The Dr Louise Newson Podcast - 188 - The importance of breathing efficiently with Dr Louise Oliver

Episode Date: January 24, 2023

Dr Louise Oliver, a GP and functional breathing practitioner and therapeutic life coach, joins Dr Louise Newson as a guest on the podcast this week. Louise Oliver has had a special interest in women��s health and menopause for many years and now incorporates her skills as a functional breathing practitioner to raise awareness of how breathing is altered by hormones, how this can lead to symptoms of inefficient breathing and how to improve the connection between our brain, body and breath. Louise’s three tips to breathe more efficiently: Be aware that your hormones affect the way you breathe and how you breathe affects your health and wellbeing. Learn more about breathing. The book ‘Breath’ by James Nestor and all Patrick McKeown books and podcasts are excellent. Assess your breathing efficiency by observing your breathing at different times over the next week and see whether it matches the description of effective breathing as discussed. Improve your breathing efficiency by learning the techniques and dedicating some time over a number of weeks and months to adjust your breathing style until it becomes more natural for you. For more about Dr Louise Oliver, visit her website. The video link mentioned in the episode from Mr Vik Veer, ENT consultant, to improve snoring and sleep apnoea can be found here. Louise is on Instagram as @drlouiseolivertlc and on Facebook here.

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based, information and advice about both the perimenopause and the menopause. So welcome to this podcast. Today I'm going to introduce to you another Louise actually, Dr Louise Oliver, who's a GP with an interest in women's health, but she's also, which is the really interesting bit I think,

she's a functional breathing practitioner and a therapeutic life coach. So welcome Louise today. Thank you. So you reached out to me through somebody we both know, And I've, many of you know, do quite a lot of yoga. And part of yoga is breath work, actually. It's really important to, well, to get the best re-eager practice to coordinate movements with breath. And breath is one of the few things that we have control of. There's lots in our life we have no control of. And there's lots of things in life we can choose to do or not do.

But breathing is something we all do. But we actually have control over it. So I've been fascinated with breathwork for quite a long time. time and actually my oldest daughter is at trombonist who's very into breath work. So when you reached out to me, I thought, yes, this is ticking lots of boxes and, you know, holistic care is really important for any field of medicine, but especially menopause as well. So for you to have an interest in women's health and breathing, it's just great. So tell me a bit about why you're doing what you're doing, Louise. Have you always been a GP? Yeah, so I've been a GP now for over 20 years

right from when I trained, I had an interest in women's health, and I've been involved with contraceptive work, so fitting coils and implants throughout that time. I've been on the HRT rollercoaster, so obviously what I used to prescribe over 20 years ago is very different to what I prescribe now, and in the middle of that 20 years, I hardly did any prescribing of HRT because women weren't taking it. And what has fascinated me now is the effect of hormones on how we breathe and how we breathe, and how we breathe affects our health and well-being. And certainly we talk about the changes of hormones on skin, brain, heart, bones, muscle. But quite rarely do we actually talk about how those hormones affect how we breathe?

I think for so long, you know, traditional medicine is that you focus on the organ and it's very organ-specific. And I think it's only been in the last maybe 10, 20 years where we've realised more about connections. and there's been a lot more even about, I think the first connection really that I thought beyond an organ was the sort of gut brain access actually. And then we talk a lot about the vagal nerve and the pathways there and then parasympathetic and sympathetic nervous systems. And it all makes sense and it's all things that we do know really. But no one, I think in medicine a lot of people don't, we don't put the pieces together somehow. We learn it as physiology. and then we learn a vision pathology

and then you get into the clinical medicine and somehow that's all forgotten and then taking a step back you realise why you learnt all these things I don't know, was that the same for you? Completely and just the interaction because breathing just, well it's our basic function isn't it?

And I think the one thing that people perhaps don't realise is because breathing is an unconscious basic process that does not mean that it's automatically efficient and sort of living in modern, day times and the changes that happen around the perimenopause and the menopause generally mean that it makes it more likely we're going to be breathing inefficiently and then the downstream effects of that can actually be quite surprising and seeing people improve when you improve their breathing efficiency is really quite amazing and I think breathing

is probably I see perimenopause and menopausal care as a sort of jigsaw puzzle and there's there's lots of different bits to that, so that would be HRT, movement, what we eat, drink, managing stress, etc. But I think breathing is one of those pieces. And I think there's a real lack of awareness. And in some women, that would be a big piece. And in some people it would be a small piece. But if they don't know that piece exists, they can't even have an opportunity to address that. Yeah, and I think that's so important because I think it's also looking both sides really. So a lot of women find that when they're anxious and stress, then their breathing pattern can change. But also, we know that we've got receptors for estrogen and testosterone actually in our lungs.

