The oestrogen effect

 

photo-1414432690990-dd3b7442fd9dWay back when in my recovery journey, I was introduced to the wonder of natural progesterone cream as a way of rebalancing the prevalent effect of oestrogen dominance (prevalent in all of us, regardless of gender…but more on that below) so that my body could gain a firm foothold on recovery. You see, while hormones are out of sync, there is little or no chance of establishing and sustaining the kind of recovery you are probably after; hormones are just far too important to everything going on in your body.

For years, to varying degrees, I used natural progesterone cream to rebalance my hormone cycle and I feel there’s no coincidence in the fact I DID gain my first proper foothold on a sustained recovery process from the Spring of 2011 when I first started using this cream consistently. In fact, I have recommended natural progesterone to so many many women now, whose “symptoms” of hormone imbalance I have all too easily recognised, only to be told…too many times to count…that I have been instrumental in transforming their lives as a result. I’m no doctor, I offer no guarantees; in fact I only offer my personal, anecdotal experience as a suggestion for others to look into themselves (and I can recommend quite a bit of reading matter on the subject too – more on that below) but everyone that I know who has pursued this route seems to have seen dramatically positive results in the way their body started to respond and rebalance as a result. Sadly, information and a willingness to speak out about natural progesterone cream is still very thin on the ground in the UK; it is far better known-about and supported as a viable route to self-empowered “excellent health” status in the US and Australia. In the UK, the belief that the middle years of a woman’s life only deliver doom and gloom seems to be an all pervasive mindset.

For me, another hormonal cliff edge appeared on the horizon just as I got properly stuck into all the yo-yoing of perimenopause and, for a short time there (perhaps ironically, since natural progesterone cream is most recommended for this very time in a woman’s life) I began to loose some of my faith in its ability to mitigate how awful I was cyclically feeling. Towards the end of last year, my dosage slipped down to where I was only using it haphazardly and then decided to stop for a while…and then my fibromyalgia symptoms only became much worse during that time…

By January, I was convinced I had made a mistake and so I returned to natural progesterone cream, changing brands (I now use Serenity) and taking the regularity and amount of my dosage even more seriously than ever; also keeping track of the effects and taking the decision to continue dosing all through my cycle, even during menstruation. The improvement in my monthly hormonal dance has been significant (I watched a u-turn occur in the worse of my weirdest pain symptoms and chronic fatigue) and, now I am several months in, has become fairly steady and reliable. Additionally, the bizarre and frightening nerve pains that had started to occur from about November until I was a month into the progesterone cream again started to settled down and are now minimal. As the dust settled on this long-running experiment, I realised I had learned something else in the process of all this and that’s what I want to share in this post.

Not all oestrogen is created equal

Its very easy, when you are bombarded with articles and research about the prevalent state of oestrogen-domaninance in our world, to regard all oestrogen as “bad” and undesirable but not all oestrogen is the same.

My journey towards menopause – and I don’t believe this is a coincidence – has been accompanied by a journey into ever more profound and alarming nerve pain and electrical sensitivity resulting in the kind of twitches, stabs, numbness and spasms that have had me fearing I am on the road to MS or the kind of intolerance of my environment that would force me to make my home on a remote island in order to get away from all the many electro-technology triggers of the modern world. As I have catalogued before, I am prone to very severe head, facial and jaw nerve pains, extreme migraine-type headaches, blinding vision disturbance and general vision impairment, impaired hearing, ear tones and almost constant head noise that becomes extreme when my nerves are super-sensitised. Its doesn’t take genius observation for me to notice how these symptoms ebb and flow on a monthly-cyclical basis; how they are much more obviously there at the end of my cycle, when oestrogen trails down lower and lower (and, now I am in perimenopause) lower than ever before…

Could it be that oestrogen was serving to protect me from the super-sensitivity that, for some reasons, makes me prone to experiencing all the effects of electricity in our environment (as EMFs from so much technology or even as the effects of the moon) as pain, as brain fog and as the temporary lapses of intelligence that sometimes feels like I am losing my marbles? It turns out, studies have now started to connect oestrogen with the kind of protective effect that helps prevent Alzheimer’s and, in an article (“Oestrogen on the brain“) on this topic, I found this quote: “Oestrogen also holds sway over the human brain. Women who are deprived of the hormone suffer from memory lapses that vanish once the hormone is replaced”. Oxidative stress and my over-reaction to EMFs are certainly related…I have come to know this already, so was my perimenopausal hormone dip feeding this issues, explaining how just as I felt I was almost recovered from fibromyalgia, it seemed to have come back for a symptom escalation? When I was in the midst of so much apparently random nerve pain earlier earlier this year, I quickly intuited that my dipping oestrogen levels were somehow impacting the effectiveness of the myelin sheath that protects my nervous system from overstimulation and yes, indeed, it turns out that connections have been made between oestrogen levels and the process of myelination. Hmmm.

