Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast, episode number 73. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone, and welcome to today's episode. I am excited to share with you my guest, Dr. Nabila Noor. I'm so excited to have her here with me today. She is a urogynecologist, she practices in Allentown, Pennsylvania, and we were having a conversation recently and realized there's just so much overlap in the field of obesity, medicine and urogynecology, especially when it comes to pelvic floor health. And so Dr. Noor, I'm so excited to have you here today and share all of the good things with my listeners. Dr. Nabila Noor: Well, thank you so much for having me, Dr. Stombaugh. I am super excited to be here. It truly is a privilege to be sharing this platform with you and talking about your gynecology and how it can help or how it relates to weight loss and obesity. A lot of my patients, I do see suffering from obesity and that can be a huge risk factor and I'm sure we'll talk about it, but super excited to be here for sure. Dr. Sarah Stombaugh: Yeah. Well, thank you. And I'm going to ask you all of the questions, so get ready. One of the things we're talking about is sometimes in the medical field we take it for granted these different things. We talk about pelvic floor and weakness in the pelvic floor. When someone says that, what do they mean? What is the pelvic floor? Dr. Nabila Noor: That's a very good question and I'm glad you asked that because there's a lot of misconception of what the pelvic floor is. So to put it simply, pelvic floor is essentially a group of muscles that essentially form the base of our torso and that helps support all our pelvic organs, and that could be our uterus, our bladder, our rectum, our intestines. So it's essentially the base that's holding all those organs together. And just like any other muscles in the body, those pelvic floor muscles can get damaged, whether it's because of pregnancy, say trauma from childbirth, but also with menopause, they can weaken right as the muscles and the nerves get damaged or it can weaken over time just because age is a big risk factor. So that's what the pelvic floor muscles is. The reason it's so important, and the reason it comes up all the time is because weakness of the pelvic floor muscles or weakness of the pelvic support structures can affect things like urinary leakage or bowel leakage, or even things like pelvic organ prolapse, which is basically the world that I live in essentially. Dr. Sarah Stombaugh: Yeah, absolutely. Well, I think in my experience, a lot of people talk about pelvic floor, especially in related to childbirth, which as you said, it's very common related to childbirth, related to trauma, even just stretching or damage to those muscles. But you mentioned menopause, and so tell us a little bit about just both age and menopause, and certainly those two go hand in hand, but how did those affect the pelvic floor? Dr. Nabila Noor: Yeah, for sure. So what happens is, I mean, menopause, as most of us know, for most women, the average age of menopause is 51, which means our ovaries have significant decrease in production of estrogen. So as a result, we can see both anatomical changes as well as physiological changes pretty much all over the body, but specifically in the pelvic floor for sure. So these can cause symptoms or anatomically we see changes, for example, thinning of the labia. We see thinning of the vagina, the vulva, there's changes in the folds of the vagina. So the vagina has a lot of folds, which allows us to be elastic. And that is what helps us with childbirth where the vagina to dilate to be able to accommodate a baby's head during delivery and for that matter with vaginal penetration during intercourse. But what we see with menopause is that because of the thinning, because of the changes in the elasticity, those vaginal walls, the rugae, the folds decrease, it becomes a lot less stretchy, a lot more restrictive. And so patients can have symptoms such as vaginal dryness, vaginal irritation, burning pain with intercourse, and we also see changes in the bladder and the urethra as well because of this decrease in estrogen. So a lot of my patients, as they go through menopause, they'll notice the symptoms of urinary urgency, frequency, and even recurrent urinary tract infections and all this because of the decrease in estrogen that happens as a result of menopause. One of the things I also like to mention, because we know we always think of menopause and hormones, but even in young women after childbirth, especially for women who are breastfeeding, we are in what we call a hypo estrogenic state. And what that means is there is a significant drop in estrogen in our body as well, which is what provides a natural contraception. But even in women, young women who are premenopausal, but right after childbirth, especially for those who are breastfeeding, we do see some of these changes and some of the symptoms that we see in menopausal patients, which is something that we always forget to mention. Dr. Sarah Stombaugh: Yeah, wow. I love that explanation. And I think a lot of women are like, gosh, my body has changed and a lot of times in many different ways, and they may be experiencing these things and their friends are too, and so it's very common, but it doesn't mean that it's normal. And so when would you recommend that someone is seeking treatment