← You Are Not Broken
You Are Not Broken
315. BONUS - Genitourinary Syndrome of Menopause Guidelines released today!
00:31:01
Loading summary
Transcript57 lines
- [00:00]
A
I started Ornod in 2013 and we make bike apparel. The best part of Shopify for me is our ability to run the business as essentially non technical people. We're able to admin everything on the back end, front end and sell things online easily. If Shopify were a bike accessory, I think it would actually be the bicycle. It's the thing that you do the thing on. We run the business on Shopify. So start your free trial on shopify.com everybody.
- [00:30]
B
Late breaking news today at the American urologic Association. The 2025 Genital Urinary Syndrome of menopause guidelines are released today at the aua. This is incredibly exciting. This is like six years in the making. For those who are just joining today, the release of genital urinary syndrome of menopause guidelines. I'm just, I'm going to beat these guidelines to death for like the next year. So buckle up. Way to give us an update. She was actually on the panel for the AUA guidelines and it's just going to tell us all about it. So Dr. Rachel Rubin, thanks for joining us from Vegas, baby.
- [01:18]
C
Hi everybody. If you look carefully you can see all of the mountains hotels behind me. We're in Vegas and there is big frickin news. We're so happy.
- [01:29]
B
So Dr. Rubin, you were part of the panel. I was hanging out with you in New York City at an event a year or two ago and you were taking a call to have a meeting for these guidelines, let people know what they are and then like the amount of time it actually takes to write guidelines.
- [01:45]
C
So I'm not an official spokesperson for the guidelines, but I was a panelist on the guidelines and they were just officially released and presented today at the American Neurologic association meeting, which is revolutionary and world changing and so exciting. So a guideline for the American Urologic association, they do guidelines which is evidence based sort of guidance on how they recommend treating certain conditions. So we've got guidelines on incontinence, on prostate cancer screenings, we've got guidelines on urinary tract infections, we have enlarged prostate guidelines, erectile dysfunction guidelines, premature ejaculation, we have premature ejaculation guidelines, testosterone in men guidelines. And this is the first guideline in women's sexual health for the American Urologic association. And it is in the genitourinary syndrome of menopause. And this has been multiple year process in order to gather the data and the research and to get all of the people together. It was a huge group of people and what's so beautiful. There are many beautiful things about it, but it was very multidisciplinary. We had a patient advocate on the committee, we had urologists, we had urogynecologists, we had people from the Menopause Society, we had people from isswish, the International Society of the Study of Women's Sexual Health. And we all got together and we would meet multiple times throughout the last couple of years and we each were responsible for different parts of the guideline. And then we had to reach consensus, we had to all get together and then it had to be approved at multiple levels of politics, including the most, the AUA leadership, their lawyers, all of these people. And again, what came of it and the consensus that came of is bold. It is simple, it is unapologetic, it is evidence based. And it is very, very clear that vaginal hormones are absolutely preventative of urinary, prevent urinary tract infections, help with pain with intercourse, help with overactive bladder and urinary urgency. They are safe to take if you have breast cancer history, family history of breast cancer, history of blood clots. They are safe and they are. And they are lifelong therapies. They're chron therapies that should be used. And so it is just to watch the advocacy that many of us, including you and all of our colleagues, the advocacy that we have done, both in the exam rooms and then loud on social media, and then the politics that we had to do to get these guidelines through for the aua, which is an often very male dominated organization, for them to do this and agree to this is nothing short of a giant, just incredible hope for the future.
- [04:32]
B
That is so cool. What's the biggest thing that you love about? Is there like something that's just bold or that you just love that is in this guideline?
