This podcast episode delves into the complexities of Hormone Replacement Therapy (HRT) for women experiencing perimenopause and menopause. Brooke Davis, founder of Elysian Women’s Wellness, discusses the importance of understanding HRT, its benefits, various methods of administration, and addresses common myths and misconceptions surrounding the therapy. The episode emphasizes the need for personalized approaches to HRT, as each woman’s experience and needs are unique. The conversation aims to empower women to take control of their health and navigate their options with informed decision-making.
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The information provided in this podcast is for educational and informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or treatment options. Never disregard professional medical advice or delay seeking it because of something you have heard on this podcast. The content discussed here may not apply to you or your individual health needs, and it’s important to consult a healthcare provider to determine what is appropriate for your situation.
Today I want to take a deeper dive into a topic that I’ll be honest, I’m not an expert in but I’m learning more and more daily and I want to share what I’ve learned because there are some raging myths and misconceptions surrounding this topic that are keeping middle aged women from optimal health – and that is Hormone Replacement Therapy (HRT) or Menopausal Hormone Therapy (MHT).
To start I want to give some definitions, so perimenopause is defined as the 10 years or so prior to the complete stopping of your menstrual cycle for 12 full months, and it comes with fluctuations and decline of our main sex hormones estrogen and testosterone – leading to complete failure of the ovaries to produce either. The 12 month mark on that DAY is considered Menopause and anything after that day is Postmenopausal.
Most women are absolutely miserable during this time. They’re dealing with hot flashes, weight gain, musculoskeletal pain, fatigue, brain fog and so much more – that seemingly came out of nowhere and that nothing will resolve.
Most women are either being dismissed by their doctors with some refusing to do any kind of testing offering up some anti anxiety or anti depression medication, some testing but saying there’s nothing to be done or worse offering birth control, and a small percentage offering the support of hormone replacement therapy – but an even smaller percentage who are actually very knowledgeable and trained on the topic.
Perimenopause and menopause is kind of the black hole of healthcare and while it’s getting better, this is a population that has been completely overlooked when it comes to research and development – which is partly why I began my mission to help this demographic.
Which brings me to what I believe (in addition to diet, exercise and lifestyle of course) to be the number one thing that perimenopausal and menopausal women can do to support their health, longevity and quality of life – hormone replacement therapy.
Contents
- There are two main types of HRT and that is bioidentical and synthetic.
- Pros of Hormonal Pellets
- Cons:
- Hot Flashes and Night Sweats
- Cognitive function, Mood Swings, Irritability, Depression & Anxiety
- Vaginal Dryness and Sexual Discomfort
- Trouble Sleeping
- Bone Health and Osteoporosis Prevention
- Myths & Misconceptions around MHRT you’ve probably heard…
- Questions to Ask Your Healthcare Provider after going through history, symptoms, etc.
The Basics of HRT
HRT—what it is, how it works, and what are your options.
Hormone replacement therapy is literally what it says. It is the replacement of hormones that the body is struggling to make or no longer makes in order to help restore hormone levels that naturally start to decline as we approach menopause and to bring balance back to the body.
During perimenopause, hormone levels, particularly estrogen and progesterone, can become pretty erratic and I want to explain why this is just for some context. Follicle-stimulating hormone, or FSH, is one of the main messengers between the brain and the ovaries. And the best analogy I’ve heard is to think of it as a thermostat system, where the brain is constantly trying to “read the temperature” of hormone levels and respond in order to keep things balanced. But during perimenopause, this thermostat starts to malfunction a little, leading to spikes and dips in hormone levels.
Here’s a breakdown of how this system works and why it changes in perimenopause:
The pituitary gland in the brain is what produces FSH, which it sends to the ovaries and FSH tells the ovaries, release the egg. When the ovaries get this message, they respond by maturing a follicle (hence follicle stimulating) – which will release an egg) AND producing estrogen. Normally, as estrogen levels rise, the brain will detect that and lower FSH production, keeping the system in balance but as the ovaries become less responsive to that cue of FSH, it won’t always release an egg, and it doesn’t always produce estrogen (or enough). This is what then tells the brain it needs to “turn up the thermostat” because it’s cold so to speak and release MORE FSH. But then they overcompensate, dumping a ton of estrogen into the system, so now your brain is trying to regulate the temperature again and “turn down” the thermostat.