The other thing that I have noticed is how – as menopause looms – my skin suddenly becomes much dryer towards the end of my cyclical month; my hair can very suddenly become like straw, my body feels “dry” at the cellular level as though everything is rubbing against everything else, even joints ache and creak, I feel like my subcutaneous fat layer disappears overnight (suddenly I am looking straight at sinew and bone where I used to be quite curvy) and I have become prone to patches of eczema in a way that I have never experienced before. Oh and that skin itch I talked about recently. These are all classic signs of low oestrogen.

So if oestrogen is so out of control and undesirably “high”…dominating my body…why is all this even happening?

The reality is that even when a state of oestrogen dominance exists, oestrogen levels do drop off as menopause approaches, its just that progesterone drops off even more (relatively speaking) and so the imbalance of more oestrogen than progesterone can still occur. By the time you reach your period – if you are still having them – levels of both hormone can be so incredibly low that you start to have issues, especially if this aggravates a pre-existing condition such as fibromyalgia. Taking away the moisture, cellular and NERVE protection that oestrogen provides leaves you wide-open exposed to everything that you are already feeling in the extreme and it HURTS.

Which is how my periods have tended to be lately – a PAIN zone and a deep dive back into the kind of symptoms I have, otherwise, been feeling like I have left far behind in the “old days” of full-on fibromyalgia, which is no longer my daily reality. The level of new pain that I can now experience during those few days of my monthly cycle can be extraordinarily disarming, like something is going badly wrong with my body all over again…

What oestrogen does

What I have come to realise is that oestrogen has a very classic effect and you can watch it play out at all levels of the human condition, from the cellular to the societal.

Oestrogen is produced by the ovaries and peaks during the part of the cycle when the egg is about to be released before tumbling down to much lower levels later in the cycle once that has happened. By virtue of this key role, oestrogen has come to stand for and embody a protective urge. It dominates the process by which we prepare for and protect the egg before its release into the world; it safeguards the hoped-for pregnancy yet only travels as far as the threshold of that potential being realised, stepping no further forward with it, like a mother stood waving at the door. It knows only “hold” and “protect” as its inner mantra – and this is oestrogen in a nutshell, without frills and, yes, generalised down to its very essence as we all know that not every egg leads to the realisation of a new beginning, nor do we want it do. Yet there is a very real truism in this stereotype of oestrogen as the egg-holder, the homemaker, coddling her creation tightly to her bosom because, when a women is in her oestrogen phase, this is what a woman tends to do and there is very real evidence that she becomes single-minded, withdrawn and less independent during that phase. To quote Leslie Kenton (Passage to Power: Natural Menopause revolution) “She is more willing to adjust herself to the needs of others. When oestrogens are running, women like to attract a mate not so much to draw him into her body as to comfort, admire and care for her. Her ovaries seem to be smiling – ‘whatever you want, I’m happy to give’ they seem to say”. She continues: “A few women who by nature are high oestrogen producers feel quite dependent on others for approval, and for the definition of their being”. Any wonder that so many doctors, even some husbands, have been so keen on advocating oestrogen hormone replacement in order to maintain this personality type in favour of its alternative, the independent, outward-thinking woman…

When oestrogen dominance perpetuates far longer than for that one brief phase when its natural purpose is to facilitate the release of an egg, we see its impulses in the very traits of our cultural mindset. We see it manifest as a sort-of dumbing down of our most independent and discerning thought processes and an almost desperate clinging onto the circumstances that are most familiar to us, an almost total investment in perpetuating them long after they have ceased to serve us. In our society, it is that urge we see played out amongst people who lock down their houses and fly flags at the threshold, who argue for the right to carry arms to protect what is theirs, who fight for tradition and to define their national identity, who insist on guarding all the borders, keeping all the strangers out.

