Nam Kiwanuka: You're listening to Mistreated. I'm Nam Kiwanuka. For over 1300 different disorders, women are diagnosed on average 2 to four years later than men. These disorders include conditions like depression and anxiety and Alzheimer's disease, which disproportionately impacts women. According to CAMH, the Center for Addiction and Mental Health, even though women are twice more likely to be diagnosed with depression, symptoms in women are considered atypical, whereas in men, the symptoms are typical. But it's not just mental health conditions where a late diagnosis happens. A 2019 Danish study found that on average, women received cancer diagnoses 2.5 years after men. They received diagnoses for metabolic diseases like diabetes 4.5 years later. That's because most of our medical knowledge, clinical trials, research, and including how to diagnose someone is based mostly on symptoms from males or the experiences of men. This health data gap means that women not only spend more time waiting to get the treatment they need or are diagnosed late, but they also spend more time being misdiagnosed or undiagnosed.

Nam Kiwanuka: Women also go underdiagnosed in five conditions: heart attacks, endometriosis, autism, ADHD, and autoimmune diseases. According to gabi.org, or the vaccine alliance. The women's health gap equates to 75 million years of life lost due to poor health or early death each year. Closing the gap would give the 3.9 billion women in the world today an extra seven healthy days a year or an average of 500 days over a lifetime. This is why researching sex and gender differences in health matters. One of the leading researchers in this space is worldrenowned neuroscientist Dr. Lisa Galia from CAMH. Dr. Galia's research is vital in filling this knowledge gap in understanding how hormones influence the female brain, especially during pregnancy and postpartum. As too often, women's health is ignored in research. We talk about why by age 60, women are twice as more likely to be diagnosed with Alzheimer's than with breast cancer, why physicians are moving away from using the name HRT to MHT, and why we don't know more about women's brain health. She also helps us to understand some recent news headlines, including the FDA removing the black box from MHT and if menopause is linked to Alzheimer's. I learned so much. I hope you do, too. Dr. Galia joins me now.

Dr. Lisa Galia: My name is Lisa Galia. I hold a PhD in neuroscience. I am the Trey Living family chair in women's mental health at the Center for Addiction and Mental Health here in Toronto, Ontario, Canada. And I'm also professor of psychiatry at the University of Toronto.

Nam Kiwanuka: Your credentials are mindblowing. I want to talk to you about the work that you do with the Galia Lab. But first I wanted you to help us understand something first. When we talk about women's brain health, what is the difference between sex and gender? Because this is something that you study.

Dr. Lisa Galia: Yeah. I mean, okay. So, sex usually people will refer to that as the sort of biological characteristics that may differ between males, females, and interex individuals. Gender is a psychosocial construct. So, it goes beyond gender identity. That's whether you identify as a woman, non-binary, gender diverse, or man. But also how society expects you to act and what your roles in society are based on your gender identity and that's society from every level home life which we were just talking about education as well as just going to the mall or your employment.

Nam Kiwanuka: Well, I'm glad you helped us understand that. But why is it important to draw that distinction that there is a difference?

Dr. Lisa Galia: Okay, so for many things, and I want to also try to draw back the attention to women themselves. So there is a concerted effort to understand any kind of difference or influence between sex and gender. So for example, you might see that cholesterol is higher in women than in men. Like I'm just giving this example. I'm not saying that this is true. But then you might also see that statins which are prescribed to lower cholesterol are more likely to be prescribed in men compared to women. So is that a sex difference? Is that a biological difference that's driving this difference in cholesterol? Or is it because women are not prescribed the cholesterol-lowering medications because they thought they're thought not to need them? You know, maybe it could be something like that as simple as that.

Nam Kiwanuka: Or even being referred to specialists. We know that women are tend not to be referred to like knee specialists and joint specialists as much as men are. And that would be a gendered difference because they have just as many injuries and need for the surgeries, but they don't get referred as often. But it's basically I guess what are societal conclusions or perceptions.

Dr. Lisa Galia: Yeah, it's perceptions, right? It's all about your perception and what should be expected of you or because of your gender. So it's not it's not driven by biology, but it's driven by society. And I'll just to sort of underscore this to me, it's kind it's kind of like nature versus nurture. And you've probably heard that argument as a nature versus nurture in terms of maybe bringing up children or something like that.

Dr. Lisa Galia: Almost always it's a bit of both. And that's going to be true for any kind of sex influence or gender influence that's seen out there. It's probably going to be a mix of both biology and the social societal expectations. But the other thing that I think gets lost in this and the government of Canada for example has made a concerted effort to ensure that scientists in general will be looking at sex and gender as part of the equation for our health. It's called SGBA or sex and gender based analysis.

Dr. Lisa Galia: And even in government documents people would see if you look online GBA which is gender based analysis. The thing is for women's health, we're still going to get lost in this. If if we don't if we're always constantly being compared to men or males, it's like we have this norm that we're being compared to, whereas women are not just one are not one thing. Gender diverse people are not just one thing. And so are, you know, are we talking about a person who's on hormonal contraceptives, a person who's had two pregnancies or three pregnancies or no pregnancies, who has a uterus, who doesn't have a uterus, all of these things will influence our health outcomes and disease risk, and it's important to study. So why I have such a focus I do have a focus on sex and gender but I also have a focus on women's health specifically and that's because I truly believe that the unique experiences and hormonal transitions that women go through are important to study on their own.

Nam Kiwanuka: Let's talk more about that because to go back a little bit women weren't included in in clinical trials women and so-called minorities until 1993 in the US.

Dr. Lisa Galia: And 97 in Canada.

Nam Kiwanuka: Yes. And throughout...

Dr. Lisa Galia: It's not quite accurate. Can I...?

Nam Kiwanuka: It's not. Yes, please clear it up.

Dr. Lisa Galia: Can I clear that up? People will often quote that. They were included not but they they made it mandatory to include women and it was mandated. Yeah. Women and so-called minorities as you say in 1993. That's only for NIH funded trials. So NIH stands for National Institutes of Health. Yeah. In the US, that's 15% of clinical trials in the world. It's Yeah. So, it's actually worse than people actually know.

Nam Kiwanuka: Give us an idea. What's it like around the world? Are women included in clinical trials?

