Picking up where we left off with Adrenal Fatigue is a Myth Part 1 back in March 2019, we're joined once again by naturopath and functional pathology expert, Beth Bundy. In part one we discussed why the term "adrenal fatigue" is misleading as well as what is actually happening with our hormones and neurotransmitters.
Today Beth takes us on a deep dive into understanding the subtle nuances of selecting the right cortisol testing. What is the right choice - serum, blood, CAR? Beth expertly navigates you through the benefits and limitations of all available options.
Covered in this episode
[00:47] Welcoming back Beth Bundy
[01:38] How do we measure cortisol in patients?
[09:23] Taking into account the diurnal changeability of cortisol
[17:56] Modifying treatment approach to suit bio individuality of patient
[25:23] Influences on cortisol to be mindful of
[30:23] Personalised medicine and SNPs
[32:47] The Cortisol Awakening Response (CAR) test
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today again is Beth Bundy for part two of "Adrenal Fatigue is a Myth, Here's Why…" Beth is a qualified naturopath of over 19 years, specialising in integrative and functional medicine. She worked previously as a technical consultant with PathLab, one of Australia's original functional pathology companies. And currently trained to help practitioners nationally as clinical consultant at NutriPATH Integrative Pathology Services where she's in high demand as an engaging, informative speaker. And she also works as a functional medicine practitioner in a busy and highly successful integrative medicine practice. Welcome back to FX Medicine, Beth. How are you?
Beth: I'm back!
Andrew: What sort of testing is appropriate? And let's then talk about how we tease apart the results that we get from that.
Beth: All right, sounds good then. Firstly, I might just mention that because we're talking about cortisol, we’re measuring cortisol, I should probably briefly mention there's generally three ways we can measure cortisol. And so there is the blood, which is the standard doctor way. Is to take a blood cortisol, a serum cortisol. And what we have to remember with this is when you're seeing a measure of a serum cortisol, most of the cortisol in the blood is actually bound by cortisol-binding globulin, leaving only a very small amount, maybe 1% to 3% bioavailable to enter the tissue and to give a biological response. So generally, the bioavailability of the cortisol will vary depending on someone's cortisol-binding globulin or CBG. And this is made in the liver and controlled by hormones such as oestrogen, thyroid, and cortisol feedback itself.
So, when we're looking at cortisol in the blood, we go, "Oh my goodness, it's excessively high. It's excessively low. It's quite normal." It does pay to look at other things as well. So if we say that in the blood, it's a good estimate of the adrenal glands' capacity for total cortisol synthesis but it's not helpful to find out then what part of that we can actually use.
Then, the latest craze, it seems, is urine testing. Even though 24-hour urine cortisol has been around in the medical world for quite some time. Again, a 24-hour collection will only give you a flat figure and you don't see any ebb and flow across the day. You just say, "Over the day, you..."
Andrew: That's your total excretion.
Beth: ...wee’d out this." Yeah, and that really doesn't tell me, were you crazy high in the morning and then fell in a heap or were you...? It just doesn't tell you enough information.
So, there is now the dried urine craze where you can collect urine...they take four samples across the day à la the saliva measurement. So what we have to remember with this is that urine is after the fact, if you get my meaning? In that, if we take a blood or a saliva measure, we are testing the here and now. Whereas urine, your blood has gone through your kidney and then come out the other end. So, if you take a first morning urine sample, that is not your first morning cortisol reaction, that's your overnight reaction.
Andrew: I must look into the history of why pathologists deem it appropriate to take a snapshot of a hormone, in this instance, that has vast diurnal variation. It's almost like taking a temperature after you've gone for a 10K run.
Beth: It's like a lot of measures we do in pathology. You know, when people say, "Can I measure this? Can I measure that?" I go, "Yes." And then you have to measure it again and again and again and again because it's constantly changing.
Beth: You know, our water-soluble vitamins are not steady. Our glutathione is not steady. Our CoQ10 is not steady. It only can give us an indication of what someone is doing.
Beth: It's not an absolute and this is really what I want to get across to praccies, is these numbers are not gospel. They are a guideline and an indication for further investigation or some treatment and then follow-up. Because people are different, not everyone is in a reference range, like when you first get out and realise that none of your patients actually fit in the textbook that you learned. It's always moving. It's just indicative. I always say, "Please look at it as an indication with the case history." Get on my soapbox again.
