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Guy Manetti: Welcome to the building, a successful female medical spa portion of the CME program. So female medical spas represent a rapidly growing industry, in part because of the treatments that have become available now to females in that perimenopausal space, and there are a lot of new treatments that have come about. So as you can see on this graph, there's been an exponential growth in the medical spa industry over the past decade, with global revenue in 2022 reaching $17 billion, and that's up $4 billion over the last five years. As urologists, our training and patient population makes us uniquely qualified to provide many of the services in the medispa industry. So vaginal restoration procedures, for example, for the management of female sexual dysfunction, in-office procedures that are nonsurgical and less invasive than traditional surgical options are the trend. And now, they are now supplanting a lot of the traditional surgical options and modalities continue to improve.

My practice does not have a female medical spa, but as I learned more about the industry, I spoke with our employed urogynecologist, and we debated the merits and challenges of taking an endeavor on like this in our practice. What services should we provide? Many spas offer cosmetic procedures such as Botox and laser hair removal, in addition to the vaginal restoration procedures that we've talked about. How can we identify the need for such services in our community? How could we efficiently set up services to take advantage of the lucrative opportunities that this industry has to offer? So our two panelists you mentioned earlier, Dr. Sarah Girardi and Dr. Anika Ackerman, they've done it.

They've set up successful medical spas in their practices, and they're going to share some of their insights with us today. They have a little bit of a slide presentation that we're going to try and talk about this in a little more of a discussion to go over the opportunities that we have to potentially start to take advantage of the growing industry that exists. So I'll give you some, so you can do your slide here now, and then we can talk a little.

Sarah Girardi: Good afternoon. Welcome, and thank you for attending this session. In the next few minutes, I'm going to lay out the need here. I promise you in your practices, there's plenty of need that you may not really recognize, but if you see any women patients in your offices, there are most likely a large number will fall into these categories. We'll start with some simple definitions. Perimenopause, and excuse me if it seems basic, but it's very important. Perimenopause is the 10 years that surround the menopausal timeframe. So it's leads up to, and including, and after. So when you're seeing a 47-year-old woman in your office with a UTI and nothing's working, you have to at least be thinking she may be approaching those years, and I should probably have this in my mind. And I'm also going to try to persuade you that urologists are uniquely suited to opening these spas and to providing these treatments.

Menopause itself, of course, is the cessation of menses, and that occurs on average at about age 51, but it can occur much earlier. It's 12 months without a menstrual period. In this country, 1.3 million women per year become menopausal. That is a huge number. Right now, there's probably about 50 million women who are in their menopausal years. 74%, three out of every four of these women, are going to have some symptoms related. Most of them will have VMS. If you guys watch the Super Bowl, I think the second ad in the Super Bowl was VMS. They asked women what it is. Most people thought it was a radio station. They didn't know what it was. VMS is vasomotor symptoms of menopause. It's the hot flashes and the night sweats. If you don't have a partner or a sister or an aunt or someone in your life who hasn't had this, I would be surprised. 60% are going to have GSM.

You should familiarize yourself with that term. It should be in our EMR. Right now you're going to see it as vaginal atrophy. The better term is GSM, genitourinary syndrome of menopause. You are seeing it every day in your office if you ever examine a female patient for her UTIs. The area becomes dry, it loses... We won't go into the detail of the physical exam, but it's very obvious when you start looking for it. And 60%, over half, are going to have that. That is what's leading to most of their UTIs, I promise you. 5% of menopause is going to occur, age 40 to 50. You have to ask these women, they come in for their UTIs and the cranberry pills aren't working and nothing's working. Ask them, do you get your period? When did you not get it? And open your ears to it.