Dr. Lisa Galia: So, here's it is not that's a really good question. I don't know the answer to it. I I should know the EU data and the Australian data. I don't. I think it's fairly new that it started to be mandated at least in Australia. But I'm I I I'm not sure of all of the details around that. But what even with the mandates in Canada and in the US, what's happened is there'll be some inclusion, but there'll be disproportionate. So say you know, of 20 people, two will be women and 18 will be men. So it's hard to draw any conclusions. But not just that, they're not what we call sex disegregated. So, we don't actually see the results based on, you know, females or males or women or non-binary or or with ethnicity as a background. We we don't see them disseminated that way. So, we have no way of knowing. And the researchers didn't look to see if there was a difference.

Nam Kiwanuka: So, we're still kind of treating the male body as the typical and the female body as atypical. Is that fair to say?

Dr. Lisa Galia: It's somewhat fair to say. It's more about like agnostic. It's almost like people are yes, we'll include everyone, but we're not going to look to see if it makes a any has an effect. So, for me, that's just as bad because we're not we're not looking to see if this has an influence or not. And when we do look, almost always you will see that it has an influence on the findings.

Nam Kiwanuka: Tell us more about that.

Dr. Lisa Galia: Uh, well, there's so many different ways that I could explain that, but I'm trying to think of some good examples. Ambien was is probably the one that a lot of people will know about and that was from the food and drug association that for the first time ever and that was not that long ago. I'm sorry, I don't remember. It's some in the late 2000s.

Nam Kiwanuka: Um like 2014, something like that. 2019, obviously not. Anyway, um it's recent.

Dr. Lisa Galia: It's recent. It's fairly recent. Where they for the very first time ever, they didn't say that a different drug needed to be used, but that a different dose needed to be used. And I think we, you know, you just have to sit back and think about this for a minute on our pill bottles, like whether it's first acetaminophen like Tylenol or Advil. It doesn't it says take one or two pills if you're an adult. It doesn't say take a certain amount if you're a man or a woman or even how much you weigh.

Nam Kiwanuka: Right? Weight weight has a big impact on how a drug is going to work in our body. And of course, men and women weigh differently.

Dr. Lisa Galia: As you probably are very well aware, there are many drugs for erectile dysfunction. There's one there's only one as far as I know for female libido which just means sexual interest libido. And I think it's something called Addyi something like that and the food and drug administration asked the drug company to and ensure that the interaction with alcohol there wasn't going to be any adverse interactions with alcohol because maybe they assume that people might be taking this drug for female libido also with alcohol. And so they tested it on 20 people. And of those 20 people, how many were female or women?

Nam Kiwanuka: Not all. I would assume all.

Dr. Lisa Galia: Yeah, you would assume all. And it should be all. It was two out of the 12.

Nam Kiwanuka: Yeah.

Dr. Lisa Galia: Yeah. I mean, it gets worse and worse. So we we did a huge study where we looked at over 3,000 studies in 2009 and then in 2019. So a 10-year gap across six different medical journals. This is for neuroscience and psychiatry. And when we looked at it, lots of studies had increased the percentage of males and females that they used in their studies whether it was clinical studies or pre-clinical studies or trials or not no trials. So I think it went from say 30% to 68% of studies were looking at males and females. But only 5% were looking to see if it made a difference and I I think it was something like 14% were using these uneven sample sizes that I just told you about this like.

Nam Kiwanuka: The young people would say make it make sense.

Dr. Lisa Galia: Make it make sense. I mean it doesn't make sense to me either and then when we looked at are you looking at are they looking at male specific studies and questions or female specific questions like women's health kinds of questions there's only 3% for women's health kinds of questions and 27% for male only or men only studies. Hm. This is like sorry. No, but it it is like you it's it's so frustrating because I think when I was younger when you're you don't really think about all of these things because you're you're healthy. You're you assume things.

Nam Kiwanuka: But once you hit for me anyway it was when I had my first baby.

Nam Kiwanuka: That's when I was like oh this is not you know.

Nam Kiwanuka: And then.

Dr. Lisa Galia: Can I ask you a question about that? Did you notice it while you were pregnant or after you had your baby?

Nam Kiwanuka: During the pregnancy.

Dr. Lisa Galia: Even during the pregnancy.

Nam Kiwanuka: Well, more after, like after cuz I had an emergency C-section and as soon as the baby was taken away, it was like, you're on your own, sister. It was just like, I'm still here.

Dr. Lisa Galia: I know. That's how I felt, too. I was like, there's so much attention to me when I was pregnant. And then as soon as the baby was, I mean, the babies are cute. Like, I get it.

Nam Kiwanuka: But I'm thinking as I get older, I'm thinking more about my brain health. Yeah. Um, and I'm really worried about my later years. And I keep hearing people saying you should do this, you should do that. A lot of things that I wish I had known when I was younger. So when we talk about brain health, can you tell us about the work that you're doing with the Galia lab?

Dr. Lisa Galia: How much time do we have?

Dr. Lisa Galia: So I I absolutely can. What I love studying is how sex and sex differences, gender differences in the two disorders that I'm really most interested in are depression and Alzheimer's disease. So I look at stress related psychiatric disorders like depression as well as neurogenerative disorders like Alzheimer's disease later on in life. And why did I pick those diseases? I also look at brain health too but because two things one more women than men suffer from both of those disorders and then my very I'm a neuroscientist which just means I love studying the brain and my very favorite brain area is called the hippocampus. I can tell you all about the hippocampus. And we study all the fun things about it. It has a lot of these hormone receptors in it. So I'm interested in how hormones particularly sex hormones like testosterone but estrogens but also stress hormones how they impact the brain and brain health and there are a lot of these kinds of receptors there which means that it's it's going to influence that particular brain area and it's very plastic and it's the first brain area that shows disruption with both of those types of disorders.

Dr. Lisa Galia: So that's and and we also look at a lot of the hormonal transitions in a female's lifespan. So we look at adolescence, we look at men menstrual cycles or estroycles, not as much work in that area, but also how pregnancy affects the brain both in the short term but also in the long term and how menopause impacts the brain as well.

Nam Kiwanuka: Well, in what ways do hormones impact our brains?

Dr. Lisa Galia: It's again so many ways. So for I the way I think about it is hormonal transitions no matter where they are across our lifespan and this is going to be true for men and and gender diverse individuals as well have an inflection they're an inflection point and so menopause for example would be an inflection point for aging. Menstrual cycles or estrocycles if you're a rodent are going to be an inflection point for your your current health but also your future health. I've I've even heard people say your menstrual cycle is a vital sign and then people will sometimes say period which I think is kind of cute. I say period I know it's great. No, no, it's great. And and even same thing with pregnancy and the postpartum. So pregnancy is actually known as the first stress test for the body. So if you are more likely to have a pregnancy related disorder like preeclampsia or hypertension during pregnancy you you are at greater risk for heart disease later on in life and that I hope that doesn't scare people. What it's meant to do is say hey this is a not not necessarily a wakeup call but like I need to pay attention to this a little bit more and it's not going to stop.