This drop and fluctuation in hormones are responsible for a lot of the symptoms women feel, like hot flashes, night sweats, mood swings, and changes in sleep.
The goal of HRT is to ease these symptoms by supplementing the body with hormones it needs to bring levels back up to a more stable and balanced place.
There are a few different types of HRT. The main types for perimenopause include estrogen and progesterone, and sometimes testosterone and DHEA but we’re mainly going to talk about estrogen and progesterone today because this podcast is going to be long enough.
The hardest thing about HRT and similar to macros is that it is completely individual to the woman. This is why you’ve maybe heard someone say “HRT didn’t work for them” which just means that you haven’t found the right combination for YOU. This is literally trial and error, even with blood tests due to the above explanation of erratic fluctuations, not only does it change throughout perimenopause but no two people will need the same dosages. Some might just need estrogen during peri, some might do better on a combination of estrogen and progesterone, and some may need to include testosterone. And then it might change every 3-6 months. Which is why a lot of doctors don’t want to mess with it.
There are two main types of HRT and that is bioidentical and synthetic.
Bioidentical hormones are structurally and chemically identical to the hormones your body naturally produces. These are mostly made from plants and can be custom-compounded for individualized dosages which can be the difference between success and not. I personally would never use anything other than bioidentical and we’ll get into some of the studies here shortly of why I say that.
The other option is Synthetic hormones and these are similar but have a slightly different chemical structure from our natural hormones. They’re “FDA-approved” and have been used for a long time. They’re what is found in birth control pills and some of the first hormone replacement therapies.
Synthetic estrogen can go by many names like estradiol acetate, synthetic conjugated estrogens, esterified estrogen, whereas any bioidentical will just be called estradiol or estrogen.
Synthetic progesterone is called progestins, while bioidentical progesterone are called progestogens.
This does not include the “brand names” of the products they are delivered by like prometrium is the most common bio progesterone pill, and estrace is one for estradiol.
That being said, there are several ways you can take HRT, and each comes with some pros and cons but ultimately it’s about finding what best fits your needs, lifestyle and preferences.
- Pills:
- Pros: Easy and familiar, just like any other medication, there’s a set dosage each day.
- Cons: Oral estrogen is processed by the liver which can increase the risk of blood clots so if you’re already at risk for that it may not be the best choice, and they can sometimes cause nausea or upset stomach.
- Patches:
- Pros: Patches stick to your skin and give you a steady dose of hormones over time, they bypass the liver (lowering blood clot risk). They usually stay on for several days.
- Cons: Some women find the adhesive irritating to their skin, and patches can sometimes come off if you sweat a lot or swim, so if you’re training like you should this might be a little more difficult.
- Creams and Gels:
- Pros: These are applied directly to your skin, and you can adjust the dose as needed without having to go back to your doctor. They’re easy to use, absorb through the skin, and don’t go through the liver so again decreased risk of blood clots.
- Cons: Absorption rates can vary depending on your skin type, and you need to be careful not to let others touch the area immediately after applying the cream or gel. A common source of increased estrogen in older males is their wives estrogen creams so that’s something to be aware of. For progestogens specifically, creams have not been proven to be sufficient to prevent endometrial thickening of women taking systemic estrogen – which increases your risk of endometrial cancer. If you are taking systemic estrogen you need something stronger than a cream to deliver your progesterone.
Hormone Pellets: These are custom-compounded pellets containing estrogen, progesterone & testosterone, or a combination of hormones are inserted under the skin, usually in the hip or glute area.
Pros of Hormonal Pellets
Longer Consistent Hormone Levels: Pellets provide a steady, continuous release of hormones over several months, which helps avoid the hormonal fluctuations that can sometimes occur with other delivery methods. This steady release can be beneficial for managing mood, energy levels, and other symptoms consistently, though the effects do tend to fade as it comes time to get a new dosage.
They’re Convenient. They last anywhere from 3-6 months so you don’t have to worry about daily dosages, pills or creams.
Cons:
They do require Surgical Insertion: Pellets require a minor surgical procedure to be inserted under the skin, usually with a small incision. Though generally quick and done under local anesthesia, this can be uncomfortable, and there is a small risk of infection, scarring, or pellet displacement.