So out of our control, some people find that their breathing can change without hormones. But the other thing is, if we can control our breathing, it can control how we are as well. So I'm sure a lot of people have been in a very stressful situations and feel that they're breathing and their heart's going or maybe their stomach's turning and everything else, that adrenaline response. But if we concentrate on things that we can control and breathing is actually a lot more easier to control than your heartbeat, for example, concentrating on that actually makes such a difference. And it's a very quick, often, easy thing to do, isn't it? Oh, definitely, definitely. And I think I'm sort of proposing like a three A's approach, so sort of aware, assess and action. So I want to raise awareness for how breathing

is altered by hormones, how this can lead to inefficient breathing and what those symptoms are. So women have that awareness and then sort of giving them a structure of how they can assess their breathing efficiency. And then if they're ready to and if so, encourage them and empower them to improve their breathing efficiency. Because there's different ways of breathing, isn't there? I think if you've never thought about it before, you just think, well, it's just something that happens. But we can be very inefficient with our breathing, which a lot of people are obviously. But there's even just how we breathe through our nose or mouth can make quite a difference, can't it? Definitely. And I think there is

more awareness coming through with that, but there is definitely a real lack of just understanding of what effective breathing is and then being able to compare themselves to whether they are breathing efficiently or not. And I think it's really important, particularly with the changes around menopause and particularly around a lot of women don't understand that there's a real increase in sleep disorder breathing around the menopause. And I have so many women when I ask, you know, ask some questions about how they breathe at night and they, oh yes, I started snoring and laugh it off and think that's okay. And I've seen it on menopause forums that people, I've got the menopause snore and people don't realize, first of all, that actually that's

affecting their quality of sleep. It can affect their blood pressure. It can affect a whole host of things. And actually, there are some simple things they could try to do to help that. So what can they do? Well, I think, I suppose if they're aware of what happens, then it's natural then that it makes sense to, for where we go. So, you know, women generally have, obviously, depends on size, but we generally have a smaller airway, smaller rib cage, lung volume, a shorter diaphragm. Even the way our ribs are attached to our spine is different. They're a different angle. And all those factors really impact how easily air enters and leaves the female body. There was a large study that actually showed that lung function declined more rapidly

among perimenopausal and menopausal women. And that decline was greater than the normal expected for ageing. And in particular, I thought it was really interesting in that study that the decline appeared to increase with difficulties breathing in compared to breathing out. And certainly that matches my clinical experience with people that women often say I feel like I can't take a breath in. And we know that menopause causes muscle loss, but how often do we discuss muscle loss from the breathing muscles and encourage breathing muscles exercises to strengthen those muscles? And then sleep disorder breathing, I think that's one thing that is just so under-recognised with women and that's a spectrum so people might not be aware of that term so a spectrum

from anywhere from just an increased resistance to the air flowing through the upper airway whilst asleep to snoring when the airway is actually sort of vibrating and then obviously obstructive sleep apnea where the airway actually closes and there was a sleep cohort study that actually demonstrated there was a 3.5 times risk of obstructive sleep apnea in postmenopausal women compared to premenopausal women. But, however, women are less likely to come into the GP saying, I'm snoring or I've got gaps in my breathing. They're much more likely to complain of daytime fatigue, lack of energy, insomnia, morning headaches, mood disturbance and nightmare than men.

