Kerry Reller 0:28

Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Cheruba, and I can't wait to have you tell us everything about fibroids. You are the fibroid doc, so why don't you tell us a bit about how you became a fibroid doc?

Introduction to Dr. Cheruba Prabakar

Cheruba Prabakar 0:45

Yes. Thank you so much for having me. I'm Dr. Cheruba Prabakar. I'm an OBGYN and a minimally invasive surgeon. And yeah, it's an interesting road how I got to be the Fibroid Doc. So I trained in New York in Brooklyn for my fellowship, where we saw a lot of complex GYN problems, including fibroids, endometriosis, and it just struck me that fibroids affect so many aspects of women's lives, from everyday bleeding to pain fertility issues. And so it just s- stood out in my mind. And then when I moved across the country to actually start practicing again, I saw more women with fibroids, and I thought back to even my own mom when I was a teenager she had fibroids, and she was very weak, and she had to get IV, like iron transfusions, and she was very anemic, and was bleeding very heavily, and she ended up with a hysterectomy that put her in the hospital for a week. And, as a young girl, I remember seeing that whole journey. So somewhere in the deep, dark recesses of my mind, I guess that also was always there with me as I continued to take care of women. And then I just realized that, no one's really talking about it. And so I decided to become the Fibroid Doc, and my life's work is to really, tell everybody about fibroids.

Kerry Reller 2:09

Awesome. I told you before we were recording that I feel like I'm going to learn a lot today 'cause this is definitely not my specialty. And I don't know, I think before maybe I knew a little bit more about fibroids. I just thought, I thought it was maybe an older woman's thing, and then they bleed a lot, and then they gotta take out their uterus, right? And I think you're gonna dispel some of those myths for us today, right?

Cheruba Prabakar 2:29

Yes, absolutely.

What Are Uterine Fibroids?

Cheruba Prabakar 2:30

So fibroids are super common. I don't think people realize how common they are. 80% of women will be diagnosed with a fibroid by the time they're 50. So this starts really in your 20s. I remember one of my best friends in medical school getting a big surgery for her fibroid, and at that time I barely knew what it was. But thinking back, I'm like, oh, I remember a lot of people getting surgery for this, like even in their 20s. So this can start really in your 20s. This is not, as you said, like an older woman's problem, as many may think it is. And a, a lot of times it goes unnoticed because people women have heavy bleeding and they think, "Oh I guess this must just be the way it is. This must just be how periods are," and they don't quite realize that there could be something wrong. And yeah, this starts very early and I see a peak around mid-30s to late 40s, where fibroids can also rapidly grow.

Kerry Reller 3:28

So what is a fibroid?

Cheruba Prabakar 3:30

So fibroids are benign tumors of the smooth muscle. So when we think tumors, we often think, oh, bad things, but the fibroids are almost always benign. There's a very small percentage that are cancerous one in several hundred thousand, so it's very rare. But usually they are formed with the same tissue of your uterus, and they form these balls inside the uterus, outside the uterus, in the wall of the uterus. Yeah, they just grow on the uterus, and sometimes many women don't even know they have them. They're just there. They don't really cause any problems. There's no way you would really know unless you did a scan. But other times they can actually cause a lot of problems, and it comes to light that, oh yeah, I have a fibroid

Kerry Reller 4:13

Yeah, I fi- it's interesting that you said that, they'd have a lot of heavy bleeding and just think it's totally normal, and I do hear that all the time. You have a We talk about how many pads or tampons and things that you go through, and they just think it's a part of it, and then they may go to their GYN or something, and they may give them a medication that can help slow it down. But maybe, I don't know where it comes into the process of where they actually do a scan, like you said, or, what do you

Cheruba Prabakar 4:37

Yeah.

Kerry Reller 4:38

Yeah

Cheruba Prabakar 4:38

I think this is where we have a huge opportunity to improve and change. Because like you said, people

Why Heavy Bleeding Shouldn't Be Ignored

Cheruba Prabakar 4:43

complain of heavy bleeding, they're given a pill especially if they're young they haven't had kids, so nobody even thinks about, talk, talks to them about surgery. Or if they've had kids, they get a pill, and then they say, "Oh, okay, when shall we schedule your hysterectomy?" So it's a very kind of this binary type of treatment that's going on. But we really need to dig in deeper, and we need to identify this sooner. So when somebody in their 20s comes to you with heavy bleeding, sure, you can put them on a pill, but we also have to figure out why are they bleeding so heavily, because that's not normal. And that right there, I think, is the crux of where this change can happen. Because if we did a scan in a 22-year-old and said, "Oh, you know what? You actually have a fibroid and that's what's causing your heavy bleeding. Sure, you can take this pill, but let's also figure out what else we can do for this fibroid so you don't have to end up bleeding every month, for the rest of your menstruating years."

