Marla Dubinsky, MD, on Lifelong Reproductive Care for Women With IBD

Dr Marla Dubinsky joins host Raymond Cross, MD, for a discussion about how inflammatory bowel disease affects the health of women, from sexual intimacy to contraception to menopause and more.

Raymond Cross, MD, is Medical Director, The Center for Inflammatory Bowel and Colorectal Diseases​, The Melissa L. Posner Institute for Digestive Health and Liver Disease at Mercy Medical Center​, in Baltimore, Maryland​. Marla Dubinsky, MD, is Chief of Pediatric Gastroenterology, Hepatology and Nutrition, Codirector of the Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center, and Professor of Pediatrics and Medicine at the Icahn School of Medicine at Mount Sinai in New York. 

IBD in Women Beyond Childbearing: Hormone Therapy, Sexual Health, and Pelvic Floor Dysfunction

• Inflammatory bowel disease (IBD), hormone replacement therapy (HRT), contraception: IBD increases venous thromboembolism risk; oral estrogen adds risk, while transdermal estrogen has lower clotting risk. Speakers favored individualized decisions, with progesterone-based IUDs generally preferred over estrogen-containing oral contraceptives, particularly in patients with additional thrombotic risk factors.
• Sexual health, pelvic floor dysfunction: Painful intercourse, urgency, fecal incontinence, and intimacy concerns were described as common and under-screened. Chronic rectal inflammation, surgery, and pelvic floor dysfunction may contribute; routine screening (e.g., asking about painful intercourse) and referral to gynecology/pelvic floor physical therapy were encouraged.
• Clinical management: Optimize IBD control to reduce disease burden and improve quality of life. Management should address patient-reported outcomes, including sexual health, while coordinating cervical cancer screening and menopausal care with gynecology according to individualized risk.

Any views and opinions expressed are those of the authors and/or participants and do not necessarily reflect the views, policies, or positions of the AIBD Network or H&P Global, its employees and affiliates.

Dr Cross:

Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center in Baltimore. I'm excited to have my friend Marla Dubinsky from Mount Sinai in New York here to talk about women's health beyond women's health and childbearing age, thinking sort of beyond childbearing age. Marla, welcome to IBD Drive Time.

Dr Dubinsky:

Thank you for having me.

Dr Cross:

So Marla, even though you're a pediatric gastroenterologist, you really manage women across all age groups. So when you're talking, we often talk about managing younger women, but when you're thinking about women that are post-childbearing, what are the most common issues that come up in practice?

Dr Dubinsky:

Yeah, I'd say one of the biggest questions we get asked from their primary care physicians and their gynecologists is the role of hormone replacement therapy, to be honest. That seems to be some leftover around how we've moved, and I'll just go backwards, to birth control for just a second. We've moved into this space, including in the global consensus guidelines that have recently been put out as it relates to preconception, that we would like to move away from oral birth control pills or at least estrogen-containing birth control pills and move towards more progesterone-based such as IUDs or more Depo for example, or progesterone-based birth control. So a lot of that discussion then sometimes feeds over when they come for their visits and say, "Well, my gynae was asking whether or not because of the increased clotting risk with IBD alone, then adding the estrogen, is this a risk factor for me?" And so we get a lot of questions around what to do around HRT.

And what's great news about it is that yes, IBD patients have an increased risk of blood clots. Yes, birth control pills, oral estrogen, increases the risk of blood clots, but less so for transdermal. So we do work with our gynes and also their primary care physicians to ensure that women who are at risk of osteoporosis, obviously in postmenopause as well as atrophy, and how it impacts their sexual health. So we are definitely working with our patients to ensure that HRT therapy when necessary is appropriately prescribed.

Dr Cross:

So Marla, I just want to follow up on what you said. I often get asked by patients what is the optimal birth control for them given that they're underlying IBD? And it seems to me like it's a bit nuanced. I think the patient in IBD that's in a deep remission, probably whatever's the most effective is the one that matters, whereas a patient that's flaring and does have a higher risk of clot, perhaps it's different. Do you agree?

Dr Dubinsky:

Yeah, I think if we take a step back and say, well, where were we? Basically the most important message, which is what you said, just take something, whatever's going to work for you and that you're going to take when it came to birth control, for example. And we're like, well, if you're not interested in an IUD, then we would say, of course, you can use an oral birth control, low dose, as low dose estrogen as possible. We may take some precautions if you are having active disease. Someone who's hospitalized and has been on long-term oral birth control and they're having active disease, we would even be more cautious around DVT risk, for example. So we do take it into consideration. But in the end, now that we have progesterone-based IUD, so hormonal IUDs, for example, and it's 5 years, and that way they don't have to forget taking their pill or have to think about taking a daily pill, et cetera.

