Botox for Pelvic Pain

In this episode of Fit as a Fiddle, we sit down with Charlotte Mueller, a nurse practitioner at the Centers for Vulvovaginal Disorders in New York City, to unpack what pelvic pain really is and why it is so often misunderstood. Charlotte shares her journey from oncology nursing to vulvo-vaginal pain specialty care, along with her own lived experience as a patient navigating dismissal, misinformation, and the long road to feeling better in her body.

Together, we explore the importance of patient-centered care, validation, and a team-based approach between medical providers and pelvic floor physical therapists. Charlotte explains how Botox can be used as a therapeutic tool for hypertonic pelvic floor muscles, how it works, and which patients may benefit most. She also breaks down why it is not a stand-alone fix, but rather a way to create space for pelvic floor PT, breathwork, awareness, and behavior change.

We also discuss an exciting new randomized clinical trial at the Centers for Vulvovaginal Disorders using botulinum toxin injections for people with confirmed hypertonic pelvic floor muscles and posterior vestibule pain. Charlotte shares what participants can expect, along with practical strategies patients can start using right away, from noticing clenching patterns to understanding the jaw-pelvis connection.

If you are a patient, provider, or simply curious about evidence-based options for pelvic pain, this episode offers a hopeful look at how science, empathy, and multidisciplinary care can help people get out of pain and back into their lives.

To check if you are eligible to get free botox through the research study, email research.cvvd@gmail.com

Connect with Charlotte: vulvodynia.com

Click here and use your exclusive 20% listener discount (Code: Fit20) to enroll in Master Your Pelvic Floor, our signature self-paced course that will change the way you understand and care for your body.

Transcript

SPEAKER_00 0:00

Botox is so great at relaxing that it creates this window of opportunity for PT. It's not necessary for everyone to get out of this cycle, but a lot of people need some muscle relaxant in addition to the physical therapy that they're doing.

SPEAKER_01 0:19

Hello, everyone. I'm your host, Dr. Sneha Ghazi, a physical therapist, course creator, and mom. I own Sneha Physical Therapy, a private practice in New York City, and created the course Master Your Public Floor to help you transform the way you think about and move your body. Use discount code FIT20 for a special 20% discount exclusively from my listeners at the link in all show notes. Each episode brings phenomenal guests in the health and wellness space who share inspiring tips and tangible advice. All things health and wellness starts right here. Hello everyone, and welcome to this week's episode on Fit as a Fiddle. Our guest today is Charlotte Newler. Charlotte is a nurse practitioner at the Centers for Volvable Vaginal Disorders in New York City. Our offices are like blocks away from each other, which is really fun. And Charlotte and I work together on some patient cases. She treats every a lot of things around pelvic health and pelvic pain. And there's lots of different kinds of pelvic pain. So she's maybe going to touch on a couple of those in a second. And as an orthopedic and pelvic fluoroptee, there's so many interventions that she offers that are so important for our patients to heal and very necessary in a multidisciplinary plan of care. So, Charlotte, we're really excited to have you on the show today. Thank you for joining us. Yeah, thanks for having me. Absolutely. It'll be fun. Yeah. So for listeners to get to know you a little bit and what you do as a nurse practitioner in this field, um, tell us a little bit about yourself and what brought you to where you are right now.

