause those problems with those would be additional risk factors for heart. Disease in particular. What are the risk factors for heart disease? In adults, has anxiety depression, PTSD. And we know that women suffer PTSD at a greater rate than men, 10 percent versus 5% and anxiety, and depression. Also correlate to developing heart disease. Has any relationship to postpartum depression, been correlated with future cardiovascular disease. So, you know when I was reading through these questions, I found that one to be really fascinating. I could not find any study that particularly linked the two things. I think that postpartum depression is absolutely a real issue. We take it very seriously in our practice. We screen all of our postpartum patients for postpartum depression. It is one of those extremely isolating type challenges that postpartum women can face and I think that the most important thing Up front like we've been saying kind of all along is to set up those expectations. And so a lot of women think especially with their first baby like, this is going to be fabulous. I've always wanted to be a mother and it is the reality is challenging that when you are a new mom, your body is gone through these major transformations. Sometimes you have soreness and pain, and cramping, and discomfort. And your body just doesn't feel slow. Stretched out, not quite right and can't feed. We're quite right. Everything's just not quite right. Yeah, and then you have this gorgeous newborn baby, but sometimes it cries all the time and your sleep is disrupted, and your breasts are so our, and there's just a lot of challenges. And you think what in the world have we done? Like this is not fun. And even though it is commonly seen as the blessing that it is. It is hard work. It is hard work and that reality smacks people in the face. Sometimes, the other thing that people don't always anticipate is that it can be scary because you are not necessarily born knowing how to raise a child. And so not necessarily having all the social support that you may need. Or, you know, just having that helping hand to say, you know what, you're doing a good job, you're being, okay. So postpartum And even for people who just have baby blues, or who don't even have that, who are just kind of overwhelmed. That is something where you say, you know what, you are not alone for heaven sakes, reach out because there are groups of women who get together and you're like, oh my God, everybody's tired. Women who have pre-existing histories of anxiety, or depression, or sometimes nothing at all, but it all pops out postpartum and then they have this overwhelming guilt. Like why do I feel this way? I shouldn't feel this way. And so I think those are all really important things to make sure like listen, this is not uncommon. If you are feeling this way, please reach out. We also tell dad's, I particularly tell dad's like if there's something where you feel like there's a problem bring your wife in because she may not be able to bring herself. Finn when she feels like this. And so, I don't know if there is a long-term connection to cardiovascular disease, I would assume that it should follow like other mental illness in that if PTSD and depression and anxiety, haven't increased risks and then this would be profession to make may as well for many women. It is kind of a period in their life that lasts for six months and then it resolves. And so, but I have not seen any long-term studies. I've always been a huge advocate for birth control for those folks who want it. And I know there's been some significant improvements in birth control over the years. So what is the current thinking on hormonal birth control and the risk of stroke or thromboembolism? What is the impact on women? So many waiting until they're older to have babies. Does it put a woman at risk for future them's? So, birth control is a fabulous topic. I will say, I think, for women who want to have some control over when they're timing of when they get pregnant, you have the obvious you abstain, you're going to use barrier protection methods, or you're going to use some type of hormonal contraception and hormonal. Contraception really needs to be given by doctor who understands all of the ins and outs of what those hormones are going to do for your body and requires somebody. See who's going to be really a willing participant to have a conversation about how they may feel while they're on birth control the long. And short of it is that birth control pills. From on contraception, does not increase your risk of heart disease. So taking birth control is not going to increase your risk of having a heart attack. When you're older, the benefits of birth control as far as controlling when you get pregnant, but also for people maybe with PCOS or not having a regular cycle. All are certainly worth having a conversation with your doctor, the downsides of birth control. So one of the things you mentioned was blood clots thromboembolism. So that is higher birth control users than on users, but is lower in birth control users than in pregnancy or postpartum. And so I think for people who are wanting control of their fertility, taking a blood control or birth control pill. The next conversation is, what are your additional risk factors for blood clots. So if you have an inheritable disorder, that's a conversation to have with your provider. There are some that are preferred over others. Maybe your progesterone only patient. Maybe you're an IUD patient for women who have elevated blood pressure. We know that estrogen can have an effect on blood pressure. And so you may be someone who's a low-dose candidate or there are there's a lot. A lot of variation in the hormones that are available, the dosing regimen, that's available, the structure of, there's a lot of options and so that really could be tailored to each individual's time in their life if they're young, if their middle age and if they're premenopausal what their Baseline risk factors are how they feel when they're on that medicine. And then, I think more importantly, for the the embolism risk, we have to make sure that women