Difficulty in Adjusting Dose: Once inserted, it’s challenging to adjust the dosage. If you experience side effects or if the dose isn’t quite right, you can’t easily change it as you could with pills, patches, or creams. You would need to wait until the pellet dissolves or have another procedure to remove it.
Some women may experience an initial “surge” of hormones after the pellet is inserted, which can lead to side effects like acne, mood changes, or increased hair growth. The body may also absorb more hormones during periods of high physical activity, potentially leading to fluctuating levels.
- Vaginal Rings:
- Pros: Rings are great if you’re mainly dealing with vaginal dryness or discomfort since they release estrogen directly in the area where you need it most. They don’t raise systemic estrogen levels, so they’re generally a lower-risk option.
- Cons: Rings only help with localized symptoms, so they’re not useful for hot flashes or other systemic symptoms.
- Anal administration of Progesterone
- PROS: The same capsules that can be taken orally can also be administered anally which some women find produce better results due to the fast absorption of them
- CONS…I’m not sure I have to explain this part…but some women do find that it can aggravate the sensitive skin around the anus over time so using generous amounts of lubrication is advised.
6. Sublingual drops
- PROS: This is super convenient and makes it very easy to control dosage variations and change them quickly. Fast acting absorption that bypasses the liver, and less gastrointestinal side effects.
- Some of the cons are inconsistent absorption, things like saliva, swallowing some of it vs absorbing it can impact how much gets into the bloodstream. They act fast but they also have a shorter duration so they might need to be taken multiple times per day. Then they can have a really strong taste as well.
MHT can give women in perimenopause relief for many common symptoms, and actually plays a huge role in their overall long term health. Some of the most common symptoms women experience are
Hot Flashes and Night Sweats
Intense heat or sweating episodes, and if it happens at night they’re night sweats. These symptoms are mostly due to fluctuating estrogen levels, which affect the brain’s temperature regulation (literally not just figuratively this time).
Progesterone can also play a role, especially for women who can’t take estrogen alone which we’ll talk about shortly, or women who are having trouble sleeping because of the night sweats.
Cognitive function, Mood Swings, Irritability, Depression & Anxiety
Perimenopausal depression & anxiety is very often misdiagnosed and prescribed an antidepressant/antianxiety medication when what you’re really missing is estrogen. Estrogen helps stimulate areas of the brain related to memory and cognition, boosting neurotransmitter activity and blood flow. Estrogen replacement can sharpen focus and improve memory by restoring more stable hormone levels. Perimenopause is also known to bring on mood changes that feel like an emotional rollercoaster— from irritability and sadness to even anxiety. This is because both estrogen and progesterone affect your mood-regulating neurotransmitters like serotonin.
Estrogen can help stabilize mood and reduce anxiety by supporting serotonin production. It’s especially helpful for reducing irritability and sadness.
Progesterone is known for its calming effect, as it interacts with GABA receptors in the brain (GABA is your neurotransmitter that helps you feel relaxed). This can make progesterone helpful for reducing anxiety and helping you chill out.
Vaginal Dryness and Sexual Discomfort
Vaginal dryness is a really common and bothersome symptom of perimenopause. This dryness is purely due to lower estrogen levels, which decreases the lubrication and elasticity of your vaginal tissues.
So Estrogen (especially in localized forms like vaginal creams, rings, or tablets) can directly improve moisture and flexibility in the vaginal tissue and also reduce the risk of urinary tract infections, which can become more common with lower estrogen levels.
Trouble Sleeping
This is huge and can be so disrupting in so many other aspects of life. The drop in estrogen can lead to night sweats leading to waking up multiple times per night. Progesterone plays a role in getting to sleep, back to sleep after waking, and supports staying asleep because it has a natural calming effect.
Estrogen also supports cognitive clarity, helps regulate fluid balance, and protects our muscles and joints – part of which is why we start to lose muscle mass in perimenopause.
- Bloating: Bloating is a common complaint as estrogen fluctuates, affecting your fluid balance and rate of digestion, sometimes it slows down which can lead to gastric distress a lot of women experience. We also actually have a whole community of bacteria in the gut called the estrobolome that helps regulate estrogen, so when this is out of balance and estrogen isn’t broken down or eliminated like it should be, this causes more of it to be circulating in the body also causing some of those common symptoms. Of course we want to work to support the gut with high fiber foods, probiotics and supporting our detox pathways but HRT can help reduce the intensity and frequency of bloating episodes, helping you feel lighter and more comfortable simply by helping stabilize estrogen levels.
