Articles, Blog

At The Forefront Live: Pelvic Health Disorders

August 18, 2019

Reproductive and urologic
health can be a cause of concern for many women. And some of these
conditions can be hard to discuss
with your physician. Now, often, the topic of
prolapses, incontinence, and public health is not
discussed until a patient has already experienced symptoms. We will discuss these
topics, take your questions, and much more coming up right
now on At The Forefront Live. [MUSIC PLAYING] And remember, we’re taking your
questions for our experts live, so start typing. Also, we want to remind everyone
that today’s program is not designed to take the place of
a visit with your physician. Joining us today is Dr. Dianne
Glass and Dr. Shilpa Iyer Welcome to the program. Thank you for having us. Thank you. So let’s just get
right to the questions. I’m sure we’ll get quite
a few from viewers, but we have a few that
we wrote up in advance, so we’ll ask those. And the first one is, what is
prolapse and how does it occur? Absolutely. So prolapse is just a relaxation
of the support of the uterus and of the vagina. And so as those
structures relax, you can have a descent of the
uterus and the vaginal walls into the vagina,
and in some cases, out through the
opening of the vagina. And I would imagine there’s
got to be a lot of pressure and discomfort
associated with this, so people know that
this is happening. It depends. Sometimes, people will have
a lower amount of prolapse and not really necessarily know. And if that’s the case,
that’s not a problem. But as they start to have
more advanced prolapse, people will experience a
pressure in the vaginal area, sometimes they will
notice a bulge, and sometimes people will
describe it as the feeling like there’s maybe a tampon
stuck low in the vagina. And then it’s time to see
your physician, obviously. Absolutely. So, doctor Iyer, who is
at risk to experience, say, pelvic prolapse
and how common is this? It’s more common than we think. So 10% to 15% of
women have surgery for prolapse every year. And that’s just the
tip of the iceberg because there are,
additionally, a lot of women who don’t have surgery for prolapse
who have conservative office management. And then there’s a lot of people
who have prolapse and never see anyone about it
or ever talk about it. So it’s probably a lot more
prevalent than we think. And people at risk for prolapse. So any woman who’s ever
walked is at risk for prolapse because we’re not designed
well to stand upright. And so even women
who have never had kids, who have
never been pregnant are at risk for prolapse. People who’ve had pregnancies
and had vaginal deliveries are at higher risk for
prolapse than others. People with connective
tissue diseases are at higher risk than others. There’s also some
genetic component. Where there’s a family
history of prolapse, we think it’s how
the tissues are that you’re more likely
to prolapse if that’s kind of in your family. Sure. And we’ve discussed
this on programs before, we kind of talked
about it a little bit, that oftentimes, I think,
that women if they have a physical issue
they just figure they’re going to work
through it and a lot of times they don’t go to
see their physician. But this is another
example where they should. If you do have an
issue, you don’t have to suffer through this. There is help and
things that can be done. Yes. So there is a lot that
can be done for prolapse. And it’s not something
that you have to suffer in silence about. It’s something that’s
very, very common. About 50% of women have
some degree of prolapse. And so it is
absolutely something that your gynecologist
or your urogynecologyst has seen before. And there’s a lot of
different options for things that we can do to help
take care of prolapse. So we can do things ranging
from pelvic floor exercises to help strengthen the pelvic
floor musculature to reduce the symptoms of prolapse. You can place something
inside the vagina like a pessary, which is
just a vaginal support that sort of helps tent up the walls
and helps tent up the uterus to relieve the symptoms
of the prolapse. Or in some cases,
we can actually do surgery to help
correct the prolapse so that it is a problem that
you don’t have to deal with. Yeah. So we’re already
getting questions from viewers, which is
always great to see. We’re excited what people want
to participate and be involved. And we want encourage people
just type in your questions. We’ll get to as many as possible
as we can in this half hour. Now, the first one is,
thoughts on surgical adhesions as a cause for prolapse. You know? It’s kind of funny
because surgical– if you’ve had abdominal
surgery, there’s two types. Sometimes, the
adhesions actually hold things up so you’re less
likely to have prolapse when things are less
likely to fall down. That being said, if
you’ve had a hysterectomy, you’re at greater risk for
things falling down again. And I think that’s just because
when we do hysterectomies, we take away some of those
natural supports of the vagina. Another question from a
viewer, can prolapse also cause incontinence? Prolapse absolutely can
contribute to incontinence. The prolapse itself doesn’t