Beth: Please put the case history into the mix.
Andrew: It's the old adage of you're always going to get the answer to the question that you asked. And if you're asking the wrong question, then you're getting the wrong answer. And I guess this is one of the issues that pathology has with functional pathology. We're not looking for disease. We're looking for dysfunction.
Beth: Yeah, well, that's what I say to my clients. I say, "Pathology tests are looking for pathology." And they are looking for it in the grey zone. Standard pathology is black or white. You either have diabetes or you don't. We're looking in that grey zone before you get to the...
Andrew: The diagnosis.
Beth: “Hello my name is Beth and I'm a diabetic."
Beth: Yeah. Yeah, so that's why we're using these things.
So you mentioned Cushing's and Addison's? And this is where, yes, you need your blood test and they're actually using saliva as well. So saliva is now a good go-to method for testing for Cushing's when they take a midnight sample. So, in standard medicine, they're using saliva cortisol for Cushing's…
Beth: Because it is also a good representation of the bioavailable cortisol, what that person is actually using at that time. And so that's why sometimes when...generally they say that there is a correlation between the blood and the saliva and that is, of course, providing someone hasn't bound it all up in binding globulins and then we're not seeing more of it out in the saliva or vice-versa.
So in practice, I use both blood and saliva to kind of look at things. I use the saliva more as an ongoing treatment creation.
Andrew: Measure, yeah, measure.
Beth: Yeah, and then the blood is...I am actually looking for pathology there. And as I mentioned before, doing these things, we have found Addison patients. You know, we have discovered patients that have gone on to being diagnosed with Addison's.
Beth: And they would have been missed had we not done this picture of blood and saliva and then further testing with ACTH and the like.
So, it is definitely… I would definitely suggest that saliva is a better way to do it. It is also easier for the patient plus we are getting a true morning cortisol. If I give you a spit tube and say, "On waking, can you do that?" yes, you can." Opposed to, "On waking, can you pop down to the blood collection centre and wake up the nurse and get your blood taken?"
Andrew: Have you seen a correlation or a total discord between, as we've spoken about before, the ebb and flow or the variancy in secretion of cortisol throughout the day, using multiple tests, versus the whole blood test at one spot during the day?
Beth: Oh, completely. This is how you can miss people like Addison's and Cushing's and what have you. Because unless you take that blood at that particular time, and I've had people… you know, we generally say to people, "You've got to go in before 10:00 in the morning," because usually, the collection centre would turn you away otherwise.
Beth: But if I've been awake for four hours, I'm just measuring my...
Andrew: It's already dropped.
Beth: It's already dropped and I'm just going to my day-to-day stuff. So that's why often you may see...as a general rule, I would say people look "normal," I'm doing my air bunny quote, "normal" in blood and then you get the saliva which they've done first thing in the morning, lunch, afternoon, evening, it's a completely different picture.
And when I correlate that with...because I'll put that in with a snapshot, I'll go, "Oh, well, in the morning, this happens." And then you hanging for your coffee and then maybe two, and then you have a little cheeky muffin to pep you up again, and I make up this little story about them and I think they're going, "Yes, how did you know?" And it's because I can read through the cortisol levels during the day that, again, still give me an indication, because yes, there'll be some bouncing around as it goes but not a really overt bouncing, if that makes sense? Unless they're literally going from really low and then they fly up at nighttime because whatever stresses them out. And you can usually discover what that is by asking the patient the right questions as you said before, and get an idea and go, "Right, well, that was an anomaly for your day-to-day life," or, "No, that's your life all the time. This is not helpful and let's talk about that and help support you through that."
Andrew: Beth, how useful do you find the multiple tests and how many of the multiple tests do you do? It starts at four but you can add further ones in depending on how nuanced you want to look for the drop or the flow of the cortisol response.
Andrew: But I also do remember Dr Andrew Heyman speaking about that we're not always seeing a drop or a low cortisol. It can be high and unwavering. So, it's kind of like the FSH response that you get after menopause. It remains high because there's nothing to cause a cycle.
Beth: Because you're not getting that feedback...
Andrew: Yeah, that's right.
Beth: ...to turn it down.