It's actually been a nice transition conversation where I'm having that with my young adults, college age, for example. That's where it does come up with a lot of my patients is I'm going away to college and I'd like to be on some form of birth control, if they're not already, for example. And we've really moved into the IUD discussion as being primary. But we do of course know some people do not want an IUD. They don't prefer that, and they would rather prefer a birth control. So as you noted, they want birth control, they need birth control, so we will go with what they will actually prefer. And we do caution them.

For example, I'll say I had an interesting case, which I think you'd be interested in. I had a patient, we were talking about birth control, and she was on a hormonal birth oral contraceptive. She had Factor Five Leiden, and she was going on a JAK inhibitor for TNF-refractory perianal disease. So you get where I'm going—that there was a lot of complexities around. She wasn't active. It was a perianal disease, her luminal disease was well-controlled. But then I had this construct of, well, there's Factor Five Leiden. And so I sent it to my hematologist colleague, and he even called me sort of like we were hedging on, well, what is the real risk? She's young, she's not obese, she's active. What is really the risk with the oral birth control? And then we decided she's going to go on probably low-dose Eliquis. That was like, man, I don't know if it made all of us feel better and whether it should have been, but I think there are nuances like that where it does come into play. And I've also talked to her about converting over to an IUD for birth control, and she has agreed.

So these are nuances that you're not going to get in a paper or you're not going to get in the books. It's literally going to be as you come and you're faced with patients where there are these merging together of different entities that could increase the clotting risk, then you really start to think, well, I should probably prefer one over the other, if that makes sense.

Dr Cross:

Yeah. And just a quick follow-up. My understanding is that the IUD-based approaches and the depo-based approaches as far as failure rates, they're more effective than oral contraceptives.

Dr Dubinsky:

Particularly the IUD. The progesterone-based pills though, that just as an aside, those you have to take very regularly because the efficacy rate is not as great as the estrogen-containing oral contraceptive pills. So we try and avoid progesterone-only pills. We would definitely prefer a depo or an IUD, for example, progesterone-based IUD. Some patients, their gynae recommended copper IUDs. I'm like, you don't necessarily need a copper IUD, but some, that's still what they're using. So because maybe they got confused that it was hormonal and they didn't think they could take based on conversation or what they've read or seen at meetings, but you're correct. So essentially the most effective is something that you don't forget on a daily basis.

Dr Cross:

So hopefully my wife isn't listening to this. I don't think she listens to this podcast, thankfully for me, but she is perimenopausal. And I just want to touch base on hormonal therapy a little bit because I find it very frustrating as a spouse and then listening to my patients who are perimenopausal. It seems like there's this dichotomy among OB/GYNs where some of them are like, "You just need to get through it and get to the other side." And there's others that are very open and amenable to hormonal therapy. And you've set the stage here that from our standpoint, it's fine. It's not from their IBD, it's our job to control the IBD. And if there's some other factor present where we're maybe thinking about clotting, that's more nuanced. But do you see that as well? Or is it just me observing that here in Maryland that many women are suffering perimenopause without treatment?

Dr Dubinsky:

Yeah, I think there is. I think maybe, I don't know if I take IBD specifically, the fear of does it increase flares? There was some discussion that hormonal…it's the same conversation, by the way, that I have for patients who are preparing for egg transfer, for example, where there's additional hormone to stimulate eggs, et cetera, and preparation for retrieval that a lot of our patients are told that they may have an exacerbation of their IBD. Data at DDW presented and data that we also have at Sinai that, yeah, you may have GI symptoms just like somebody who doesn't have IBD, but it's not triggering a flare. And we even put that in the consensus actually, because there is a lot of myth around the role of hormones impacting your IBD. So whether or not, and fast-forwarding that into the HRT story, is it possible that there is this discussion, which maybe we need to deconstruct and educate both from our society and educate women and have a focus of that to try and educate the primaries as well as any gynae or reproductive or endocrinologist, for example, who may be working with our patients, that we are very much in support of women getting HRT if necessary, or if the patient agrees that that's what they want to do.

So I think that maybe a little bit of it is this carryover effect from birth control pill. That's what I was saying in the beginning, there was a long time ago where there was a feeling that birth control pills may cause IBD. I don't know if you remember that from the nurses' health study. There was some message around there. And then there was also quite a bit written historically around it increasing flares. And then that got, I think that debunked over time. We have come to realize that that was not true. So maybe it is a communication problem and maybe we need to be more proactive telling our female patients. We're so busy counseling them on birth control and then pregnancy and preconception and immediately postpartum. We're not focused enough on setting guidance for treating postmenopausal women. And I think you've brought up a really important topic, and it was funny, so we're so focused even in the guidelines, we didn't talk about postpartum. And maybe there needs to be an emphasis and maybe a position statement or maybe a consensus on managing women perimenopausal and postmenopausal with a little bit more intent.

