CEimpact Podcast

Evidence-Based Insights on Hormone Replacement Therapy

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Hormone replacement therapy (HRT) remains a cornerstone of managing menopausal symptoms, but understanding the latest evidence is crucial for safe and effective use. This episode dives into evidence-based therapies, weighing benefits and risks and highlighting the pharmacist’s role in guiding personalized care. Tune in to stay updated on the science behind HRT and its evolving role in patient care.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Ashley Meredith, PharmD, MPH, BCACP, BCPS, CDCES, FCCP
Clinical Professor
Purdue University

 
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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the latest evidence-based approaches to hormone replacement therapy (HRT) for managing menopausal symptoms.
2. Identify key considerations for pharmacists when counseling patients on the benefits, risks, and appropriate use of HRT.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-087-H01-P
Initial release date: 3/31/2025
Expiration date: 3/31/2026
Additional CPE details can be found here.

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Speaker 1:

Hey CE Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, Josh Kinsey, and as always, I'm super excited about our conversation today. Hormone replacement therapy has long been a cornerstone of managing menopausal symptoms, but navigating the latest evidence is essential for safe and effective patient care. In this episode, we'll explore the science behind HRT, discuss its benefits and risks, and highlight how pharmacists can guide patients in making informed decisions about their treatment options. It's so great to have Ashley Meredith as our guest for today. Ashley welcome. Thanks for joining us.

Speaker 2:

Thanks, Josh. It's exciting to be here today.

Speaker 1:

Yeah, we appreciate you taking time out of your schedule to be with us today. So before we jump in, I always like to give our learners a little background information on the speaker for today, our guest for today. So if you want to take a few minutes to tell us a little bit about yourself maybe your practice site and just anything that you're passionate about in the pharmacy world- Absolutely so.

Speaker 2:

I'm currently a clinical professor at Purdue University in Indiana. I've been on faculty there for basically my whole career. Post-training I did residency training but then started on faculty right after that. So I've been a proud Boilermaker faculty for going on 15 years now and I practice in the ambulatory care world, so doing you know, sort of one-on-one patient interactions, more of that patient engagement. But really the area of reproductive health is something that for me, over the last I would say probably seven to 10 years, has really become a primary focus, both for my research and my teaching but also in the way that I engage patients. And so I think it's something that you know. For me, as I've gone through different phases of my own life, it has hit home in a different way and I have two daughters myself, and so just the idea of the whole reproductive health across the entire lifespan is something that I feel really strongly about.

Speaker 1:

Yeah, yeah, that's great and it's interesting.

Speaker 1:

We have done a few podcasts already kind of on similar topics and and it's allowed me an opportunity to kind of reconnect with that learning because I feel like, you know, I haven't really had a connection to that, those topics since pharmacy school.

Speaker 1:

So it's really allowed me to kind of remember some things, learn some new things and kind of really be up to date on stuff. So, and you know the, as you mentioned, it's, it's such, it is a lifetime span, you know, like it is something that we're looking at over life and in the female reproductive system, and I think it's really important to be sure that we understand all the working parts and how they go together. So, yeah, so, thanks again, I really appreciate you joining us and I'm excited to dig in and talk a little bit more about hormone replacement therapy. So I always like to just kind of set the stage for our learners, make sure that we have the foundation and the background and we're all on the same page as we start talking about a topic. So if you can just remind us exactly what hormone replacement therapy is, kind of it's you know, it's history, it's inception, what's its overall purpose and goal, and just kind of give us the foundation there and then we can kind of jump into the bigger topics.

Speaker 2:

Absolutely so, josh. Before we even jump into that, I do always like to give a little disclaimer around language use when talking about reproductive health topics, and so many of the studies and things that have looked at HRT or other reproductive health categorize participants as women or men, and so please know that if I'm discussing and using the word women, it's because that's what was used in the studies, but really I'm intending to include all people that either currently have a uterus or previously had a uterus. So I always just like to start with that disclaimer around language use here.

Speaker 1:

Yeah, that's perfect. And again, it's great to set that foundation and just make sure we're all understanding what you're discussing. That's perfect, thank you.