necessarily cause incontinence, but you sort of have
a similar relaxation of the supports of the vagina. The bladder sits– if you think
of the vagina like a house with four walls and
a roof, your uterus sits in the roof of the vagina
and the bladder actually sits just in front of
the wall of the vagina. So as you get relaxation
of that bladder wall and it descends into
the vagina and kind of towards the opening, the
bladder is going with it. And so you get less support
of the urethra, which is all those mechanisms that
help hold the bladder shut and keep you continent. But you also can
sometimes have a kinking of that area, which makes it
all the more difficult to empty your bladder. And there are a
lot of things that can be done for incontinence. So we’re going to discuss. There was one on the
list of questions, but since we’re talking about
it, if we can jump to that now. Yeah, absolutely. I think it’s
certainly appropriate. So, again, there is hope. So if you’re
suffering from this, there are things
that can be done. Can you talk to us a
little bit about that? Yeah. I think the thing
that people get confused with the most
are the different types of incontinence. So there’s the type
of incontinence where everyone talks
about it, and when you laugh you have to
squeeze your leg shut and you pee on yourself, and I
have this since I’ve delivered. So does Dr. Glass and a
lot of our colleagues. And that’s the one
everybody talks about. And that stress incontinence. And that’s due to
a weak urethra. So if you have your
bladder and the urethra, which is the tube from the
bladder to the outside, as you lose the support that
doctor Glass was talking about, you catch it anymore,
your urethra, so you go. [COUGHS] You used to be able to catch it. So it actually moves? But now you can’t, so it’s like. [COUGHS] You can’t catch it, and
that’s why you leak. Interesting. And so that, we have the same
kind of similar treatments, like pelvic floor
physical therapy to strengthen those
muscles, a pessary, which is the device that you
can control yourself that goes in the
vagina to keep more support underneath the urethra. And then we have procedures,
very simple procedures that we could do to help
with stress incontinence. Then there’s urgent
continence, which is different and a totally different beast. So if you think about the
bladder like a balloon, where stress incontinence
is a problem with holding the balloon shut,
urge incontinence is a problem with
the balloon squeezing when it’s not supposed to. And so with urge
incontinence, you will often get that sense of, oh,
I’ve really got to go and I can’t make
it to the bathroom. That’s when people will rush
off and a leak drops on the way, or in some patient’s case
can lose their entire bladder volume. And so that is a completely
different kind of incontinence and so we treat it
in different ways. Often we will treat
that with focusing on things that maybe make
your bladder a little bit more irritable, so things like
coffee, tea, alcohol, citrus, carbonation and spicy food, so
a lot of the fun things in life will irritate your bladder
and make it a little bit more sensitive. So kind of when you get a
sunburn on your arm, how it’s just a much more
sensitive thing, it will make your bladder
contract more than it should. So avoiding some
of those things, that is a good first step. But we have medications. In some cases, we can do
things like inject Botox into the bladder. We can also do electrical
stimulation of the bladder so we have a lot of options. So it is fascinating
to me the diet is that big of a
contributor to it. Yeah. That’s interesting. So, again, I think, like
you said, some of those are the fun things, but that’s
a fairly easy step that people can take to make a difference. And also, knowledge
is power, right? So it doesn’t mean that
just because your bladder is sensitive to coffee, that
you can never have coffee. You just may say,
I’m going to be out– I’m going to go
out shopping today and I would really
like to make sure that I don’t have to
rush off to the bathroom, or I’m going to be out
having dinner with friends, I want to be there for
most of the dinner, not consciously running back
and forth to the bathroom. And so you opt not
to have it that day. But a day that you’re
going to be at home, then, yeah, for
sure, no problem. Have as much coffee
as you’d like. Right. So we’re still getting
questions from our viewers, which is good. And we’re kind of
sensing a theme here now. The next one is, why do
you leak when you’re older? So does age have an impact? I’m guessing it does. And can you talk to us
a little bit about that? I probably there’s
different humps as to when people
get incontinence. There’s the right
after delivery when I’m a young person, and
then after menopause, about 10 years after menopause. And we think this really happens
because as you get older, you lose the blood
vessel supply, as you lose the estrogen
to your bladder, your vagina, and
your urethra, which is the tube from the
bladder to the outside. And then, losing
the blood vessels, you also lose the nerves
that control your bladder. So we know that
as you get older, everybody who eats anything