know that smoking is so bad for you and that cigarette smoking. Can certainly increase your risk for blood clots and is just really damaging to your body. Just a bad thing all the way around. It really, is it really is so that's for our birth control pill users and sometimes for women who don't stop smoking, that's one of the reasons why they say, oh my gosh, I can't get pregnant. I need to do something. I really like my birth control that's going to be the reason for me to quit birth controls certainly has changed significantly since I was eligible for birth control for sure. Yeah, it is. And there are so many options that I don't even think we can get into some all the different choices here today Cathy, because between the different progesterone agents between the different delivery devices, there's really pretty much something for everybody, and it's definitely worth having a conversation with her gynecologist. East. But for the purposes of this does not increase your risk of cardiovascular disease. You are, which brings up another question. What is the current thinking on HRT, or home hormone replacement therapy. I know many women. My age are using what they call bioidentical hormones. In fact, they come as little pellets that are inserted Under the skin, every four to six months, a little less. June progesterone. If you have a uterus and testosterone these pellets are being advocated as good for bone, health heart health and mental health. Can you discuss what the current science tells us? Certainly. So hormone replacement is a hot topic here in Southwest Florida. And I think that there has been thankfully, a lot of data that's been put out on how to responsibly use hormone replacement therapy. What we really understand is that That hormone replacement therapy that comes as oral medication, transdermal medication or pellet. Has you described really should be used for the treatment of menopause. So specifically saying hot flashes night, sweats vaginal dryness, and discomfort, what hormone replacement really shouldn't be used for is prevention of heart disease and osteoporosis, the reason. That is, is that estrogen and estrogen with progesterone has been shown to increase your risk of breast cancer after five to seven years of use, depending on which ones you're using and does increase your risk for blood clot and potentially stroke. So given the risks that are associated. With that medication, there has never been a primary prevention study for heart disease that It shows that it decreases your risk of of end organ. Heart problems. So, for our patients and personally, I like Mormons, if you are having hot flashes and night sweats and you are a miserable little puppy. Like yeah, let's try to find a way to make you more comfortable in land that plane smoother, so that so that you have a better quality of life. I have patients in my practice. To start their hormones in that perimenopausal period and then we talked about weaning them down as time goes on. That would be the kind of national recommendation. The other options is you do have some women and they get to that five to seven years and you try to wean them off and they're just not successful. They have hot flashes, they have night sweats. What we had always been told in the past was that menopause only the symptoms of menopause. They're only really for those five years around the time that you're hearing is done. And then it just goes away. I would say for about 85 percent of the populations. Well, 85% of the population that generally is true. But you have those poor women at the end who are always sitting there with their fan and they're 80 years old and they're like, yeah, it is like the day my period stop and for those people they should be able to continue to use their hormones through to improve that quality of life as long as they understand those. Chris. So for my patients who are hormone replacement, they absolutely have to have a 3D mammogram every single year. They need to make sure that their blood pressure is under good control. They cannot be having significant, uh, not well, understood migraine headache. Like there's a lot of different components where you say, let's just make sure that we have this all in place because I don't want to do something for you. That is going to kill you. The pellets are a Different scenario and the problem really with the whole pellet world is that they have not as a whole gone with the, let's treat the symptoms of menopause hot flashes and night sweats with the lowest dose that fixes that problem and then he's off pellet therapy and I kind of jokingly around refer to it as like hormonal, crack is more so giving really high dose. And so it's Supra physiologic doses of estrogen progesterone, testosterone and long term that I don't believe is healthy for women. I think there's a lot of risk there. I see a lot of irregular bleeding in women. And so, I am not a advocate for pellet therapy and it's not that I have a problem with a pellet. It's a problem with the dose. So for, or I'll transdermal pellet. It just needs to be appropriately, dosed and then managed to minimize those symptoms. I think women who are on hormone replacement, estrogen, in particular are going to have improvements in their bone health or stabilization within their bones, you it's absolutely proven. It's true. We all know it and it's wonderful. It is one of those great side effects that you get. There are other bone medicines that are on the market for sure. That's worth a conversation with your provider. The Why it is not recommended as Primary Therapy for bone health is because of those risks of stress disease and cardiovascular stroke. So the other I know where I was going to go with that. So with with my patients who do not are not able to successfully transition down or off of their hormone replacement after that five to seven years we say, okay, you know, your risk for breast cancer is actually increased now and so you get to choose and there may be some other risk factors that Willing to let go of and one of those is alcohol. So alcohol and heart disease is very interesting one because everyone's like, oh