Speaker 2:

Absolutely so. Then, jumping into sort of HRT or hormone replacement therapy, what it's used for some of the you know history of it. Really, when we're talking about HRT, we're thinking about during the menopause or perimenopausal time, you know, in the years before menopause, and so current recommendations are that HRT be considered for people who are experiencing moderate to severe symptoms. So that would be hot flashes, vaginal or urinary symptoms. That spectrum of symptoms is what we're really talking about. When we're thinking about what HRT can be used for, it's available in a lot of different formulations. So it can be oral, it can be local in creams and gels, or it can be transdermal, just really to meet folks, sort of where they're at and what they're looking for and how severe their symptoms are. So you know that's kind of what it's used for, how it's available.

Speaker 2:

But when we think about the different types that are out there, we break it down really into more three big buckets of the types of HRT that's out there. So we have estrogen only therapy, which really should only be used in people who have had a hysterectomy or no longer have a uterus. Then we've got combined therapy, which combines both an estrogen and a progestogen, and the reason for that is because in someone who still has a uterus, if we give estrogen alone it does increase the risk of endometrial cancer. So adding that combination with the progestogen as part of it helps to really reduce that risk of endometrial cancer. And then the third bucket, which I think you know, at least in the last probably decade or so, has become a little bit trendy you hear about it a bit more is this idea of bioidentical hormone therapy. And that's really where more synthetic hormones are designed to be chemically identical to naturally occurring hormones, and so they may come from plant sources, they may come from other places.

Speaker 2:

They do claim to be more natural and safer, but really there's limited evidence that supports those claims of safety and being more natural and really they're compounded, so you open up a whole other potential risks in terms of not being regulated. Do they actually contain what they claim to contain? Everything that I'm sure all of our listeners think about when they think about compounding medications.

Speaker 1:

Yeah, yeah, no, that's great, and how you know, I guess, one thing to kind of bring about or reiterate as well as how long has HRT been around? Obviously, I think I know the answer, but I might be shocked. So how long have we really had this sort of therapy?

Speaker 2:

Yeah, so HRT has been used for decades and decades. It really first started being used back in the 1960s, is where we first started really seeing come into play and I would say it had a sharp increase in use, with maybe a peak sometime in the 1990s really meant to manage those menopausal symptoms.

Speaker 2:

And so you know what has been found and why it had such a large initial uptake and why there's still a role, for it really comes down to the fact that during menopause, estrogen levels decline and that can really cause some bothersome symptoms for folks, and so by providing some extra estrogen it can really help to alleviate those symptoms and then may also play a role in preventing some of the complications we may see with osteoporosis and osteoporotic fractures as well. So it even goes beyond symptom relief and may help to prevent additional problems down the road.

Speaker 1:

Yeah, yeah, that's great I would have. If pressed to guess, I would have said around the 70s, so I wasn't too far off.

Speaker 2:

You're close, you're close.

Speaker 1:

Yeah, Great. So let's talk about key evidence. Obviously, you know this episode. We want to focus on evidence-based treatment, and so what is some of the latest research that we're seeing? You've put into perspective the kind of the three buckets, which I think is important, but what are some of the latest research surrounding kind of which option to choose? I guess?

Speaker 2:

Yeah. So you know, I think to understand what the focus of the current research, we do have to take a step back a little bit and understand why maybe there is this gut reaction of HRT is bad, we shouldn't be using it right. So that really comes from. There were two trials that were published in the late nineties early two thousands. That really changed the public and maybe provider perception about using HRT. And so the first of those that came out in the nineties was the Heart and Estrogen Progestin Replacement Study, or HERS, and it was a randomized trial. It enrolled lots of folks, average age of 66 years. They had established coronary heart disease. So that's an important point about the folks that were enrolled in this.

Speaker 2:

They were followed for an average of about four years and really the goal of the study was to look at HRT's effect on reducing overall cardiovascular events. So that's what the trial set out to prove, and so they did not find that as a positive outcome and in fact found that particularly during the first year of use, risks and rates of those events actually increased. Then it leveled off after that first year, but in that first year there was a significant increase in cardiovascular events that were happening. So we had that. That came out in the late 1990s and then in the early 2000s we had the Women's Health Initiative study. Results start to come out and I think that's probably a study that most people have heard about as being a major groundbreaker in terms of hormone use in women's health over a long period of time. And so the Women's Health Initiative study really began to find major health issues. So they started to see a higher incidence of things like breast cancer, heart disease, stroke, blood clots, and that arm of the study was stopped early, was stopped early.