And if you don't have time, that's what this is all about. You need that relationship with a spa or open one or get this thing started, because those women really need you. Many women will spend close to half their lives, we're all living longer, going to spend half their lives in this state. The symptoms you probably know, but I'm making this long list for a reason. Hot flashes, sleeplessness, depression, weight loss, excuse me, weight gain, typically middle of the body, decreased libido, osteopenia, sarcopenia. We know all these. Arousal disorders, hair loss, vasovaginal atrophy and GSM. I make this laundry list to just say there are many women, if you ask them, they'll go into a doctor's office with a variety of these symptoms, and depending on who they see, they'll come out with an antidepressant, a weight loss medication. They'll come out with something for their hair loss.

They may come out with five prescriptions. If someone had asked the right question and said, "Has anyone ever addressed your menopausal symptoms?" they might have come out with one, and it might've just been an estrogen patch. The history is really interesting, whether you ever would read about it, but it's kind of interesting. These hormones actually were used, if you ask your generation ahead of you. In the fifties, this was just done. Women had estrogen, they got their estrogen, they went through their changes and they got estrogen. In 1966, Wilson's Feminine Forever paper and book was recognized, he recognized that menopause is in fact a hormone deficiency disease. The only thing that's funny about that is that it was a controversial thing at the time because some women felt that this was natural and it was kind of an embarrassing topic. In his paper, it really was about women becoming more serviceable to their men.

He felt they'd be less cranky and more agreeable. So it's a little bit of a twisted thing, but it was important. And it did show that estrogen and estrogen replacement was very important. In the seventies, unopposed estrogen was associated with endometrial cancer, and that's when we got into the importance of progesterone in women with a uterus. In 1988, the FDA approved hormone replacement therapy for VSM, for vasomotor symptoms of menopause, excuse me, and the prevention of osteoporosis. And that is critical. It is extremely effective in that realm. And then we got to the Women's Health Initiative. I won't go into too many of the weeds. It's something if you have questions about, we can answer in our questions' session. However, it's important that you know why these hormones got vilified. It is such a mess, and we did such a good job of miseducating.

It's phenomenal how well we got across this bad messaging. And the bottom line is this study had good intention. Estrogen hadn't really been studied. Is it safe? We're giving it out, estrogen, progesterone, is it safe? And the intention was to just prove safety. And at the bottom it says, what was the outcome? What were they looking for? Did estrogen or estrogen with progesterone increase the risk of cardiac coronary artery disease, stroke, and stroke, really the outcomes, and death. So they actually geared it toward older women. It wasn't about vasomotor symptoms of menopause. And if I can just summarize the upshot, it's a fascinating discussion. There's a lot of really good papers on it. The bottom line is, it stopped. Estrogen replacement stopped. This was in 2002 and 2002 to 2004, and the sales went plummeting. And it was very dramatic. People kind of remember it, who were in this field.

Gynecologists remember it. It was on the front page of the papers, all that kind of thing. And it just abruptly stopped. Upon review, 17 years later or so, JAMA put in a little kind of apology, on reassessment, whoops, we realized that those women in those critical 10 years surrounding menopause leading up to and just following are actually benefit enormously, IE protective against heart attack, protective against stroke, protective against dementia, protective against osteoporosis and colon cancer. So that's a special group. So when you're seeing your patients and they're 48 to up to about 63, 65, and they're having issues, don't back away from estrogen. Please uncouple this fear factor. It's irresponsible, quite frankly. This is the NAMS position. NAMS is the National Menopausal Society. It is now just called the Menopausal Society. And for those of you like myself who want to practice responsible medicine, we're not just jumping into these med spas to make a buck.