swanI watched it play out the other week when I saw a swan sitting on her nest with some geese nearby. Though there was no sign of an egg on this flat twiggy nest, the swan was singularly focussed upon most meticulously tweaking its boundaries, picking up sticks and moving them from one side to the other with an obsessive-compulsive attention to detail that was almost endearing. The goose-pair and their offspring were really nowhere near the swan but, rather, paddling in the water quite some distance away, watching over their small-ones as they tested out the shallows. Suddenly, and without provocation, the swan took exception to this and was risen off her nest in a powerful display of outspread wings, launching at the goose family in a way that was quite terrifying for the youngsters who, in  running away, got far too close to the swan nest so, of course, the swan only escalated its now “justified” attack upon these tiny pom-poms of fluff and their loudly honking parents. We stood watching with breath held, watching this overblown scene play out, as indignant at the swan’s over-reaction as we were anxious for the babies and their parents and all our feathers equally ruffled. Then, all at once, I suddenly knew what I was seeing here: it was like a living metaphor for how unchecked oestrogen plays-out in the human body.

Oestrogen’s profound effect on personality

Yes, I would agree from my own experiences over many years of unaddressed oestrogen dominance, it makes us (emotionally) far less adventurous, far more likely to cling to routine and the familiar, to stay home  and safeguard those things that are most predictable in favour of looking outwards to where we could otherwise be and how we could be expanding our horizons, diversifying our experience and evolving. Oestrogen can make us tremendously reliant on other family members or on a partner; and it can make us inclined to put up with far more than we ought to rather than rock our steady boat. Looking back, I see how I was oestrogen dominant for all the years I took the contraceptive pill (which, through the use of progestin – an artificial version of progesterone that does not act like the natural version at all –  messes sufficiently with the natural hormone status of the body to trigger oestrogen dominance). As soon as I stopped taking the pill  – almost a decade later! – it was like the scales fell from my eyes and I didn’t know who I had become, why I was married to this man or why I putting up with the awfulness of my domestic routine in the name of ‘security’; it was like finding someone else had taken over my body, making all the decisions or I had been sleep-walking for the whole of my twenties. Once I was off them for long enough for my more natural impulses and true personality-type to reemerge stretching and yawning from its coma, coming off those pills was the beginning of a massive change in direction for my life; like waking up from a drug-induced sleep.

So, looking back, it was like I had had a personality transplant during those years of chemical hormone manipulation when oestrogen must have been running riot (and I have the health history to correlate with that picture; my health was an oestrogen dominant mess in my twenties, though I didn’t understand how to interpret the symptoms at the time). Bigger than that, I was bewildered for a long time by why I chose to be with my ex-husband for so many years, it made no sense to my cognitive brain after the marriage was over and I could clearly see our incompatibility by then. What had changed so abruptly? Of course, it occurred to me, I had only recently gone on the pill when I first met him and remained on it until just a couple of months before, guess what, I suddenly and distinctly knew the marriage had been a terrible mistake; we had nothing whatsoever in common, he wasn’t even my physical type! If you think this sounds too crazy to have any basis in science, I recently tripped upon a study (see resources below) that has flagged up that the contraceptive pill has this very effect on women’s behaviour and particularly their choice of partner; with women who come off the pill very-often looking at their partner with all-new eyes and wondering why they are even together, indicating just how hormone-driven our life choices can be.  I recommend reading up on this, especially if you have daughters to advise, as the effects of messing about with hormones can be (as I have demonstrated) extremely far-reaching. Gather together with other women and casually initiate a light-hearted conversation on how the pill seems to alter a woman’s personality overnight and you will find yourself with a lively, anecdote-fuelled discussion on your hands in no time, as happened to me recently at the hairdressers – we all seem to know someone that this happened to and, it turns out, I was right in there amongst them, for years!

The impact of messed-up hormones upon a woman’s wellbeing can be even more profound when we consider how her hormones determine the very rhythms of her connectedness (or, indeed, state of disconnect) with her spiritual self. To quote Leslie Kenton: “So central are hormonal events to how women think and feel that it would be no exaggeration to say the female endocrine system is an interface between body and spirit…Changes in hormonal balance from day to day – even from moment to moment – can not only alter the way you feel emotionally, they can even affect your view of reality”. So you can see, how tampering with a woman’s hormones could be more detrimental to whatever is playing out on world stage (let alone in her personal evolution) than most people would probably give credence to; it affects life choices at every level. Imagine a world where women are taken offline by hormone imbalances that dull down their senses, make them want different things, keep them small, complacent and accepting of the status quo…well, you get the picture.