or evaluation rather, and what does that evaluation look like if someone were to come into your office? Dr. Nabila Noor: Yeah, no, I love the fact that you mentioned that age is a risk factor or some of these triggering factors, whether it's childbirth, pregnancy can cause changes in the pelvic floor, but that by no means mean it's normal. And I think the unfortunate part is very often, well, first of all, women don't talk about it enough, and even if they do, a lot of the times they're shut down being told that, oh, it's normal for pregnancy, it'll get better. Oh, it's normal in the postpartum period, it'll get better. Or it's normal for menopause, it'll get better. Well, it doesn't get better. And for a lot of women, by the time they come to see me in the office, they've been suffering for five, 10, sometimes even longer years, which is so sad, especially in today's day and age. So when patients come to see me in the office, the first thing I start with just in any other specialty of medicine, is with a good history. Now, what's interesting is a lot of the times patients may come to see me with what they think is one condition, like say maybe they come to see me thinking they have urinary leakage, but as we start to talk, I ask them about their bowel symptoms. I ask them about whether they're having urinary urgency, frequency, whether or not they feel like there is laxity or a vaginal bulge, whether or not they have pain with intercourse. And what we discover is that they thought they had one thing, but then they have so many other things that they didn't even realize could be an issue, or most importantly, that there could be help for that. So once we do a full thorough history, then of course I move on to doing a very detailed pelvic exam, which is similar to what you may expect at a gynecologist's office. But again, because of what I do, it's a lot more involved in the sense that first we start with just observation, like anatomically some of the things we talked about, is there thinning of the vaginal tissue? Is there changes in the labia? Do I see any cysts? Are there any anatomic problems? Is there a lot of laxity? We do a measurement called POP-Q, which is the pelvic organ prolapse quantification that allows us to see if there's any vaginal prolapse. We check for any tenderness in those pelvic floor muscles because very often we talk about pelvic floor and pelvic floor exercises and kegel exercises, which is contracting your pelvic floor muscles. But just as important is learning how to relax those muscles because if you don't, what we see in women, especially those who have been very religious about doing a lot of Kegels, is that they develop something called myofascial pain syndrome where because of so much tightening, they forgot how to relax those muscles. So now when they're going to urinate or go to have a bowel movement, they're not being adequately relaxing those muscles and not being able to evacuate properly, which is the opposite problem of what they initially came with. So those are some of the things that I do when I see my patients. And then of course after that, together we have a discussion of what are some of the treatment options, and that sometimes may include conservative options, which are nonsurgical, and sometimes we talk about surgery and together we come up with a plan that works for their lifestyle and then essentially helps them move on to the next stage. Dr. Sarah Stombaugh: Yeah, thank you. That was such a detailed answer, and I think it can be really intimidating for a patient going in honestly to any doctor's visit, but especially to a doctor's visit like a urogynecologist where there is such an intimate and vulnerable exam that's happening, being able to understand a little bit of that in advance, see what your doctor's looking for, that's such a neat thing, especially you think about women who understand that there may be one thing going on, but realizing, oh, wow, this is really a broader picture, and really feeling like they can learn and then honestly sort of reconnect with their body. So thank you for sharing that. People might- Dr. Nabila Noor: Yeah, Dr. Sarah Stombaugh: Please. Dr. Nabila Noor: No, I was just going to say, it's interesting you say that because I hear it so commonly. Sometimes patients will come to me and say that, "Hey, my primary care doctor referred me to a urogynecology, but what is urogynecology? What do you even do?" And it's not even just patients. Sometimes I'll get it from healthcare providers and even physicians because believe it or not, urogynecology as a specialty is a baby, is very new. We just became a board certification as of 2013. So physicians or even pelvic floor providers who may not have had a lot of exposure to urogynecology may actually not even understand the exact role of what we bring. So I think it's worth talking about that we were joking about it, but it is very relevant. Urogynecology is basically a subspecialty where, so my background is in gynecology. So after medical school, I did my training in obstetrics and gynecology, and then I specialized in urogynecology, which by the way, previously was known as female pelvic medicine and reconstructive surgery. So it was a mouthful. So thank God they changed the name to urogynecology. It's a little bit easier to understand, but a urogynecologist is somebody who specializes or has extensive training in gynecology, urology, and