So I think women, if they've got those symptoms, need to really be sort of perhaps asking anybody if they've got a sleeping partner, can they just observe occasioned their breathing? How are they breathing? Do we have some concerns about sleep apnea? Are they snoring? Is the mouth open? Is it closed? And then just getting awareness then that this could be affecting them. Yeah. And that's really important actually because obstructive sleep apnea is something that sort of when I graduated in 94 and it was just starting to be swoken about then. And the incidence has increased, partly I suppose because of awareness but also associated with obesity and weight gain and we know it's more common in men and there are multifactorial so many different reasons why it can occur more in

the menopause and we know that women without hormones often do put on weight because of the metabolic processes that can occur but we also know that muscle tone and strength is reduced and people don't realise actually this really important muscles aren't there that help with our breathing but also around our upper airways as well and our throat and like you say the jaw and everything else and some of you might have listened to my podcast with Dr. Saj Rajpa talking about bone loss around the jaw and even that, you know, visually you can make a difference to your face but that can make a difference like you say especially when you lie down and the muscles are relaxing and then we know that any sleep disturbance can have health risks of course with associated to a

even heart disease and some types of cancer have been shown to increase. But the sleep disturbance might be because the woman's getting a night sweat. It might be because they're wakling with crippling anxiety. Or it might be that they think they're sleeping, but like you say, if they've got obstructive sleep apnea, then they're not sleeping as well, are they? And sometimes or often as a witness person, but sometimes, or many times I speak to menopoles,

and that partner is in another room because they can't bear to be sleeping to the woman whose dube's on or off or tossing or turning. So then it can be very hard and then they wake up feeling exhausted. What is it because they're menopausal and their energy is reduced? Or is it because of their sleep? No one's telling them. And you can see how it's very difficult to tease out, isn't it? No, definitely, definitely.

And certainly there needs to be more research on this. There's some research out there, but we're not completely sure about how the hormonal changes affect breathing. But definitely, as you say, they do seem to have this protective effect on the airway. It keeps the tone of the upper airway muscles toned and gives a drive to breathe. So that's helpful. But interestingly, sometimes the hormones can have a negative effect we're thinking. So progesterone, as we know, is a female hormone and it's a powerful respiratory stimulant. So that means it actually increases how fast we breathe. And it does that by making the body more responsive to a low oxygen or a high carbon dioxide level. So a faster breathing rate could

mean that it helps keep the airway open, but it could also mean it causes a vacuum effect and it's more likely to make the airway collapse. So I think it's really interesting and obviously people's hormones change so much over the perimenopause that I think it's really important. So you mentioned before about the autonomic nervous system and actually that's really important to understand about that. So that system obviously changes the things that we don't need to have conscious control over moment to moment. And that can be in that fight, flight, free system, or it can be in that sort of rest and digest system. And when we're breathing in a fight, flight system, we would generally, so if I went and tried to attack you, you would probably start to breathe sort of hard, fast, probably an

open mouth, upper chest. Whereas when you're in the rest and digest, generally the breathing would be more relaxed, the mouth would be closed, it would be soft, it would be gentle. And there seems to be evidence to suggest that our amygdala, which is our, it's involved in fear, it has all the roles, but you could say it's a fear centre in the brain, spies on our breathing centre. And we think this has been developed by evolution that when our breathing becomes hard, fast, upper chest with an open mouth, it sends a signal to the body to actually activate the fight, fight, fight, freeze system. Now obviously if we're asleep and we're breathing in that way,

you can imagine that your body's being told you're not safe, there's a threat. So your amygdala's firing a signal off to say there's a threat here, they're breathing in this erratic way. And then your body's trying to be woken up. And that means then people are just not getting that rest. And because the adrenaline and the cortisol levels remain up, that fuels weight gain and diabetes and heart disease, risk, et cetera, et cetera.

Yeah. And it's also interlinked, isn't it? And I think for far too long, I've said this before in the podcast, that people think about the hormones in isolation and they think about menopause is something that affects our periods or affects fertility, which obviously it does. But they forget about the bigger impact on the body and also the knock-on effects. So a symptom should never be taken in isolation, I think. And I think you're saying about, you know, this effect on our cortisol.