- [04:44]
C
There's so many statements that I haven't opened because it all just makes me want to cry. The biggest thing is this idea of shared decision making, this idea that we don't tell women what to do. We do shared decision making. We do this in men all the time. It's a very common thing at the end of you have prostate cancer and you want testosterone. Let's talk about this in a shared decision making fashion. And so at the core of the GSM guidelines is this idea of shared decision making. And there is no longer any first line, second line, third line therapy. It's a toolbox. So hormones are above any discussion of lubricants and moisturizers, which it was very intentional and it is a toolbox. It says, yeah, you can use lubricants and moisturizer to help with pain with intercourse. Help a little bit, but you could also use them in conjunction with vaginal hormones and oh, guess what? There is no data to show that vaginal lubricants and moisturizers help with urinary tract symptoms and urinary tract infections. It makes very bold statements about breast cancer, about saying that. But there is no evidence linking low dose vaginal estrogen to the development of breast cancer. And in patients who have a history of breast cancer, we recommend low dose vaginal estrogen in the context of multidisciplinary shared decision making. This guideline, it says the word androgen. I have to do a search of how many times does it say the word androgen in it, this idea that it's actually not just about vaginal estrogen, it is about estrogen and androgens. It's at least eight times it's mentioned throughout the guideline and in multiple statements. It talks about how vaginal dhea, which is the only FDA approved product that has androgen in it is just as good for all of these pain with intercourse, urinary symptoms and UTI prevention. So it gives. It is really incredible. Well actually it just is really incredible. It does give a statement on laser based therapy and says that there truly is not enough data to recommend the use of vaginal lasers for gsm. But that if you have patients who, you know, if you want to do shared decision making, then that of course is up to you and the patient and that we would love to see more research on this. Listen, I am not, I don't use lasers. I'm not a big fan of. I don't see much impressive data on lasers. That being said, if you're going to use a laser therapy, use vaginal hormones in addition to your laser therapy. I think the synergistic effect should be studied in more detail.
- [07:24]
B
So just to go off on a laser tangent, some people are so atrophic, their skin is so sensitive that the laser actually can cause harm because they're so far behind treatment. So that's where I would put caution like on the extreme cases. Don't just laser super fragile skin without good skin care. Talk to me, do they, do they mention at all the FDA guidelines and how the data is incorrect on the safety of vaginal estrogen? Is that mentioned at all in there?
- [07:54]
C
Yeah, it's because they are very clear in. So there's a statement that you do that, that you don't need endometrial surveillance. In people who you treat a gsm, it makes statements that there's no data linking vaginal estrogen and breast cancer. So, and in the subtext, it does talk about the labeling and how the labeling is. It makes it a bit challenging as doctors to prescribe these products because the labeling is based on. It's not even based on systemic estrogen therapy. The labeling is actually based on false interpretation of the data on systemic estrogen therapy. And so it's funny. Anyway, so the data, the labeling isn't even based in real data for us to show new data to remove the label. It's not even based on real data. So it's very frustrating. It also says, it talks about the idea of we really should be talking to these patients about pelvic floor disorders and using pelvic floor physical therapists. It talks about the biopsychosocial nature of GSM and how we should be working with mental health professionals because these issues are devastating to our patients. That's not to say treat GSM with a therapist. It's to say, yes, give vaginal hormones and talk to your patients about how they're doing and how they feel about having these horrible symptoms of gsm, which is not just a little vaginal dryness. This is urinary frequency and urgency, recurrent urinary tract infections which kill people. It is pain with sex, dryness, muted orgasms, absent arousal. It is. It is. And it doesn't get better with time. Sometimes hot flashes get better. But as your audience knows, the genital and urinary symptoms do not get better for most people.
- [09:40]
B
Absolutely. So people can find these on the American Urologic association website. I haven't seen if Google has it up yet. If you Googled 2025 GSM guidelines, if that's going to pop up at this time. But it just released today, so it's out. It's not behind a paywall. That's exciting. You can print these out. You can bring them into your doctor or your provider. You can read them yourself. That's wonderful access. And I love that the guidelines are available free online.
- [10:11]
C
This is so wonderful. Thank you for doing this with me. I'm just so happy for the world today.
- [10:16]
B
Me too. Hey, how do you so a woman a side effect of vaginal estrogen? If you haven't been on estrogen for a little bit, you start vaginal estrogen. It changes the PH of your vagina. It's changing the microbiome side effect of that. Some women will get Yeast infections when starting their vaginal estrogen. How do you work through that? I've got my way.
- [10:35]
C
I want to see what your way. So don't, don't stop, don't stop. Okay. As the microbiome is acidifying and changing, some yeast cells can say, oh, we like this environment. We're going to overgrow. Treat the yeast infection, right? Do a diflucan, do an over the counter yeast infection medicine. But those aren't my favorite. I prefer sort of a diflucan approach. And keep going with your vaginal estrogen because once you reach peak healthy microbiome, the yeast does not overgrow. And so what I find is that people often stop at that point and they get so scared and they just need to get through it. Is that how you do it as well?