SPEAKER_00 2:00

Um, I think that as I was going through my career as a nurse, I was, you know, thinking about what I like and don't like, what I'm good and not good at, what fulfills me and what doesn't. Um I really found that I liked coordinating care, like helping people navigate the system a little bit. And I worked in oncology before this, and so there was a lot of coordination of that um as a nurse and helping people find appropriate resources. Um, I also found that I liked talking about quality of life, like being involved in those conversations. So like I, you know, in the in the cancer community, like you call survivorship was some of the conversations that I enjoyed. Um talking about how we can now feel good in our bodies after you've gone through all of the treatment. Um, I like uh condition thinking about conditions that have multiple factors that are contributing to what's going on. It feels like creative thinking and problem solving. And I think that I find all of those aspects in treating vulvo vaginal pain conditions. I like the ability to really be able to take time to hear a patient's story, um, hear where they're coming from and hear what their concerns are and what they're they're asking for. Um, I also got into the field of vulvo vaginal pain because I was a patient first, and that was sort of my introduction to this world. Um, I then took a step away because I had to process the whole experience, and I didn't want to um be dealing, uh, be treating patients before I fully under uh understood how I was getting myself better. Um, but I did get better, and I I feel that it gives me um a perspective of where patients are coming from and and how difficult it is to navigate and and how easily it is to be dismissed. Um because it's it's hard to go to providers with these symptoms and then be told we don't know, um, or you know, at worst it's all in your head, or you know, there's there's tons of bad advice out there. And so I like working in this space and being able to um really break down, you know, the reasons for the pain and explaining why there is pain and and why um it's not all in your head, and um helping coordinate with all of the providers that are needed to treat these conditions. So we work with pain management, specialists and physical therapists, and all types of all types of providers. Um so I think I address your issue. I think all of those factors are why I like being in this field. So it's a combination of what I like about my nursing uh and nurse practitioner role and also my patient perspective.

SPEAKER_01 5:06

So I do love that. And I think that, you know, while every cardiologist doesn't have to have had heart surgery and every, you know, every person who has been a provider in some field does not have to have personal experience. I do think when it comes to a lot of this pelvic health stuff, it's it's it's nice to have some level of empathy and understanding for patients. And that can even come from a loved one or just a friend or just somebody that you know in your life or yourself going through that. Um, not that I ever wish that providers have the same problems, but um, it's really helpful because I think you come from a strong understanding of patient-centered care, and that's just so important in in this field and all fields, but really um in cancer field in oncology and in in um pelvic health and and stuff that's can really be hard to understand, that takes a lot of upper level expertise and training to be able to do. And so I think your patients are probably just so much more grateful for you and the type of that side manner that you have, and the type of understanding and the type of education you provide, probably because you've gone through something like that. I have a similar story with um pelvic issues on my own end and overcoming that. So I always have a lot of empathy for my patients who struggle with these quality of life issues, as we've said. Um okay, so let's kind of jump into our topic today. Um, Charlotte is in the middle of a research study, and so she is going to talk to us a bit about Botox as it relates to pelvic pain. So we have a lot of misconceptions and maybe preconceived notions of the uses of Botox in the general public, right? So people most of the time will typically see it as a something that people use for cosmetics in various ways. So, Charlotte, can you please explain to our audience what is Botox in the first place? And then what are its uses from like a therapeutic sense versus a cosmetic sense? What does that look like?

SPEAKER_00 7:21

Okay, so Botox is a is a neurotoxin, so it's toxic to our nervous system. So Botox specifically is called is called botulitum toxin type A. It comes from a bacteria called Clostridium botulitum. Um, and it works by disrupting the signaling between our nerves and our muscles. So it leads to a paralysis of the muscle temporarily. So drug manufacturers are able to get this toxin and purify it and put it in a powdered form, and then we basically reconstitute it in a solution and are able to inject it in small amounts intentionally to paralyze the muscle for either a therapeutic or cosmetic effect. And so most people understand it from a cosmetic use when it's injected like just in the muscles under the under the skin. And so when those muscles are paralyzed, the overlying skin can't form those creases. I don't have Botox right now. And I if I did, like no matter how hard I wanted to raise my eyebrows, I couldn't because the signal is blocked. So I'm telling my muscle, my brow to ro to to rise, but acetylcholine, which tells then the muscle is signal molecule, um, the muscle doesn't receive it, so it doesn't move. And so it's it's it's blocked and it's temporary. It always wears off. But therapeutically it's used for so many different conditions that are involved with having two-type muscles. So team J, migraines, and it's it not only relaxes the muscle, but also does inhibit some pain signals, so it improves the actual pain of the condition. Um, so this means that not only like the peripheral pain signaling is is improved, but there has been improvement in central sensitization, which is is something like that that occurs when you have chronic pain, you can have heightened um nerve signaling. Uh so even when there's no longer that acute injury or reason to have such a heightened pain signaling, but it can develop from having chronic pain. So Botox helps in in both muscle paralysis and in pain signaling, which makes it really good for pelvic floor dysfunction. Um so we are just starting our study actually screening our first patients coming in in New York for baseline visit today. So this is pretty early on in our recruitment of participants. We're going to be recruiting 54 patients in totals over the next year and a half. So if you're thinking about it now, but you may not qualify now or may want to do it later, there's a big window of opportunity to enroll in the next year and a half. Um, I think your question is about Botox.