Speaker 2:

And so then also looking at those who were receiving estrogen but didn't receive the combination therapy, they had had a hysterectomy that also was stopped early because of a significant risk of stroke that was seen without additional benefits in preventing heart disease. So I think these two trials are really pivotal in defining why there was a shift away from using HRT and why folks are maybe scared to even think about it. As a reasonable option.

Speaker 1:

Right, yeah, no, and you? I mean, you bring a great point. But also I feel like we need to reiterate the fact that in the first study, the patients already had known heart disease, right, like they already had.

Speaker 2:

Exactly.

Speaker 1:

Exactly. So I feel like that is important, because not all of our patients who are on HRT have a cardiovascular diagnosis in some way, you know right. So I think that that's really key. And I think what I heard in the second one is that they had a uterus right. Was that all that was looked at?

Speaker 2:

There was a small group that didn't have a uterus. And those risks were different than the folks who still had their uterus.

Speaker 1:

So I feel like that's kind of informed how we look at treating and I hope I'm sure you're going to bring that kind of back around and make that point later. So yeah, but that's great to set the stage because it's important, like you said, and we were talking in the green space before where we were kind of discussing our plan and you know I was going to call out that there's a lot of scare out there around cardiovascular events, stroke, blood clots, cancer, all that kind of stuff. So I think it's really important that we really break down what those studies said, and so I appreciate you doing that because it's key to make sure that we fully understand exactly what their implications were. So that's great. So, on that note, that was the foundation research. So what has that led us to now? What has that informed how we move forward with research?

Speaker 2:

Yeah. So I really think, thinking about where the research has gone in the last five years, even just sort of limiting it to the most recent timeframe, really, the focus has been on who are the appropriate patients to use HRT in, because we know it improves the menopausal symptoms that people are experiencing and we also know there are certain risks that come along with using hormones right. So I think the evidence most recently is focusing on how do we use it safely, who can it be used in and what does that look like? And so.

Speaker 2:

I really think you know where we have seen the shift is in identifying. Okay, how do we more appropriately look at those who have maybe low to moderate cardiovascular risk factors? Those are likely the folks that we can more confidently, more safely use HRT in, whereas in someone who has established cardiovascular disease, no, we want to make sure we're avoiding HRT because the risks just outweigh the benefits at that point but you know, if we're looking at someone, it's really focusing on what are those traditional cardiovascular risk factors, and so the data is just helping to support that.

Speaker 2:

So we're taking into consideration things like someone's smoking status, what's their blood pressure, what's their cholesterol, do they have diabetes, do they have metabolic syndrome? I mean all the things that take it outside of menopause and you're going to say they have a higher cardiovascular risk already right. So it's just taking that and then applying it in the context of what is the additional risk that's going to come along with adding hormones on top of that.

Speaker 1:

Yeah, and you know it's not, this doesn't sound like a foreign concept that we're actually, like you know, making sure that the therapy is appropriate before starting it on a patient. Like I feel like it's, you know it. Just it just seems like HRT has gotten a bad rap in years past because of I feel like those studies and they may have just not been fully understood or, you know, it just hasn't really fully come back to circle. That, okay, that happens with a lot of medications. Like it may they're not all right for everyone, you know, we have to still make sure that it's an appropriate use and it's safe and effective. So, again, it doesn't sound like a foreign concept. It makes total sense to me.

Speaker 2:

So yeah, right, it shouldn't be, but I think part of it, josh, is that natural reaction of something comes out and it seems so great right, and then all of a sudden, it's like pump the brakes, there's some things we need to consider, and so then it's that reversal of like okay, now we shouldn't be doing this, but, exactly like you said, it's like we should be doing with a lot of our medications. It's not one size fits all. It's what's most appropriate for this patient.

Speaker 1:

Exactly, exactly, yeah, so we've touched on a little bit well, kind of barely, but I really want to focus on what's the pharmacist role in HRT, like where, you know, where do we come into play with that? Is it appropriate therapy? Or, you know, are they on the right thing? If, if it is been deemed that they should be on hrt, are they on the right combo or not combo or whatever? Like what? What's our role as a pharmacist? Where should we be coming into play?