even a little bit of colorectal surgery to be able to provide the most comprehensive care to patients who are suffering with these pelvic floor disorders. It's not just gynecology, it's not just urology. And I think that's where sometimes patients can get confused and it becomes difficult when somebody's dealing with leakage of urine. They think, oh, I need to go see a urologist, but they may also have pelvic organ prolapse. Well, now they have to go see a gynecologist. So it's this need that led to the development of a field where we can combine all the relevant aspects from all these different fields and provide the best care for our patients. Dr. Sarah Stombaugh: Yeah, wow. I love that explanation because I think a lot of people may not necessarily know what is a urogynecologist, and as you mentioned, you're really the specialist in the full evaluation and treatment of the pelvic floor. And so even those rectal conditions, for example, light constipation or the way the pelvic floor can impact us in that way, you may be able to support patients in that. I wanted to ask you, so you're here on a weight loss podcast, and so patients may be wondering, even though I did do an episode previously talking about the pelvic floor, patients may be like, well, what does obesity have to do with the pelvic floor? So tell me a little bit about what is the role of obesity in our pelvic floor health? Dr. Nabila Noor: Well, that's actually a really great question, and in fact, it's very well studied and we have a lot of good data that states that obesity is a big risk factor for pretty much most of the conditions that I see and treat in my clinic. So urinary incontinence, it's very well established how obesity and weight loss can affect improvement in urinary symptoms. So for women who are obese, so what obesity does, it increases your intraabdominal pressure, it puts an extra pressure on your pelvic floor muscles that can affect what we call stress urinary incontinence. Stress urinary incontinence is women who have leakage with laughing, coughing, sneezing, exertions, anything that puts pressure in their abdomen. As you can imagine, having that excess weight increases that intraabdominal pressure, which makes their urinary symptoms worse. So with prolapse or it relates to prolapse, the relationship is not as obvious as the urinary incontinence, but we do see anecdotally that just being able to lose the weight, or when women go through bariatric surgery overall, they do much better with regards to their outcomes As it relates to pelvic floor disorders, I mean urinary incontinence, we know that even as less as losing 8% of your current body weight, but just behavioral changes and maybe an exercise program can have significant improvement in your urinary symptoms. And the other thing that I like to tell patients is a lot of the times patients will come to me and maybe they're overweight and we're thinking about surgery, and I'll tell them that just being overweight itself can be a risk factor with regards to us being able to do some of the complicated surgeries and then with recovery, and then afterwards the outcomes may be affected, even though we don't have good studies to establish that. I can tell you as a surgeon, sometimes it's challenging to operate on patients who may be morbidly obese, and we may not be getting the best outcome, even if we're performing surgeries for these patients. Dr. Sarah Stombaugh: Lemme ask you, what are the most common conditions that you treat? Dr. Nabila Noor: Yeah, so it's a whole gamut of things, but I would say majority of my patients will have conditions such as leakage of urine, whether it be with laughing, coughing, sneezing, as we mentioned, that's known as stress urinary incontinence. I also treat women with urgency related leakage. So those are patients who feel like they have to go, they have to go, and when they have to go, they can't really hold it or they have a lot of nighttime urination. Pelvic organ prolapse is a significant portion of my patient population as well. So these are patients, they feel is that there's a pelvic bulge or pressure vaginally, and that's because of the laxity of the pelvic floor muscles or the pelvic support structures. Their pelvic organs, which could be the uterus, the bladder, the rectum, or even small bowel are essentially pushing through. So what they see is something like that feels like a ball that's hanging out from the vagina. I also treat women with fecal incontinence where they have accidental loss of bowel and not be able to control stool. There are some nonsurgical pathologies that we see as well. For example, recurrent urinary tract infections, bladder pain, bowel pain, as well as some more reconstructive kind of work, such as women who may have a fistula, whether it's from trauma from childbirth, or maybe they've had a hysterectomy and now they had injury into their bladder. So it's a whole gamut of conditions which keeps it interesting. Dr. Sarah Stombaugh: Yes, absolutely. So no two days are the same. Tell me- Dr. Nabila Noor: No, no. Two days are the same. Dr. Sarah Stombaugh: If you imagine, let's say a patient with stress incontinence, so that's one of the more common issues that you may treat. Tell me about what treatment options may look like, both some of the more conservative measures, and then even if you're proceeding to surgical options, what are some of the things you may