SPEAKER_01 10:17

I'll stop there and then Yeah, let's actually talk about uh pelvic pain and then as it relates to the study, and you can explain this Skype further. So, what kind of patients, what kind of symptoms, um, what would a patient like typically look like who would come in and would possibly be a candidate for Botox being a part of their plan of care?

SPEAKER_00 10:40

So pelvic pain doesn't mean one thing. Um, there's a lot going on in the pelvis and many potential causes of pain. So to answer that, I think thinking about the structures and function of the pelvis, it is the first thing. So you have your organs like the bladder, the reproductive organs, the uterus, the ovaries, cervix, vagina, and then the bulba is the external. Um then you have your pelvic bones, um, which are connected to your spine and your legs, and these connections, which are joints, are secured by connective tissue. You have your blood vessels that are carrying nutrients and oxygen and hormones to all of these organs, and you have your nerves from the spine that are communicating between the organs and the brain. So there's a lot of coordination and communication and organs and a lot going on. Um, and then you have the muscle groups, which you know as a physical therapist, um, there's a lot of muscle groups in pelvis. One of them is the pelvic floor, which is like the bulb, this the bowl of muscles that's at the bottom that supports the organs and it also helps coordinate their functions. Um, so if these muscles at the floor are too loose, you can get um incontinence. That's not what they're that's not the ideal patient for this study. The ideal patient for this study is someone who has their pelvic floor muscles are too tight because the tightness causes pain. When muscles are too tight in the in the pelvic floor muscles, they cause pain because they constrict blood flow. So the there are blood vessels that run through these muscle groups and they kind of cut off that blood flow when they're really tight. And so the tissue overlying these muscles will become painful because what blood carries is oxygen, nutrients, and hormones to the cells. And without those, without oxygen, the cells move into a process called anaerobic respiration, which you may recall from biology. Um, basically the cells create energy in a different process, and the byproduct is lactic acid, and lactic acid burns. And when you work out and you feel that muscle burn, you're that's the lactic acid production. Um, that's what's going on like in the pelvis, and the pain versus you know, weak versus tight muscles, which I think is one distinction we have to make before regarding this trial. Um the other key piece of anatomy that put this picture to uh together for me when I started working at this job, not I did not learn this in school, about the pelvic floor muscles, is that they have attachments in the back of the vagina and the the vestibule, which is that um small area of tissue at the entrance of the vagina. It's between the um heart slime and and and hymen, which is if you separate the small lips called the labia menorah, and you put your finger about like one nucle deep, then you're in vestibule territory. So muscles attach at the bottom part of this. So that's um important to know. Um, really important to understand in evaluating anyone who says they have pain with sex, pain with tampons, pain with speculums, pain with tight clothing or sitting or anything that touches that area, you have to assess whether that pain is only in the muscle groups that are where the muscles attach, which is the bottom half of the vestibule, or is there pain elsewhere? So if there's pain up by the urethra or other places in the vestibule, the Botox is not going to be the right treatment for that for that person. So it's very possible, and it's also very common to have more than one cause of your pain. So you might have uh multiple things going on, pelvic floor muscles may be tight and be contributing to the pain. Um, but you want to address those other sources generally first before we target the muscles. Um because if you have something like an autoimmune skin condition that's causing you all this pain all the time, even if you give Botox, the muscles are still gonna have a hard time relaxing because you're in pain for soap for another reason. Um so I think once you identify the cause, like the location of the pain and understand that the pelvic floor muscles are involved, you then want to think about why their pelvic floor muscles got into that place. And I can talk more about I think about that. Um I think I got off track with your question.