Nam Kiwanuka: I think it's empowering people.

Dr. Lisa Galia: It should empower people. Yes. Exactly. And and I hope now that people are getting that information so that if they do suffer for some of these gestational disorders that they are aware of the potential implications later on. I think part of the frustration is there's been a lack of research done with women's health and so a lot of these conditions if you know it then you can actually say okay I'm at a higher risk of this I'm going to pay attention to that right. So during you mentioned puberty young girls may there you might be a suggestion for them to go on birth control.

Nam Kiwanuka: But women with conditions like fibroids like I had or endometriosis we can also we we can be asked to go on birth control to manage those symptoms, right? What impact does this have on our brain health during those times? And is it different for an adolescent versus an adult brain?

Dr. Lisa Galia: Yeah, so there's so I think I said it earlier that 300 million people worldwide take hormonal contraceptives. Maybe I didn't say that. And they've been on the market for 70 years. So of all of the studies, you know, worldwide throughout time, can you guess what percentage of studies are on brain health and hormonal contraceptives? Is it zero? It's very close to zero. 0.15%. But there has been a sort of recent like more interest in how hormonal contraceptives affect the brain. There other areas of the body, yes, but not so much brain or mental health and there is some suggestion in the literature that it increases risk for a number of mental health disorders earlier on in life. So if you're taking them during adolescence, you're more likely to it it increases your risk for depression for example or anti-depressant use which is not exactly the same as depression. If there's been a number of huge studies now done looking at adults taking hormonal contraceptives and at an adult age like 21 or or older there is zero indication that it's it's increasing risk. And there are some really great studies out there right now looking at if the person w had a great if they were um if their mood was already at a a state where they maybe were a greater risk to develop depression or anxiety they were probably more likely to be sort of tipped over the edge with hormonal contraceptives where somebody else wouldn't have been.

Nam Kiwanuka: Like insert the emoji with the mindb blowing blowing. Oh yeah, I could tell you more.

Nam Kiwanuka: Because and the reason why my mouth is on the floor is because.

Nam Kiwanuka: And I'll just use birth control just for um.

Nam Kiwanuka: That it's this thing that's just used as a stop gap for everything.

Nam Kiwanuka: And then there's a lack of studies on how it's impacting our brains because if you go on birth control from like I I had my first menstrual cycle at 11.

Dr. Lisa Galia: Yeah. Poor thing.

Nam Kiwanuka: Right. Yeah.

Nam Kiwanuka: And to now that would mean that I was on it for like 35 30 plus years.

Dr. Lisa Galia: Yeah. So yeah.

Nam Kiwanuka: And no one would say that that could have an impact on my brain health.

Dr. Lisa Galia: So again we don't have that many studies but I will give you some reassurance. So for some people it's you know we're all different right? That's why one size doesn't fit all.

Dr. Lisa Galia: And there are so many different kinds of birth control methods as well that not you know one pill is not going to equal the other. An IUD is not going to be the same. Copper IUD versus Monura is not going to be the same outcomes necessarily. But they've been starting to just starting to look at how hormonal contraceptives might impact later life brain health and some early work using something called the UK bio bank has shown actually might be have a protective effect. But something else I'll just say is for some people like myself, I loved it and it made me feel better. It evened out my periods. It you know maybe evened out my temperament a little bit more and as soon as I noticed when I had some permenopausal symptoms at 47 I was really really irritable. I was in Venice I should have been having the time of my life and I was just like so mad at my husband. The poor guy.

Nam Kiwanuka: Was he chewing too loudly? I am totally chewing too loudly and you know not smiling when I wanted him to smile.

Dr. Lisa Galia: The call. Um anyway, I was having the time of we were on Bragelina's boat like with the boat that they had rented. You know, we were had somebody touring us around. Anyway, really, really fantastic, but I was irritable and I real I remembered, oh, the last time I felt like this hormonal, in my case, it was a pill. It helped it helped even out my mood. And so, I went back to my family doctor and I said, look, I I'd like to go back on hormonal contraceptives and she she put me on the same pill that I was on before. But that's the kind of re research we're we're trying to do now. So for some people it might not work for them but for other people it might actually be you know mood boosting or or or helpful for their.

Nam Kiwanuka: But the fact that you're doing research because women are not a monolithic.

Dr. Lisa Galia: Yes. Exactly. We talked a little bit about how you mentioned the pregnancy was the first stressor on a person's body. But what happens to her brains during postpartum because again it's this kind of like this cutie word baby blues because some some mothers have baby blues and some don't.

Dr. Lisa Galia: Yes. Correct. I mean it is a pretty common I mean it depends on the study you look at. It can be anywhere from like 20 to 80% of people will say that they experienced the blues during that period.

Nam Kiwanuka: Which is postpartum, right?

Dr. Lisa Galia: Yeah the postpartum sorry the um so so let's just sort of back up a bit pregnancy itself it is amazing and a wonderful thing I am a neuroscientist but I also am a neuroendocrinologist which just means I really like to talk about hormones. So I'm going to talk a little bit about hormones. Um and I know I shouldn't have favorites. I have two kids and I don't have a favorite kid. I love you both. Um uh but estradiol is my favorite hormone. So I'll just talk about estradiol for now. And estradiol is just a very powerful of the estrogens, the most powerful of all the estrogens. So it's about 200 times normal levels by week 20 of pregnancy, 300 times normal levels by week 30 of pregnancy. And it climbs even more dramatically than that up to almost a thousand times normal levels. And then what happens with the birth of the baby? the placenta comes out and that the placenta is the one that's been shooting out all these hormones. It's not just estradiol.