- [11:10]
B
Yeah, and they get scared. So to me, I'm like, you can go lower, go lower on the dose because they're freaked out, they want to stop it, right? So I usually say back down, go slowly, treat through it and ramp back up because otherwise they just want to stop. And to me, I'm like, back that back, back off. Micro, dose it for a little bit until your microbiome adjusts and go back on. But treat it. It's not a reason not to do it. It is a known, I don't say issue, but a known function of literally changing the ph and the microbiome of your vagina.
- [11:44]
C
I see some questions below. I completely agree with you always. Not always, but a lot of times. Which is why, okay, so can we just say the idea that we all as colleagues have to agree with 100% of things is kind of ridiculous. I don't agree with 100% of things my husband says or my family members say. And so this is how science works, right? You bring people together and you get, you get to consensus. And so there are always going to be things that people want and they don't get in the guidelines. There are always going to be things people don't want. Like you have to work together to achieve your goals. And so what I love about our sort of group and all of the people within it is we don't all have to agree on every little detail, but we all have this big guiding force of women need better people need better education about their bodies and about hormones and about menopause and that people deserve the toolbox and the, and the, and the guidance and they deserve access to these therapies. And the problem is no one, you know, we can talk about the minutia of. Do you do blood levels or saliva levels or, you know, how you measure? Do you ever get labs? Do you never get labs? We can talk about that all day long and get into the weeds, but the reality is less than 4% of women are on hormone therapy or really are being offered hormone therapy. And that is horrific. And this is, you know, this is what we're trying to do to save lives.
- [13:04]
B
The other thing I want people to know about guidelines is I see a lot of people hang on to guidelines like, they're like. They're like the biblical ten Commandments that can never be changed.
- [13:14]
C
Guidelines change. This is the proof these guidelines didn't exist. We just wrote the chapter, we wrote the book, and you know what happens? They're gonna. The AUA has a process for updating them every couple of years. And so these guidelines evolve. They change. They take the new data. And so they're a set point of like, okay, we started here. And so. And. And you don't get in the game. If you don't get in the race, if you don't roll your sleeves up and do the work, then guidelines will never change. Advocacy, like. Like, laws will never change. And you will sit around just complaining about how there's not enough being done for women. That is why I mentor students. That's why I have a research team. That's why I'm building an army to do the work. Because, no, if you're just going to sit around and complain that the work's not being done, get involved, get in the ring. And there's. You can get in the ring at every level. And so whether it's yelling, you know, whether it's inspiring other people to work or doing the work yourselves, like, these are the things that need to get done. Somebody asked about who endorsed this guideline, and this is what's really cool. So the American Urologic association is the head of this guideline. The sufu, the Society of Urology is. The Female Urology Society endorsed this guideline. The American Urogynecological association endorsed this guideline. And then the Menopause Society and the International Society for the Study of Women's Sexual Health, they were all a part of creating and endorsing this guideline, which is really fabulous.
- [14:39]
B
I love that. I think it also, the view that 80 million women over the age of 40 need to be treated by 28,000 gynecologists in this country is bad. That's bad for everybody. Gynecologists are busy. 50% of people own pelvises that have vaginas and vulvas in them. Everybody needs to get involved. This is 50% of the nation's health care. This is not. Don't just put this on the gynecologist. They're busy, busy, they're overworked, they're saving lives. This isn't. This is primary care, this is internal medicine. This is infectious disease with the recurrent UTIs. This is urology with the overactive bladder. This is sexual medicine. And the fact that these guidelines didn't come from gyne speaks to that.
- [15:23]
C
It's very important that it didn't come from the gynecology society because they should not be the only people responsible for taking care of women. They have a lot of other really important things to do as well. And so we must get these guidelines in the hands of every kind. Every clinician who takes care of women, period. Every clinician who takes care of women, period. And so we have a resource on our website on rachelrubinmd.com under Educational Resources. It is a PDF that has the symptoms of GSM, information about GSM, and then it has a graph of how to write the prescription so that patients can download it, bring it to their doctors and say, here's the tools. So it's, you can use estrogen cream, you can use estrogen inserts, you can use a vaginal DHEA there and how to write the prescription and how to do it. So if you are a clinician, you can go download that resource. It's in within the guidelines as well. We do put that in the guidelines of sort of how to give vaginal estrogen. We have a YouTube. This is why we started a YouTube channel as my 40th birthday present to myself of starting a YouTube channel, answering questions about vaginal estrogen. And we're going to continue to put videos up. But this idea of giving you the tools and the resources to know how to do this. So we have a whole physician lecture or clinician lecture that you can will teach you how to write the prescriptions, what to counsel patients, how to do it. We will give you the tools to learn how to do that. So no excuses of, oh, go see your gynecologist to get the prescription. They don't have time to wait for. This is life and death. They don't have time to wait for that prescription, to wait for that visit.