SPEAKER_01 15:33

No, that's perfectly on track. I actually really love that you explained that. Um, hopefully, listeners, I know that there's lots, a couple of terms that you use, like Karg's line, um that maybe people don't fully understand. But I think tell me if I summarize this correctly, that pelvic pain can be coming from various causes, right? So it could be coming from a muscular reason, it could be coming from a dermatological reason. So that would be related to the skin. Um, it could be coming from a nerve disruption of some kind, um, that's usually coming from the lumbar spine and the sacrum. So the lower back is where the nerves come out of. So it could be a nerve dysfunction. Um, there could be all the like basically different structures. It could be a ligamentous or a bony injury that could be referring pain and reproducing pain in the pelvis, like you mentioned. So because there's all those structures, the bones, the ligaments, the blood vessels, the nerves, the muscles, pain can be coming from a disruption of any of those structures. And specifically with pelvic floor muscles themselves, their uh location makes them basically susceptible for pain and dysfunction and issues with bowel, bladder, and sexual function, just because of the nature of where they are. So if somebody's coming in who has female anatomy and so they're having pain with some kind of vaginal penetration, um, like you mentioned, the speculum, the tampon, penetrative intercourse, things like that, then one of the things that go that you should be thinking about is is there pelvic floor muscle dysfunction? Because there's other kinds of pelvic floor dysfunction. Like, for example, I've like mentioned this in my course as an example. Um, and tell me if you agree or have a comment on this. But I've had patients coming in with like straight up urinary urgency frequency incontinence. And there's absolutely nothing wrong with their pelvic floor muscles. They're just doing something absolutely insane with their diet soda and their iced coffee and like not eating food and just like constantly peeing and leaking because their overfluid intake is just too much for them. So we changed their nutrition, and so that affects their pelvic floor, but they had good pelvic floor muscle coordination on an exam, right? So I don't know if you have could comment on how or like continue to elaborate on how there could be many sources for pelvic floor issues in general, but when there's pelvic floor muscle dysfunction, and that muscle dysfunction specifically comes from an over-contraction or a tightness of muscles where it's stuck in a tight space and has lactose acid development, that would be a good person for the things that we're about to discuss in a second here. Does that sound right to you? Can I do that?

SPEAKER_00 18:22

No, it sounds right. I think you asked a question there. I guess I think of the causes of pelvic floor muscle dysfunction or hypertonic pelvic floor muscles as a few different categories. So you can you can one of them is guarding. So if you have pain from recurrent infections or a skin condition, the the natural response of the body is to guard to protect you. So your muscles are trying to protect and serve you in some way, but they get trapped in the cycle that they cannot get out of. It can be starting with guarding. Uh, the other category we think of see a lot is compensation, I is how we think of it. So especially in the hypermobile patients. So the pelvic floor helps support all of these, has connections to all of these bony structures and helps support or helps support them. So if you have a joint that has um that is very hypermobile, and the reason they're hypermobile is as you know, because the connective tissue can be very stretchy. And so if that connective tissue is stretchy, then you have an unstable joint. And um the body subconsciously, their muscles will contract to support that joint so that you can walk and move and not be wobbly. We the the pelvic floor muscles can get in a chronic state because they're constantly supporting an unstable joint. So Botox can get them out of that cycle, but then they have to learn how to strengthen the muscles around the joint. Because if you are a hypermobile person, you don't want floppy joints because that leads to injury and pain. You want to have control over your joints, and that's when it comes down with your strengthening and you work, someone like you, physical therapy to learn that about your body. But um the I guess the other group of reasons why pelvic floor muscles can get into this chronic cycle is behavioral. Um so if you're someone who holds your urine all day, or if you're someone who does a lot of intense core workouts, um, someone who just generally holds stress in their in that part of their body, um, you know, we see a lot of connection between jaw clenchers and people who hold their stress here in their jaw will also hold it in their pelvis. They're like kind of floors that mirror each other. So you know the the jaw, the diaphragm, and the pelvis. And so learning how to breathe with your diaphragm and relax that is also helpful for the pelvic floor. So I think the guarding compensation and behavioral causes are usually what gets people into these cycles. Um Botox is so great at relaxing that it creates this window of opportunity for PT. It's not necessary for everyone to get out of this cycle, but a lot of people need some muscle relaxant in addition to the physical therapy that they're doing.