or other hormones, they all work together, don't they? Our sex hormones work in associated with our thyroid hormones, with our stress hormones, with our happiness hormones, with our, you know, all sorts of hormones. And they don't just work together. And that's why the body is so absolutely incredible. But if one hormone's out of kilt or out of sync, then all the other hormones can have an effect,

and then that can have changes on the body as well. And we also know that when, especially when women are parents, menopause or often the time when their Easterdale level is at its lowest, it's early hours of the morning. And so if you've got that dip, and that's often when people wake with crippling anxiety, and like you say, then they've got this fight and flight when they should be resting and relaxing, and when people often catastrophes and they've got these awful intrusive thoughts, and this vicious cycle is going on. And I cannot imagine anyone who has very negative, dark thoughts or thoughts of anxiety is going to really be having very relaxed, calm breathings. That's

going to make it worse as well, isn't it? Oh, definitely. And I think I want to just raise the awareness that, you know, when you should be sort of quiet, distracted to maybe doing emails or watching a TV, you know, what's your breathing like then? You know, your breathing should be sort of in and out through the nose. It should be to be calm. It should be, you know, sort of slow, gentle, driven by the diaphragm. If you've got really effective breathing, you know, the out breath is actually longer than the in-breath and there's actually a slight pause after the out-breath before you breathe in and if you're not breathing like that then you're constantly telling your body that you're not safe that are threats there there's a condition that I think one of

the psychologists noticed when people are in I think she called it email apnea where people sort of hold their breath and their breath becomes very dysfunctional when they're sort of looking at emails and I think it's been shown on phones as well so it's how to you're breathing over a 24-hour period that's important and you want that to be as efficient as possible and then you're telling your brain that you're safe most of the time and then that fight-flight freeze response only comes on when there's a true threat there so what can we do then I mean I have ways with my breathing just looking at your energy breathing and how I manage with yoga against a sort of closed epic lotus really and really focus on my breathing but what do

other people do? What's an easy thing for someone that's never thought about breathing? What could they do if they were feeling that things are coming out of control? Well, I'd probably say the first thing to do is just assess your breathing and then see where you're at with it and then you can monitor for improvement. So just, you know, over like a week, just think, you know, effective breathing is through the nose, slow, gentle, exhale longer than the inhale, short pause after the exhale and it's driven by the diaphragm. And I mean by that that the lower ribs expand size. ways on the inhale, because it is possible to do belly breathing but not actually move your diaphragm. And just check in with your breathing intermittently over a week and actually just does your breathing

match that description? And if it doesn't, then you know that you're not breathing as effectively as you should do. And the best time to do that is when you're distracted, you know, on the computer, watching the TV and asking others, how you're breathing at night. Now, breathing in efficiency, the medical term for that is dysfunctional breathing. It really lacks. a rigorous definition and a clear method of assessment because it's different ways that you can breathe inefficiently. Some researchers, Keisel and colleagues, they've actually explored all the different methods and they've proposed a breathing screening procedure which consists of measuring a breath hold time and answering four questions. Now this doesn't actually diagnose dysfunctional breathing.

I'm not suggesting that, but I'm saying it's a really useful tool just to indicate if you benefit from improving your breathing efficiency. So you've kind of agreed that you'll have a go with that now. So I'll... But just to give people a little bit of background. So why would measuring the time you hold your breath indicate inefficient breathing? So at some point after you hold your breath, your brain sends a signal to breathe. And frequently individuals think that's because their oxygen level is dropping, but that is not the case. When you hold your breath, you're not breathing the carbon dioxide out so the carbon dioxide increases.

We've got enough oxygen in our lungs and blood to maintain oxygen levels during a breath hold of this type. But we've got receptors in our body that have a specific sensitivity to carbon dioxide and that's personal to the individual. And when that carbon dioxide level reaches that sensitivity, then the body will send a signal to breathe and that will be felt as an involuntary contraction of the muscles of either the neck or the diaphragm, which is underneath the lower ribs, and the individual will feel an air hunger. So that's a feeling that they're either not getting enough air into the body

or they need to take more air in. And that can be a really useful tool to help guide if you're breathing efficiently or not. Now, the ideal time is after waking and before eating. So it's not an ideal time and we're in a middle of a podcast recording. So it's, I wouldn't say, you know, you're not at the most relaxed, ideally sort of relax maybe for 10 minutes beforehand, just to sit quietly. But we can just practice. So I'll just talk you through it first and then I'll get you to do it. So obviously we need to sit up right to make sure we've got a good posture. I changed my posture then. Have the time. Yes. Keep your mouth closed throughout the assessment. And what I'm going to indicate is that you're going to take a small silent breath in through your

nose, a small silent breath out through your nose. Then you're going to hold your nose with your fingers. So obviously, mouth is still closed. And then I'm just going to, I've got my stop watch. So any form of stopwatch and just record the number of seconds. Just relax into it and I wait to let go once your brain sends the signal to breathe. And that's an involuntary contraction, neck or diaphragm. And breathing should be calm afterwards because we're not testing willpower because that varies between people and it skews the result. So it's just the comfortable breath hold time. Okay.