The protection impulse run amok

The thing is, when we are oestrogen dominant, we get over zealous in our inclination to protect and preserve the status quo, just like that angry swan; we pace those boundaries with shotgun in hand (hopefully, only metaphorically speaking – but the body has these mechanisms in place and we know their outcome as “inflammation”). When we are oestrogen dominant, we are protection-obsessed enough to over-protect our cells by almost any means at our disposal, from laying down surplus fat to water retention to widespread inflammation. When not out of control, oestrogen is meant to be the gentle cushion of our system, keeping cells moist and fascia gliding smoothly, our nerves well protected in their myelin sheaths, the whole system well lubricated so that it functions perfectly well; in balance and easy cooperation. When oestrogen gets voted in as the president of our entire system, we go off into overwhelm, inflammation, red-hot flushes and fiery heat, we get excitotoxicity firing up the brain neurones so avidly that they start to fight with each other and the stalemate that results is the brain fog that can swoop down and take all your systems off line at once, leaving a void of chronic exhaustion, a full-system crash where you are no longer equipped to best support yourself. This is fibromyalgia in action.

What we have when oestrogen runs the show is an unsavoury state of affairs and yet it is still possible to discern the benefits of some oestrogen support; balanced by its close partner progesterone, which keeps it in check. Progesterone brings a whole other set of outlooks to the equation and the one can’t fully operate without the other; in fact, they’re an inseperable team.

The important thing to note here is that there is more than one kind of oestrogen. According to US researcher Devra Lee Davis (this is quoted from Leslie Kenton in “Passage to Power: The Natural Menopause Revolution) “when the body produces estradiol this oestrogen can be broken via two different metabolic pathways. One turns into a form of oestrogen…which can damage DNA. Its the kind of bad-guy oestrogen implicated in triggering breast and testicular cancers. The other metabolic pathway breaks down estradiol to form an oestrogen…which is not only harmless but is beginning to be hailed by scientists as beneficial and protective against cancer”. That’s two very different impulses from the same starting point and to treat them both the same is to throw the baby out with the bathwater, which it how it is all the way down the line when you look at the different types of oestrogen that affect us.

The riskiest type of all are the ‘man-created’ xenoestrogens that are bombarding our environment (more on that below) and how they get into our drinking water, the air we breathe and the food we eat. Our bodies readily accept these and, once in there, they mimic the effect of natural oestrogens; only they disrupt the balance of oestrogen and progesterones in the body, taking over the whole show you could say. A powerful mitigating factor is to choose to not eat animals or fish and to avoid tap water but what else can we do to avoid these toxic versions of a hormone that our body’s oestrogen receptors recognise as the real thing? Well, actually, by introducing some phytoestrogens (plant-based) into our diet, we can “fill up” those receptors with a healthier alternative which makes them less susceptible to the environmental ones – and that’s where certain legumes, phytoestrogen containing teas and natural supplements can come into the equation (certain foods contain oestrogen-like compounds called isoflavoids). I drink raspberry leaf tea, consume a controlled amount of soy (for health reasons, not too much of that…but that’s another story), edamame beans and a supplement called Nutrition FX made from green beans….and so I find that, if I keep my oestrogen levels as well as my progesterone levels “up” towards the end of my cycle, I tend to have a far better time of it.

What makes the difference between oestrogen running amok and gun blasting everything that looks like it might be a threat and it having a gentle cushioning effect that keeps our system well-protected and optimal, supporting bone mass so we can stand tall well into old age and protecting our brain from oxidative stress so we can cope with our highly-stimulating modern environment. Seems to me that the all-important mitigating effect is progesterone; that its a team effort – a best of both scenario with no extremists. Topical, eh!