SPEAKER_01 21:27

Absolutely. I love this conversation and geeking out to this. And it's really nice to like speak with a non-pelvic floor PT in this way, because uh obviously, as you know, there's like not a ton of uh healthcare providers and medical professionals who understand this field so well, Charlotte. And um, the way that you explain it is so perfectly beautifully understandable to listeners, or at least I really hope that it is, because this is the same way that we talk about it as PTs is there's so many causes for public. For dysfunction, and then when there's a muscle issue, there's different types of muscle issues. Like we we spoke just about tightness and weakness, but it could be a coordination, it could be endurance, it could be sensitivity, could be other things too, or a combination of them. And then why is that happening in the first place? And you just beautifully described how it could be because of the guarding, the compensations. And we see this a lot in our clinic where sometimes it's one thing and sometimes it's a little blend of a couple of different things, especially if it's been going on for so long. So then I always say to people, like, it's kind of like a chicken or an egg situation at this point, because I didn't see you 10 years ago when this first started presenting to you. And there's been so many changes. But here's what we see right now. What we we see, what we treat, what we see. We treat what we find and we use our best clinical judgment. And as providers who actually like physically work inside and outside of the pelvic floor structures, having a really good understanding of the structures in the first place, how they function and what does dysfunction look like is really important. Because if you don't, then you turned into what you what Charlotte mentioned earlier, a provider who might just you might bump into a provider if you're a patient listening, or if you're a provider listening who doesn't treat it, you might be compelled to say, I don't know what's going on, or maybe it's in the patient's head, or you know, bump them off to maybe the wrong referral source because and that person might also not understand. So this starts the cycle of people just suffering unnecessarily.

SPEAKER_00 23:33

Well said.

SPEAKER_01 23:34

Yeah.

SPEAKER_00 23:35

Completely agree.

SPEAKER_01 23:37

Yes. So let's um dive into a little bit specific because I know we talked about the Botox. We talked about like what kind of a candidate would be would be able to benefit from this. What are some other things that you offer other than Botox in your treatment strategies? And why would you offer them um as maybe a comprehensive plan of care for patients? So stepping away from the study just a little bit.

SPEAKER_00 24:04

Specifically for hypertonic or tight pelvic floor muscles. Um exactly. We also have muscle relaxants that come in suppository form. So you can do uh a suppository of valium diazepam that's inserted at either vaginally or rectally, depending on where which muscles we need to target more. Um and they're absorbed mostly locally, right in those muscle groups, a little bit of absorption in the bloodstream. I mean, that's really the first muscle relaxant I would start with. Is um there's others like called another one is baclefin, which we can we can do for all the polar dysfunction. So starting with something that's less expensive, Botox expensive, and Botox requires um an injection. It's a very, very thin needle. It's the size of an acupuncture needle, but it's not zero pain. It's a you know, you feel the poke and you feel some burn for about four seconds. Um so try to avoid that initially, unless someone has already tried everything and they're ready for the next big gut muscle relaxant that will, but usually not the first.