I get my glass of red wine. And so yes, when you're talking about heart disease alone, there. There may be a benefit to very moderate or low consumption. I don't know what you guys would say. Like, maybe three glasses and week one last a day. I don't know. But for breast cancer, that answer is actually completely different. And for to decrease one's risk of breast cancer, there is great data to show that alcohol is bad for you and it's bad for women and it affects your liver and your metabolism of estrogen. And so it is Lifetime consumption of alcohol. That's what they need to hang in the Frat House, lifetime, consumption of alcohol, that increases your risk for breast cancer. And so as you get to that point in your life, when your Rags with hot flashes and night sweats, you thinking I really don't want to Um, off of my estrogen and I really don't want to develop breast cancer. Then I say, gonna have to double think that Martini because that may be something that you are willing to let go of. It will make your hot flashes worse. It is not good for your breast tissue. And and so that's something where people get to make choices. And I have patients in my practice who are taking their hormone replacement and drinking their martini, and they're getting their mammogram and they say, I have to live my life. And I say, just live your life with your eyes wide open. Yeah, and and understand the risk, go for it. Yeah, and and there are other people who are like, you know what that's not it's important to me. I got a new grandbaby on the way and and I don't need that Martini, okay? This has been so informative and I think our listeners are going to gain a lot from our conversation. Is there anything you want to add before we sign off? I do. There's one thing that I just wanted to say and that is it is really cool taking care of women from when they are teenagers which is kind of when I start all the way through postmenopausal and into their 90's and One of the other cool things about that is that women have a lot of control like you said before over how Health Works within their family for future generations, and I don't know maybe about five or seven years ago. I was really delving into the literature regarding plant-based Lifestyles. And there are a number of studies that actually come out of Scandinavia and they talk about women's nutrition during pregnancy and what Impact that has on the developing fetus and there is a term called epigenetic modification. And what that means is that even though you cannot change the genes that you pass on to your children, that's defined by that egg and a sperm. You can change the expression of when those genes create their proteins and when those proteins kind of activate, that end product of any disease, Based on the environment in which you grow that fetus. And so if a baby is growing in a woman who is eating more healthy, nutritious food, and being exposed to less air, pollution less, smog less, cigarette smoke, less marijuana, the modifications to that genetic code are such that. The gene stay the same. But the time that those proteins, Expressed in those n products occur in those disease. Processes are initiated can be significantly augmented both for the better and for the worse. So that is a remarkable power that women hats fascinating. It is really when I read that I was like Wow, wrong away. So I irritatingly tell all my pregnant patients four servings of vegetables. A day 4 servings of vegetables a day. That was to reflect the Thresholds in a lot of these studies. And so I think that that is one message that I would like women to hear is that, yes, you can look back in your family history, and you can bemoan all the heart disease that you've seen are all the diabetes that you've seen. But it doesn't mean that it has to happen to you or to your kids. If you are able to find the way to make those changes. And I think what is really nice about what you're doing Kathy and what the Shipley Center is doing for. Is to number one, provide that education. And then also say, okay, where are the resources? How do we get it? So that women have the time to cook or have the resources to buy those foods that are healthier. We all have run through McDonald's because you don't have time for something else and we have to try to figure out for ourselves. How do we do better? How do we plan better? How do we teach better? How do we teach our kids better so that we can really live that lifestyle? That that we want to and I'm still learning it myself. Well, I think we all are into your point. One of the problems that we that here United States. I think we have this we're coming off of this generation of over achievement which has really translated into no time. No time, no time for anything except careers in moving forward, in trying to accomplish and I think we've lost the concept of a simpler life. In a simpler life was about being home. Being able to cook being able to access a plant-based diet in the way. Our grandparents actually lived. I mean, that's how my grandparents would we. We go to their house and it was basically there'd be vegetables on the table. There would be some form of protein. Of course. But essentially, it was more vegetables and lots of carbohydrates that time as well, but I think we just have got to be able to modify somehow what we're doing here in the States because women don't have time. And then we make them feel guilty for not having time. And at linking it to this Rat Race. And then, basically, you can't get out of. And, and then, as you say, when you add kids to that, it It complicates matters even more and we all suffer for it. I love the idea that epigenetic epigenetic modification is just so cool. Yep. It is that it is really a powerful thing that you can pass forward to your kids. Yeah. Thank you again to Dr. Sarah DiGiorgi board-certified obstetrician and gynecologist with premier women's the care of Southwest Florida. Until next time I'm Cathy Murtaugh Shaffer and this has been Heartbeats Shipley Cardiothoracic centers podcast, dedicated to bringing research, innovation, and education to our patients and the community.