Dr Cross:

Sounds like a good topic for Advances in IBD, I think, for one of the breakout sessions. Speaking of that, we are the official podcast of the AIBD Network. That's our sponsor. We're on Spotify and Apple Podcasts. We do have an AIBD regional coming up in Seattle, August 15th and August 16th. So we hope to see you there.

Marla, let's talk about sex. Everyone wants to talk about sex. So women with IBD, I had some research interest in this thinking about therapies and whether it improves sexual function, and I think anecdotally it certainly does. But when you actually start asking women about sexual dysfunction, pain with intercourse, it's way more prevalent. It can't be a hand-on-doorknob question. So talk to us about that.

Dr Dubinsky:

Yeah, which unfortunately, as you know, it's not going to happen. Because two things we know is that one, of course, unless we proactively ask, a lot of our patients feel that they must be the only one. That was what we found out, by the way, when we did the CONFIDE survey, which I'll talk about the sexual health piece in a second, is that did you know that up to 40 to 50% of our patients are wearing some type of protective undergarment for fear of having an accident weekly? I don't think we ever knew that until we asked it anonymously.

Dr Cross: I did not know that.

Dr Dubinsky:

We did not know that, and we weren't asking. Maybe that's why. But also we knew that when patients, that perception of it or why they felt like if it was important, my doctor would bring it up or it was too embarrassing to discuss because I must be the only one.

Again, this shame associated with it, and we weren't necessarily being proactive about it. That changed the way that I think about my patients and what I'm missing and how I'm not validating them on very important life-altering symptoms or events and their quality of life. And so that sort of moved into the next phase of CONFIDE, which within that anonymous survey, by the way, sorry, CONFIDE was sent to Europe and US and Japan and was really focused on the impact of urgency and fecal incontinence and its impact on social life, our patients’ social life, as well as sexual health. And it was very clear that a significant, we're not talking 30-40%, we're talking north of 65-70% of our patients reported an impact on their sexual health overall, their sexual relationship, their intimacy with their partners, and their impact on their sexual quality of life.

So I think, again, just like the urgency thing, I myself as well, are not equipped and/or educated enough to understand how to ask it, what's the minimum sensitivity around it. And really in my pregnancy clinic where our gynae, I'm there with my preconception team, which is our MFM and our OB/GYN. And part of what I started to learn is the way they were asking about intimacy and sexual health and painful intercourse, because that's part of their review of systems. For us, we're very focused on very IBD-specific.

And I started to uncover this concept of many of our patients have reports of painful intercourse, which of course made me realize that probably one of the most understudied or under-discussed impact of having chronic rectal inflammation or just chronic urgency or fear of an accident is pelvic floor dysfunction. I would venture to tell you that if you actually start to listen to your patient who we have a lot of patients where have a lot of urgency, multiple bowel movements, and they say they just can't get off the toilet or they feel like they just are not empty. When you really listen to patients and you then ask the question about painful intercourse, my gynae partner says that is synonymous for pelvic floor dysfunction, to a point where we're doing pelvic floor PT in a preconception for anyone who may have, now I'm very attuned to their discussions around pelvic floor during pregnancy. Because postpartum, and of course, as you get increased pelvic pressure, the impact long-term on pelvic floor dysfunction, it is really something, again, you talked about another area that we need to be focused on, not just postmenopausal, but also what is happening with the sexual and intimate health of our patients and how do we, in a sensitive way, normalize it to a point where that should be part of our intake because it is what our patients most want to have back in their lives. That is viewed to them of having a really normal quality of life comparative to their peers.

And so what I've begun to really understand is just the impact of chronic inflammation, particularly rectal. And I tell my patients and I say to them that it makes sense if you have anxiety or fear of going to the bathroom or having had one accident, truth be told, you know that, and we've discussed it, that a patient would rather have four sort of bowel movements that they can make it to the toilet than one urgent bowel movement that resulted in fecal incontinence. All you need is one for that to really create a lot of disability and anxiety that it's going to happen again. And that's why I say, I tell my patients, it makes sense. They've been walking around, their sphincters are really flexing really hard and they haven't been able to relax. It's really important that we start talking about the impact of uncontrolled inflammation.