Dr. Lisa Galia: It nose dives. So you're actually like like menopausal levels. They call it hypoganatal in that period. So it's like this these really high sustained levels for a long long time and then a drop and not just an estradiol and and a variety of hormones. And a friend of mine who's a psychiatrist in Denmark, her name is Viva Fyager, love her. She said to me, it's like the perfect storm. And I think that's a really good analogy, perfect storm for mental health challenges. We have these drops in hormone levels which we know is also associated with some mood exacerbations just during the menstrual cycle. During parmenopause, it's the same kind of thing. We also see changes in the brain. So the hippocampus, that brain area I love, it actually shows it shows that it shrinks during the postpartum period. There's some lovely work out of Europe looking at that specifically. That doesn't mean it's a bad thing. They they've they've looked at memory tests. They don't see any connection with memory. They actually see a good connection with what they call maternal child attachment. So it's it's meant to happen. It's a natural adaptive change. Same with all these hormone changes. Inflammation all sorts of what we call biomarkers of particularly depression all change in the same direction in the postpartum. And so maybe it's no wonder that the postpartum period is the time of greatest risk to develop any kind of mental health disorder in anyone's life. And and it's because of this confluence I think it's because of this confluence and of these biological changes that happen at the same time that are just natural. So some people will be more susceptible and some people will not be.

Dr. Lisa Galia: I think historically the idea has been or the what's been pushed out is that when you have your baby, you have these happy hormones. You look at your baby, you fall in love, and you feel amazing.

Nam Kiwanuka: And then for the women who don't feel those things.

Nam Kiwanuka: Then you feel like you're failing before you've even started.

Dr. Lisa Galia: Yes. Exactly. It's a it's an it's an awful story that is is getting to told. And even if you are brave enough to talk to your practitioner about like, hey, I'm not feel I'm feeling some other kinds of feelings, it's often brushed off as, oh, it's normal. Don't worry, you're just tired. Um and in some cases that might be the case but for for some people and the estimates are around 12 to 20% of individuals will experience something more severe including something called postpartum psychosis which is a pretty devastating.

Nam Kiwanuka: What is that?

Dr. Lisa Galia: So psychosis is um is one of the characteristics that or symptoms that you have with schizophrenia. So it'll be hallucinations. That's probably the most common one. So you might hear something or think, you know, another one that's quite this is not psychosis, but is postpartum anxiety. And usually how that's wrapped up is that people are very anxious about that they're going to do something harmful to their baby, that something bad is going to happen to their baby. And obviously these are really serious issues that can happen in the postpartum and not something that should be ignored.

Nam Kiwanuka: But I think you also have to talk to tell you have I had two pregnancies and in two different countries in the UK and Canada.

Nam Kiwanuka: And neither doctor said to me that this could happen.

Nam Kiwanuka: And so if it happens there's that shame and stigma at saying this is how I feel right. So.

Dr. Lisa Galia: Oh, I mean 100%. Like this is a big part of the problem and something that a group that was is called the Canadian Perinatal Mental Health Society. They they were trying to release a strategy in Canada to make to make it mandatory that in your postpartum care you're also asked about how you were doing, how you were feeling and even being administered the something called an Edinburgh Postpartum Depression Test to see are you are you scoring highly on these things because it's really important to it's very it's highly treatable it's it's treatable through pharmaceutical agents but also highly treatable through things like talk therapy. There was a really fantastic trial that was released through CAMH. Daisy Singler was the principal investigator of it and it's called the Summit Trial so people can look it up but really really really great results from the Summit Trial and just very briefly it was giving you because obviously it's hard to find a psychiatrist. It's hard to find the time. I mean you have a baby it's hard enough to have a shower never mind. Yeah. Go and try and seek support for your mental health. So in that case they train midwives and social workers to to administer something called behavioral activation. Basically it's talk therapy to to help people's moods. And for people that are you know not very severe cases but the sort of mild to moderate cases it re it was just as helpful as talking to a psychiatrist or a psychologist.

Nam Kiwanuka: Something else that we hear during pregnancy after you've had a baby is mommy brain. Yes, cute name. But what is mommy brain?

Dr. Lisa Galia: Um, so I don't So there was a an article that was written not long ago saying we shouldn't we shouldn't call it that because it's got this like sort of uh negative connotation to it, right? Um, but it definitely as I told you when during the postpartum period you have this decrease in the epic campus. The hippocampus the reason another reason I love this structure is is really important for memory. Um, so it's it's it's really important for getting those new memories into into into your new experiences that you have into memory. So consolidating that information, that's the the big one for it. And um there is some evidence that in the sort of uh t during pregnancy um particularly in the third trimester uh that there are some um some cognitive deficits that you can not deficits but cognitive changes that you can measure. Uh not a ton of them and it looks like it like I said it depends on trimester depends on actually even what the sex of the baby you're pregnant with. So if you're pregnant with a boy, you have fewer of these cognitive symptoms. And if you're pregnant with a girl,

Nam Kiwanuka: I had a boy then a girl that I had a boy, too. Um and and the idea is that you sort of have this almost like brain fog, right? You get a little more but you're also really distracted, right? You have these really high levels of hormones and you have these low levels of hormones and it's it is likely contributing to some of these kind of changes that are that that are that can be measurable. However, when we bring people into we have a paper that was published a long time ago, but when we brought them into the lab and actually gave them like tests to do in a room where they were not distracted, they didn't have their baby with them, everybody performed just fine. Um the only thing that they didn't perform very well on was something that we call perspective memory and that's remembering to do something in the future and we gave them an envelope that was still stamped and they had to me like mail it back in a week and that didn't happen. But it's not so super surprising, right, that that didn't happen. There's just so many other things to think about when you're out in the real world.

Nam Kiwanuka: Yeah.

Nam Kiwanuka: I wanted to shift our attention to menopause. Um a time when our hormones wreck havoc. Yes. Historically, I think there's been this kind of like culture of silence, fear, stigma about menopause, but there's still a lot of confusion. A recent article from the BBC came out in January of 2026. It was titled Menopause linked to Alzheimer's like brain changes. I just wanted to read you a quote from this from one of the researchers when talking about women going through the menopause transition. This is the quote. Menopause could make these women vulnerable further down the line. While not the whole story, it may help explain why we see almost twice as many cases of dementia in women than in men. Um, I read the article and I immediately became even more worried. But later I saw other scientists and researchers saying that this wasn't a complete picture. What does the study say? And what exactly happens to women's brains during menopause? Does menopause make us more likely to getting Alzheimer's?