good at all has heart disease, diabetes contributes. It’s so said when you say it. [LAUGHTER] Sorry. But we all know that. We love our chocolates, OK? But that all contributes to
losing blood vessel supply and nerve supply
to your bladder. So that contributes to the urge
incontinence or the leaking on the way to the bathroom
or overactive bladder, where you’re in the bathroom all the
time, because that’s really a nerve problem between
your bladder and your brain. And as you get older and
you lose your estrogen and you lose your
good nerve connection, that becomes more of a problem. So that is associated with age. Stress incontinence is
similarly associated with age just because you’ve had
more time to put pressure on those structures. So the older you get, the
more times in your life you’ve been constipated,
the more heavy things that you’ve picked up. And those tissues
are wearing, out just like anywhere else in your body. You have your cartilage in
your knees that’s wearing out. And so you, again, kind of have
trouble catching that urethra. And so when you
cough and sneeze, you will tend to leak
more as you get older. That makes sense. More questions. Actually, this one’s a comment. And I want to pass this along. He says, I love these ladies–
many exclamation marks– amazing physicians– many more exclamations
marks and a big heart. So you have fans out
there, so that’s nice. Maybe a nurse. [LAUGHTER] Question, does
incontinence cause UTIs? It’s interesting
because, unfortunately, I think that some people,
there’s some overlap. So about 10 years
after menopause, as you lose the estrogen and
the blood flow to your bladder, women tend to have more
urinary tract infections. And I like to think
about it like when you lose the estrogen
to your bladder and you lose the blood supply,
your own fighter cells can’t get there to fight off those
little small infections that you could have
done when you were 20. And also your bladder
and your vagina is just more delicate, so you’re
more likely to let bacteria into the walls that cause
those little infections. So those just happen kind of
after you go through menopause. And that’s a common thing. And we can treat those and
prevent those very easily. So don’t suffer with those. When you have
overactive bladder, there is some kind
of research that’s shown that when you have those
little kind of contractions, like little spasms, like the
Charlie horse in your bladder that Dr. Glass was talking
about that you don’t want, a little bit of
urine in your urethra goes back into your bladder
kind of every time that happens. And so with that,
you’re a little bit more likely to get bladder infections
than if you didn’t have that. But you could also just
have bladder infections from losing estrogen over time. Patients can also get
bladder infections because patients
with incontinence are wearing more
pads, and so kind of having that dampness
there all the time can contribute, as well. Another question from a viewer. We’re getting a lot,
so this is excellent. Kind of a follow up question
to the one we just had. So when you’re a diabetic,
can you get UTIs more often? You absolutely can get UTIs
more often as a diabetic. The main reason is
actually that you have more sugar in your urine. And so diabetics,
their body is trying to get rid of sugar
in any way it can, and so it will put a lot
of sugar into the urine. And so it contributes to
urinary tract infections, also that sugar is going to
contribute to yeast infections. But additionally, diabetics,
as their disease progresses, are going to have more
damage to the blood vessels, and so they have similarly
a little bit less ability to fight off that bacteria
when it does get there. Yet another viewer question. Can pelvic disorders
affect bowel movements? Yes. It’s different. There’s different types of
bowel movement problems. You have just constipation,
old fashioned constipation, which is really common
and can just wreak havoc on your poor pelvic floor. So the good solution
to that is adding fiber to your diet, which could
be in the form of fruits and vegetables, water,
or a fiber supplement like Metafiber, Metamucil,
any of those ones. Buy the cheapest
one and go with it. And then, if you’re having
a lot of constipation, those same nerves that are
making it hard for your bowels to empty are the
same nerves that are connected to your bladder. And they cross talk a lot. So if you have a
lot of constipation, your overactive bladder
is probably worse. So addressing the constipation
will likely help your bladder, too because those nerves
kind of go back and forth. You can with constipation
and prolapse actually have some issues with
constipation from the prolapse. So going back to what I was
saying about the vagina, kind of like a house with
four walls and a roof, if that back wall is
sagging into the vagina, the mechanics are
not aligned anymore. So where your body was
pushing and pushing the stool towards the
opening of the anus, it’s now kind of pushing
it into this pocket. And so, sometimes, patients will
have that sense that they’ve had a bowel movement,
but they feel like there’s still
something left, they can’t quite get
it completely out. And that is something that’s