Speaker 2:

yeah. So I think, just like in any condition, pharmacists can certainly help patients understand their options right. So whether you're a pharmacist who's dispensing HRT right Taking that extra minute to sort of evaluate and say, okay, is this patient on lots of other medications for cardiovascular disease and should that sort of raise a red flag that maybe there should be some questions about, is the HRT the safest? I think that's certainly one role.

Speaker 2:

I think another option you know, if you we are seeing more and more pharmacists in clinics, in offices that are providing women's health focused services- and so there are opportunities for pharmacists to be the ones who are actually selecting the medications, adjusting the HRT, choosing the route of administration with that patient to figure out what best meets their needs. So I think it kind of spans that whole spectrum, just depending on what environment you're working on. But certainly lots of opportunities for pharmacists to be engaged.

Speaker 1:

Yeah, and I think that's the take home is that we do have a role, and it might take you a little bit of effort to find out what your specific role is, but pharmacists certainly have a role in HRT. So with that, let's segue straight into opportunities. So what are some of the opportunities? I guess we can position this as a couple of things opportunities of like implementing HRT, you know, like actually having HRT in a patient, and then also opportunities for pharmacists like where else can we be involved? So one of the things that obviously comes to mind is improving quality of life of the patient, and clearly we've touched on how that kind of works with treating the symptoms and that they are effective at that. So I think we've really kind of covered that opportunity.

Speaker 1:

What are some opportunities for collaboration? So let's say that we're in more of a dispensing role as a pharmacist and so we're getting it after the decision has been made. You mentioned like making sure that it's appropriate, you know that kind of thing. What if we find a red flag? What are some collaboration opportunities for us to kind of reach back out to the other members of that team?

Speaker 2:

Yeah, I mean, I think it's you know. For me I would take it as first talk to the patient have they already had some of these conversations with their prescriber? Because if they have and they're comfortable with the risks and benefits that come along with it then fantastic, maybe that's where the intervention ends right.

Speaker 2:

But if they haven't, then maybe it's that opportunity to say okay, are you comfortable with me reaching out to your provider to voice these concerns, like I would for any other drug-drug interaction that comes up, or inappropriate dosing, or is that a conversation that you, as the patient, would rather have with the provider the next time you follow up with them? So that would be how I would think about approaching that type of situation where you notice, ok, maybe maybe there's something more here, maybe this isn't the best choice, and you know, and then it's really just taking the time to reach out to that provider, that provider's office, provider, that provider's office. We know it's often difficult to get the provider themselves on the phone, but relaying the information and just, you know, continuing to provide the evidence, I think is really where.

Speaker 2:

I always end up back at is what does the evidence actually say? And then what does that mean for this patient?

Speaker 1:

And you know that's that reiterates what we've talked about many times before in the podcast with other episodes, where we talk about the collaborative opportunities, the opportunities to reach out and advocate for a patient or change something or whatever. It's important to make sure that you have the facts and to make sure that you have the evidence to back it up, because oftentimes what that provider says is okay, well then, what do I need to do? Or what are my options, you know? And to just sit there and say, oh well then, what do I need to do, or what are my options, you know? And to just sit there and say, oh well, I don't know, I didn't have anything planned for that.

Speaker 1:

So I think, again, that's important to be sure that we do have the facts, that we can back it up and that we know what the evidence is. You know, again, if we see a single therapy, when we think it should be a combo therapy, backing up the fact that we're going to advocate and recommend for combo therapy, and this is why. So I think that's really key as well. You touched on the bioidentical and I want to make sure that I fully understand. That Is that kind of where we get the whole idea of like personalized therapy. Like is that where testing occurs and you determine kind of what options they need and then it's compounded to suit the patient.

Speaker 2:

Yeah, so that's where, when you hear personalized therapy for HRT, that's really what we're talking about. Now, you know there's probably goes beyond the scope of our conversation here today, Josh, but just the like pros and cons of monitoring hormone levels and what they mean and who should be doing that, I mean that's a whole other.

Speaker 1:

That could be a whole other episode. Yeah, for sure.

Speaker 2:

But yes, when we think about personalized medicine in terms of HRT, it is aligned with that bioidentical therapy.