Kerry Reller 5:40

Yeah. You mentioned, the younger person, but what also about that perimenopausal person where you hear, "Oh, maybe I didn't have heavy bleeding my whole life," right? But, they say sometimes during perimenopause you can have these heavier periods, and then a light period, and then the, the separation, like a longer distance between your periods. So like,

Cheruba Prabakar 5:58

Yes.

Kerry Reller 5:59

could

Cheruba Prabakar 5:59

Yes.

Kerry Reller 6:00

something playing in there, right?

Cheruba Prabakar 6:02

Absolutely.

Fibroids vs. Perimenopause

Cheruba Prabakar 6:03

I just did this this live a couple weeks ago that said, "I'm bleeding in perimenopause. Is it menopause or is it fibroids?" A lot of people in their 40s just think, "Oh I guess it just must be perimenopause because I'm bleeding heavily." And like you said, you're getting two periods a month, and then you don't get, a period for a couple of months. It may be perimenopause, but we shouldn't ignore the fact that there could be something else going on. Perimenopause is like a diagnosis of exclusion if we know that there's nothing more serious going on. So a couple things that I always say to look out at this age group is definitely to do a pelvic ultrasound. Do you have fibroids? Do you have, adenomyosis? Do you have other conditions? And also you should do a biopsy to make sure you don't have uterine cancer or something weird in the uterus going on that, you just think, "Oh, this is just fibro- this is just perimenopause," and you just blow it off. So yes, I think in general in this country, we need to do better with taking these concerns seriously and working it up. And if you do an ultrasound, and really there's nothing there, then you can say, "Okay, I'm 49 and I'm bleeding like this. I guess this is likely perimenopause." But without doing that workup, we shouldn't just, assume that's what it is.

Kerry Reller 7:12

So the scan will essentially reveal any fibroids pretty,

Cheruba Prabakar 7:17

Yes,

Diagnosing Fibroids with Ultrasound

Cheruba Prabakar 7:17

the pelvic ultrasound is the best test for fibroids. It is a fairly easy test, 15, 20 minutes. There's no radiation. A lot of times we do it transvaginally, so there is a probe that goes in the vagina. We use a lot of gel. It's, it's not the most comfortable, but it's not a painful test either. It's not invasive in that, like it's going into your uterus or anything. So that's just a very simple first line test to see if you have fibroids. A lot of times your gynecologist or primary care doctor will order this. And you can also get it cash pay in a lot of places. And once, once you are diagnosed with fibroids, if we are actually thinking of operating on them, then we often do an MRI, which is the next test to really look at like the location of the fibroids and their relationship to each other. But a pelvic ultrasound is perfectly fine as the first test.

Kerry Reller 8:09

You mentioned, doing transvaginal ultrasound. Is it possible to identify them without having to do that? With the, with just a pelvic ultrasound without the transvaginal probe? Just...

Cheruba Prabakar 8:19

yeah, so you can do a pelvic ultrasound abdominally.

Kerry Reller 8:22

Yeah

Cheruba Prabakar 8:22

so we can definitely do that. But, depending on everyone's body habitus and shape, like sometimes it's difficult to see the pelvic structures because they're pretty deep in there. So it just depends on the patient. Sometimes we can see enough, but other times the tr- transvaginal is the best way

Kerry Reller 8:37

Yeah, you also mentioned, I think, how your mom had anemia and, some of those downstream effects that could be coming from the fibroid. And so we talked about the heavy bleeding. Is there anything else that you might see to make you think, "Oh, there could be something going on"?