very related to prolapse. And can that cause issues
down the road, then? It is more uncomfortable than
something that causes a health issue, but it makes it
more difficult to have bowel movements and so
patients are unhappy with that. I have to do a plug for– we have this Center
for Pelvic Health and we work very
closely with our couple of colorectal surgeons,
who are specifically interested in pelvic floor. So if you have problems
with both your bladder and your bowels, we
all work in a team with our physical therapist,
with our colorectal surgeons, and we address things together. So there’s a lot
of help out there. Great. Couple more questions
for our viewers. They are really
coming in faster– they’re not allowing
me to ask my questions. But that’s good because your
questions are better than mine, quite frankly. So this is good. Keep them coming. I like this one. Does lupus caused problems
with pelvic health? Interesting. Lupus is one of these
autoimmune disorders. So I think when
it causes problems with public health, what I’ve
seen is there tends to be– sometimes your body
can fight itself, which is part of what lupus is. So sometimes patients with
lupus have this thing called bladder pain which is
really your body reacting to your bladder,
that can cause pain, make you feel like you
have to go to the bathroom all the time, also make
you feel like you have a pressure, a bladder pressure. And then we can treat that too. That’s kind of what I’ve seen
with patients with lupus. Another viewer question. How often should you do
pelvic floor exercises? And I guess the follow up would
be, what would that entail? Well, I’ll start with
explaining what a pelvic floor exercise is. Most people know them as kegels. What you do is– I tell people the
easiest way to try and figure out how to do them
is to sit down and urinate and while you’re urinating,
see if you can slow down the stream of urine. If you can slow it down,
you’ve got the right muscles. Most women can’t stop
their stream of urine. I think that’s a myth that
a lot of people come in and they say, oh, I
can’t stop it anymore. Well, most women can’t, so don’t
worry, you’re in good company. But if you can slow down
the stream of urine, you have the right muscles. And then you do kegel exercises
actually away from the toilet, so do not do them
while you’re urinating. So away from the toilet, you’re
going to squeeze those muscles and hold them for 10 seconds. Relax for 10 seconds,
hold for 10 seconds, relax for 10 seconds. And I have patients
do that in sets of 10. Is just something you should do
when you’re sitting, standing? You can do them in
any position you like. You can do them right now. You can do them while walking. I could be kegeling
and you never know. Yeah. I’m kegeling right now. [LAUGHTER] But I have patients do
50 or 60 of them a day. And I tell patients
the easiest way to remember doing them
is every time you’re done urinating, do 10 kegels. While you’re washing your
hands, getting your clothes back in order, you just do
10 kegels, and then it’s just part of your day. It’s not something
you have to say, OK, tonight I’m going to do my
kegels, because you never will. It’s just like any other muscle. You exercise it and
you will build it up and you’re in better shape. Yeah. And the good thing about
pelvic floor exercises is that they are helpful
with most all pelvic floor disorders, they’re
helpful with prolapse, they’re helping with
stress incontinence, they’re even helpful
with overactive bladder because when you do
those good strong kegels, it helps to cue the bladder
itself to relax so that you’re not having that same sort of
kind of bladder contraction. Another question from a
viewer, and I probably will mispronounce this but I’ll
do my best, diastasis recti. Is that correct? Close? Can it be corrected? I think that’s more of a– when
you have this rectus diastasis, so sometimes what happens
is when you’re pregnant, your rectus muscles, which are
your big abdominal muscles that kind of go up and down that
are trying to hold things in, at some point they give way
because they can’t keep it in any longer, which
is just normal. And sometimes that doesn’t
always go back together. So that can be corrected. You can do exercises with
a physical therapist, that can be corrected surgically. We don’t usually do that but,
it definitely can be done. But I think patients
have a lot of success with physical therapy,
with exercise. And so if that is something
that is bothersome for you, then I highly
recommend mentioning it to either your gynecologist
or primary care doctor and see if they can refer you. We also work with pelvic
floor physical therapists, so this is a new topic
for a lot of people. And I have to say that these
are physical therapists who work on the pelvic floor. So they work on the abdomen
too, but these are ladies– they’re almost all women,
although some men are pelvic floor
physical therapists, they’re specially trained
to work on the pelvic floor muscles. They do put their fingers
in people’s vaginas, they help you locate
all of your muscles, and they really work on it. I have never had one