Dr. Lisa Galia: So um uh so let's back up. So it is true that women are twice more likely to have Alzheimer's disease, not dementia but Alzheimer's disease than men. Dementia is the umbrella term. Alzheimer's disease is a specific form of dementia but it accounts for about 70 to 80% of all dementia cases. But there's something called vascular dementia. There's no women are more not more likely to get vascular dementia than men for example. But Alzheimer's disease there is something a little special about it. So, so we are more likely, in fact, at the age of 60, if you're a woman, you're you're twice more likely to to be diagnosed with Alzheimer's disease than you are breast cancer. So, I do think it's really important for us to be aware of of the potential for our brain health and what we can do to mitigate that risk earlier in life. I think it is really important, but that doesn't mean everybody's going to get Alzheimer's disease, okay? But the top major risk factors are advancing age. So, the older you are, the more likely female sex. So if you are a female signed at birth and an a certain form of genetics which I'm happy to talk about the Alzheimer's disease you're the sort of average age of diagnosis is around like 70ish 70 73 something like that depends on a number of factors and the idea with Alzheimer's disease that as we're learning now is that some of the neuropathological features we see in the brain which are amaloid beta plaques and neuropiary tangles that they actually show up 20 years prior. So you actually can see the formation of these even earlier now that we've been.

Nam Kiwanuka: In like your 50s?

Dr. Lisa Galia: Right? So what also happens in your 50s? Average age of menopause is 51.4 years of age. So it actually does seem like as I said earlier, these hormonal transitions are inflection points and for a variety of things, right, for our health outcomes and disease risk. Menopause is no exception. It's an inflection point for our aging. And so what we do at this time period and how how our menopaus have manifests can really inform on our brain health later in life and not just brain health, bone health, heart health, all of these things. And I think it's it's great that the conversation is growing louder. I in term again we don't have this so I we did a big survey of all the Canadian funding that went out over 15 years and specifically for women's health it was 6.4% 4% of the funding. So that's your tax dollars not going to a lot of women's health research. I would love to change that in Canada. And for menopause specifically, we we haven't released this study yet, but I will give you an early sneak peek, which is 22% as on menopause. 02 for over 15 years. Very little work is being done in the area. I'm trying to get a grant funded right now for from CIHR on this specific question. But what I can tell you is that consist so whenever people see these headlines it's really important to ask in the study did people look at what type of menopause in what population how did they measure it what type of menopausal hormone therapy was used if they did look at it that at all and I just like hormonal contraceptives or birth control there's 200 different formulations of menopause hormone therapy so when people my pet peeve is when people say menopause hormone therapy did or didn't do this. Like what kind and in whom did it work or not work? And so there are many types of menopause that we go through. Some of us have a lot of symptoms. Some of us hardly have any symptoms. And the little bit of research that's been done, we will we know that all of this will be an indicator for our brain health later in life. And so one of the more consistent findings is the earlier you go through menopause the greater risk for dementia you have later on in life. So that is sort of a another inflection a piece of information to have. Does it mean that you're going to get dementia? Absolutely not. But are there things you can do to mitigate that risk just like knowing that you had preeacclampsia during pregnancy to influence your health later on? And the fact that we have very little research around women's health but also fewer research around hormonal Yeah. impacts.

Nam Kiwanuka: Yes.

Dr. Lisa Galia: Oh yeah. I mean exactly. So I mean I I can I can give you the exact percentages of things but they're really I think the menopause hormone related therapy I think it was like four grants over 15 years. And people have to understand it's about a thousand grants that are funded every year. So it's it's a really really tiny fraction that's being funded.

Nam Kiwanuka: It's a thousand. But if it's a thousand grants, we make up 50% of the population. I feel like we should get 500 of those grants.

Dr. Lisa Galia: Wouldn't that be nice?

Nam Kiwanuka: I mean, that makes some sense or, you know, at least tw.

Dr. Lisa Galia: At least at least something. But talking about hormones, in November of 2025, the US Food and Drug Administration announced that it would remove the black box for most menopausal hormone hormone therapy products of what a lot of us know as HRT. The black box is the strongest warning the FDA can issue, and this goes way back to 2002 in the Women's Health Initiative clinical trial. Can you help us understand why the FDA issued the black box in the first place and what it means that they have now removed it?

Dr. Lisa Galia: Uh politics and I think good news you said why did they put it on the first place. So okay so just like we were talking about before the WHI study the women's health initiative used one kind of menopause hormone therapy. I know you said HRT and I know a lot of people know that. I I don't love using that acronym because it stands for so it's hormone replacement therapy.

Dr. Lisa Galia: And they were never designed to replace our hormones. So the levels were given are really really low compared to what we had premenopausal. So that's why a lot of scientists have sort of shifted to say menopausal hormone therapy rather than replacement. I mean.

Nam Kiwanuka: Thank you for but thank you for clarifying that because a lot of us are getting our information from social media. We're seeing HRT, then we're seeing MHT and it's like I don't understand what's the difference.

Dr. Lisa Galia: Yeah, exactly. But that's it's they're the same thing. They're talking about exactly the same thing. But again, it's not a monolith, right? There's so many different formulations. And the particular one that they used in the WHI, there's a bunch of things that happened with that study. It was the largest study. They're still being released. Like a lot of data is still being released from that study. I I would love it would take us so much longer to talk about you know randomized control trials versus clinical trials versus observational studies. I think all of them are really important and they all give us pieces of information. It was a random what's called a randomized control trial. It only uses one form of menopausal hormone therapy that's called Prem.

Dr. Lisa Galia: Prem stands for pregnant mayors. So they took you pro you may or may not know this. They took horse urine and then they synthesized the different estrogens and progesterines from that from that horse urine and really it was all estrogens and then made this formulation.

Dr. Lisa Galia: The main one it's about 50% of it is estrone. So there are many kinds of estrogens. There's not just one kind of estrogen. We have at least four in our body right now. And estrone is the is is actually quite a weak one of the estrogens. Estradile, my favorite one is the more powerful one. And so we were and what happens during menopause is both estrone and estradi estradile is much higher at much higher levels than estrone. And at menopause they both decline but estradile much more so than estone. So actually end up having a post-menopausal woman will have more higher levels of estrone than they were estradi. Premenopause it would have been the other way around. So it was in my head I was kind of I was curious to me like why they decided to use estone versus an estradile replacement. So that's one thing. This particular one works may may work well for some people may not work well for other people. Another thing is that the average age of the participant in that randomized control trial was 63. You might have heard this as well. Average age of menopause 50 51. So they were more than a decade past menopause. And we do know there's quite a bit of good research to say, you know, if you want the benefits of menopausal hormone therapy, it's better to take it earlier, in your menopausal transition rather than later. It's like the effects sort of wear off. Your body compensates for this lack of of estrogens. And so.