SPEAKER_01 25:19

Yeah. And then of course, we want to make sure that, you know, as you mentioned, helping patients understand, right? Like why they're having their symptoms can be actually one of the first pathways to helping them heal. So explaining to them that even if you do this Botox and then you don't understand how to relax your pelvic floor muscles and relax your jaw and take deep breaths, as soon as the Botox wears off, it's gonna literally just like go back to how it was. And so giving patients that education of that behavioral change, I feel like can be so beneficial from day one.

SPEAKER_00 25:53

Um Absolutely. I don't think we have the conversation about Botox or muscle relaxes in general without talking about how you need to retrain your muscles and get them back to their natural happy place.

SPEAKER_01 26:08

Yeah. So first, I oh anybody who's a patient listening right now will be like, yeah, I know, I know. But uh my two things that I tell anybody on an evaluation, no matter who they are, whether they're coming in for knee pain or back pain or headaches or shoulder pain or pelvic pain, it doesn't matter. But I tell them two things. It's one, I just need you to start becoming hyper aware of how you are holding your body in like all of your body. And then if especially if it's somebody coming in for back, hip pelvic stuff, I'll tell them I need you to become hyper aware of where your pelvic floor is. And I would have explained to them with usually an intravaginal pelvic floor muscle evaluation on that day of what those different states of the pelvic floor are and how you move them and help them. I mean, I'll usually say don't change anything. I just want you to understand and begin to bring awareness to it. And then usually come in the next session on um session number two, and they'll be like, I had no idea that I was doing, and then go into like what they took notes on, whether that could be, oh, I didn't, because I'll explain them various scenarios and they'll be like, I didn't realize that I was just like curled up on the couch watching TV for two hours on my left side, and then my the whole night I can't sleep because I have left-sided like pelvic girdle pain and lower back pain, and I'm sleeping on that side too. And then all these things are like, you know, it's if there's so much that we can do that will help us. And once we become aware of what we're doing in the first place that could be changed, that's almost the most powerful thing that people can understand. Um, because it's something that they have control over, whether they think they do or not. They really do. It's just this awareness that needs to build. And so providers like us give you that awareness because we can teach you what the space is in your body, which feels so a shameful, be confusing, C hard to get to literally physically. And so that connection is um what we do in different practices in slightly different ways, which is really cool.

SPEAKER_00 28:12

Yeah, um, as I I can Gregory, I as you were talking, I was checking even with my own positioning and tension and where it is. Uh yeah, you have to be sort of guided and educated and reminded and learn these things. So that's why I love physical therapists. Can't do our job without you, we always say.

SPEAKER_01 28:34

Uh, we can't do our job without you. Steam work. Exactly. I love it. Charlotte, do you have anything else to add to our conversation today? Anything else you think that is important for listeners to learn about our topic, about your study?