person go and say, OK, that didn’t work for me. It is great. It sounds like it would be an
incredibly awkward experience. I’m sure it is the first time. But I will say that
almost universally, my patients after they have
seen the physical therapists say that they are
incredible at making sure that you were
comfortable with them and that they are
comfortable with you, and everybody really feels like
it was a good experience where they learned a lot and it
has improved their health. That’s a common theme. Anytime I talk to
people about other types of physical therapy, but
we have some very, very fine professional physical
therapists and accross the spectrum they do– it’s almost like
miracles, it seems like. Yeah. I am always impressed
with the work they do. It is really impressive. They’re impressive people. Another question from a viewer. Been doing kegels forever,
any other options? There are other options. So it depends on specifically
what the problem is. So kegels are usually
the first step in our treatment algorithm. So if you have a little bit of
prolapse that’s bothering you, people will do kegels to
try and reduce the symptoms. And sometimes it doesn’t work. So sometimes you do need
to step to the next level on that algorithm,
and you might need to use a pessary if that’s
appropriate for you, which is that vaginal
support for prolapse. Or in many cases, women
don’t feel like that’s something they want to do. And so perhaps that’s
somebody who might need to progress to surgery. Somebody with
stress incontinence that’s been doing kegels may
need to do that next step and choose to either
do a use a pessary to help support the urethra
or move to a small procedure to help correct that
stress incontinence. And with overactive
bladder, it’s helpful and can be good in the beginning
and is great for many people, but other patients need
to do things like progress to a medication, or potentially
progress to using a Botox injection in the bladder. So if your kegels aren’t
getting the job done, definitely see somebody because
there are excellent steps that can be taken. Along the same
lines, another viewer wrote in, yoga has a
sequence for pelvic health, have you practiced it? Do you think it works? I have not practiced it,
but I’ve heard about it from some patients. And I think what
yoga really improves is your core body strength,
which is generally your abdominal
muscles, and it helps you hold your body correctly
or in a more upright fashion. Which is not a bad thing. Which is always a great thing. And by improving
your core muscles, you also improve your
pelvic floor muscles. And this is what our pelvic
floor therapists also work on, they work on both the core
abdominal muscles as well as the pelvic floor. And so I certainly think
that that’s beneficial. It’s not something that
you should shy away from. Exercise in general
is beneficial, but I think bringing your
attention to your pelvic floor is very helpful and is not
something that a lot of women have ever really
thought much about. Well, I like this one. Do you only see
patients in Hyde Park? No. We see oceans all
over the place. No. Everywhere. Exactly. I see patients downtown
in Streeterville at 680 Lake Shore. I see patients also in
Indiana and Chareville, So we have quite a wide range. I see patients in here at
the main Hyde Park location, as well as in Orlean
Park and in Hinsdale. And we have partners that
go to these locations, as well as Silver Cross, one
of our partners goes there. And if you look at the bottom
of the screen right now, you can go to or call the number
888-824-0200, and that’s how we can work to get you an
appointment with either of you or somebody like you
that can be very helpful. So it’s great. Another question from a viewer. What age should I
expect menopause? We’re getting a little
bit of a different– Little bit of a difference. The average age for
menopause is about 55, give or take a little, maybe a
little bit younger than that. A good indicator for when you
might go through menopause is when your mother, your
aunt kind of family members went through menopause. Usually in mid to late 50s. If prolapse is untreated,
what can occur? What are the dangers of that? I think there’s a bunch
of people who come to us and they have prolapse. And we don’t have
crystal balls yet, so we don’t know if it’s
going to get a lot worse, if it’s going to get better. So on average, when we
look at our national data, about 40% gets worse, 40% stays
the same, and very, very rarely it gets better. And I think the
people who get better as they get older and
older and things tend to suck in a little bit. And those are the
people who prolapse gets a little bit better. But most people stay
the same or get worse, and we don’t really know
who those people are or we can’t really predict it. You’re going to be one
of those people that gets worse or better. If you don’t want to do
anything about prolapse, we generally can watch
prolapse and the only time we do something about
it is if we think that– let’s evaluate your
kidneys and make sure that you’re able to
empty your bladder well and that the urine isn’t
going back up to your kidneys and damaging that. And sometimes we do kidney
