Mind Your Hormones: Perimenopause, Menopause, and Fibromyalgia - Here's What You Need to Know

Season 2 Episode 43  Mind Your Hormones: Perimenopause, Menopause, and Fibromyalgia - Here's What You Need to Know 

My practice in Louisville KY -    https://www.wholehealthrheum.com/

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Transcript

"Perimenopause, Menopause, and Fibromyalgia: What You and  Your Rheumatologist Need to Know About Hormones"

Welcome back to Mind Your Fibro. I'm Dr. Olga Pinkston. If you've been listening for a while, you may have noticed this podcast has been quiet since 2023. There's a story behind that silence—one that's directly related to today's episode.

Around 2023, I noticed something I'd never experienced before: I couldn't multitask. For my entire life, I've been a high-functioning multitasker—juggling a demanding rheumatology practice, four kids, the podcast, speaking engagements. I loved doing it all. And then, suddenly, my batteries were missing. 

I couldn't function as before. Couldn't multitask, couldn't finish tasks, couldn't perform at my previous level. I planned to record podcast episodes and just... couldn't. The mental energy wasn't there. Creativity was off. I couldn't push through. I thought it was stress. I thought it was burnout. But the reality was more complicated than that.

This is the story of what I missed—and what I'm now seeing in my patients every single day.

WHAT IS PERIMENOPAUSE AND WHY IT MATTERS

Today, we're diving into a topic that affects millions of women but doesn't get nearly enough attention in clinical practice: the musculoskeletal syndrome of menopause and its profound similarities with fibromyalgia.

Menopause is everywhere right now. It's on morning shows, in magazines, on social media. Celebrities are talking about it. Hormone therapy is being prescribed again. Practices are starting to focus on menopause care. And honestly? It's about time. 

But we need to talk about more than hot flashes and mood swings. Women feel terrible. There are so many symptoms that aren't being recognized—including the musculoskeletal symptoms that often get labeled as fibromyalgia when something else can be happening.

Here's why this matters: Suicide rates increase significantly in women aged 45 to 65, peaking between 45 and 55. Divorce rates climb during this same period. When women are suffering from debilitating symptoms without proper diagnosis or treatment, while managing demanding careers, raising children, and caring for aging parents, the consequences can be devastating. This isn't just quality of life—this is a public health issue.

THE SYMPTOM OVERLAP: FIBROMYALGIA VS. PERIMENOPAUSE

Fibromyalgia and the musculoskeletal syndrome of menopause share substantial symptom overlap—diffuse musculoskeletal pain, stiffness, fatigue, sleep problems, and brain fog. But they are distinct clinical entities with different diagnostic criteria and pathophysiology. Yet they're easily confused and often go unrecognized.

Until I educated myself on perimenopause and menopause, I likely diagnosed women with fibromyalgia who actually had musculoskeletal syndrome of menopause—or whose fibromyalgia was worsening because of perimenopause—and I didn't recognize it. 

I want to be clear about something important: I'm not suggesting you jump to the conclusion that your fibromyalgia diagnosis is wrong, or that it's "all just hormones." The last thing I want is to confuse or mislead anyone. But symptoms can overlap significantly. And addressing the hormonal piece can make fibromyalgia more manageable, even if you do have it.

Let me tell you about one of my patients—we'll call her "Sarah."

Sarah is 44 years old. Her symptoms started at 40 with suddenly disrupted sleep. She'd wake up in the middle of the night, around 3 or 4 am, with mind racing. At first a few times per week. Later, almost every night. 

During the day, she felt fatigued and had brain fog. She'd forget words mid-sentence. Couldn't finish a basic to-do list. She became irritable with her kids, husband and co-workers.  

Labs came back normal. "You seem anxious and depressed, and this is why you don't sleep," her doctor said. She was prescribed an antidepressant.

The medication helped somewhat, but sleep problems continued. Fatigue worsened. Then heart palpitations started. Then pain began—first in her hands and shoulders, then spreading everywhere. She felt stiff all over. Felt like she was 80 years old.

More labs. All normal. "Manage your stress better." A rheumatologist found no inflammation. A cardiologist tested her palpitations—all normal. "It's probably anxiety."

Eventually, someone checked her hormones. Normal. Her periods remained regular, perhaps a bit heavier, but nothing drastic.