We're trying to help a population that's vulnerable and we want to do it in the responsible way. This organization, the Menopausal Society, is outstanding. They are doing everything as close as they can to evidence-based medicine where it exists, but there's not a lot of it. Evidence-based, that is. And the other societies is ISSWSH. I highly recommend if any of you're thinking about it, just write down I-S-S-W-S-H. That's the International Society for the Study of Women's Sexual Health. And that's been really important in really giving us responsible information on these issues, HRT. And I'm almost going to hand it over to Anika and she's going to tell you about what's available that's not hormone replacement. So when you're talking to your patients, you may not want to get into all this, but at least recognize it. Say, "Listen, this may be a hormonal issue. Has your gynecologist addressed this with you?"
And sadly, a lot of them will say, "They don't seem to be listening." They probably don't want to get into it, because clearly as we're talking now, it's not a one-minute discussion. It's nuanced. And that's the point of that NAMS statement that I had on the screen just a moment ago. It's a busy slide, but what it says is, you can do this. You can absolutely use topical estrogen, really almost within impunity. That is so easy and so safe and not absorbed systemically. And systemic hormone replacement is absolutely the number one treatment for women who are experiencing vasomotor symptoms. You have to assess risk and all of that. And again, that's a bigger discussion, not for this particular session, but it can be done responsibly. So just be responsible. Don't just say no. That's too easy. It's not no. And you could really benefit these women.

So systemic hormone replacement comes in the form usually of a patch or a cream. That's what's recommended. There's sprays and there's pellets. They absolutely will, that is still the number one treatment for vasomotor symptoms of menopause. What was on the Super Bowl ad is the new medication called Veozah, which is very interesting, and that's actually a credit to the science. They now established that the hypothalamus is the area that's responsible for these vasomotor symptoms. And so this is a medication that actually helps vasomotor symptoms and is non-hormonal. So that's what was in the Super Bowl. Local estrogen, I urge you, I entreat you to use it. Local estrogen cream is so easy, it's just an estrogen cream around the opening and it is extremely effective for genitourinary syndrome of menopause or GSM. Having said all of that, you can coax your patients to do this.

I do this all the time. I do take the time, if I can't do it in my office hours at that moment, we set up a telemed and discuss these issues further. But many of them will still say, "Not doing it, not touching hormones. I'm still fearful. What else do you have?" And what else we have is going to be Anika's talk. This is all about breast cancer and HRT and I think probably a little more than we want for this discussion. But again, it can be done safely with your breast cancer patients. You need to have a really good relationship with your oncologist. Many of them are very good with this. You can start with other things, hyaluronic acids and some other things can be very effective. But just open the discussion. You'll look like a hero to them because you're actually listening. You may not have the answers at that moment, but you just want to have that little card or that little referral.

We are doing this now, and we hear you and we want to take care of you. So alternates to hormones are the following, and this will be my introduction to Anika's, Dr. Ackerman's presentation. There are compounded creams that you can use, which typically use some hyaluronic acid, which is basically like a moisturizer for the face. You can then move into treatments, which Dr. Ackerman will go over. Laser treatments, there's radiofrequency ablation. Platelet rich plasma is something we use. The Emsella chair is something else, and VTone. So I'm going to hand this over to Dr. Ackerman to say she will now discuss the treatments that are available, because in our experience, having gone through that whole rigmarole of the importance of recognizing all of this, you're still going to get a good number of women who will say, "What else do you have?" And we will say, "Well, welcome to our spa."

Anika Ackerman: Hello. So there are a lot of options out there, and this is not meant to overwhelm. So we were all discussing that with all these options, really probably important to choose if you're really thinking about opening up a female sexual dysfunction program or clinic, to choose one or two and see how it goes, and then consider introducing other ones. So with that, so the first one is a CO2 laser device, and the most common brand I believe in the United States is the MonaLisa Touch. Does anyone in the room have one of those? So people are already using it? Good. So the MonaLisa Touch is a CO2 laser. Just like people get lasers on their face for their skin to make their skin look better, we do it to the vagina. And it causes microtrauma to the tissue, which then basically tricks your body into restoring itself, repairing itself.