Andrew: Yeah, so he speaks about these people mainly with a chronic inflammatory response. But he says that it can even be inverted throughout the day. The big picture that I took away though is that they're not getting that traditional drop that you get in the morning. They're always high, or sometimes always low.
Beth: They’re always on. Yeah. They're what I call my meerkats.
Andrew: They're your meerkat...
Beth: They're always on alert.
Andrew: So always high as your meerkats and what if they're low?
Beth: They're either a sloth or a koala who sleep 18 hours a day or something.
Beth: Yeah. And people usually get that if you put a picture of an animal in their head, they go, "Oh, yeah, I get it. That's what I feel like," and that's, well, yeah.
And it is because they're not getting that feedback mechanism to say, "Hey, hey, hey. It's okay. You can turn off and slow down a bit now." They're constantly on alert. So, you've got to remember that we talked about last time about the CAR, the cortisol awakening response?
Andrew: Yeah, so let's talk about this.
Beth: Yeah, so up until recently-ish, it was the 4-point cortisol test where you looked at the morning, somewhere between 6:00 and 8:00 to 10:00 in the morning, midday, afternoon, and evening. That's kind of been turned on its head when they really discovered this cortisol awakening response. Which is, to just remind people, is your built-in mechanism governed by the hippocampus and the light-sensitive...I can never say this right, suprachiasmic nucleus of the hypothalamus. Let's call it the SCN. And then also we have the natural rise with cortisol that starts several hours before waking due to normal circadian HPA axis activity. So, you know, the ACTH saying, "Come on, let's go," and then the exposure to light. That's where the SCN comes in. We get that temporary exposure to light.
Now what we have to remember is this only happens in the morning, only the morning light. It doesn't happen if we've had a little nana nap in the afternoon and then wake up or, yeah, if we're being exposed to...we've been at the casino all night and there's light on for 24 hours.
Andrew: Right, that was going to be my next question.
Beth: Yeah, you can't go to the casino, Andrew, it doesn't work. You can't be a meerkat at the casino, that's dangerous and expensive.
So, yeah, so it's morning light and the ACTH. So how that happens then is also the ACTH has a rise and then...so that's our normal first morning awake, we go, "Oh, the morning has arisen, here we are." Then in the next 30 minutes, we have this, I'm going to call it a ‘surge’ of cortisol, to kind of get us really up and going and here is the day. Then it comes back down a bit and then it continues declining over the day.
So if we just take one sample, depending on that one sample, are we taking it when they first wake or somewhere in that half an hour surge? Will change our belief of that person of what they're doing. So if they start off really low, we go, "Oh, dear, they're a sloth," opposed to we measure them, they get up and they start spitting and we get it half an hour to 45 minutes later. All of a sudden, they’re a meerkat. And so we're going to label them as an animal, perhaps incorrectly, because we're not seeing the beginning, the rise, and the fall. And it has been widely studied now that this is more indicative of the HPA axis talking to the adrenals rather than before we've always just talked about we're measuring the adrenals, we're measuring the adrenals. And what we're actually more interested in is the HPA axis dysfunction or maladaptation to the day. And it's about how we perceive the day is going to hit.
So what happens is, someone might wake up a bit more sloth-like because they've not quite hit their straps and then all of a sudden they start thinking, "Oh my God, I've got this, I've got this, and I've got that meeting. I've got that podcast scheduled. I've got this." All of a sudden, poof, up their cortisol goes and they're in meerkat mode. And then some people will stay in that mode all day. So that might be what Heyman was talking about when they stayed up. They're just in that fight-or-flight mode. That's the adrenaline kind of kicks in and they keep going with the cortisol all day.
Beth: And people will still say...the clients will still say to you that they're fatigued and you'll say, "Yes, because running around like that is exhausting because you're supposed to come down somewhere." Just like the people that are flat-lining who say they're exhausted because they're not getting any spikes.
Andrew: What about the difference in therapy for the meerkats versus sloths or koalas? Do you find that the therapy differs dramatically or do you find that no matter what the issue, if they're stressed, you're still going to be using these nourishing herbs? You know, I guess, particularly you would be cautious if somebody is flat with cortisol with stimulants, like for instance you said coffee.
Andrew: It's great to wake up and you need to function but how do we best do that that's going to look after your health in the long term?
Beth: Yes. And I don't deny people their morning coffee. And I understand that that person needs that. If they need that, it becomes their normal that they have to do that.