Nam Kiwanuka: Let's talk a bit more about that because I think when we talk about the menopause transition, we hear hot flash. Again, another kind of cutesy word. Hot flashes. You get kind of ragy and all of these sound kind of not serious. Maybe it's just, oh, you know, those women being women, moody and all over the place.

Nam Kiwanuka: But there's actually something.

Nam Kiwanuka: Moody women.

Dr. Lisa Galia: Moody women. That sounds like a band. It could be a band name.

Nam Kiwanuka: It could be. I love it as a band name. But it's like what I'm like what I'm learning as I'm going through pmenopause is that um.

Dr. Lisa Galia: Join the club.

Nam Kiwanuka: Serious journal.

Dr. Lisa Galia: Yes.

Nam Kiwanuka: But like menopause hormone therapy, it's going to take me a while to get used to say that. Um, it's not just about hot flashes, it's about your heart health, your bone, your brain health. Can you talk a bit more about that?

Dr. Lisa Galia: Yeah. Okay. So, so I have, again, I wish we had more time. Um, so, you know, there's so many symptoms that can occur during the menopausal transition, including things like itchy skin and dry eyes and, uh, yes, many of us have vasom motor symptoms. Those are your hot flashes and your night sweats.

Nam Kiwanuka: Frozen shoulder.

Dr. Lisa Galia: Frozen shoulder is another one. There's just there's so many. And some people will sort of roll their eyes and say it's just aging. Like just, you know, suck it up, buttercup. Like it's just it happens to all of us. Well, it doesn't happen to all of us. It doesn't happen to all of us at a certain sort of age range. And let's think about this just for a moment. With menopause, your ovaries are they don't shut down completely, but they're they're ramping down, right? So est estrogens and progesterone are declining. These hormones work through to to help your body and your brain. They work through something called receptors. And so estrogen receptors, progesterone receptors, where are they in your body, they're not just in your boobs and, you know, in your um pride parts. I don't know why I'm not going to say vagina or uterus. They're not just there or on your ovaries. They're they're everywhere in your body. Every single including your skin. No wonder we get including your your muscles, including your heart, including your lungs, including your it's every single organ in our body has these hormone receptors, right? So, so then when you think about that and you know that, you think even when I was going through I' I've passed now. Um, but even when I was going through and I was like, what the heck is this new symptom that I have? And I'd I'd look it up and I'd even try to talk to my practitioner who's fantastic, but you know, they don't have all of the education that they could possibly get around menopause. Um, it it actually makes some sense. It makes some biological sense why we have these variety of of symptoms. I I vasom motor symptoms themselves, those hot flashes and night sweats are also sort of a barometer of our our vascular system and how well it's sort of working and listening to different signals. Yes, it they can die down after menopause, but in many women it doesn't die down.

Dr. Lisa Galia: And so even for myself, I still experience them when I'm, you know, no longer if I forget to change my patch, for example. Yes. Listeners, I wear an estradile patch. I can tell you more about.

Nam Kiwanuka: Yes. And I love it.

Dr. Lisa Galia: Love it. Me, too. I love it. I don't like the little like gummy stuff afterwards, but whatever. Um, but I when I forget, then I I know right away because I I I don't I actually have night sweats. That's my my big symptom. So, I'll wake up in a big pool of sweat and go, "Ah, right. I forgot. It's Wednesday. I've got to change my patch." Anyway, um it's very important for us to mitigate those symptoms because those symptoms have been related to more adverse health consequences down the line. I think it makes sense, you know, psychologically we don't love experiencing those symptoms or at least I'm I'm speaking for me. Um if you have them during night, you you're going to wake up and it's going to create some more sleep disturbances.

Dr. Lisa Galia: Um and and sleep is another thing that also is affected during menopause as we know even outside of these night sweats. Uh but it's you know sleep hygiene is one of the most important things we can do for our health.

Nam Kiwanuka: And brain health.

Dr. Lisa Galia: And brain health. It's one of Yeah. The the acronym I always use is stress which stands for diet reducing your stress and that's any way you can do it whether it's watching heated rivalry. I just finished it last night. So good. Um uh you know binge watching um or you know uh the retail therapy whatever way reduces your stress exercising both your body and your mind and it could be as little as 10 minutes a day uh social support and sleep those those are the sort of pillars of brain health I would say.

Nam Kiwanuka: And I'll just do a quick followup this is just to debunk anything that might be on social media. Menopausal hormone therapy can that help prevent Alzheimer's?

Dr. Lisa Galia: So I don't think we can debunk that yet I think that there I think jury is still out and I I I and it's so interesting because it's almost like there's two camps. People that believe in it versus people that don't believe in it. And it's it shouldn't be a this or that because again we're all different. We all went through different menopauses. Some of us had basic symptoms. Some of us didn't have vasom motor symptoms. And we all might take different forms of menopause hormone therapy. And we had a study that was just released last year that showed in terms of memory performance and this was Canadian data the Canadian Longitudinal Study of Aging we found that transermal estradile the patch was and vaginal estrogens actually and we'll come out with another paper to show this was more likely to be associated with higher memory scores than oral estral and there's some biological reasons for that which I'm happy to discuss but so different formulations even how we take our hormones can have different influences on our brain health. But again, 0.22% very few data points out there that we can specifically point to.

Nam Kiwanuka: It's really exciting to hear you talk about all of this research that's being done. Because when we hear stats like 70% of Alzheimer's patients are women and we're now just understanding how hormones impact women's brain health.

Nam Kiwanuka: Again, I wonder why don't we know more about women's brain health?

Dr. Lisa Galia: You know, I I don't know the I wish I knew the answer to that. I I think that there are three main things, if I may. One is that I think some researchers just don't think that there's much of a difference between males and females or interex individuals. Why do we need to study it? It's not a real big factor. We have two arms and two legs and two eyes and two ears. We're we're not different except for what underlies our bikini. Uh, but our chromosomes are XXXY that determine whether we're, you know, assigned female or male at birth or Xnot or XXY. Unlike what you might hear, there's more than two. Um, they're in every single cell in our body. Every single cell. So, that's why all of our organs are going to be affected by these um our sex hormone compliment and why there are sex and gender differences in a lot of things. Uh, so I think there's there's that. Uh there's that women's health isn't seen as serious like it's not you know it's maybe maybe it's an equity issue but it's not real science not serious science but I'm here to tell you it's serious science I think most of us would understand it's serious science um very little medical education goes to women's health like so our our medical doctors or other we can't you can't blame them very much right because they just don't get the education um I think they get a morning or something on menopause like that a lot a lot more maybe on pregnancy but very little on any other sort of life stage.