So it's a fractional laser, so it injures a part of the tissue and then your body rejuvenates itself. It restores collagen, it increases blood vessel formation, it enhances nerve supply. When I think of MonaLisa Touch, I think of postmenopausal women with vaginal dryness, painful intercourse and itch, of all the symptoms of GSM, but also for the urologists, urinary tract infections. And although the data is not quite there, anecdotally, probably everyone in this room who has a MonaLisa Touch does notice that patients get fewer UTIs after having the treatment. It's a once a month treatment, so every four weeks for a cycle of three. So they usually complete within three months. And then in our practice, we do a booster treatment for those patients who notice their symptoms are returning in about a year. And you can see from the slide that that glycosaminoglycan layer is much thicker. This is taken from one of the research papers, and that is a protective barrier that also helps to prevent urinary tract infections and increases moisture, all the good things.

Next is radio frequency. Another device that I can correlate with something that you may find in a med spa for facial rejuvenation. There's something called the Hollywood Facial, which uses radio frequency to, again, give you glowy skin. And so we use it in the vaginal area as well. Again, a once a month treatment for three treatments. When I think of the radio frequency, which in my practice I use something called the FormaV from InMode, and I believe Sarah's using...

Sarah Girardi: The THERMIva.

Anika Ackerman: THERMIva. Anyone in the group have one of those? Perfect. So again, when I'm thinking of these, I mostly use this in postpartum women. So women who are having vaginal laxity, possibly painful intercourse, decreased sensation. This is going to increase tightness and increase sensation. It's contraindicated in pregnant, but it actually is not contraindicated in medical with metal, so we don't worry about it with IUDs and defibrillators. So we use this pretty much on everyone. And the tissue is heated 10 degrees. So it's heat energy, again, stimulating collagen and elastin, which helps with tightness. This is a newer device. This is the Morpheus V. It combines radio frequency with microneedling.

So microneedling is, again, used on skin. A dermatologist, microneedle the skin, and it causes skin turnover. Do the same thing in the vaginal canal, combine it with the heat energy. This is a sister treatment of the Morpheus8, which was like the most popular med spa treatment in 2022. They basically just made it for the vagina. Another once a month, three part treatment. There's also anecdotal evidence that just one treatment is good enough for this. So a lot of women who just want to be one and done will choose Morpheus8, at least in my practice. Morpheus8 V. I Should say. It improves incontinence as well. You do treat the area right underneath the urethra. Actually, the past three treatments all will help with urgency, incontinence and stress urinary incontinence as well.

Platelet rich plasma. This is very well marketed as the O-Shot and the P-Shot. Anyone in the room doing P-Shots? Not really? A little bit? So platelet rich plasma is used in all different aspects of medicine. Orthopedists use it in joints, it helps to restore joints. Dermatologists use it on the skin. It helps to regrow hair for hair restoration. The platelet rich plasma comes from your own blood and then it's injected back into the tissues wherever the doctor's going to put it. This is another three part treatment. This is the marketing for the O-Shot. The correlate is the P-Shot or the orgasm shot PRP shot. So again, it's a simple blood draw. The patient comes into the office, usually one of the nurses draws the blood. We place it into a centrifuge and that spins and It helps to extract the platelet rich plasma. We draw it up. We usually mix it with some calcium chloride, so it makes a gel that stays where you put it.
And then for the females, we inject it into the clitoris and the anterior vaginal wall, the G-spot, and it's supposed to help with orgasmic function. It's also been studied for lichen sclerosus. A lot of people in the room have probably seen this. We call this the Kegel throne. It's the Emsella chair. It's nice because women can sit on it, or men, whoever want to sit on it, in all their clothes. It is contraindicated with metal in the body, specifically in the hips. It mimics doing 11,000 Kegel exercises in 30 minutes, so it's basically PMR on steroids. It helps with stress incontinence and urgent incontinence. In our practice, we are also using it for our patients who are undergoing radical prostatectomy, and it's been shown to help with their recovery time for continence. And it's a 30-minute treatment, and usually we recommend six treatments. So once a week for six weeks, they're in our office.
This is similar technology to the chair. This is something called VTone, which is again from an InMode platform, and it delivers that high intensity energy straight to the vaginal tissue. So the patient does have to get undressed for this one, but it's a very similar treatment. And this is the summary slide. I guess I can go through this one. So again, as Sarah said, over 60% of women will experience symptoms of menopause. Education is needed to better understand the risks and benefits of the HRT. Although at this point, most of us believe that HRT is very safe and I'm doing a lot of hormone replacement in my practice. And then there are all these other options for women who want to pursue HRT in addition to things or in place of things. And now we will open it up to questions. Thank you.