"You're definitely not in menopause," her gynecologist said. "You're too young. You're only 44, and your cycles are regular."

By the time Sarah found me, she'd been on antidepressants for three years, was taking sleep medication, and was questioning her sanity.

Here's what nobody told Sarah—and what I didn't know about myself: She was in perimenopause. And it doesn't always announce itself with hot flashes and irregular periods.

WHY PERIMENOPAUSE IS SO HARD TO DIAGNOSE

Perimenopause is more challenging to diagnose than menopause. Once your periods stop for 12 months, the picture becomes clearer—you're postmenopausal. But during perimenopause, hormones fluctuate dramatically. Estrogen spikes one week, plummets the next. When your labs are drawn, you happen to be tested when estrogen is at a reasonable level—so results come back normal.

This parallels fibromyalgia exactly: normal labs, normal imaging, everything appears fine on paper while you feel terrible.

Women experience profound fatigue, sleep disturbances, cognitive impairment, brain fog, anxiety, heart palpitations, body aches, heightened pain sensitivity with regular cycles and normal labs. And more often than not, nobody connects the dots.

Recent evidence shows that classic perimenopausal symptoms—hot flashes, night sweats, mood swings, anxiety—can begin before any changes in menstrual pattern. In many women, they begin years before.

Both depression and anxiety can start before hot flashes appear. New-onset anxiety in women who've never been anxious. Or severe worsening of previously mild anxiety. It can begin as nervousness, constant worry, or irritability—just as disruptive as depression. Racing thoughts, especially at night. Heart palpitations. First-time panic attacks.

Many women won't have obvious hot flashes for years. They often come later—or they're suppressed by the antidepressants we prescribe. SSRIs and SNRIs like Duloxetine (Cymbalta) and Effexor actually reduce hot flashes, Paxil and Effexor are actually prescribed to treat hot flashes.  So the antidepressant prescribed for anxiety may mask the hot flashes that could have tipped off the diagnosis, making recognition even harder.

In my case, I didn't have hot flashes for years. When they finally appeared at 48, they were brief and not dramatic—perhaps because I'm cold-natured or have hypothyroidism.

THE BIOLOGY: WHAT'S HAPPENING WITH YOUR HORMONES

Let me explain what's actually happening during perimenopause. I'm going to focus on estrogen, but I'm really talking about estradiol, which is the primary estrogen we replace with hormone therapy.

There is a difference in how hormones decline: Progesterone declines earlier and more consistently during perimenopause. But estrogen shows marked fluctuations—up, then down, then up again—often at levels higher or lower than a normal cycle, changing unpredictably month to month before ultimately declining. By the time you are in menopause, the estrogen an be low or even undetectable, but before that it goes up and down like it’s on a roller coaster.  Testosterone and progesterone also get low, and FSH gets high. 

This pattern—particularly the variability of hormones —drives perimenopausal symptoms. The ups and downs of estrogen matter more than the absolute levels.

Low Progesterone Effects:

Progesterone drops first, and this often happens while estrogen levels are actually elevated and highly variable. It feels like an exaggerated PMS to some women.

Low progesterone during perimenopause causes:

- Mood issues (anxiety, irritability, depression)

- Sleep problems (insomnia, that "wired but tired" feeling)

- Heavier or irregular periods

- Worsened PMS

- Breast tenderness

- Brain fog

- Migraines

- Bloating and weight gain

Estrogen Fluctuation Effects:

Classic perimenopause symptoms involve erratic periods—lighter, heavier, or skipping—along with hot flashes, night sweats, sleep problems, mood swings, decreased libido, vaginal dryness, and brain fog or trouble concentrating.

But here's what's crucial: Estrogen affects far more than reproduction. It influences pain processing. It regulates sleep cycles. It has anti-inflammatory effects. It influences mood-regulating neurotransmitters.

 In early perimenopause, progesterone goes down while estrogen fluctuates wildly, affecting your brain and nervous system before it affects your menstrual cycle.

The anxiety and depressive symptoms that increase during perimenopause appear driven by hormonal dysregulation—the variation of estrogen levels and low progesterone—rather than by hot flashes or night sweats themselves. These mood changes reflect complex alterations in neurotransmitter systems: GABA, serotonin, dopamine, and other hormonal messengers.