Dr. Lisa Galia: And the third thing is, and I'm going to be a little more open than I have been in the past, and I think it's some sexism rolled in there. There's this idea, and and some of it comes from other scientists, and it doesn't matter if they're a man or a woman, but this idea that we shouldn't study any sex differences in the brain because that somehow makes female brains inferior. And my question back is like, why doesn't it make male brains inferior? Like people like that that just because they're different just because we're different doesn't mean.

Nam Kiwanuka: We're less.

Dr. Lisa Galia: We're less or weak and same thing with our hormones. Sometimes I get some flack about that but you know we we know that that for certain people our hormones are tied to brain health and are tied to our mood. Is that is that weak or is that an opportunity to understand how the different disorders could be treated and maybe they need different kinds of treatment depending on who we are like and that that there's a whole field of research called precision medicine which is exactly that, right? Not one sizefits-all. So I think I think that's part of it. Um, I would I mean I'm a little biased, but I would say we're actually herculan because of the things that we're able to do% considering all like I don't I I love watching these little videos on social media of um girls who put the period on there are great boys are like, "Oh my god, I can't even do two."

Nam Kiwanuka: Yeah. And it's like, "Oh, that's nothing." Um, you know, because we can joke about this and we kind of, you know, but what what kind of harm does this cause?

Dr. Lisa Galia: Oh, yeah. So so much so so we know and they because they've done some really large scale studies looking at over 1300 different disorders that women are diagnosed on average if you take all those 1300 different disorders two years later than men are. If you take the 75% of them that are diagnosed later in women and just add that that's four years and that includes things like depression and anxiety and Alzheimer's disease like the ones that disproportionately affect women and females. So we two years later we have 90% of new therapeutics we have side effects on or more side effects for that and I think you know there's going to be many reasons for these delays in diagnosis but one of the major ones is that most of our medical knowledge including the way we diagnose people and that's really really important how we diagnose people like your cholesterol levels your blood pressure Alzheimer's disease depression it's actually based on mostly on symptoms in.

Nam Kiwanuka: So, we're atypical.

Dr. Lisa Galia: Yeah. And that's one of my favorite phases. You see this atypical label all the time. And and again, you have to ask yourself, how do you how are you atyp especially for something like depression where you see two to two to three times the risk higher risk in women. So, you know, that many more women. How do we have atypical depression? But look it up. You we have a we're more likely to have atypical depression. How is that? No, that's the typical depression. That's what the more the people show that rather than they.

Nam Kiwanuka: The small man with boobs. Yeah, we'll cut that part out. You wrote this in a paper for policy options in September of 2020 when talking about the lack of proper funding for women's health research against the backdrop of COVID-19 pandemic. And this is what you wrote. Quote, "Diversity breeds discovery."

Dr. Lisa Galia: Yes, my favorite. Um, we're seeing a push back on diversity because of politics and the word uh women women has been flagged as DEI for scientists in the United States when applying for grants to conduct research. When it comes to women's brain health, how does diversity breeds discovery?

Dr. Lisa Galia: I mean, I think we've been talking about it even during the show, right? If we can understand let's let's take perinatal depression. That's the that's the term that people will use. It's actually it's not it sounds like it's one thing like oh special form of depression but actually there's there's four different trajectories you can have. You can have depression during pregnancy only. You can have depression throughout pregnancy and the postpartum. You can have it only during the early postpartum or you can have it only in the late postpartum. And that suggests to me because our biomarkers which just means our biolic our inflammation, our metabolism, our hormones, even our social situation can change so dramatically across those different time periods. That suggests to me that they have different causes and probably, you know, and probably need different kinds of treatments. So again, it's beyond this oneizefits-all. Um we know pain mechanisms already differ between males and females and even COVID-19 vaccines I know vaccines un like inexplicably are controversial now I I don't know how we got here but nevertheless we are you take COVID-19 vaccines and we already know that for flu and COVID-19 vaccines females women in general have stronger responses to our vaccines so that would have suggested and I I don't know if we wrote that in the article but would have suggested that you know um with a shortage of vaccines in the in the across the world at that time, maybe women just needed a half dose or threequarters of a dose and we could have vaccinated other people that much faster.

Dr. Lisa Galia: Um so like to me that's a small thing like the the dose of Ambien, the dose of vaccines and and it obviously it's a huge equity issue, but that diversity will bring us closer to better treatments um earlier diagnosis. That's why it's so and it's going to save money. So the McKenzie report like if nobody else thinks of anything else um the they released a report suggesting that if we could achieve uh like reduce the gender gap in our medical knowledge, we could save the worldwide economy $1 trillion.

Nam Kiwanuka: A year.

Dr. Lisa Galia: A year. And they've done the estimates for Canada and it's 37 billion again a year. Now, I think that's an underestimate because they're not including everything in those estimates, but.

Nam Kiwanuka: Yeah, we we did that on the podcast. We had someone from Mackenzie talking about that, which is an an astounding amount of money. Um, but also like when you do have diversity, it expands knowledge.

Nam Kiwanuka: It uh if you have blind spots, I have blind spots. It just feels like it.

Nam Kiwanuka: Um you we've talked about the NIH a couple of time. Um the United States and the NIH, they have been a leader in research. Um there's a lot of cuts that are being done right now with the shifting priorities of the current administration. Uh what role do you see for Canada? Is this an opportunity for us to step up? I know it's 6.4% that you mentioned.

Dr. Lisa Galia: Yeah.

Dr. Lisa Galia: I mean yes. I mean to me that's an obvious thing. Why not take up the flag and fly bravely? And I will also say about diversity that's also true in our like business portfolios, right? Like I think finance not that I'm I'm out here but I know that mutual funds for example do better rights like diversify your investments the same thing with science because we don't know where the next great discovery is going to come from. So you want to diversify your scientists you want to diversify ideas because you put all your eggs in one basket. It's not likely to come up with as many discoveries as if we put many eggs in many different baskets. That's why it's so important. But absolutely it's time for Canada to step up. Um, I hope that our politicians recognize there's a bill right now before the Senate. The final reading, I think, is in the end of February. It's uh uh 243, I think, S243. Um, if people believe that women's health deserves, it's about um um creating a framework to um push forward progress for women's health both in terms of research, innovation, and our access to care. Um, it's really important that we have a framework so we know where to best place the limited resources we have in Canada. Uh, so I just encourage people to write their senators and their MPs about it if they uh, this resonates with them.