SPEAKER_00 28:49

One of the most important things for any physical therapist listening is that if someone is interested in participating, we will want them to have a diagnosis from a physical therapist or expert who knows how to assess the pelvic floor muscles and knows that they're hypertonic. We will then confirm when we see them that their pain is only in the back part of the vestibule called the posterior vestibule. So I do a ket test to confirm that. If they have pain elsewhere and there's other causes of pain going on, we we don't want them participating because they need multiple other forms of treatment. Um so that is one of the main criteria to be included. Um we are enrolling women who are 18 or older and who are pre-menopausal and who are not pregnant, breastfeeding, or trying to become pregnant. So we do do a urine uh pregnancy test before any injections. Um, we're just not studying for this for safety and pregnancy. You are allowed to be in physical therapy and you are allowed to be doing home exercises when you're enrolled in this trial. Um, we actually request that if you are in physical therapy, that you continue throughout the trial and that it doesn't change. So if you're going weekly, we want you to continue going weekly. And we don't want you to start immediately before the trial because then we don't know if the benefit is from the P, you know, the Botox or not. So if you are in PT, you need to be in PT at least for two months before enrolling. And that includes also home exercise. If you if you're doing home exercises, be consistent with we'll ask you to be consistent for about two months before you start enrolling. Um, if you've ever had pelvic floor botox in the past, that's okay. You just cannot have had it in the past year, but you can still enroll. Um and you can use you, if you use muscle relaxants, you would just have to stop them two weeks before enrolling in the trial. It will be up to like the clinician's judgment if there are other like causes of of pain that would exclude you. Um, but if you're interested, I would um contact our email, our research email, and you'll get a call from our research coordinator and they can go over all of these details with you and talk to you about whether or not you'd be eligible before you even come in for a visit. Um, then what would happen is you'd come in for a baseline visit and you wouldn't have any injections on that day. We would just confirm that you're eligible, and you would come back two weeks later and you would get your first series of injections. Um, you will either be randomized to receive the Botox, or in this case, Botox is a brand name. We're using the same toxin but from made from a different manufacturer. So it's not called Botox, but it's this it's the same. Um you either receive the Botox or you receive the placebo, which would just be saline injections. And so I don't know what you're receiving, you don't know what you're receiving, it's double-blinded, and it's uh randomized. So 50% of people will be placebo, 50% will be the drug. Then six weeks later, you come back for a second series, and then you will have two more visits that are just follow-up visits. And we assess um how you progress by doing um a dilator test in the office and by also doing questionnaires that you'll fill out. So the dilator is a validated way to measure pain with penetration. So it's like you start with a very small dilator and then the increases in diameter, and that's how we measure your progress objectively. Then at the end of the trial, if you were randomized to the placebo group, you'll actually have the option to then get the medication for free. So everyone who enrolls, I like talking about the study because for a few reasons. Everyone who enrolls gets the drug. Um you may have it initially, or you may have to wait until afterwards. We've been doing Botox repelvic floor, hypertonic pelvic floor for about 20 years at least, I think. Like it's we know it works, um, but we need the studies to demonstrate the effectiveness and also to then get FDA approval for so that insurance will cover it. So that's really what's also very exciting. And my boss, Dr. Goldstein, has been fighting to do this for 10 years, I think. And we finally have interest from this um manufacturer who's enabled us to do the study now. That's all I have to share right now. About I we spend the smart time talking about Botox and public floor, not the study, but um please include the the research emails that August sent to you um so that anyone who's just listening who's interested can can reach out to our research coordinators, learn some more, find out if they're eligible, and um get some free Votox and get out of paid.

SPEAKER_01 34:02

Yes. I will include um Charlotte Wilson me their the research email, which I will drop in the show notes for listeners, along with CBBD's um website, just in case you are curious about um the center's services and want to book an appointment or any other reason because they treat more than just hypertonic pelvic floor dysfunction. There's lots of other things that um uh this particular clinic treats as well. So the website actually does a very beautiful job. I sent some patients there just to help them explain um various conditions because you guys have a nice little um pretty diagram of explanations where you can click and then it expands and and helps people understand like what is pudendal neuralgia, for example, like that's a nerve dysfunction. And then I think there's like a lot of those. So for people who are just curious about hearing different types of pelvic issues, I actually send them there to a very credible way to help them understand. Um, so I'll drop that on the show links as well. Um, Charlotte, thank you so much for talking to our listeners and spending your very valuable clinical time with us to help us understand these concepts. And we really hope that um if you're a listener, that you gained something, that you understand something differently, whether you're uh patient side or your provider side, and that um if you're interested to enroll in the study, this um episode this particular episode's coming out in summer of 2026. So you'll have like a full year of enrollment that you can do. Um, and so if you're interested, please do uh reach out with the information in the show notes. Thank you so much, Charlotte. Thank you, Slanna. It's good to see you. Thank you all for tuning in and investing in yourself and your well-being. If you listened to the show today and gained anything out of it, share it far and wide. It means a world when you rate and review the show. Don't forget to use your exclusive 20% discount code FIT20 when you sign up for our signature course Master Your Public Floor, linked in the show notes. See you again next week with an exciting new guest and topic.