Warning Signs and Iron Deficiency

Cheruba Prabakar 8:52

I think the heavy bleeding and the cramps, really bad cramps, is the probably the giveaway here, but really the heavy bleeding. And a lot of women may wonder what is heavy bleeding? I- this is how my periods have always been." 'Cause when I talk to a lot of women, they say I didn't know that this was heavy. It's... i've had them t- throughout my 20s." So if you're bleeding a pa- like a pad or a tampon, every hour, that is too heavy. If you are lightheaded and dizzy, that is too heavy. And if you are having to call out of school, work, you are having to miss social engagements because you're bleeding too heavily, then that is a problem. So yes, nobody loves their period, and it can be annoying, but you should still be able to function and do all the things that, you need to do. Yeah.

Kerry Reller 9:39

Yeah, so from my perspective is more on the primary side, not dealing with much GYN. I'm seeing the patient fatigued, right? That's the most common thing. And, sometimes we do labs and things, and I'm like, "Oh my gosh, you're iron deficient." And then I might get into the subject of, the the menstrual period, and heavy bleeding, and perimenopause, or whatever it is. So I feel like I'm coming at it from a different angle, and then I would send them to someone like you, obviously. But I w- yeah, with the fatigue, I think that's been a red flag. I've just seen so much iron deficiency lately, and it's, frustrating that I haven't been getting all the answers to it. But anyway, so we know it's

Cheruba Prabakar 10:12

So fatigue, yeah

Kerry Reller 10:13

doing a pelvic ultrasound. And you mentioned maybe doing the MRI as the next step, what kind of... How can fibroids be different from something else that may be presenting?

Cheruba Prabakar 10:24

Yeah. The one thing that often presents with fibroids is endometriosis. And which is a whole different disease process, but they often coexist together and can be confused with one another. But endometriosis can also cause bleeding, can also cause pain. And a lot of times when I operate for fibroids, I also see endometriosis. So that's something to also think about. And when endometriosis, when a glands of the uterus start to go into the wall of the uterus, it can become this condition called adenomyosis, and that can also cause very heavy bleeding. And on scans, it can look like a fibroid, it can act like a fibroid, but it's not a fibroid. It's a completely different disease process. So all of these things could be going on together and, it takes women an average of four to seven years to get these diagnoses. Yeah. So as primary care physicians, OBGYNs, we all have to be looking out for this and thinking about these diagnoses.

Kerry Reller 11:18

So you also mentioned, the younger population maybe having fibroids, and you mentioned infertility. Can you explain that a little bit more?

How Fibroids Affect Fertility and Pregnancy

Cheruba Prabakar 11:27

Yeah. A lot of women figure out they have fibroids when they're actually trying to get pregnant. They either have multiple miscarriages or they're not able to get pregnant, and then they go see a specialist who says, "Oh what's, let's take a look." And then somebody does a scan and then realizes, oh, you actually have fibroids. And it doesn't mean that if you have fibroids, you're not gonna be able to get pregnant. But if it's inside the uterine cavity where a baby would form then of course it's gonna be blocking the implantation of an embryo. And so that can lead to recurrent miscarriages. There's also something about just having fibroids that creates a negative environment in the uterus. There can be some inflammatory markers that are secreted, and it makes the whole environment unfavorable. So we have also seen that, where there's like nothing else wrong, but the patient has one fibroid that's not even inside the cavity but just having that can cause infertility sometimes. And other times, it's people get pregnant, and then during the pregnancy, they're already, 20 weeks along, and then they're diagnosed with a fibroid. And so that is a little more tricky because there's really nothing to do right now because we just need to wait for the pregnancy to come to a term and have the baby and everything. But fibroids can also cause a lot of fertility or pregnancy issues where they can start to degenerate or shrink or shrivel up because there's competition with the fibroids and the placenta. And the placenta and the baby is, taking all the blood from the uterus, and the fibroid is no longer getting this blood and starts to get mad and angry and create a lot of pain. This is probably one of the most painful things in pregnancy, is degeneration of fibroids. And then you end up having to, get admitted for pain control. Also, fibroids can grow during pregnancy. So as the baby grows, the fibroids can grow. And then you can imagine that there's like a space issue. There's only so much space in the abdomen. And so this, sometimes this can cause preterm labor, preterm birth, growth restriction problems. So fibroids really traverse the whole lifespan of a premenstrual, pre-premenopausal woman.

Kerry Reller 13:43

Yeah. What I'm imagining with the ones that like is shriveling up is that it's like the blood supply, like you said, is being cut off or something, and that usually can cause like cramping. I'm like thinking like mesenteric ischemia pain,

Cheruba Prabakar 13:54

Yes. It's so painful.