When hormone levels change:

- Sleep architecture deteriorates

- Mood-regulating neurotransmitters become dysregulated

- Energy plummets

- Cognitive function declines

- Brain fog appears

- Pain threshold decreases

- Inflammation increases

 The data on antidepressant prescriptions is striking: Antidepressant prescriptions in women increase substantially several years before perimenopause is diagnosed. Many women are treated for anxiety and depression when the underlying cause is hormonal change. Of course, anxiety and depression can coexist with perimenopause and often do, and those symptoms must be addressed. But we need to understand that hormones matter.

PERIMENOPAUSE ISN'T JUST ABOUT PERIODS

A critical point: Perimenopause doesn't start at 50. It can begin in your mid-to-late 30s, most commonly in your mid-40s, with average around age 45.

When you hear "average age of menopause is 51," remember—menopause is just one day. One day when you've gone 12 months without a period and after that you are postmenopausal. Perimenopause is the transition leading up to that moment, lasting on average 7 years, up to 14 years. 

 I've heard perimenopause called "puberty in reverse"—and it's a great analogy. Puberty took us years to go through: developing breasts, starting a period, the whole process lasting years. So is perimenopause.

For many women, perimenopause begins with symptoms unrelated to the menstrual cycle—similar to puberty. We developed breasts long before we got our period. In perimenopause, your periods can remain completely regular for years while sleep, mood, and energy are disrupted.

The pattern I see—the pattern I lived: A woman in her late 30s or early 40s develops sleep problems and anxiety. She's constantly exhausted. Her cognition feels impaired. Because her periods remain regular and she's "too young for menopause," she receives a diagnosis of anxiety or depression and an antidepressant prescription.

Here's my own story: I'm 49 years old. Until about a year and a half ago, at age 48, I had no idea I'd been in perimenopause—probably for several years.

I had my last child at 41. I went back to work and was able to juggle breastfeeding, work, and kids. Sure I was tired, but I felt “normal” – if I got a good night sleep I felt rested. 

Around age 45 or 46, I started having trouble sleeping. I could fall asleep, but I'd wake up at 3 or 4 AM and couldn't fall back asleep. Later, I started waking multiple times per night. I felt exhausted. I blamed stress. I was surviving a COVID pandemic, raising four children—a preschooler and three teenagers—and experiencing burnout working at my previous practice before opening my own in 2024.

Of course I was tired and anxious. Who wouldn't be?

But someone who had always managed it all suddenly couldn't. I couldn't multitask anymore. Couldn't finish my charts at work. Projects like this podcast just stopped – I had to drop everything that was “optional”. My focus and attention declined. I couldn't cope with things I used to handle easily. I was diagnosed with anxiety, complex PTSD, and ADHD—but not perimenopause.

And I'm a physician with Mayo Clinic fellowship training, board-certified in rheumatology and internal medicine, trained in integrative medicine. I should have recognized this in myself.

But I didn't. Because perimenopause and menopause were essentially absent from my medical education. Not discussed in my rheumatology fellowship. Barely mentioned in internal medicine residency. I don't remember much from medical school. These conditions affect half the population for decades, yet we receive virtually no training.

 So I did what everyone does—I normalized my symptoms. I blamed life circumstances, the stressors. I tried to exercise more, improve my sleep hygiene, take magnesium, and do psychotherapy. These things helped. But they didn't address the underlying hormone deficiencies and chaotic hormonal fluctuations causing my symptoms.

Not until those hot flashes appeared at 48 did something click. Once I started studying menopause, everything made sense. The sleep issues. The disproportionate anxiety. The mental changes—brain fog, fatigue, difficulty finding words, remembering things I shouldn't forget, difficulty with focus and multitasking. The stalled podcast. All of it pointed to perimenopause going on for years.

Once I understood what was happening to me, I started seeing it everywhere in my practice—patient after patient with similar stories. Women dismissed. Told it was stress, anxiety, depression, or just getting old. Women suffering without anyone connecting the dots.

WHAT I'M SEEING IN MY PRACTICE

Here's what I've observed since opening Whole Health Rheumatology over the past two years: women in their late 30s, 40s, and 50s presenting with what looks and feels like fibromyalgia, or who were recently diagnosed with fibromyalgia. Widespread pain. Crushing fatigue. Brain fog. Disrupted sleep. Significant anxiety that seems to appear from nowhere.