Are you ready for me to? Okay. I'm ready. So make sure your mouth is closed. Take a small silent breath in through your nose. a silent breath out through your nose, pinch and hold, and just relax into it. Just relax into it. We're not testing willpower, just relax into it and let go when you feel that first muscle contraction.

All that's happening now is just the carbon dioxide, it's just building up. And then when you reach your sensitivity, that'll be when you let go. And the breathing should be calm afterwards. You're just relaxing into it, relaxing in it. relaxing into it. Perfect. Excellent. So you got 26 on there so that's really good. Did I? Is that good? It didn't feel very long actually. I felt like I started to panic after. Well, because we do the breath out after the exhale, you won't be able to hold as long, but it seems more reliable that way. Now, we'll remember the number of seconds and then the other thing mentioned four questions that

Kaisel and colleagues suggested. So if listeners can just think about these four questions, what we want to know is, do they experience any of those symptoms often or very often? So the first question is, do you feel tense? Do you feel a cold sensation in your hands or feet? Do you notice yourself yawning? And do you notice yourself breathing through your mouth at night? Interesting. No. So the breathing at night, that may need to be assessed by, another person. If individuals have a very dry mouth in the morning or they're very noisy with their breathing or they're snoring, that can be suggestive of that. And the screening protocol suggests that if you score less than 25 seconds and you've answered often or very often to

one of the questions, then essentially inefficient breathing might be a factor. So we're not diagnosing it, but I would just say, well, what have you got to lose? Just, you know, encourage and empower you to have a go at improving your breathing efficiency and see what happens. It's very interesting. I mean, it's certainly something everyone can try, I think, can't they? And certainly, I mean, I know you're going to leave lots of notes and do some writing for balance as well because I think the whole mouth breathing is really interesting, actually. And it's something that we do naturally actually is to breathe through our mouth. But once you get in the habit of not doing it, you can quite quickly notice the benefits.

and sometimes my daughter sounds a bit barbaric, doesn't it? Sometimes my daughter tapes her mouth clothes, especially when she sleeps, and she sleeps a lot better when her mouth is taped clothes. And it's done quite a lot, isn't it? It's not just her doing that. And it's about learned behaviour. We all get into bad habits. Even when you told me to sit up straight, I'm thinking, yes, I'm slouching, I really need to.

And I think it's very easy with breathing, because a lot of us don't realise that there is such a connection. And I know if I'm ever got an important lecturer or I'm doing a big media appearance, I'll always do yoga in the morning beforehand. I'll always do a headstand beforehand. But just that immediate few seconds before, I will zone everything out and concentrate on my breath because I think that's the one thing no one else can control for me. And it reduces some of that noise in my head and there's sort of other people telling me I should

or I shouldn't or I'm this or I'm that. Actually, I'm just going to focus within. in and it's very powerful actually, isn't it? Oh, it's so powerful. And that number of seconds, obviously, it will vary. So individuals mustn't think that that number, it's actually going to be quite interesting for people to actually do it every morning and see what happens.

Obviously, it will change according to hormones. So we know if people say had a natural menstrual cycle, so they were ovulating normally prior to perimenopause. In the second half of the cycle, they get an increase in the amount of progesterone. That's natural, that's normal. But the breathing rate increases and you become more sensitive to calmed outside. So you'll notice a drop in your breath hold time, which if you can imagine, if you've got a very inefficient breathing pattern, you suddenly start breathing even faster.