Kerry Reller 13:57

blood supply to something.

Cheruba Prabakar 13:58

You're losing blood supply. It's so painful, and I just remember the faces of these patients during residency. They would come in with so much pain, and they would have to be admitted for two or three days with morphine, just to get this pain under control

Kerry Reller 14:14

Did we talk about why fibroids grow or get there in the first place?

Cheruba Prabakar 14:19

Yeah,

What Causes Fibroids?

Cheruba Prabakar 14:19

this is a million-dollar question. We don't really know why fibroids start in the first place, and there's a lot of theories. There have been a couple of genes that have been identified pathways where things go wrong that cause more deposits of fibrous tissue. There have been environmental factors. Certainly family history is a huge player, so when, That, that's one of the things we should always be asking our patients, d- not just do you have fibroids, but anybody in your family have a hysterectomy for fibroids, and a lot of times we'll hear from these patients that their mom, grandmother, all had fibroids. And so we should be screening these patients more closely. So yeah, it's... Right now it's frustrating because we don't know exactly what causes it, so we can't go after it, but we know that it's a combination of genetics and lifestyle.

Kerry Reller 15:15

Does, is the incidence growing, like in the last

Cheruba Prabakar 15:18

know that it's growing. I think it's always been around 80% with the leading cause of hysterectomy 600,000 hysterectomies done in the US every year for, And that's all causes of bleeding, cancer, all the things, but actually no, 600,000 benign hysterectomies. So mostly that is from fibroids. So that number has gone down a little bit to 400,000 recently, but that's still a big number. So yeah, it's a big problem

Kerry Reller 15:48

So when does it come to a hysterectomy? What are the options that these patients have?

Treatment Options Beyond Hysterectomy

Cheruba Prabakar 15:53

Yeah. So I always tell patients it really comes down to what your symptoms are. So if you have fibroids and they don't even bother you, you didn't even know they, you had them, and it was just identified in some scan you don't have to do anything at all. Just, get a scan every few years to make sure it's not growing so you're not surprised suddenly that you had a one centimeter fibroid and now it's 10 centimeters. So keep an eye on it, but you don't need to act on it. Other patients have severe bleeding. So in that case, definitely we have lots of hormonal medications to stop that bleeding. But if they are trying to get pregnant or, pre-fertility phase, then we don't want to do anything too invasive. But if the fibroids are inside the cavity you can stop the bleeding through pills, but you're not gonna take care of the problem. So in that case, we do recommend removing these fibroids. Other women are done having kids or don't wanna have kids, then we can do some ablative procedures and embolization procedures. So those are a little bit more invasive, but they go in and cut off blood supply to the uterus or cut off blood supply to those fibroids and shrink them over time. So that's good enough for some patients who don't want anything too crazy invasive, but they also want some relief from bloating or just feeling that their fibroids are big, they can't zip up their pants, like those kinds of things. And then

Kerry Reller 17:10

when you do that, when you cut off the blood supply, is it as painful as when the pregnant patient is fighting for the blood supply?

Cheruba Prabakar 17:16

Can, yes, it can be very painful, and some, some hospitals, they will admit the patient overnight just for pain control. Yeah. So it can be pretty painful.

Kerry Reller 17:25

process then?

Cheruba Prabakar 17:26

So when we do an emboliza-

Kerry Reller 17:28

Yeah

Cheruba Prabakar 17:29

embolization is done with a, by a radiologist, and they... interventional radiologist, and they shoot these little pellets right into the uterine arteries, and it shrinks these fibroids and the whole uterus. That can take up to a year. So it's not a oh, we do it today and tomorrow your uterus is, half the size. It can take a long time

Kerry Reller 17:48

Wow. Okay. So when then after all of those options, there's Is it just left with hysterectomy?

Cheruba Prabakar 17:54

So after all of those options if we've done all of those things, then we can do a myomectomy. So if you've got 10 fibroids and you don't want a hysterectomy or you're still trying to get pregnant, then we go do a myomectomy, take out all those fibroids, clean it all up. So that's the next step. And then finally, if you've got all those fibroids and this is your third surgery, and you're like, "Ugh, I just don't wanna keep doing this over and over again," or you're done having kids or you don't have kids and you're never interested in them and you just want a good quality of life, then a hysterectomy is the final option. Yeah

Kerry Reller 18:28

So what would a woman do if they're, like, told, "You need a hysterectomy"? Is there certain questions that they would ask before kinda making that final decision?