do there? Dr. Nabila Noor: Yeah, so stress incontinence in general, it's so common. And of course as females, we don't talk about it enough, but once you start talking, one in two women will have some sort of leakage of urine, believe it or not. So stress incontinence, like we discussed before, is because of a weakness of the support structures for the rugae. So when somebody is having any kind of exertion that puts pressure in their bladder, then women have leakage. So that could be activities like laughing, coughing, sneezing, jumping on the trampoline, any of that. So because this is an anatomical issue, when we are talking about treatment options, we're essentially trying to address the anatomy, which is basically strengthening that support structure for the urethra. Now, non-surgically working with pelvic floor physical therapy, your pelvic floor exercises to strengthen those muscles can have some significant improvement. There's also a vaginal insert that we use. It's called a pessary. It almost looks like a modified tampon if anybody have ever seen a diaphragm that we used to use for contraception before. So similar idea, you put it inside the vagina and it pushes against the urethra and stabilizes it, and that can help with the leakage as well. But of course, if somebody is wanting something more definitive, then we're talking about surgery. I think two of the most common surgeries that I talk to most of my patients, number one is what we call the sling procedure, where we put a tiny piece of mesh under the urethra. It's done with a tiny incision through the vagina. It's a short procedure, 12 to 15 minutes. The outcomes are excellent, like 90% and higher patients go home the same day. And it really has changed how we treat women with incontinence. And then there's also a bulking injection, which is almost like cosmetic fillers that people do for bulking up their cheeks or their lips, the same idea. You inject these fillers into the walls of the urethra, which thickens them, and then narrows the actual hole through which urine comes out. So I mean, all it is is just two injections. So literally there's no downtime and patients do great, the success rates are not as good as say the sling, and it does wear off just like the cosmetic fillers. But again, for the right patient who may not have a lot of downtime, it could really be a game changer. So those are the big ones. Dr. Sarah Stombaugh: I had no idea. Dr. Nabila Noor: There are others, but it's more involved. So these are probably, I would say 99% of my patients would get one of these options. Dr. Sarah Stombaugh: Yeah. Okay. And what about for patients who are trying to lose weight? Would you have recommendations about losing weight beforehand, afterwards? I know you said that certainly weight can impact surgical outcomes, so I can imagine that might be part of it, but if someone lose weight after a procedure like this, is there any concern that it'll affect the procedure? It won't be as good. Tell me about some of the- Yeah, that's an excellent question. And it does come up, especially because where I practice, we do have a significant patient population that goes through weight loss surgery. And if I know somebody is planning to get the weight loss surgery, for example, they come to me and they're like, "Hey, Dr. Noor, I have my bariatric surgery scheduled in one month." So those patients, I would say, well, maybe go through the surgery because I know that once they go through the surgery, they're going to have a significant amount of weight loss. So I want them to stabilize that weight because for some patients, they may lose somewhere like a hundred pounds. So now their body anatomically is completely different than what it used to be when their patients were trying to lose weight in their own way through appropriate diet or exercise. So that's more of a gradual weight loss. And I tell them, just like we were discussing that yes, weight loss will help improve their symptoms. And so a lot of patients may want to do the more conservative route while they're losing their weight and not necessarily jumping into something surgical. And then I have other patients who come in, they're like, "Dr. Noor this is really debilitating. I'm not being able to exercise in the gym because every time I'm doing aerobics or I'm doing my spin classes or doing something high impact, I have a wet underwear, I have to wear diapers. It's really not a way for me to live." So those patients, I'm not going to torture them and tell them like, "No, go ahead and lose the weight and then I'm going to do your surgery." So the discussion again we have and kind of taking into consideration what's the outcome that they're looking for, and then we come up with a plan that works for each individuals. Okay. That's great to know that it may really work either way. And so it's going to be dependent on what their goals are and what their concerns are right now? Dr. Nabila Noor: Yes, for sure. Dr. Sarah Stombaugh: And then tell me also about mesh surgeries. What are the surgeries by which or for which you would be doing mesh? Are you even doing mesh? There's been a lot of controversy. You hear it on late night television. What are your thoughts about those and how might that impact doing weight loss surgeries, for example? Dr. Nabila Noor: Yeah, no, so I definitely use mesh. And mesh, it's gotten such bad rep, and part of that is we kind of