When we dig into their stories, guess what? Many have already been put on antidepressants—sometimes years ago. They've been told they have anxiety or depression. Their periods? Many still have unchanged, regular periods, or perhaps they're a bit shorter or heavier. Many have no hot flashes. Often, nobody—including the patients themselves—thought about perimenopause.

Just like many patients with fibromyalgia, they've been to multiple doctors. They've been told it's stress. They've been told to exercise more and sleep better—as if they haven't tried. Labs come back completely normal. They've been told "You might just be depressed" or "Welcome to your 40s" or "That's just part of being a woman juggling kids, home, and work."

THE MUSCULOSKELETAL SYNDROME OF MENOPAUSE

Let me shift focus to the main topic of this podcast—the less talked about but incredibly common symptoms of perimenopause and menopause: the musculoskeletal symptoms.

 The science is clear: there is a real, physiological connection between the hormonal changes of perimenopause and menopause and the development of musculoskeletal pain syndromes.

The musculoskeletal syndrome of menopause encompasses:

- Joint pain, muscle pain, and stiffness

- Loss of muscle mass

- Increased tendon and ligament injury

- Frozen shoulder or adhesive capsulitis

- Cartilage fragility with progression of osteoarthritis

- Loss of bone density with increased fracture risk

 More than 70% of women experience these musculoskeletal symptoms during the menopausal transition. About 25% experience severe symptoms and become disabled by them. And 40% will have no structural findings—meaning normal workup results, just like fibromyalgia.

The relationship between estrogen deficiency and joint symptoms is well-supported by research. The ups and downs in estrogen levels are associated with stiffness, aches, and joint pain. Similar syndromes occur following sudden stopping of hormone replacement therapy or treatment with aromatase inhibitors during breast cancer.

Joint pain and stiffness affect approximately 70% of perimenopausal women, making musculoskeletal complaints the most common symptom in some populations, particularly among Asian women. These symptoms increase significantly during perimenopause, with symptoms most prominent around ages 50-60.

Here's what's happening: Estrogen plays a significant role in regulating inflammation and prevents generalized arthralgia—the all-over pain or subjective experience of joint pain. More than half of perimenopausal women experience arthralgia or joint pain symptoms, and even more have stiffness.

Estrogen also plays a vital role in muscle mass and strength. With declining estrogen, women experience sarcopenia—muscle loss, weakness, reduced strength, poor balance, slow walking, difficulty opening jars and climbing stairs. Declining estrogen and other hormones accelerate natural age-related muscle loss, leading to increased fat, inflammation, and risk of falls and osteoporosis.

FIBROMYALGIA: WHEN HORMONES AND PAIN OVERLAP

Let me outline what we're seeing:

Perimenopause presents with: sleep disturbances, fatigue, cognitive changes with brain fog, anxiety, aches and pain, stiffness, and normal labs.

Fibromyalgia presents with: sleep disturbances, fatigue, cognitive impairment (fibro fog), mood symptoms, widespread pain, and normal labs.

The overlap is remarkable. For many women, hormonal changes may be triggering a fibromyalgia-like syndrome, exacerbating existing fibromyalgia, or what's being diagnosed as fibromyalgia may actually be the musculoskeletal syndrome of perimenopause.

The key similarities include:

Musculoskeletal Symptoms: Both conditions present with diffuse or all-over pain, aches, joint pain, and stiffness affecting multiple body regions.

Systemic Symptoms: Fatigue, poor sleep quality, mood disturbances (particularly anxiety and depressed mood), and cognitive dysfunction such as brain fog, memory problems, and difficulty with focus occur in both.

Both predominantly affect middle-aged women, with fibromyalgia most common between ages 40-65—coinciding with the menopausal transition.

And here's the important part: patients can definitely have both. I still diagnose fibromyalgia in my practice, including in women who are in perimenopause or menopause, just as I diagnose it in patients with lupus, RA, or EDS. But I also consider hormones as part of the picture, because addressing the hormonal piece can make fibromyalgia or RA more manageable.

Fibromyalgia is a chronic centralized pain syndrome characterized by disordered processing of painful stimuli, requiring specific diagnostic criteria and treatment. 

The relationship between perimenopause and fibromyalgia remains debated among researchers. Some propose that fibromyalgia may represent a characteristic symptom of the menopause syndrome in some women, given the shared mechanisms involving brain neurotransmitter changes from hormonal fluctuations.