- Musculoskeletal Issues (Frozen Shoulder, achy joints & muscles): Dr. Vonda Wright just published a study on The musculoskeletal syndrome of menopause and this states that more than 70% of women will experience musculoskeletal symptoms and 25% will be disabled by them through the transition from perimenopause to postmenopause. That’s crazy. Estrogen is crucial for maintaining your joint health and flexibility because it helps to reduce inflammation and supports collagen production in your connective tissues. As always, motion is lotion so staying moving is also going to help support the joints but estrogen therapy can alleviate stiffness, joint pain, and even issues like frozen shoulder, which so many women experience during these hormonal changes.
Bone Health and Osteoporosis Prevention
On the skeletal side of things, Estrogen is the key hormone for protecting bone health. When estrogen levels decline in perimenopause, the rate of bone loss increases more than 2% per year, putting us at a much higher risk of developing osteoporosis.
- HRT with estrogen can help slow the rate of bone loss, reduce the risk of fractures, and support overall bone density by helping the body retain calcium and other important minerals within the bones.
- This of course is supported by proper resistance and impact training along with adequate nutrition – but estrogen replacement cannot be overlooked.
Myths & Misconceptions around MHRT you’ve probably heard…
- HRT isn’t safe.
- Estrogen causes breast cancer:
- Estrogen & progestogens increase risk of breast cancer
Studies…
WHI women’s health initiative published a study in 2002 that most people have the misconception that HRT is still referencing. This has since been walked back by the women’s health initiative themselves so lets go over this study. The study included about 16,000 postmenopausal women who were given either a combination of premarin (horse urine derived estrogen) and provera (a progestin which is a synthetic form of progesterone) or a placebo (a pill with no active ingredients) to see if HRT could help prevent heart disease, fractures, and certain types of cancer.
When the initial findings were released, there was major concern: the study suggested that women taking HRT had a slightly higher risk of breast cancer, heart disease, stroke, and blood clots compared to those taking the placebo. So of course doctors took their patients off, women were deterred from starting it and the misinformation has perpetuated even to now. But here’s what the actual results were to put it in perspective.
Increased the risk of breast cancer by 9 additional breast cancers per 10,000 women after 5.6 years or 1 out of 1000 users which is a risk just slightly greater than what we’ve seen with one daily glass of wine, LESS risk than 2 daily glasses of wine and similar risk as reported with obesity and low exercise.
The increased risk that was seen was in women who had PRIOR EXPOSURE to hormone therapy. For any women who had not ever had any hormone therapy there was zero increased risk.
They continued estrogen only in the group of women who didn’t have a uterus and when compared, these women actually had a LOWER risk of breast cancer as well as bone and cardiovascular benefits.
But in the years that followed, researchers began to question the WHI study’s conclusions. Here’s why it’s now seen as misleading:
- The age of participants: Most of the women in the study were in their 60s and 70s—not in their 40s and 50s, the age when women typically start perimenopause or early menopause and often begin HRT. Studies have since shown that age and timing matter, with younger women generally seeing more benefits and fewer risks. Most women over 65 are not typically advised to start MHT but as always it’s worth a chat with your doctor if you’re low in other risk factors.
- Another issue is the type of hormones used: The study used synthetic progestin, not bioidentical progesterone, and a form of estrogen derived from horses, which we now know may act differently in the body than other forms of estrogen and bioidentical progesterone. Today, more doctors prescribe bioidentical hormones, which are considered safer and more compatible with the body’s natural hormones.
- Newer research and reanalysis: When scientists reexamined the data, they found that for women who started HRT within 10 years of menopause, there was actually a lower risk of heart disease and no significant increase in breast cancer risk.
In another WHI observational study, looking at estrogen only women who had had a hysterectomy – after 8.2 years invasive breast cancer did not differ when comparing dosages, delivery when delivered in the first 10 years of menopause.
Transdermal estradiol may be SLIGHTLY less risk than oral when it comes to but the sample size was really small.
JAMA 2020 WHI longer term data analysis (20 year follow up)
Estrogen alone reduced incidence of and mortality from invasive breast cancer while combination estrogen – progestin therapy elevated incidence of but not of mortality from breast cancer even in women with family history of breast cancer.