ultrasounds just to make sure that things are normal. The other time that we would
want to do something about it is if you keep getting
bladder infections and we think that emptying
your bladder is a problem and that’s why you’re
getting infections. And so then we would
probably recommend something like a pessary or
something like that to help you empty
your bladder more so you don’t get infections. But otherwise we
could just watch it. Yeah. What I usually tell my
patients is, as soon as it bothers you is when it’s
time to do something about it. Because I’ll have
patients who are kind of on the reverse of
the spectrum coming in, they’re like, well,
it’s not that bad, but it really bothers me,
I feel it all the time and I really dislike it. And so it’s reasonable to do
something both early and late on the spectrum,
depending on kind of what your personal preference is. And we have different options
for the whole spectrum. A lot of people think like, oh,
I’ve got to take care of this now because I’m going to be too
old later to take care of it, and that’s just not true. We have a variety of
treatment options. Even now, when we
talked about surgery, we have many different
ways of doing surgery and we can find one
that’s right for you. I’ve had many patients
well into their 90s that I’ve done
surgical things for. And again, the key here is
to always encourage people, you don’t have to
suffer in silence, there are things
that can be done and people who can help you. So that’s the best way to go. Another question from a viewer. Are there alternative procedures
for us to stop cystoscopy? Cannot pronounce that, but you
know what I’m trying to say. So what cystoscopy
is, for those of you who aren’t familiar if it, is
you take a very small camera and it goes through the urethra
and looks into the bladder. So the people who have
cystoscopies, seemingly most often, I think,
are probably men and they will tell you it
was a horrific experience. I don’t think it’s
quite horrific, but for women it’s a much
easier thing to have done. So a woman’s urethra is
about 4 centimeters long. So it’s similar to
having a catheter put in. So if you’ve ever
experienced that, it’s not something that is
particularly uncomfortable. We do it for patients
when they’re awake. When we look inside the
bladder, we actually get a really good sense of
what the surface of the bladder looks like and that
tissue is really thin, and so it’s not something that
is imaged particularly well. So doing ultrasounds
or doing CAT scans doesn’t really tell us the same
information as looking inside with a cystoscope. And so I would highly
recommend a cystoscopy when your physician
is telling you that that’s what they need
because there’s really not a good replacement for it. We’ve only got a
couple minutes left, but I wanted to see if
you could share something about your research on
pelvic organ prolapse. We have a lot of
research going on. That’s exciting. We have two trials
we’re enrolling in for overactive bladder. So one of our
studies is, there’s a lot of people who have
overactive bladder, meaning going to the bathroom
too frequently and when they don’t want
to and leaking on the way to the bathroom. And we try the dietary stuff
that doctor Glass talked about, as well as medications
that worked on those nerves to the bladder. And then we have a bunch
of other therapies, like the one doctor Glass
talked about, like Botox in the bladder, electrical
stimulation and acupuncture, the electrical one,
pacemaker stimulation. And very few people go on
to that next level, even those that are suffering that
medications are working on. So we’re now doing kind
of interviews and surveys as to why people
aren’t progressing. We also have a new
therapy and we’re going to be involved in this
FDA trial that’s coming up, we’ll start for a new
bladder therapy for people who fail medications and diet
for overactive bladder as well, and we’ll probably start that
by the end of the Summer, we’ll get everything going. And then we have
interesting work. We’re collaborating with some of
our minimally invasive surgeons on fibroids and type
of prolapse and race, as we see it a
clinical difference. And there’s not that much
data out there on that. So that’s kind of
a new study we’ll be starting this Summer too. And then, doctor
Glass is involved in very exciting research, too. I am involved with a
multi-center regenerative engineering consortium. And we’re trying to look
at ways to regenerate bladder tissue, as
well as muscle tissue to help with stress
incontinence. And so it’s very exciting
research as well. A lot going on. But it’s good stuff. So you guys were great. Thank you very much. Thank you. Appreciate you being
on the program. I had a good time. And thank for watching. That’s all the time we
have for the program. I want to thank all of you for
your excellent questions, which were very good. To learn more, please visit our
website site at or you can call 888-824-0200
to schedule an appointment. Also be sure to keep checking
up on our Facebook page for updates on future At
The Forefront Live programs. Thanks for watching. I hope you have a great week.

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