Cheruba Prabakar 18:38

I always recommend that you get a second opinion, a third opinion. So it's your body. It's kind of a big decision. You're going... It's a big surgery, so you just don't wanna sign up for it on the first get-go. You really wanna think about it and really weigh through your options. And so that's what I would suggest before doing that. But some patients when they come to me, they've already, they've been already fighting this battle for 10 years, and they're just done. So it's... But if you're ever surprised by that recommendation from someone, it's always nice to get another, another opinion

Kerry Reller 19:08

Would you say you're on the boat of, we don't need the uterus anymore if you're done having children, or, and they just take it out? A lot of women kinda say that kinda thing when, oh, I don't need it anymore, just take it out. Or what would you

Cheruba Prabakar 19:20

Yeah.

Kerry Reller 19:21

risks and all that are involved?

Cheruba Prabakar 19:23

Yeah, so the uterus, we do have some information now that we always thought the ovaries were the ones that are providing estrogen and giving hormones, which is true, and the uterus is just like a muscle for carrying children. But there have been studies that show that even if you keep your ovaries and just remove your uterus, you actually reach menopause a year earlier than the average patient. So there's something about the blood supply that it's all a little connected there. And they also showed that there is increased risk of cardiovascular disease in patients who have a hysterectomy. So again, is that because there's some shared blood supply to the ovary and that blood supply gets cut off a little bit? Unclear. So it's not a willy-nilly decision to make. There are some repercussions there, and also it's a major surgery even though now we do it laparoscopically, robotically patients go home the same day. So it may seem ah, it's not a big deal and, you... for many it's not, but it's still a major surgery. So I would take that into account. But on the flip side, it also depends on how much the patient is suffering. So if you're like, "I have a bad quality of life because I'm not able to enjoy any vacations with my family. I always need a bathroom nearby. I'm tired. I'm fatigued. I'm anemic. I'm getting blood transfusions." How long are you gonna do that? So I... it just has to be something that, makes sense, and I think many... most women are very careful about ma- in these decision-making processes as long as they have the information.

Kerry Reller 21:01

It's kinda interesting and maybe being nitpicky, but when you say that they reach menopause earlier after having the hysterectomy, how do you even define that if menopause is just the definition of your last period, right?

Cheruba Prabakar 21:14

Yeah. Yeah, that's a great question.

Kerry Reller 21:16

figure that out?

Cheruba Prabakar 21:17

Yes, so if you have your ovaries, you're still ovulating we can still do a blood test to see where you're at. So yes, if you don't have a uterus, you're not gonna bleed because there's nothing to bleed from, but we can determine that by blood test.

Kerry Reller 21:31

Yeah, that's

Cheruba Prabakar 21:32

Yeah.

Kerry Reller 21:33

Anyway,

Cheruba Prabakar 21:34

Yes.

Kerry Reller 21:34

yeah, so what else have we missed or have we not mentioned with the with everything about fibroids before we ask you about your big activity,

Cheruba Prabakar 21:43

Yes. Yes. I I think my biggest message

Advocating for Your Health and Fibroid Resources

Cheruba Prabakar 21:46

for women is to be proactive. If something doesn't feel right, go see a doctor. Go get checked out a second time. Get a scan. That's where many people miss it. They're given the birth control or whatever, but nobody's given a scan until they're in their 30s, and who knows how long these fibroids have been there. So the more knowledge you have, the more power to you, and the better decisions you can make

Kerry Reller 22:09

That's awesome. So tell us about what you've been up to and why, why you

Cheruba Prabakar 22:14

Yes.