- [16:57]
B
The exciting thing is there's many, many more online resources for vaginal estrogen and vaginal prescriptions too, because some people do live in places where Going to the doctor is actually very hard. And that's what's so great about the world of telemedicine right now, is that you can go online. There's multiple companies off the top of my head. Evernow, Midi, Alloy, Interlude are all company and there are more than that. Genev for people to go online and to very safely receive prescriptions for vaginal estrogen.
- [17:29]
C
Absolutely. And so you can use it as a cream and you want to use again. In my opinion, you should use the right dose. Don't just put a little dab of it on your urethra. You want to put at least a gram inside the vagina and rub it inside the walls like you rub sunscreen on your face. Rub it inside the walls. It not messy. If you have only cream that you have access to inserts, they make little tiny pills that you put in the vagina twice a week. They make DHEA suppositories that you do every day, but if you want to do, three times a week is fine. They make a ring that you can put in the vagina that stays for three months at a time. There's even a medicine that the guidelines talks about called osamine, which is an oral medication. So if you really don't want to put something in your vagina, there is a medicine that you can take by mouth to help with the genitourinary syndrome of menopause. So there's a toolbox and that you should have access to this toolbox. If you've never been to the doctor about this, you should go to one and it should be able to be a primary care, a gynecologist, a urologist, even in. I've taught plastic surgeons how to do this. I have an ENT who said she prescribed it the other day. We can't afford women having urinary tract infections. Nobody's got time for that. The hospitals are full, the doctor's offices are full, the urgent cares are full. Economically, as a society, we don't have time for it. There was a paper, I have to find it presented at this meeting today that shows if they compare women on vaginal estrogen versus women not on vaginal estrogen, the amount of sepsis visits, the number of. I'm pulling it up so I can see if I can find it. The 22% risk reduction in hospitalization rates, 51% risk reduction in sepsis and 73% reduction in mortality. This is Elise Day's paper out of Albany that looks at. I'm going to send you the abstract
- [19:29]
B
of the aua, or is that a published.
- [19:30]
C
Yeah, no, it's an abstract of the UA that's being said today. Yeah.
- [19:34]
B
Oh, my God. That's amazing. Well, you published a paper that said if Medicare shipped. I'm being dramatic, but if Medicare shipped, everybody on Medicare who has a vagina, vaginal estrogen, and they used it, it would save Medicare billions of dollars a year just in decreased urinary tract infection.
- [19:52]
C
Between 6 and 22 billion dollars a year. Between 6 and 22 billion dollars A YEAR. This is so serious. And, you know, here again to tell them why.
- [20:00]
B
Why aren't people. Why aren't ICU doctors having it in their protocol to put ICU people on vaginal estrogen?
- [20:07]
C
So. So it really needs to be. And this is, again, where the labeling needs to change. Many people don't know this. My mom was in the ICU before she died for six months, and I had to fight. Every week the team changed, and every week I had to fight to say, hey, this is a very sick woman who's at very high risk of getting urinary tract infections. Vaginal hormones could say, you know, could prevent her from dying of a urinary tract infection. And the doctors. I had to. I had. I was like. I had. I don't have guidelines, but I had the data. I was literally on the guidelines committee when this was happening. And I had to convince the doctors, they didn't know how to write the prescription. Once I told them how to write the prescription, the pharmacy wouldn't dispense it because they said this causes blood clots. Then they did dispense it, but they gave the cream, but there was no applicator. And the nurses didn't know how to give it. And so I had to do every step of the way. And. And what a nightmare for me to navigate. As someone who knows a lot about this, how do you think the rest of the people feel? Right. Like this is true.
- [21:08]
B
Yeah. Nobody else is going to be able to advocate like you. And it was impossible for you to do.
- [21:12]
C
Yeah, it was impossible for me to do it.
- [21:15]
B
We need to look at giving women with chronic catheters giving them vaginal estrogen like you're going to have decreased.