Guy Manetti: So that was great. Thanks, guys. So I was shocked at that other slide, the exponential growth of this industry, the medispa industry. And so a practice like ours, what kind of challenges did you guys face making this female medical spa? If you knew then what you know now, if you guys can share, because on the phone calls, you guys came to this a little bit differently in each of your respective groups? If you guys can share your experience and some challenges as we start to try to do that?

Anika Ackerman: Sure. I could start. So our med spa started as a complete med spa offering all types of aesthetic procedures in addition to the things I just went through. So botox, fillers, laser hair removal, everything. And it was a lot for us to take on. We initially were modeling it that we were going to try to feed the med spa. So the urologists were going to try to feed patients into a place that was doing all these sort of out of the box for urologist procedures. And we realized that that wasn't possible. So we then shifted gears and paid a lot of money to do some marketing, and that worked for some time. But now we've really scaled back. We've put the aesthetics to the side and we are focusing just on female sexual dysfunction and male sexual dysfunction.

So we have now a Garden State Urology sexual dysfunction space, and we're doing a much better job of keeping true to being urologists and not trying to sort of confuse our patients by saying, "Oh yeah, we do Botox and fillers and all these other things too." And I think that has been a lot more successful for us.

Guy Manetti: Sorry, you did not use a company to help with the marketing and all of that, I think in yours, right?

Sarah Girardi: We didn't use a company to start up as completely as you did, but that's a natural. So what will happen with one of these is you have to decide what your offerings are going to be. Is this going to be strictly a more of a women's sexual health spa? Is it going to be men's and women's sexual health? Because a natural is once the word gets out, there's going to be the aestheticians are going to want to... Not want to, it's sort of a natural to have those offerings. So do you want to get into that and start offering the aestheticians start doing botox and that sort of thing. But the other aspect with startup is marketing. And if you're even thinking about this, that has to be a very serious consideration and you have to figure out exactly who you want to market it. And this is a rather nuanced type of marketing. It's not your general marketing. So they really have to know who's out there, who your target audience is. So you have to be a little bit careful.

Guy Manetti: Was there one particular challenge that if you sort of said, looking back, maybe you would've done things differently with that marketing or with any of your diligence as you're purchasing capital equipment or expanding staff, or?

Sarah Girardi: I'll let you answer just after. I'll just comment that we tried to be as cautious as possible initially. There's a lot of toys, as you can see, and these guys, these people who are selling the toys. There's always a new one every year and it gets to be a little bit annoying. So I have to say our MonaLisa has been a workhorse. It still works well. And if it worked well before, it continues to work well. And I don't think you have to do something new there. But we were pretty cautious and really addressed vaginal health to start with. And something like PRP is so easy, because it's just a kit and it's their own blood. So anything like that is great to just get the volume through the door, let them have a good experience. The other is space, and maybe you can comment on that.

We started, we got bought our MonaLisa as part of our practice. I was just doing that in the office. It was separately, the billing is totally separate. They're paying cash for that, so you have to separate that out. But they were in my office doing it there. And then we expanded into a very beautiful space. So you have to decide if you want to do that, do you first want to get some revenue and then move to a space? But I do think that's part of the whole, if they're going to pay cash, certainly I didn't feel comfortable having my cash paying patients coming through our regular office. I didn't think that was quite a, we tried to treat them with kid gloves, but it didn't always work as well. So I think it's important for you to consider having a space.