learned from it as well. So early in 2000, there were a lot of controversies about mesh as it relates to my field, which is the urogynecology, by the way, mesh is nothing new, right? General surgeons use mesh for hernia repairs, and that's been way before we started using mesh. But what happened is, like I said, early in 2000, we were doing a lot of surgeries with mesh, and what we learned, or we started to see is a lot of women started complaining that after their mesh surgeries, whether it was for incontinence like a sling surgery or for prolapse, that they were having complaints of pain with intercourse afterwards, vaginal infections, the mesh was coming out, there was a lot of discharge. And so then the FDA got involved and basically said, well, what's going on? So then both surgeons and companies who were making these products and using these products started looking at their own data. I started looking at what's going on, and we learned a lot from that experience. Number one, the quality of the mesh makes a huge difference. So the kind of mesh that we use now, we call it type one polypropylene mesh. It's very soft. It's very light. So that's a huge impact. And also, like I talked about, my whole specialty is relatively new because we realize that maybe not everybody who is doing these surgeries should be doing these surgeries and that we need people with specialized training who understands these surgeries, who knows how to deal with complications. So that's how urogynecology was born. So a lot of those factors, whether it's changing the quality of the mesh and trainees and practicing physicians getting the appropriate training really helped improve outcomes. So with regards to what kind of surgeries we do with mesh now, so mesh like we're talking about for sling surgeries, it's really the gold standard for treating stress urinary incontinence, and even for prolapse, there's a surgery called sacral colpopexy where we use mesh to basically suspend all the vaginal walls and the support structures to help women with prolapse. And that's also something that I do regularly. Before we used to do a lot of mesh vaginally, and we realized that a lot of patients who were having these problems were from that particular cohort. So those we don't do. And in fact, the most recent patient safety guidelines that came out in 2019 in April actually states that mesh used for sling surgery and prolapse surgery, abdominally is safe and that it's totally fine to do. So to your point, it's a big discussion that I spend a significant amount of my time talking to my patients as well because I want to make sure that they feel comfortable knowing that what we are doing is safe for them, and it's probably the best option for them. Dr. Sarah Stombaugh: Yeah, thank you for addressing that because I think it's a question a lot of people have, and the reality is it's still mesh, but the mesh of 2024, as you said, is very different from the mesh of days prior. And using it both the 2024 mesh as well as using it appropriately in the appropriate locations by someone who's experienced you are really reducing any of the risk or many of the risk of complications there. So thank you for sharing. Dr. Nabila Noor: But I think just like anything else in medicine, I mean, if you see somebody and you talk to a surgeon or a provider, and I always encourage my patients if they're not comfortable with what I'm offering them, by all means seek a second opinion. I feel very comfortable telling my patients what I do and why I do it. But patients may have reservations and they may get a second opinion, and then they do their whole research and then they come back, they're like, oh, we have talked so and so and so, but then now we are ready. And those are my favorite patients because by then they know what they want and they're committed, and it's just an easy sell. Dr. Sarah Stombaugh: Yeah, absolutely. Well, and I think any physician who does not want you to get a second opinion, I think you should run away. I think any physician who feels confident in what they're offering, what they have to support once their patients also feel that same excitement and confidence and security in their decision. And so a physician should support you in getting a second, third, or however many opinions that you need. And so I dunno why I felt compelled to say that, but I just think it's a really important thing for people to be advocates. Dr. Nabila Noor: And I'm sure it's exactly what you do too, Dr. Stombaugh, right? It's a connection that you have with your patients. It's not about it's a wrong thing or right thing. Sometimes it's just that somebody feeling comfortable with you and you feeling that, okay, I can really help them. And it's important for patients to feel that this is a physician that I trust. I think something else that I also tell my patients is everything I do in urogynecology, it's not life-threatening a quality of life issue. So my job as their physician is to make sure that I improve their quality of life, just like you were doing with weight loss, right? Yours would be more relevant to actually debilitating diseases, but mine is primarily quality of life. So what I don't want is take somebody who is okay and then make their quality of life worse. So I take that education component very seriously. It's a connection that we build. It's a relationship that we have, and I want to make sure that my patients