Kerry Reller 22:15

Yeah

Cheruba Prabakar 22:16

I wrote a book. I have it right here. It's called Fibroids Finally Heard. And I wrote it because so many women in my office come with all these fragmented ideas of their treatment plan and what they should do, and they're going on Instagram and TikTok to get answers. They can barely get time with their doctors. And i- I just was like, "This isn't... This cannot be. Like, this cannot be the way we are dealing with fibroids." And so I decided to write a patient-facing guide. It's called The Practical Guide from Diagnosis to Recovery, and I literally go through s- all of the things we talked about. I talk about my mom's story everything you need to know about fibroids. I talk about the fact that they're not alone. Many women are isolated in this journey and feel like, "Ugh, no one else is going through this but me," but that's not true. We've got 27 million women in the US who have fibroids today. And I talk about how to get the care you deserve fertility treatment options, surgical considerations, optimizing your experience before and after. I have several helpful checklists. So it's just like someone's diagnosed with a fibroid. You're like, "Oh, what do I do now?" You pick up this book, and then you just read it from beginning to end. It takes about 90 minutes to two hours, and you've got all your resources right there, and you'll feel a lot more empowered to make those decisions from an informed place. And then at the end, I have a link to my online community on school. It's called the Fibroid Circle, and this is where we have a live Q&A every week... i'm sorry, every month on cases that various women bring how to make these decisions, and women from all over the world join in in this discussion. You're more than welcome to join that too,

Kerry Reller 24:03

that is super cool. I didn't know you had the community, and that really I'm sure helps so that they can ask these questions that, they probably need to ask their doctor too, and I'm sure you have to do the disclaimer, this is not medical advice or whatever. But

Cheruba Prabakar 24:15

correct

Kerry Reller 24:16

that I- it's so nice that, they, that women can go and feel heard and get their questions answered and get, it's like you said, like a guide, right? For what could they do and ask, and what to ask and what the next steps may be. And, not only feeling alone in general, they might be alone, but if they even have a partner, sometimes men just really don't wanna hear anything about this kind of stuff, right? And, being able to have a source or a community that, that you're

Cheruba Prabakar 24:40

Yes

Kerry Reller 24:42

thing to have.

Cheruba Prabakar 24:43

Yeah, because so many women feel yeah, alone, and that's just no way to feel, especially this is a long game. Fibroids the fibroid journey is a marathon. It's not a race. It's can be long, it can be multiple treatment plans, multiple surgeries. And especially if you- if you're not wanting to do a hysterectomy, it can be a long road, and a lot of things come up during this time, so

Kerry Reller 25:09

Yeah. I think what you've done is great, and like I said in the beginning, you're known as the fibroid doc, which is super exciting. So how can they follow you and find you if they wanna, work with you, other than the book, obviously?

Cheruba Prabakar 25:21

Yes. So you can find me on Instagram, TikTok, YouTube as The Fibroid Doc, and yeah, across all social media. You can join my Skool community join our newsletter at The Fibroid Doc. There's a website, thefibroiddoc.com. So you can get on there and yeah. And if you are anywhere in California, I'm happy to see you for a consult. Or if you're not anywhere in California and somewhere else in the country or the world, we can set up a coaching call that's one-on-one where I just answer your questions about fibroids

Kerry Reller 25:51

Nice. I did-- Do you wanna say a little bit about your practice?

Cheruba Prabakar 25:54

Yeah I am in Northern California right outside the San Francisco Bay Area, and I have a very boutique practice that is just focused on complex gynecology. So we do a lot of fibroids, endometriosis, menopause, sexual medicine, and so wherever you are in California, it could be LA, it could be San Diego. You don't have to be in the Bay Area. We can always do a tele-visit to discuss your issues.

Kerry Reller 26:18

Awesome. Yeah, thank you so much for joining me on the podcast today. Is there anything else that you'd like to add before we close?

Cheruba Prabakar 26:25

No, thank you so much for having me, and this is such an important topic, and so I'm so glad that you decided to focus on this. And I just wanna encourage everyone who's listening to be proactive about your health. And if you are a physician or healthcare provider, think about fibroids when you see people with heavy bleeding

Kerry Reller 26:43

I know I will. I feel like it's going to be right in my differential, differential now instead of,

Cheruba Prabakar 26:48

Yeah

Kerry Reller 26:49

I don't know. Like I said, it's not my specialty, so I am... It's gonna be forefront. Every time I do these podcasts, I learn so much. So thank you so much for educating me and our listeners and everybody. It's been a lot of fun. And everybody, stay tuned next week for next week's episode and Get Healthy Tampa Bay. Thank you, Dr. Cheruba

Cheruba Prabakar 27:05

right. Thank you. Bye

Kerry Reller 27:08

Bye