But certainly, yes, as a general rule, you would treat...because you're still treating that HPA axis adrenal process the same generally. However, yes, if someone's really, really high, I would be using more of the calming...perhaps bring more nervines in? And also I would also look at...this is where the neurotransmitter aspect comes in as well, which is a whole other podcast again, to try and bring that down.
So things like your GABA, your LCNE, your tryptophan to try and temper some of that excess aggravation for want of a better word. And then when they flat-lining, certainly, you have to be careful with going, "Right. Well, let's give you all the stimulant adaptogens and really give you a spike." Even though they might ask for it, they go, "Oh, can you just give me something?" I just say, "Yeah. Pop down to the local nightclub, that will give you a quick high," but it’s not sustaining. So I tell people we have to build them up slowly, plus they have to do stuff for themselves. This is where we talked previously about sleep and sunlight and exposing themselves to the actual natural daylight, which gets a bit hard here in Melbourne in the winter but yeah, it's definitely all those other things and looking at their lifestyle and what have you.
And the other thing you have to look at again, when you're measuring, or you're looking at a result and going...this is what I have a lot of praccies will ring me at the lab and say, "I've got this result, what does it mean?" And I'm like, "Well, tell me about the patient?" Because just reading numbers, I could make up a hell of a story and be way off the mark because I don't know they're on suppressive medication, or they're on...this is… they’ve got a disease or 101 things I don't know.
And what we also have to remember is that when we're measuring the CAR, so the CAR we measure it immediately on waking, the next 30 minutes, as in, there has to be a break, you don't do it ongoing. So if someone can't sit well, you're not going to get...again, you're only going to get an average overall this time, you're not going to get the actual rise and fall. They need to be able to half fill a tube soon as they wake up, then 30 minutes later, and then another 30 minutes later, then we go on to the midday, afternoon, and before bed. Forget the evening one. What is the help when you're 8 o’clock at night and I'm doing the washing up, or I'm still in the middle of dinner and you want to measure my cortisol? I want to know what my patients are doing when they're going to bed at 10, 11, 12 o’clock at night, where is their cortisol then? Because that gives me an indication of how well they're going to sleep and also then, do they ever come down at nighttime to start back again the next day? You know, some people are like hovering or in a holding pattern on high because they never come down at nighttime before they're back up again at 11 out of 10, sort of thing.
So it's more important to look at the nighttime one because then you can also plus or minus a melatonin measure, especially if people are talking about difficulty getting to sleep or staying asleep. The other thing to be mindful of when you're doing these measurements is to generally do it on a normal...more air quotes, a "normal day." Not when someone's on school holidays and relaxing or maybe they're not because on school holidays, they...
Andrew: They've got their kids.
Beth: I take that back. They've got all their kids around them. But a normal workday, because remember we said it's about your anticipated stress for the day. So, doing it while I'm in Bali, drinking a Bintang and I'll do this spit test, that's not the real world. School holidays are probably not the real world. You know, a Sunday is not your real world. So it will show a different measure for a different day, you see what I mean? Like what they're doing.
And the other thing is exercise. So, if someone is a mad exercise junkie, that is going to raise your cortisol anywhere from 30 minutes to 2 hours post-exercise. So, you need to preferentially ask your patient not to exercise on the day they're doing the test because it can falsely elevate it. Also, you have to be careful with your ladies because strangely they found in studies that around ovulation, a lady's cortisol would be more elevated than normal. So just have to check with your menstruating ladies when they're doing that, so you don't call them a meerkat when they're not.
Beth: Shift work is always a problem. Because if someone's on shift work and they're not normally waking up at 6 or 7 o’clock, they're waking up at 2 o’clock in the morning. I generally get those patients to follow their time.
Beth: So if their morning is 2 o’clock, then that's when we do it. And then, yes, I am going to expect that they don't have that morning light to wake them. But it still gives us an idea of whether we have that ebb and flow from the HPA axis first thing in the morning and then across the rest of the day.
So you also have to be careful with saliva. So, no exercise, no eating or smoking or coffee just before they go and do a sample as well. Because eating will increase their glucose, their insulin, and then their cortisol. Caffeine, well of course, can spark. Smoking just buggers up the pH in the saliva and changes how we can measure it. And no brushing their teeth because in case they get microbleeds and we get haemoglobin contamination into the sample.