Even with these statistics, what we’re looking at with combination therapies of SUBOPTIMAL types of hormone therapies being that they’re not bioidentical, is that it would be responsible for less than 1 additional but NON FATAL breast cancer diagnosis out of every 1000 women who are treated with menopausal hormone therapy.
Other studies…
Smaller Randomized control trials – menopause 2023 – reduced risk of breast cancer
Nurses health observational study 5-9 years no increased risk 20+ years slightly increased risk
Million Women Study (survey study – least reliable form of studies) – saw 35% increase but is a total outlier.
Vaginal estrogens in low dosages for genitourinary syndrome menopause (vaginal dryness, leakage etc.) this is purely local; it’s such a low dose there is no impact systemically.
Next myth is: Women over 60 should stop HRT
A new study released in April 2024 was an analysis of 10 million senior medicare women from 2007-2020.
The results were that estrogen alone beyond age 65 was associated with significant risk reductions in mortality by 19%, breast cancer reduced by 16%, lunge cancer by 13%, colorectal cancer by 12%, congestive heart failure by 5%, blood clots by 3%, atrial fibrillation by 4%, heart attack by 11% and dementia by 2%.
Estrogen and progesterone combo therapy increased risk of breast cancer by less than what the WHI came up with but can be mitigated by using low dose transdermal estrogen or vaginal systemic dosages
Estrogen plus progestins (synthetic) showed reduced endometrial cancer, ovarian cancer by 45%, ovarian cancer by 21%, ischemic heart disease or the narrowing of arteries by 5%, congestive heart failure by 5% and blood clot by 5%
Estrogen plus progestegen was only seen a risk reduction in congestive heart failure by 4% but no increase in any other issues.
That being said there are 3 french observational studies that looked at 2354 cases of invasive breast cancer in a group of 80,3077 post menopausal women over 8 years found that estrogen + progestins (synthetic) slightly increased breast cancer risk more than estrogens + progestegens (bioidentical.)
Proven Progesterone doses for endometrial protection 100mg daily w/ average or less than average estrogen or 200mg 12 days out of the month. Above average estrogen doses could require higher progesterone for endometrial protection.
Conclusion of this was that Among senior medicare women, MHT use beyond 65 years vary by types, routes and strengths. Risk reductions appear to be greater with low rather than medium or high doses, vaginal or transdermal rather than oral with E2 (bioidentical rather than premarin but this hasn’t been proven in randomized control trials which is the gold standard of studies).
AFTER AGE 65 – RISKS ARE INCREASED.
If you’re taking oral estrogen, it is advised to switch to transdermal due to the blood clot risks and reduced metabolization of hormones on the lowest effective dosage (which you should be anyway).
Weighing risks & benefits looking at overall health from metabolic health to osteoporosis etc.
Starting MHT after 65 is not generally advised.
Vaginal local estrogen for genitourinal syndrome is fine at any time but systemic hormones ideally are started within 10 years of your last period to help support urogenital atrophy, dementia (better within 5 years), and cardiovascular disease.
Within 3-6 years is best for bone loss prevention or treatment.
Starting after 10 years increases the risk of blood clots, stroke, cardiovascular disease and dementia.
Last myth: Birth control is the same as HRT
One very common misconception is that birth control pills or IUDs and menopausal hormone replacement therapy (MHRT) are essentially the same. While they both involve hormones, they have different purposes, different formulations, and different effects on the body, especially during perimenopause and menopause. Here’s a quick breakdown of how birth control differs from HRT and why they’re not interchangeable.
Birth control pills are designed primarily to prevent pregnancy, so they contain higher levels of synthetic hormones (often estrogen and progestin) to suppress ovulation.
HRT, on the other hand, is designed for replacing or balancing hormones that naturally decline during menopause. The hormone levels in HRT are much lower than in birth control because the goal is not to prevent pregnancy or suppress ovulation, but rather to restore balance that can alleviate menopausal symptoms like hot flashes, mood swings, and vaginal dryness.
Another key difference is the types of hormones used. Birth control pills are synthetic hormones, which don’t mimic the body’s natural hormones as closely, whereas HRT often uses bioidentical hormones and this can feel more natural and have fewer side effects compared to the synthetic
The kicker is that birth control can mask some perimenopausal symptoms, but it doesn’t actually address the hormonal imbalance, which can sometimes make things worse in the long run. Long story short, don’t let your doctor tell you that getting on birth control will solve your problems.