What we do know: Women with fibromyalgia tend to experience more severe symptoms during perimenopause and after menopause, and early age-of-onset menopause is associated with greater pain sensitivity in fibromyalgia patients. Early onset menopause also associated with more osteoarthritis the wear-and-tear type arthritis and more joint replacement surgeries. 

WHY THE RHEUMATOLOGY PERSPECTIVE MATTERS

Here's why I believe rheumatologists need to understand hormones and take a whole health approach to patients with the conditions we treat.

As a rheumatologist, I see many women in their 30s, 40s, 50s, and 60s—exactly the ages when autoimmune conditions often declare themselves and when perimenopause occurs.

Here's what makes this complicated: autoimmune conditions, hypermobility disorders, osteoarthritis, fibromyalgia, and perimenopause can all mimic each other and also coexist.

Dry mouth—common in estrogen deficiency, affecting 40% of women who complain of dry mouth and burning tongue—can also indicate Sjögren's syndrome. Anxiety worsens Raynaud's phenomenon. Joint pain and stiffness: Is that inflammatory arthritis flaring, fibromyalgia, or perimenopausal musculoskeletal syndrome?

We see autoimmune conditions flare after pregnancy or pregnancy losses. Some conditions like rheumatoid arthritis are estrogen-sensitive—improving during pregnancy when estrogen is high, then flaring postpartum when it drops. The same pattern occurs during perimenopause.

EDS or hypermobility spectrum disorder symptoms worsen during perimenopause and menopause. MCAS has a significant hormone component. POTS worsen. Dysautonomia gets worse, especially as vasomotor symptoms such as hot flashes and night sweats increase. 

We can't dismiss everything as "just your lupus" or "just fibromyalgia" or "just menopause." We need to tease out all symptoms, treat appropriately, reevaluate, and adjust. We need broad differential diagnosis, clinical judgment, and an open mind.

I'm probably the only rheumatologist I know who prescribes vaginal estrogen for elderly patients with recurrent UTIs or vaginal dryness, incontinence, due to genitourinary syndrome of menopause. I'm looking at the whole picture. 

Let me be clear about my practice: it’s not a hormone practice. My passion is traditional rheumatology—diagnosing and treating autoimmune diseases, inflammatory arthritis, fibromyalgia, Ehlers-Danlos Syndrome, MCAS, and other complex conditions. About 70-80% of my practice consists of the same types of patients I treated in my previous hospital-based clinic—autoimmune conditions like rheumatoid arthritis and lupus. I treat women and men. I prescribe the same biologics and medications because patients need them.  

But in my private practice, I'm now able to practice whole health, integrative rheumatology and lifestyle medicine. I use evidence-based complementary and alternative treatments—supplements, lifestyle changes like diet and exercise, we work on sleep—and I now consider hormones as part of my comprehensive assessment. Because hormones play a role in how our patients feel, function, and respond to treatment. 

This doesn't mean attributing everything to hormones. It means looking at the whole person, considering all contributing factors, and addressing whatever needs to be addressed. Sometimes that's immune-modulating medications. Sometimes it's hormone therapy. Sometimes it's both, along with lifestyle interventions. So I prescribe female hormones too - mainly when my patients can’t find another physician to prescribe.

When a woman with rheumatoid arthritis mentions terrible insomnia and anxiety and worsening joint pain, I don't just adjust her arthritis medications. I ask about menstrual cycles, vaginal dryness, and hot flashes. I consider whether hormonal changes might be contributing. We talk about pelvic health, sex, libido, and practical solutions.

 When a woman develops new-onset widespread pain in her mid-40s, I don't assume it's fibromyalgia. I also consider whether perimenopause might be contributing and whether addressing that might improve her overall picture. And she can still have fibromyalgia.

WHAT YOU CAN DO: PRACTICAL NEXT STEPS

If this resonates with you—if you're thinking "this explains so much"—here's what you should know and do:

Find the Right Provider

You need someone who understands that perimenopause can begin with mood and sleep symptoms before cycle changes. Someone who knows that normal labs don't exclude perimenopause. Look for OBGYN or gynecologists specializing in menopause, certified menopause practitioners, or primary care physicians who take a comprehensive approach to hormonal health. If you have autoimmune disease, a rheumatologist who considers hormonal factors can be especially valuable.