Beth: And especially not when they're sick, like not when you're sick, we don't like mucus and doobies in the saliva. And your cortisol is going to be different because you're fighting a virus or some other illness.
Beth: Well, we don’t.
Andrew: And then I guess you can go down several rabbit holes as to how you intervene. And forgive me for mentioning his name again and again but he's a very impressive practitioner this guy, Dr Andrew Heyman. When he was talking about the chronic inflammatory response syndrome, CIRS, there was a few pearls that I got from him, just about the responsibility that we've got about testing for, and then the biggest no-no, was what was touted as the panacea about a decade ago and that was supplementing with cortisol.
Beth: Yeah, mm-hmm, mm-hmm.
Andrew: Would anybody give prednisolone if somebody had an active infection?
Beth: They do. I was prescribed prednisolone for an active infection. I was a bit like, really?
Andrew: But alongside other agents, correct?
Beth: Yes, yes.
Beth: And you know, in hindsight, yeah, it saved me from going to hospital. So that was pretty okay and it was short term. That's the difference, short term versus...and you're talking prednisolone whereas some practitioners use cortisol acetate or hydrocortisone.
Andrew: Thinking, yes, yes, of course.
Beth: So different kettle of fish. One is way more powerful than the other. But you still can go into problems when people are using cortisol supplementation. Because again, you're working with feedback mechanisms and then do we… you know, it's a bit like if you over utilise testosterone, if people are overdosing testosterone, they turn off the feedback mechanism from their brain to their testes. And then we have to put that back together again. So it can be a bit like that with cortisol.
And it's like, if they're in an infection, they're in an inflamed...so let's call it inflammation, right? Because it may be an infection, it may be an ongoing inflammatory thing.
Beth: So sometimes, we will...not sometimes, most of the time, we will elevate, or the body will put out more cortisol, to try and...because we've got to remember cortisol is anti-inflammatory, that's why they invented prednisolone. So sometimes you have to look if someone is flying high on the result picture of cortisol, you have to found out is that because they're running like a meerkat, or is that because they've got a major inflammatory situation going on?
Beth: And then, yeah, to be turning that down, will that aggravate the inflammation? That becomes the see-saw of you know, how to do this gently? And I always just go gently first because some people respond really well and then some people need a bit more. I'm talking about supplementation and they also have to do...it's like I tell people we can give you these tablets but if you're still sitting in the frying pan, you're not going to stop getting burnt.
So I have to try and get people to the concept that...you can't stay where you are or keep living that life. You know, I had a patient recently who said, "Oh, I only sleep four hours a night and I'm fine." They weren't fine. They were really highly strung when they came in the office. And clearly four hours of sleep is not doing them a favour. Especially when they get up at 4-5 o’clock in the morning to do exercise.
Beth: I really had to strap her down and sit on her chest and say, "Slow it down, girlfriend." Because you can't maintain that, you cannot maintain that without breaking somewhere. And people...you know, when we talk about anxiety or stress, I find that there's this concept that it means running down the street naked, screaming or something. People forget that it can be insulin resistance, inflammatory conditions, hello autoimmune conditions or things like that, metabolic syndromes. They don't put that under ‘stress’ and it's like, it's long-term stress. People forget that it's there...
Andrew: Yeah. Stressor.
Beth: Stressors, or if they've been in a bad relationship, a job that's killing them, they've had dramas with their children. I mean, look, the list is endless of what can happen to people. And they forget that they are all tickets that they're collecting along the way that affects these results of what they see, of what we see as the practitioner when we get the results.
Andrew: We're entering the age of personalised medicine and more and more, we're seeing the usefulness of SNPs and how we can....if nothing else, you can't change it but you can get it as a clue to other aspects that might be influencing how people respond to stress. Say there words adrenal fatigue, it's not. But what about things like SNPs and their effects on cortisol response, like for instance you know, methylation or COMT?
Beth: Don't say MTHFR!
Andrew: Or COMT or things like this? How we actually handle adrenaline and coffee and oestrogens and...
Beth: Yeah, COMT is definitely a SNP that can affect people, especially if they're homozygous. Those people tend...and this more on a neurotransmitter angle, those people do tend to be more anxious from all that high cortisol. And again, I don't like to be...it's a bit like when people just go under or overmethylation. To me, that's too simplistic. And it's a bit like hypo or hyper unless you're Addison's or Cushing's, then you truly are. But otherwise, in the middle there, you’re varying degrees of, at different times.