Speaker 1:

Okay, perfect, that's what I wanted to make sure that I was making the right connection there, and so I think that that's what we can leave it at. You know again for time's sake is that there is an opportunity there. If that's something that pharmacists want to explore, there is an opportunity to dip their toe into that. Personalized care, the testing and then the compounding and whatever, if you're equipped for that, if you have the compounding lab and you meet the standards and all that kind of good stuff, which, again, whole nother conversation, a whole nother topic. But yeah, I just wanted to be sure we touched on that. So let's talk again some about some of the challenges surrounding HRT. We've really hit on those misconceptions and I think it's important that we did, and we spent a lot of time on that, because I do feel like you know, even I remember as a kid my mom went on HRT super early. She had a hysterectomy early in her life and she would have gone on one of those first conjugated estrogens I won't say the brand name, but we all know what it is probably and then all of this negative stuff started coming out. So I think that it really shaped me. That was about the time I was thinking about pharmacy school and going into pharmacy school and she kept asking me should I stay on them, should I go off of them? You know the side effects are terrible if I go off because of my hot flashes and whatever. So I think it's really important that we address those misconceptions, because they were real and they really, you know, they really made patients ask questions and pharmacists really had to kind of step up. So it's key to still understand that those misconceptions may still exist in patients because that information didn't go away. I mean those, those studies stayed firm as far as, like, even prescribers deciding whether or not to choose to initiate HRT.

Speaker 1:

So I think we touched on that, I guess is my point. Sorry to go down a rabbit hole there, but I feel very connected to that because I remember when all of those negative things coming out and then how that weighed into, like patients decisions and what they did. So anyway, very personal for me on that one um. So then, managing patient specific risks. So again, you taught you touched on determining whether or not they have other cardio risk, cardiovascular risk factors. Um, I think that's key. Is there anything else you want to add there? Any other things that we're looking for, that would yeah, absolutely, josh.

Speaker 2:

So I think, beyond just the risk of cardiovascular disease, we do know there are some other patient characteristics that are going to lend themselves to HRT being a bit safer of a choice, and so really, the way it plays out right now is it should be.

Speaker 2:

Hrt should be recommended if someone is younger than 60 years of age, if they're within 10 years of the onset of menopause, if they have a low risk of breast cancer.

Speaker 2:

So that's one thing that we didn't really talk about earlier. But in addition to that cardiovascular disease, you know what, does that family history of breast cancer look like and are they at increased risk because of that? But assuming family history of breast cancer look like, and are they at increased risk because of that, but assuming their risk for breast cancer is low, they're sort of in that low, moderate risk of cardiovascular disease and they're less than 60 years of age. That would be the type of patient that we'd really be looking at as saying, okay, this is probably a relatively safe use of HRT, but if someone is above the age of 60, or they've had the onset of menopause for a long time because that's the other piece is, these symptoms can last for a long time after menopause itself has actually started or occurred, and so you know, making sure again that they're younger relatively close to that onset of menopause and then low risks for breast cancer and cardiovascular disease.

Speaker 1:

How defined does that low risk of breast cancer have to be? Like are we talking about? Is it enough to just say, oh, no one in my family that I know of has had breast cancer, or are we talking about the need to actually have the test to see if they're? You know what I mean.

Speaker 2:

Absolutely. Yes, I see exactly where you're going with this, josh. So from my perspective and I think for most providers it's going to be just that there's not a significant family history, and you know, take it at that. Of course, if someone wants to go down the whole testing and you know, make sure that their risk isn't any higher than they think it is then fantastic if that's going to make them more comfortable with using HRT. But that's not where we see most clinical practice playing out.

Speaker 1:

Decision factors. Yeah, okay, okay. One other thing I wanted to touch on too. While we're in that, with that whole the cancer scare and whatever, because you touched on a couple of different types, is there anything else around that that we need to be aware of? Or even with conversations with patients when it comes up and says, oh, I thought HRT caused cancer, like, what other things do we need to be aware of from the pharmacist's perspective when the cancer word gets thrown into the mix?