It could tip you into symptoms of over-breathing. Or, for example, say you were an athlete and you suddenly, for half of the month, you're breathing much faster, your sports performance is going to be affected. I have some individuals with chronic pain, long COVID, sort of multiple, medical problems, they'll have a breath hold time of, I've had someone with 3.5, I've had five seconds. I mean, and these people are so affected by their breathing just at rest. So you can imagine if you tell someone who has a breath whole time of that, oh, you just need to do some more movement to do some more exercise. It's impossible. Impossible. You need to start with the basic

breathing efficiency first and then they can exercise more easily. For functional breathing, ideally you want it above 40 seconds, but it can take some time to shift it to that. The difference it makes in the breathing is just amazing. We want our airway to be as open as possible. And actually, there's three parts to that. So we've got tongue position is one, throat exercises is another, and then ensuring nasal breathing. So the tongue is crucial for the airway. You know, the back of the tong forms the airway. If the tong's in the correct position, it opens the airway. So correct position so people can practice this so it's the tongs flat against the roof of the mouth it's not touching the front teeth the lips are sealed we're not clenching our teeth and we've got a nice

relaxed face so if you do that louise you get your tongue in the right position for me yeah you can see you've got your face relaxed your mouth your mouth and then open your mouth and what happens to your tongue well i'm conscious of it so it's staying at the roof of my mouth but if unconsciously it drops to the bottom of your mouth and if it's in the bottom of your mouth it goes back too far and it's impacting on the airway. So I would say to people, if your tongue's not normally in that position, it takes time to build a strength up in your muscles and your upper airway in your tongue. But actually, it does actually, you get tighter muscles under your chin, tighter muscles on your face, so it's actually quite beneficial. And just tag reminding yourself about the tongue position

to everyday activities. So if you fill up your water bottle, just say tongue in your head. or putting the kettle on or walking up the stairs and just go through the checklist and just keep reminding yourself. And then if your body will learn that's where you want it to be, it'll be less likely to fall backwards when you're asleep. Now, the other thing, obviously, we've talked about is the muscles in all this area get weaker after the menopause. And we need to actually strengthen that up. If we don't want them to vibrate or actually collapse during sleep, we need to increase the strength of those. Now that actually is probably the role, it is the role of a Maya functional therapist and there's lots of those working in America, particularly with sleep clinics, but it's not

available in the NHS unfortunately. So Mr Vic Veer, he's an E&T consultant and lead for sleep surgery at the Royal National E&T Hospital in London. He's created a YouTube video providing these exercises, which he's found in studies that there's some evidence that they improve snoring in sleep apnea. So we'll put a link to that in the show notes. and I'd just suggest watch the video a few times very quickly people know what they're doing they don't take very long at all and just tag it to an everyday activity so that they do it once

the day you know before brushing the teeth at night when they put the kettle on in the morning and just be patient because they've got to build that muscle strength but it does work. Great advice. I think we could talk for hours and it's been really useful and I'm sure I get you to come back to talk more but I think this has been really useful because we've not spoken We've spoken a bit about breathwork with yoga and with mindfulness, but actually to have a dedicated session on it has been really useful. And I hope whether people are perimenopausal, menopausal or not, there's something for everybody about breathing and just being aware,

reading the notes, watching this YouTube video, and just reflecting and thinking. And we all have times when we're driving a car, or like you say, looking at your phone or emails, watching television. Just think where your tongue is. think if is your mouth open or closed, think about your breathing and see how you can improve and optimise it, which will help your mental and physical health as well. So before we end, though, Louise, I'm very grateful for your time, but before we end, three tips. So for people who,

this is all a bit of an unusual concept thinking about breathing or just something they're not sure, what would you say for them to do to get into their breathing more? So the first tip is just be aware. So be aware that your hormones affect the way you breathe and how you breathe, health and wellbeing. Improve your knowledge on breathing. So the book Breathe by James Nestor is brilliant. All Patrick McEwen books and podcasts are excellent as well. Just update your knowledge on it and you'll be surprised on how breathing affects everything in your body. My second tip would be assess your breathing efficiency. Use the tools that we've discussed on here and actually just observe your breathing over the next week at different points and see whether it does match the

description of effective breathing. And then I'd encourage and empower women to act to improve their breathing efficiency by actually dedicating some time over a number of weeks and months to actually just see whether they can improve. And then over time, it just naturally becomes how they breathe and it can help themselves regulate their autonomic nervous system. Very good. So thank you very much indeed. It's been really interesting and look forward to speaking again more on this topic. So thanks very much, Louise. Thank you. For more information about the perimenopause and menopause, please visit my website, balance hyphen menopause.com, or you can download the free balance app, which is available to download from the App Store or from Google Play.