Nam Kiwanuka: But I do think this is a place for Canada to to um, fill that gap.

Dr. Lisa Galia: Uh, and really what I think we need is our own icebucka challenge. Um so I spark a challenge raised 115 million for ALS which is a neurodeenerative disorder in 2014 and and five years later it had doubled the number of publications doubled the number of researchers working in the area. There were 10 times the number of clinical trials and there has been some progress even in treatments for ALS in this very short time period really about 10 years now and we need that for Canada um for uh women's health in particular.

Dr. Lisa Galia: Because I think sometimes people just don't know what that you know what you know right um we began our conversation talking about the importance of sex differences in brain function and disease.

Nam Kiwanuka: You are credited with over 200 scientific publications and you are old now you're uh you're very accomplished and you are quote one of the few neuroscientists globally recognized for integrating sex and gender considerations into research design. Um why is this work important to you and what have we lost in this delay in research into women's brain health?

Dr. Lisa Galia: I mean for all the same things that we've been talking about for me I'm I am like so thrilled to be in this area. I I I love doing the work I do. I love thinking about women's health. I love thinking about, you know, why there might be this disparity and trying looking at it from all different angles to try and figure this out. It matters to me because not just because I'm a woman, not just because I have a daughter or you know, my mom passed away about 10 years ago now and she had Parkinson's disease and end endometrial cancer as well as arthritis. The poor thing.

Dr. Lisa Galia: Yeah. Was a little bit rough at the end there, but she actually said to me, I like, you know, Lisa, why haven't you found a cure for Parkinson's disease yet? And I said, well, mom, I a um I don't study Parkinson's disease and b if it was simple, we would have figured it out already. And and that's going to be the same thing for women's health issues as well. If it was simple like menopause hormone therapy reduces the risk of dementia, we would have that answer already. We don't because there's so many different diversity in terms of women, menopause, menopausal hormone therapy. Um, but it's important to me because I want answers for women. I'm like I'm sick of it. I'm sick of going to hearing people say that they're their their doctor called them a medical mystery and that we don't know or there's nothing they can do for me or are you one of my biggest biggest pet peeves is you're menopausal. You go to your doctor, you say that you're having these hot flashes and night sweats and yeah it's um you don't feel like yourself and yet it's like well are they bothering you like maybe just come back in three months and we'll see how you're doing. No, if you're disclosing to your physician or your health your nurse practitioner that that you're having these that means by definition they're bother you've noticed them and they're bothering you.

Dr. Lisa Galia: Um so.

Nam Kiwanuka: We never talk about the quality of life, right? We never talk about that and that's so important and so I mean for me it's like a.

Nam Kiwanuka: Uh would I like to go on vacation more 100%. But I I see this desperate need and to for people and politicians stakeholders community to understand that this is a very large gap we need to fill. It's going to benefit everyone. It's not just going to be beneficial for women's health. It's going to help men's health. It's going to help gender diverse health. And I can give you examples of why I think that if you want please.

Dr. Lisa Galia: Yeah. You want.

Dr. Lisa Galia: Because we miss we miss the we if we're not taking into account sex and gender if we're not looking at whether that makes a difference or you know the type of person this is their social experiences we miss um we miss crucial drugs that could be on the market right now and one of them is Lazaroids uh it was a drug that was was named after Lazaroid Lazarus sorry obviously not very biblical.

Nam Kiwanuka: From the Bible.

Dr. Lisa Galia: From the Bible yes the Lazaroid is because it literally rose people from the dead. So if they had a stroke, it rose them from the bed. Um so really great trials beforehand, but when they did their randomized control trial at the end, their fa what it's called phase three trial, it failed. Why did it fail? It worked in men. It didn't work in women. So we now no longer have this drug on the market that could have been a life changer for men. There's another drug that another company has tested for depression. Works really well in women. Doesn't work in men at all, but they can't bring it to market because it doesn't work for everyone. And and we have to get away from that kind of thinking about it. Um uh because again, it's not one sizefits-all. It's all I you know, we all we know already. I think we recognize already that it's precision medicine, but we we're we're missing precision medicine is not just about our genetics.

Dr. Lisa Galia: But it's about our because sex is also part of our genetics actually anyway. It's about um our experiences along the way and how that's shaped us in our health.

Nam Kiwanuka: Is there anything that um you wanted to mention that I didn't mention?

Dr. Lisa Galia: I encourage people if they're interested in learning more about women's health to look at um organizations like Women's Health Research Cluster or Women Mind and and donate to um uh to institutions and organizations that are that are actually doing women's health research like Women Mind at CAMH.

Nam Kiwanuka: Dr. Galia, it's been an absolute pleasure. Thank you so much for being on the podcast.

Dr. Lisa Galia: So easy. Thank you for having me and putting up with me.

Nam Kiwanuka: You were great. This was Mistreated. Thanks for listening. You can follow our show wherever you get your podcast so you can get notified each time a new episode is available. We would love to hear your feedback. You can write me an email at mistreatedodcast@tvbo.org or reach out to me on my social channels. Here are two comments from our episode last week featuring the Ontario Medical Association President Dr. Zanab Abdul Ramen. The first comment, Ontario Public Health published research in 1999 that we would run out of enough healthcare providers in 2030. We had foresight just not political will. And just to reference that comment, the study being cited here is on the supply of physician services from a researcher named Barry Chan. What the research showed was that even though the number of physicians had gone up during the 1990s, the distribution of those doctors was uneven. So, urban areas were serviced, but not rural areas, which is something we continue to grapple with even today with emergency room closures and huge lineups for new family doctors. Another comment, we deserve a system that supports a healthy population, is easy to access, and equitable for all. It is sad that the Canadians feeling the brunt of the system failures are the ones who need the system the most. As always, thank you so much for your comments and send us anything comments, kudos. We want to hear it all. This week's episode was produced by Matthew Omera and me and edited by Colin Kish. Production support from Jonathan Hallowell and TVO's digital media services team. Lori F is the executive producer of digital. John Ferry is vice president programming and content. And special thanks to our studio crew here for making the podcast look so fantastic. We appreciate it. And thanks always for listening.