Consider Hormone Therapy

Despite decades of fear surrounding hormone therapy, the evidence is clear: for appropriate candidates, menopausal hormone therapy is safe and highly effective during perimenopause, not just after menopause. It can dramatically improve sleep, mood, anxiety, fatigue, cognitive function, and musculoskeletal pain. For some women, including myself, it's transformative. I am now on all 3 hormones – estradiol patch, progesterone and testosterone – it took me over a year, but I am finally starting to feel better, although not to the same level as in my early 40s. 

Not everyone is a candidate—treatment must be individualized based on personal and family history, personal preferences, and individual risk factors. But don't let outdated concerns or fear-based messaging prevent you from considering it as an option worth discussing with an informed provider. Educate yourself – don’t rely on social media alone – look at quality evidence-based podcasts, books. There are many bioidentical options available at the pharmacy, my treatment is by prescription that is covered by insurance, bioidentical hormones, don’t fall for gimmicks and high cost treatments. 

Understand Lifestyle Interventions: What Helps and What Doesn't

Exercise, nutrition, stress management, magnesium supplementation, and psychotherapy all matter. I tried all of these myself during my perimenopause. And they helped. But they didn't treat the underlying hormone deficiencies and chaotic fluctuations.

I practice lifestyle medicine—I know its value deeply. But here's the truth: lifestyle interventions are part of a comprehensive approach, not the complete solution. Fundamental things are fundamental. Good sleep, using food as medicine, movement, positive human connections, and mental health support—these matter for all conditions and may help you not just survive but thrive. But they can't replace appropriate medical treatment when needed – for autoimmune conditions or menopause. 

Reevaluate Your Medications

If you're on an antidepressant, work with your provider to discuss whether addressing hormonal changes might allow dose reduction or changes. Some women do need antidepressants during perimenopause—and that's okay. But treating only mood symptoms without addressing hormonal causes is incomplete care. Many will need to address ADHD – it’s not a new diagnosis; it’s often an uncovered childhood ADHD but menopause symptoms made it impossible to cope with it and no longer manageable with whatever worked before. 

If you've developed fibromyalgia-like symptoms, medications like duloxetine or Cymbalta, or low-dose naltrexone may help. Work with your doctor on what's appropriate for your situation. 

Don't Ignore Coexisting Conditions

If you have autoimmune disease or conditions like Ehlers-Danlos Syndrome or MCAS, perimenopause presents additional challenges. Your conditions may flare. You may need medication adjustments. This requires specialized, coordinated care from providers who understand both rheumatology and hormonal health.

CLOSING THOUGHTS: YOU'RE NOT ALONE, AND THIS IS TREATABLE

I want to say something directly to anyone listening: If you're thinking "this explains so much," understand this—you're not being dramatic. If you are in perimenopause or menopause, your symptoms have a physiological basis and deserve appropriate treatment.

Medical understanding is evolving, but medical systems change slowly. You may need to advocate for yourself, educate yourself, your doctors, or seek new treatment team. But you're not alone in this experience. 

This is treatable. You don't have to endure years of suffering. Effective medical interventions exist. I know this because I lived it, and I'm treating it now—in myself and in my patients. It is very rewarding to see women feel better. 

Perimenopause is a transition. It doesn't last forever. With appropriate support and treatment, you can navigate this transition and emerge feeling strong and healthy. You can get your batteries back, like I did, well maybe at 70% but it’s better than none.

I'm planning to records more episodes, I decided to not stress on when. For today, I hope sharing my story and explaining the connection between hormonal changes and symptoms that may feel like fibromyalgia helps you understand what might be happening in your own body.

Thank you for listening to Mind Your Fibro. Thank you for being patient while I figured out my own health journey. If this resonated with you, please share it with friends who are struggling and with doctors who may not yet learned about these connections. And if you're in the Kentuckiana area and looking for care that addresses the whole picture, my practice is accepting new patients.

Until next time, take care of yourself. You deserve it.

DISCLAIMER

This podcast is for educational purposes only and does not constitute medical advice. Please consult with your healthcare provider about your individual symptoms and treatment options. Individual medical decisions require personalized evaluation by qualified healthcare professionals familiar with your complete medical history, current medications, risk factors, and clinical presentation.