at the end of our conversation, feel comfortable with our decision. And if that means it's 1, 2, 3 conversations, sometimes I've had patients have three different pre-op consultations because they just have so many questions and they just want to make sure that they feel comfortable with the decision. And that's absolutely okay. But what is not okay is just living with these conditions and thinking that there's no other treatment option. So that's where I want to emphasize to make sure, if you have any of these conditions, please talk to your care provider or your OBGYN and have them refer you to a urogynecologist so you can discuss some of these options. Dr. Sarah Stombaugh: Yes, absolutely. I think one of the most powerful things, I did a pelvic floor episode maybe a month or two ago now, and I even had some patients who were like, oh my gosh, I didn't realize that this was an issue. And we discussed it at our visit and did referral for pelvic floor physical therapy and additional as it was appropriate. And so I love being able to provide the educational component. I think you've expanded on that so much. And so just know if you're suffering, you do not have to ask for help. There is likely someone like yourself who could be really beneficial in supporting anyone who's listening. Dr. Nabila Noor: And I actually listened to that podcast and I thought it was brilliant, by the way, first of all, and I think I love the fact that you mentioned that even though we talk about pelvic floor muscles, the pelvic floor muscles have connections to your hips, to your back to your core. So just like you mentioned in your podcast, absolutely, that's a conversation I have with my patients working on core building, making sure your hips are aligned. Those are things that when PT works with patients, even though patients may think like, oh, wait, my issue is in the vagina, but those muscles are not restricted to the vagina alone. So they have other components they extend into your pelvis, they extend into your lower abdomen. So I love the fact that when you tied it with all those other muscles as well. Dr. Sarah Stombaugh: Yeah. Thank you. Well, let me ask you, as we wrap up our conversations today, is there anything else that you feel is really important to share with everyone? Dr. Nabila Noor: Yeah, so I think we kind of have hinted at it throughout the conversation, but I think urogynecology, like I said, it's a new field and a lot of the conditions I treat sometimes can be really debilitating and embarrassing truthfully for patients to discuss with even your loved ones or even your closest friends. But I think some of the things that we mentioned in today's podcast, if you or your loved one is suffering with any of those, know that there's some amazing treatment options. And I think a lot of the times the misconception is I'm a urogyn surgeon. Oh, if I go to a surgeon, they're only going to operate on me. I don't want surgery. And that could not be far from the truth. Like we discussed, there are lots of amazing nonsurgical treatment options. My goal, and really my responsibility is to talk to my patients of all these treatment options and then see what works for them. My patient who is 40 years old, who has young kids who loves to do exercises and is limiting themselves because they are urinating in their pants every time they're jumping in the park or exercising, is a very different patient than, say, my 85-year-old who has multiple different health conditions is wheelchair bound and also has the same problem. So when I'm talking about treatment options, those are factors that I definitely take into consideration. And so it's not just one size fits all. I hope patients understand and realize that there are lots of treatment options that I can have a say in these discussions and come up with a plan that works for me. Dr. Sarah Stombaugh: Thank you so much for sharing that. And I know you are active on social media sharing lots of these great tips and tricks for everyone. Where if patients are interested or if my audience is interested in learning more about you, where can they find you? Dr. Nabila Noor: Yeah, so I recently started my YouTube channel. It's still a little baby, but it's growing and that's a Dr. Nabila Noor, and similarly on Instagram as well as on Facebook, you can find me on Dr. Nabila Noor. And my goal, like I said, is like you mentioned, is to do these short videos about things that patients ask me some of the things we talked about today and then put in resources that they can find. I'm actually working on developing my own personal website where I'm hoping to start a newsletter. Again, if patients are interested or if anybody just in general are interested to learn more about it, they can sign up. And I'm hoping to start launch that soon. So look out for that. Dr. Sarah Stombaugh: Yes. Oh, that's so exciting. So we will put all of your information in the show notes, and so if people are like, how do I spell that? It'll all be in there, so you can click it from the show notes. Thank you so much, Dr. Noor, for joining me today. That was really a pleasure. Dr. Nabila Noor: Oh, of course. Thank you so much, Dr. Stombaugh, and thank you so much for what you do. I mean, honestly, on behalf of all my patients and the field of urogynecology, we're so grateful that you help patients lose the weight because it really makes a difference in my world. So thank you.