Anika Ackerman: I think to answer the marketing question, we learned that we were sort of falsely advertising ourselves and doing all these other procedures. And I think our patients sort of stepped back and say, "Why are you doing botox and fillers and things like that?" So initially we probably should have just stuck with the sexual female sexual dysfunction, male sexual dysfunction treatments. But hindsight is 2020 and now we're doing great. We probably shouldn't have spent as much money upfront on the marketing for those other procedures and just focused strictly on what we know because it's really easy to recommend the procedures I just mentioned to my patients because they just make sense for them.

Guy Manetti: And have you guys employed some of the physician extenders into your medispa? And if so, how?

Anika Ackerman: In my practice, well, so I'm in New Jersey, the laws for lasers are very strict, so a doctor has to fire a laser in New Jersey. And so I do all the MonaLisas, but a lot of the other things are delegated. The nurse obviously helps with the platelet rich plasma. I do some of the orgasm shots. As far as the men's side, we do have a nurse practitioner that does shockwave therapy. He runs our hormone program. So it's integrated.

Guy Manetti: Same for you?

Sarah Girardi: Yeah, ours is very similar. So I like to be hands on, just in the beginning, I feel very responsible. So I want to make sure that this is all going smoothly. So I'm still very hands-on and right now physicians do all the procedures in our office. But certainly, if you got up and running with this, it would be a very easy thing to do. The initial of a three series, whether it's a MonaLisa or, well, you just mentioned the laser in New Jersey, you have to be careful and there are a lot of differences state to state, but you could have an extender do some of the procedures after you do an initial one. So it's a really nice use of them, and nurse practitioners, physician assistants, they can learn these procedures quite easily.

Guy Manetti: When you guys were starting this, did you incorporate the medical spa time into your clinical hours? Separate out a little bit of time? How did you guys kind incorporate that into your day or your week?

Anika Ackerman: Initially, our practice had me. I'm pretty much the only doctor that sort of worked in that space for the beginning. And they had designated half a day, just half a day that I was going to be there doing procedures. And then we had aestheticians, we had nurse practitioners and some other personnel within the space. And now we pretty much weave all the treatments. So I'll see 20 patients in the morning and I'll have a few MonaLisas scattered in.

Sarah Girardi: Yeah, that's another part of the calculation. When you do your initial math and you're trying to figure out who's going to run your spa, your medispa, if you have a particular practitioner in your practice now who might want to take this on as their project. I was very sensitive to that as well because I wanted to continue my clinical practice. I had always had Monday mornings. That had always been kind of a flex time for me, so that worked easily. And then I opened up Saturdays and people really enjoy Saturday, so that has worked for me. It's not going to work for everybody, but they really appreciate Saturdays, and it's so nice. It's very relaxing. Compared to a busy clinical office, it really is very relaxing. They're so appreciative. It's very gratifying. It's really a very gratifying thing to do. They really do appreciate the care and the attention to this very intimate area.

Guy Manetti: You were saying you both also incorporated men. Did you have a sort of spa for men or did they kind of go hand in hand? You started to do female and then some male spa and medispa type of stuff as well?

Anika Ackerman: Initially we created a menu for men. So we would do platelet rich plasma for hair, we would do for erectile dysfunction, we would do shockwave. And then we recently added the hormones and took out some of that other stuff. We also had an Emsella machine that helped build abdominal muscles. So we always incorporated and welcomed men into the space. The medical spa industry is like 90% females, but they are integrating more and more men yearly.

Sarah Girardi: In ours, that's similar. Ours, we always had the male on the female side in mind because we knew that we wanted to get into shockwave and potentially the use of PRP. We started our marketing when we did our website and tried to find sort of a neutral name and all that so we didn't get too down a female pathway because we wanted to serve both. So we have both. And the space, we just share the space. So I'm there on Monday mornings and he's there on Monday afternoons for the P-Shot and the shockwave.