Its a vastly complex subject of which I am only scraping the surface here and I recommend you do your own reading, draw your own conclusions and make any adjustments you feel you need to make to your hormones based on your research and the trial and error of seeing what works for you as none of us are hormonally identical. All I was wanting to flag up here was the over-view I have gained about the element of teamwork that progesterone and oestrogen are meant to fulfil together which, if we allow ourselves to be taken off balance by lifestyle or drugs, can get dangerously out of whack and catalyse chronic behaviours that we fail to connect back to their hormonal source. Neither hormone is meant to run amok in our system but the effects seem to be most precarious when oestrogen goes haywire and this, I’m sorry to say, seems to be a chronic condition for much of the populace, yet most people have no idea its even happening to them. At the very least,we need to be the drivers of our own health vehicles and not accidentally allow our bodies to be taken over by unconscious factors that have such a dire effects on our health and overall wellbeing; we don’t have to “just live with” any of these circumstances or believe they are just the inevitable outcome of getting older, living in a fast-food convenient world.

Final note

Being told (yet again) by a radiant not-quite fifty year old woman the other day – this time my hairdresser, who had looked very different the previous time I saw her – that I had “changed her life” by telling her about natural progesterone and recommending some books to read really made me smile. She’s lost weight without even trying, regained energy, stopped going home from work feeling utterly fatigued and bad tempered, she swears that she looks and feels twenty years younger (and I would agree), has noticed her face and skin are much more relaxed, her sex life has improved, people are commenting that her whole outlook and mood has drastically altered and the vague feeling of non-specific depression that had been building seems to have gone completely. She’s so much more cheerful…excited about life, even…and laughing much more, feeling lighthearted and girlish again. It doesn’t surprise me – its a well-proven thing that “when oestrogen is not balanced by progesterone it can produce weight gain, headaches, bad temper, chronic fatigue and loss of interest in sex” (Leslie Kenton – “Passage to Power: Natural Menopause Revolution”). Yes, I can testify to all of  my hairdresser’s reported affects and more from regularly, consistency, using a good natural progesterone cream. Imagine this for everyone; imagine it as a society.

Is there a possibility that we – as an entire population – are now so oestrogen-dominant as a result of xenoeostrogens in our drinking water, our food, our houses (leached from common household materials, plastic objects, the containers and wrappers around our food…), our rivers and seas, our fish and meat, our pharmaceutical hormone treatments and so on that its has tipped the balance of the very personality type and behaviour of the western world? Do we all need to rebalance, lighten up, get off the defensive and address the chronic inflammation of our world?

What can we do to keep balance in place within our own sphere; what can we each do?  I remain deeply suspicious of manmade attempts at manufacturing an ideal version of these hormones and trying to modulate them through chemical means; this hasn’t ever gone well and the problem is that where the hormone isn’t bioidentical, it is an end product (like a chemical piece of plastic) not a series of molecular building blocks and so the body cannot modify and recycle it in new and useful ways (for instance, converting one hormone into another hormone when there is too much of one or a shortfall of another – as is perfectly ordinary behaviour in Nature). Pharmaceutical products that attempt to mimic natural processes go in blind to all the complex and subtle spin-off effects of introducing that substance into the body; they simply don’t know the whole story and go into the body’s cells “guns blazing”, often causing more harm than good in the immediate and (even more concerning) long run.

Both progesterone and oestrogen seem to have neuroprotective roles (including a role in protecting against glutamate-induced excitotoxicity, as I’ve talked about before) if numerous pieces of research are to be believed but there are variables that are complex and, as yet, not fully understood and timing and the combination of these hormones with other factors seems to be very significant; not to be blindly charged through as though irrelevant by anyone approaching this in the form of a manufactured drug. Also my own point of view is that oestrogen needs very little interference from us once we have appropriate levels of progesterone since the latter is a precursor to oestrogen and so the body can convert one into the other meaning that, by addressing progesterone through the use of natural progesterone cream, we are effectively addressing both. If further supplementation of phytoestrogens (that is, plant-derived oestrogens) is warranted, as I am finding towards the end of my cycle, then why not stick to natural sources, by eating legumes and soy, drinking herbal tea such as raspberry leaf or chaste berry etc,. and then you will soon start to sense if they are helping and can easily modify how much you consume as necessary.