Speaker 2:

I mean, I think there's obviously a lot right and I think every day we learn something new about potential causes for all the different types of cancer. I think for me, what I would include as part of this conversation for the person in menopause who's seeking guidance is also kind of looking at have they used hormones at other points in their life and what did? That look like right. So were they on hormonal contraceptive for extended periods of time, which, again, not that that's a definitive tie to cancer, but it's additional hormone right.

Speaker 2:

And so does that factor into it versus not? So I think those would be some of the questions that I might think about exploring a bit more. But really, in terms of the types of cancers we're talking about, it's breast cancer and it's endometrial cancer are really the two that are potentially a higher risk when we're looking at HRT.

Speaker 1:

Okay, one thing I wanted to talk about too and maybe this is a challenge, I don't know determining dose like is it just, is it arbitrary? Is there a way to start? Is there a guideline for starting dosing? You know, because I know that there's multiple different strengths of the different, you know, hormones on the market. So what are the? How do you start with dosing? I guess?

Speaker 2:

Yeah, so really I mean we think about it as use the lowest dose, see how the symptoms respond If they don't fully respond, then intensify the treatment dose. I mean and you'll also see recommendations of try, you know, treat the symptoms for a year and then take a break and see if the symptoms recur, right, because I think what we also see, that's maybe a challenge is, once someone gets started on HRT, when does it get stopped? At what point is it appropriate to stop?

Speaker 2:

And if the symptoms are being treated. You don't know if you're still having the symptoms. So you're sort of taking a couple months off after a year or two of treatment and reevaluating, I think is also a really important consideration when we're talking about managing these medications.

Speaker 1:

That's great advice, because I feel like that was also something with my mother. It was like when is it appropriate to stop? And she was so worried about stopping and those terrible side effects coming back or symptoms coming back that she was fearful of stopping, you know. And so I think that's a really important conversation to have with the patient. So that's great. Are there any sort of contraindications otherwise that we want to be aware of when talking about initiating HRT?

Speaker 2:

Dr Amy Moore. Yeah, so I mean really what we think about in terms of true, absolute contraindications, would be someone that has current or a history of breast or end not happen, depending on the situation? And the reason for any undiagnosed vaginal bleeding has been evaluated and assessed. Got it?

Speaker 1:

Where does the whole stro and clot come into play? Like, is the stroke part of the cardiovascular contraindication or is there? You know what I'm saying. And then also with the clot, is that that bleeding part, or is there another thing that we should be aware of, because those were kind of two things that were come from that study?

Speaker 2:

So I mean the stroke is part of that cardiovascular disease spectrum for sure, exactly. Exactly. And then the blood clots. You know that's always a hard thing when we're talking about what puts someone at risk right. So again we're looking at things like do they have a history of it? Do they have a family history? Are they overweight and sedentary?

Speaker 1:

I was going to say does it come into mobility and exercise? And weight, because I feel like those would also put you at risk for a clot.

Speaker 2:

Absolutely so. It's just taking again that whole patient picture and looking at what are they otherwise at risk for, and then is adding this medication going to make that risk unacceptably high yeah, yeah, no, that's great.

Speaker 1:

Um, well, I told you we would be shocked to find that we get through our time quickly. I say that every episode. I can't believe we're already over time. Um, actually, is there anything else that you definitely wanted to be sure that we covered that, that you didn't get a chance to Anything in the whole world of HRT? I think we've discovered there's plenty of things we could talk about right.

Speaker 2:

I think we certainly hit on the most important points that I would want to make sure someone has heard about.

Speaker 1:

Yeah, perfect To set them up to have success with either discussing with patients or collaborating with other healthcare teams and whatnot. So, yeah, that's great. Well, as I do with every episode, I always like to ask the guest what's the game changer here? So, ashley, what's our take home point? What do you want to leave with listeners?

Speaker 2:

I think that the game changer for this is that HRT is not universally bad and that it can be really safely used as long as you're making sure to evaluate that person, particularly for cardiovascular disease risk.

Speaker 1:

Yeah, so being aware of those risks, those contraindications and being aware of everything the patient has going on, whether they are at cardiovascular risk or they do have a history of breast cancer and whatever so yeah, that's great. So hopefully we gave you listeners some nuggets to take back to your practice site with HRT and Ashley. Thank you so much for joining us. We really appreciate it.

Speaker 2:

It's a pleasure, Josh.

Speaker 1:

Thank you. If you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week.