Guy Manetti: Any additional advice for someone who's getting started to say, okay, you know what, after a year, because you guys have been about a year into your spa, if I remember correctly, that you kind of feel like it's already pretty busy as you anticipated based on your market research?

Anika Ackerman: Yeah, so our spa has been open for four years.

Guy Manetti: Oh four, okay.

Anika Ackerman: We're not calling it a spa anymore. It's sexual dysfunction space. And I'd say that, as I mentioned before, there's a lot of toys, there's a lot, every rep will come into your office weekly with a new thing to buy, a new thing to try. So it's probably best to just stick to some of the more popular, some of the more studied things that people have heard about and are seeking out, and you can add a nice little cash stream to your practice.

Sarah Girardi: Yeah, I would add to that, the terminology you just said is so important. So Dr. Ackerman corrected the terminology. It actually is important. I get a little sensitive about this. There was the 2018, the FDA came down and really got on these laser treatments in particular and really targeted them and said caution. And there really was a caution to patients and just saying, there's a lot of stuff out there making false claims, and we know this. How long have we seen things on penile enlargement and all this other stuff that's just nonsense? So we have to be very careful. So I actually also, we don't really refer to it as a spa, just when we're in our meetings we do. But I'm a little careful about the term rejuvenation. I think that's really lost. That has a bit of a... It's not an authentic, it's not as good.

We talk about vaginal restoration. We're serious about what we're doing, really are doing things that we think, know, are helping women. And we really do want to get those clinical studies. So we've avoided the term rejuvenation and use the term restoration. I've avoided the term spa as well. Ours is a center and it's a center for female intimate health. And then one side note, which I had discussed with you a little bit, was that interesting when we first did our marketing, this term, GSM, is an acceptable term now and you can use genitourinary syndrome and menopause without difficulty. When we first did our marketing and were trying to get our pages out, the word vaginal couldn't be used. So how do you do that when you're opening up a vaginal restoration? But the word vagina, it is censored practically on social media. You couldn't get it by anything.

So I thought, this is really crazy that we're going to try to market this stuff without using the word, tiptoeing around. That was very creative stuff. So now if you're using terms like GSM, there's a lot to it. The marketing's fascinating. I've never been involved in any of that before, but it's very interesting. But social media is critical. Your marketing team is critical. Once you get up and running, Dr. Ackerman's in this four years, we're in it one year, December's our anniversary, and we're still on the up. We're still working it out, but I think we're right now really fully adopted the importance of social media, the importance of a good webpage, and then just all the specials and it's all that stuff that marketing people do so well. But you want to make sure you get a team that knows what they're doing in this particular space.

Guy Manetti: And you got a separate marketing team for this?

Sarah Girardi: A newer one, yeah, we did. We made a little bit. We have two that are a little bit overlapping, but we're transitioning to the one that's a little more current, a little more up to date.

Guy Manetti: Did you need to build out a lot in your office footprint to be able to accommodate this or you were able to do it because it was a little off hours for both of you guys? Did you have to make a lot more space or no?

Anika Ackerman: We have a large separate space, yes. A very beautiful, white, welcoming sort of spa-like experience, because these patients are paying cash for these services. So you're supposed to create an atmosphere that's a little different than a medical office, I think.

Guy Manetti: So we don't have too much more time. And certainly, I think this is certainly something that I think should be considered and adopted. And I'm going to go back and speak with our group and our urogynecologist because I think one of the main points that I think has come up here and also on our calls is just you can start small. You don't necessarily need to put a big capital output there and hire a lot of staff and you can start small and potentially start to see and build and maybe with some additional companies to help with some market research and marketing. Any other final points or things that you would say, you know what, if you want to start something like this, this is what you might want to consider doing? Or things that I would've done differently, to kind of wrap up? I know we don't have too much time left.

Sarah Girardi: No, I think that's pretty much what's been... We've got it covered.

Guy Manetti: All right, well that's great. Thank you very much.