In order to stay as close to Nature as possible, I would say stick to “bioidentical” sources and so at least consider natural progesterone cream (yes, even men – more on that below) but don’t throw out the potential to bolster “good” oestrogen levels through diet and lifestyle as above. Eat and drink as purely as you can; diet really is so fundamental and no recovery can get started without establishing this firm base on which to build it. Keep your anti-oxidant status well supported – that means supplements as well as great diet (I use olive leaf, vitamin C, choke berries, selenium, vitamin E, Co-enzyme 10, green tea…). Keep yourself well lubricated, inside and out – take omega oils and lots of olive oil, apply oils containing oleuropein  (as I talked about in my post Itchy skin – putting out that fire). When inflammation occurs, tackle it swiftly and naturally (I swear by boswellia and take taurine) before it has the chance to become chronic. If you identify triggers – such as EMFs in your environment – do something about them (as I spoke about before in my post Meeting our electric selves). Then, be kind to yourself during any hormonal dips that make you extra sensitive; I mean, switch off the technology, cancel appointments, get out in nature, go and read a cheerful book…breathe deeply…allow your life to be dictated a little by your natural female rhythms rather than battling with them, as we are constantly told we should do.

In fact, hormone balance is all about attitude to life; the chemicals in our body are just there to show us the way – they “shout” at us to make the tweaks and adjustments we most need when our lives are not working with us or for us. One thing I’ve come to understand is that its time to stop steam-rolling over them but, rather, to start hearing what they have to tell us through their natural rhythms, the seasons of our life. Menopause invites us to learn this lesson more than at any other time of our lives and so if my body has something more to shout about, I am all ears and ready to hear. As every woman’s body is testament to, there is a time for everything…no two days or weeks are identical, no month or season the same as the previous one, there are times for pulling inward and times for uncoiling ourselves out into the world; the middle or later portion of her life should look nothing like her earlier seasons and that’s truly a blessing, not a curse. The sooner we start working with those rhythms, understanding their gifts, the sooner we find our way back to the kind of harmony that permeates everything in our world.


Related Articles and Resources

Partner Choice, Relationship Satisfaction, and Oral Contraception The Congruency Hypothesis – S Craig Roberts et al

Going off the Pill Could Affect Who You Are Attracted To

Birth Control Pill Affects Long Term Relationships (article in a mens magazine with the somewhat disturbing advice that “staying on the pill” so you don’t disrupt your relationship could be a long term answer…)

HOW HORMONE IMBALANCE CAN CAUSE DEPRESSION How Symptoms Tell the Story of Hormone Imbalance- An Interview with Robert Gottesman, M.D.

Progesterone and the Nervous System/Brain – Women in Balance Institute

Official website of Dr John R Lee (who ‘discovered’ natural progesterone cream)

Natural Progesterone Advisory Network


Products I use

Wellsprings Serenity Natural Progesterone Cream

Nutrition FX – phytoestrogen supplement


Natural progesterone for men

Progesterone Cream Can Help Prostate Cancer – Dr Mercola

Why Would Men Benefit From Taking Natural Progesterone – Catherine P Rollins

Men and Serenity Natural Progesterone Cream


Recommended Books

Passage to Power: Natural Menopause Revolution – Leslie Kenton

What Your Doctor May Not Tell You About: Menopause – Dr John R. Lee MD

Natural Progesterone Cream: Safe, Natural Hormone Replacement (Good Health Guides)


Related research

The Effects of Estrogen and Progesterone on Blood Glutamate Levels: Evidence from Changes of Blood Glutamate Levels During the Menstrual Cycle in Women: “Estrogen has been shown to attenuate glutamatergic- receptor activation [7]. In rats, pretreatment with intravenous 17-beta-estradiol before the local application of glutamate was shown to significantly reduce the size of the glutamate-induced lesion [47]. Progesterone also has been shown to attenuate responsiveness to excitatory amino acids and to protect neurons from glutamate toxicity in vitro [14]”

Oestrogen receptor beta ligand: a novel treatment to enhance endogenous functional demyelination “These findings show a direct neuroprotective effect of oestrogen receptor β ligand treatment on oligodendrocyte differentiation, myelination and axon conduction during experimental autoimmune encephalomyelitis.”


Disclaimer: This blog pro­vides personal, anecdotal information and dis­cus­sion about med­i­cine, health and related sub­jects. The words and other con­tent pro­vided in this blog, and in any linked mate­ri­als, are not intended and should not be con­strued as med­ical advice or recommendation. If the reader has a med­ical con­cern or questions relating to the suitability of treatments referred to, he or she should seek professional medical advice.

 

 

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