The hardest part about menopausal hormone therapy is that no two people are the same, your hormone needs and dosages will not be the same even as someone experiencing similar symptoms. It’s a highly personal choice, and every woman’s needs are unique. This is why finding a provider who can take your individual information, medical history and your current symptoms into account that ALSO has education on hormone therapy is important but also really difficult.
That being said, I want to give you some ways to approach this decision, including questions to ask your healthcare provider, things to consider, and steps you can take to feel confident in your decision.
1. Before starting HRT, it’s helpful to get a clear picture of your symptoms and your goals for treatment. Track your symptoms daily for a few weeks, noting the severity, frequency, and any lifestyle factors that might influence them, like sleep, diet, or stress levels. This can serve as a baseline so you and your doctor can measure improvements and any side effects over time. I have linked a chart in the notes from the Menopause charity that can help you keep track.
Also, taking a moment to define what success actually looks like for you. Are you hoping for more energy, fewer hot flashes, improved sleep, or better mood stability? Knowing your goals helps you make an informed decision and allows your healthcare provider to recommend the best HRT approach or alternatives for what you’re looking for.
- Like I said, Your health history is an extremely important factor when considering HRT. Make a note if you have certain conditions, like a history of blood clots, certain types of cancers, or liver disease, may make HRT less suitable, but not necessarily out of the question. Be sure to review your health history and any genetic predispositions with your provider.
- Think about the different delivery methods. (pills, patches, creams, etc.), and some may suit you better than others depending on your daily routine and comfort with different applications. Make a note of which sounds most preferable to you.
Questions to Ask Your Healthcare Provider after going through history, symptoms, etc.
- What type of HRT would you recommend for my symptoms? Some women may benefit from estrogen-only therapy, while others may need a combination of estrogen and progesterone. The best type depends on your specific symptoms, health history, and whether or not you’ve had a hysterectomy.
- What are the potential side effects and risks? We’ve talked about some of the potentials, but this will also vary based on your medical history and genetics.
- Are there other supplements that could give me support for these symptoms? There is a whole host of herbal and nutraceutical supplements that may be beneficial to some of the specific symptoms you’re experiencing. I do have a menopause supplement bible guide if you want to explore that but of course always ask your doctor before taking anything!
Like I said before, it’s really about finding what works best for your body and it can take 3-6 months to see resolution of symptoms once you find your correct dosage so continue tracking your symptoms and any changes you notice, both positive and negative to help your provider make the best adjustments.
Deciding on HRT is not a one-size-fits-all process. Your needs, symptoms, and preferences should drive the choice. With the right information and support from your healthcare provider, you can find a solution that works for you and helps you feel more in control of your health during perimenopause.
Change is inevitable but suffering is not!
I hope this was all super helpful, I hope you feel more empowered to take on this conversation with your doctor and get the support you need. If you are struggling to find a healthcare provider that is willing to give you HRT, or you don’t feel is a good fit for you you can check out the resource linked in the show notes to 3 telehealth HRT providers and see which might be a good fit for you. I’m not affiliated with them in any way, but have gotten good feedback from clients and people I know who have used them.
If you need more support in navigating this, we do offer a Free hormone analysis that I will also link below that we can talk over nutrition, exercise and lifestyle habits that will help support your goals.
Coach Brooke Davis Links:
Website: elysianwomen.org
LinkedIn: Brooke Davis – Owner – Davis Fitness
Facebook: Brooke Davis, CPT
Instagram: Brooke Davis (@brooke_elysian)
Free Community: Women’s Fitness Simplified: Lean down, tone up, build confidence!
Take Our Free Hormone Analysis: https://brookedavis.typeform.com/to/quKUjmTI
Book a Discovery Call: https://scheduler.zoom.us/brooke-davis-mjzn71/discovery-call
Menopause Supplement Bible: https://www.canva.com/design/DAGKqrYVzHg/dwZqHPHwQTT-WWb5ewhV0Q/view?utm_content=DAGKqrYVzHg&utm_campaign=designshare&utm_medium=link&utm_source=editor
Telehealth Guide: https://www.canva.com/design/DAGWamXe2TU/VrfNVCd2xxdTISNwMo3Mpg/view?utm_content=DAGWamXe2TU&utm_campaign=designshare&utm_medium=link&utm_source=editor