So, it's hard to say, "You are anxious, so, therefore, you're always going to have high cortisol." Because eventually, I find, long term, people can't keep running on that little hamster wheel, at speed. So then, over time, you end up seeing that saliva cortisol result start to flatten a bit. Because the feedback mechanism, remember we talked last time about the feedback mechanism to the brain that's going to try and slow you down, by reducing the output of ACTH.
So again, we still have to kind of manage their stress so they're not internally turning themselves down so they're not getting the heat from that fry pan to keep moving.
Beth: The CAR. The CAR test, or the cortisol awakening response test. Because we do those three samples within the first hour of waking, this is when we're truly seeing how the patient's HPA axis is working or...I'm not going to say not, is working. And how they are responding to the day, to see stresses that are coming. So it gives a bit of an idea of how that patient internalises stress.
Because if we just do the old four-point where we just do that one in the morning, as I mentioned earlier, you don't know whether you're hitting the low or the high of the CAR. So the CAR definitely gives you an idea that, "Okay, well, that tells me the HPA axis is working correctly and then their output of cortisol diminishes, so we still support," opposed to showing that someone's CAR is highly elevated and so that is, you know, we need to calm that down because they're in a heightened response and that is fast-tracking to our long-term chronic diseases. Versus if they're not having any response, then you have to look at why is this so?
And this is where the case history...just briefly, we didn't mention where the case history fits in about why people are high or low. So, we've also got to remember if someone's high with their cortisol, or elevated CAR… so we mentioned about ladies around ovulation, but also older patients. As we age, we spit out more cortisol and less melatonin. So we need to consider the age of the patient, what fat levels they're carrying? You know, if they've got a lot of central obesity. Any sort of mental health disorders? And then if it's really low, we have to find out questions about depression and chronic fatigue and posttraumatic stress or SAD, seasonal affective disorder.
Andrew: Ahh, yes.
Beth: We're measuring this in the winter and feels like this, so it really gives us more of a...it just rounds out really what we're testing. Which is cortisol, not necessarily adrenals. It's cortisol, and then it really directs us more to, "Right, well, this is where further testing or better questions...how can we talk about diet, lifestyle, and supplementation to assist this person?" Do neurotransmitters come into it? Do we need to look down the inflammation pathway? Do we need to put this into the mix of their metabolic dysfunction or diseases?
So I'm definitely a new fan of the CAR. All my patients get that nowadays and it's definitely just fine-tuned what I'm looking at.
Beth: The patient understands it better. I remember being so excited when I'd just discovered the four-point saliva, but this has just really increased how I treat and how the patient understands themselves better.
And I find that this is a way...So I had a patient who told me wasn't stressed. We did the CAR and we saw how she completely flew off the handle between first waking and that first half hour. And it was enough for her to realise...she changed her whole working lifestyle from that. And because she was able...with her own business, but she worked with her husband but she was able to go back to her husband and explain why she needed some more ‘me time’ and why they needed to change their hours and how they...they worked smarter.
Beth: It changed her to make her work smarter and she's so much better for it. And I think that's the key, is if we've got a picture that we can explain to patients and they understand why we're asking them to make the changes that we are, we've got a win-win.
Andrew: Yeah. I think the concept of measuring an anticipatory stress response gives you so much information as to how somebody can cope with future assaults or future stressors. Obviously, you then need to put your detective hat on to find the causes or the antecedents. Are they infections? Is it marital, is it interpersonal communications? Whatever it be? But that's the practitioner part.
But I can just see this also evolving further down the track with the access to, or the greater access to neuroimaging now that some of the practitioners are using, particularly in Melbourne where they've got this awesome setup down at Swinburne. It would be very interesting to tie-in these measurements of hormones with changes of volumes over time of brain capacities and things like that.
Beth: Oh yeah, NeuroQuant.
Beth: Yeah, yeah.
Andrew: It'd be really interesting to see the actual responses to treatment and intervention that you can find, and recovery, for these patients.
Beth, thank you so much for taking us through and finishing off "Adrenal Fatigue is a Myth and Here's Why."
Beth: My absolute pleasure and you can go and have a lie-down now.
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.