- [21:24]
C
Women need. The orthopedic surgeons need to start giving vaginal estrogen before a hip replacement because they cannot afford for these patients to get infections. They cannot afford it. And so the lives that are going to be saved like these need to be in the protocols for everyone. The orthopedic surgeon should be able to write a Tablet insert in the vagina for twice a week. They do not have to examine the person's vagina. I repeat, while it is recommended. And we love exams, and you should have exams on your genitals. The orthopedic surgeon does not need to examine your genitals in order to prescribe you a tablet insert to prevent urinary tract infection.
- [22:02]
B
I love that. Does the guidelines. I mean, I clearly need to still read them and do a podcast, but does the guidelines mention that perimenopause menopause can be.
- [22:11]
C
This was on the. Oh, my gosh. This was on a whole slide at the plenary today. It said there are other. Not every, but not all GSM is menopause, breastfeeding. It mentions. It mentions birth control pills. It mentions gender affirming hormones. It mentions the SERMs and the aromatase inhibitors. There are. So anytime you mess with hormones, you can risk urinary tract infections because of what it does to the microbiome of the genital infection. So there are so many things that can cause gsm, which is a problem with that. Menopause is in the name perimenopause. If you are in perimenopause and you still get periods, you should be on vaginal hormones to prevent urinary tract infections. If you're getting urinary tract infections or if you have pain with sex, vaginal dryness, urinary frequency and urgency. If you have urinary frequency and urgency, you should be on vaginal hormones, period,
- [23:05]
B
which includes starting to get up at
- [23:06]
C
night to pain, which includes getting up at night to pee or even just, you know, there's a symptom of GSM that nobody talks about, and it is this vulvar awareness, genital awareness that people suddenly get. You go your whole life not thinking about your genitals, and then all of a sudden they're on your mind all the time. Oh, these underwear. Really uncomfortable. Oh, I can't get comfortable in these pants. Oh, my gosh, this is really dry. It is a. It is this like, when we think of dryness, it is not like, oh, this is a little dry. Use a little lubricant. This is so much dryness that you have awareness of your genitals that you never had before. Yeah, you were just.
- [23:42]
B
I think your name was on this. It was an abstract that just got published talking about decreased sensitivity of the genitals post menopause as well.
- [23:51]
C
Yes, I mean, that's true.
- [23:52]
B
The flip side of that coin.
- [23:55]
C
Like not having. Yeah. So orgasm arousal. Right. Like all of that decrease. So I do a lecture that I talk about how vaginal estrogen and DHEA are female Viagra, but they prevent urinary tract infections. They are better than Viagra. What does Viagra do? It helps with arousal erections. Vaginal hormones help with arousal. Viagra and Cialis can help with urinary frequency and urgency. So does vaginal hormones like it is. We actually and these were available before Viagra was available. So we have always had vaginal, we have always had female Viagra. So we have a marketing problem. My friends, this is not its safe, it's affordable, it works. It literally hurts no one. Everyone can take it, even your 98 year old great great grandmother. And yet no one's on it. Why? Because of marketing. It is literally a marketing problem, which
- [24:49]
B
means we can solve the incorrect box warning.
- [24:52]
C
And so that's where the advocacy comes in. These guidelines help us go to the FDA and say, hey fda, these labelings that you have on these products are not based in science, reality, data or literally anything. It is time for change. Enough already. So for all of you watching who work anywhere or know anyone, right, we are working hard to change that labeling and we. And again, it doesn't matter that the guidelines are written if nobody reads them. That's why I'm here on Instagram. That's why we yell, that's why we scream. Because if no one reads them and people don't change their management, we can't save lives.
- [25:31]
B
Absolutely. I'm going to be in Dallas for Let's Talk Menopause Thursday night and Friday advocating doing a panel on sex and GSM after menopause. And if you guys want to get loud, I can't handle the Instagram people who tell me how bad it is and they don't do anything about it. So go to let's Talk Menopause Unboxing estrogen. Google it. You will send a letter to the FDA, whether you're a practitioner or a layperson, saying we need to get the incorrect information off of these products. Please go help us advocate.
- [26:07]
C
I loudly. Louder for everybody in the back.
- [26:10]
B
One more question. Is there is it in the guidelines that says if you're on systemic hormones that it's still safe to take? Rachel? It is.
- [26:19]
C
I actually think it might be a statement. Hold on. Systemic. Hold on. That's so cool. Guideline statement number 11. In patients with GSM who are on systemic estrogen therapy, clinicians should offer the option of low dose vaginal estrogen or dhea.
- [26:39]
B
It's there now you have a guideline to print out and bring in, dude. I hope that the makers of vaginal estrogen realize today's happening, because I don't think they do.
- [26:52]
C
It was secret. I couldn't tell. I couldn't make some more product. I couldn't tell anyone about these guidelines because they had to be released first. And so I've been sitting on these just like I, they. They. The. The leader of the guideline committee, as she saw me in the hallway and she said, rachel, you're like a little Chihuahua shaking with excitement. And I was like, I was literally shaking, tears streaming down my face. When they were presented it in a room full of. Of thousands of urologists listening to this, and they presented these beautiful. I'm going to post videos of is a labor of love. And what's so beautiful is that all of us contributed, all of our collective voices have contributed to this happening. And to see that advocacy in motion. To see, listen, the GSM wasn't even a term until 2014, when one urologist, my mentor, Erwin Goldstein, who also was on the guideline committee, he begged and yelled and screamed and said, the word urinary must be in this guideline. The word urinary must be in this word. And so it became genitourinary syndrome of menopause. As you know, it used to be called vulvovaginal atrophy. It used to be called senile vagina. It used to be called just a little vaginal dryness. And now we're evolving and we are changing the landscape. And so watching the history and the advocacy that goes into it and the human beings behind the work, and so many of my colleagues, brilliant colleagues who got together to do the work and roll up their sleeves to know I did not have to do all the work and you didn't have to do all the work, but the work is done. And it is. It is truly just a. An aggressively simple document that, that. That just makes no apologies for the fact that this is important and will save lives.
- [28:34]
B
This document took about six years to be created. I want people to understand the amount of work that goes into this. It will not take six years for the world to know about this, because we're going to get loud. We need all of you guys to get loud, to share that we now have guidelines to say how saf this is, that you can be on it even though you're on systemic hormones, that you can be on it even though you're not all the way in menopause yet. We have guidelines that are being published today. It's incredibly exciting.
- [29:01]
C
Thank you so much for having me. Thank you to all the people who logged in today. Thank you for everybody who's going to watch this and do it till the very end. Please follow me on social media. If you don't follow me, follow all of our friends. Share these guidelines loudly with everybody you know, every single person you know. Whether you are a clinician or not, you will save people's lives by giving them evidence based, realistic information. And I'm just, I'm so proud to share with the world today.
- [29:30]
B
Love it. Thank you, Dr.
- [29:31]
C
Safer. Safe. If you're 99 years old in a nursing home, people, they're getting the questions below like, like this is safe for every human being on earth to take and so there is no age with which you cannot take vaginal hormones. Truly, I gosh, we could just, we could literally be on all.
- [29:48]
B
Just answering, answering questions. Yeah, you're have to come back and swipe these questions so that you can make YouTubes for them. What about how long can you take it for Dr. Rubin?
- [29:56]
C
Till death do you part. Dr. Casperson, has you taught me how long do you wear your seat belt? How, how long will you brush your teeth for? How long will you wash your face? If you want to not get urinary tract infections and you want to not have urinary frequency and urgency and leakage. If you want to have intimacy with your partner or yourself, vaginal hormone, just like washing your face and brushing your teeth become lifelong therapies. And these are local. This is not hormone therapy for your whole body. These are local. This is like, you know, again, this is like micro dosing fruit locally, locally to help with the genitourinary syndrome of menopause. And so the skin,
- [30:38]
B
It's groundbreaking. It's amazing how many people don't know this. It's amazing that we have guidelines. It's amazing that women are getting loud now. I liked your point that this has been around before Viagra. That was very powerful. That was like probably the most powerful statement of this Instagram Live. Any final thoughts for anybody? What's left at the AUA now that the guidelines have been released?
- [31:03]
C
So tomorrow morning we have a course where we're teaching doctors how to implement the guidelines and the tips and tricks. And so we're teaching a course course and really it will close out the meeting which is really lovely. And we got a lot of work to do to implement and to advocate and to get this marketing done because that's what really needs to happen.
- [31:24]
B
I love that you're in this orchestra with me. Thank you so much.
- [31:27]
C
Love you back. Thank you. Have it. Thank you. Bye. Bye.