Regardless of people saying, "Well, I have proctitis. I was told that I can use suppositories." No big deal. And you and I know that disease extent does not equate to severity. And you've had patients with the most severe proctitis who are suffering more than somebody who may have right-sided disease or transverse colonic inflammation. And I just don't think we focus enough time. And the impact of pelvic floor dysfunction also impacts sexual intimacy and sexual health. It is, again, yet another understudied area that impacts so many of our patients' lives.

Dr Cross:

So there's a lot to unpack there, and I want to summarize and then come back and ask some follow-ups. So for the listeners, painful intercourse is incredibly common. In my practice, the high risk groups, and Marla, you highlighted this, are those with active disease, particularly that have disease in the rectum, perianal disease, patients with prior surgery, particularly ileal pouch anal anastomosis, patients with stomas. So I routinely in patients with a recent abdominal surgery, a new stoma, I ask them about intimacy and understanding that intimacy and painful intercourse are not the same thing, that you can have intercourse that's not painful and still have issues with intimacy because you have a new ileostomy. They can be different.

So you mentioned how in your multidisciplinary clinic, how they ask the question. So if you are going to incorporate a screening question or two, how can someone ask this sensitively to our female patients?

Dr Dubinsky:

Yeah. I mean the main question as you notice, which is, do you have painful intercourse? That's probably one of the bare basic questions that we could be asking beyond even the high-risk patients, like what you said, Ray, that you know that patient group tends to have because people have studied that in the past. But across the board, I would also tell you that patients who have superimposed disorders of gut-brain interactivity, the pelvic floor equally falls within that. I mean, Lori Keefer spends a lot of time focused on not just the functional abdominal pain patient, but our pelvic floor dysfunction patients to me fall similarly beyond just brain gut. This is like mind, body. This also, so I'd say patients with high anxiety, patients who've had some trauma due to their disease, like medical trauma, of course, undergone surgery, perforations, accident, things that have resolved, resulted in high anxiety around their condition.

I would bet you if we started asking this question around their pelvic floor, it would be very dominant for many of our patients. And I think painful intercourse is just one way of asking whether a flag for after you've gone through your other questions around, well, they feel like they have inadequate emptying, they describe tenesmus, or they just sit on the toilet for a very long time and nothing comes out. There's a lot. These are very, very simple cues to listen to as it relates. And then I also now have added, thanks to my colleagues, the question on painful intercourse. And when you put all of that together, that's where you really start to think about the role of pelvic PT. And I'd say that's like for patients with chronic urgency, chronic issues with incontinence, et cetera, we do underestimate that it's probably also due to or impacted by pelvic floor. So pelvic floor PT, which they're very popular. Pelvic floor PT is not an unpopular type of PT that is popping up. I mean, we have a lot more pelvic PT private practices that have now opened up in Manhattan. And so I think it's becoming more to the forefront of what is being discussed. And so for us, we must be conscious of the impact of chronic inflammation, prior surgeries as you noted, as well as asking patients about painful intercourse as a marker that our patients should be evaluated for pelvic floor dysfunction.

Dr Cross:

You're a high resource center. You have a medical home at Sinai, and Mercy doesn't have a medical home, but I would consider us having a high resource center. But most of the patients with IBD cared for around the world, in the United States, are going to be from lower resource centers. So for those that are listening that are a bit anxious about asking these questions, if they did get a positive screen for something like this, they're not going to manage it themselves as a gastroenterologist. So would they be asking the patient to follow up with their OB/GYN to discuss this and to get referrals? I'm sure you can do a little research in your area to see what pelvic floor centers are around you that specialize in this. What would you recommend?

Dr Dubinsky:

Yeah, I agree. So one, you can of course obviously search in the area that you live, but I would venture to say that the gynecologists who are very, this is part of their bread and butter, that they've developed their network of pelvic floor therapists that are specifically, for example, uro/gyn pelvic PTs. There are even, believe it or not, subspecialists within the pelvic floor PT, and they've used rectal valium, vaginal valium. They do a lot of biofeedback in some of our patients, which is true, is that they really don't want anything inside of their rectum, which makes biofeedback very difficult because there's just this trauma or this pain. And it's really an unbelievable sort of interaction because you didn't actually realize how much distress or how much struggle they were going through as it relates to this. And that's why opening up the dialogue actually is going to be a big relief for them to know that this must be something validating, my doctor is asking me, this must not be something that I'm the only one. I think that's the most important. But the pelvic PTs, like I said, you can look them up absolutely in your area. But the gyne is usually the one who has the best network who they've worked with for their patients. Yeah.

Dr Cross:

So Marla, I don't know if this is the right thing to say to patients, but I have a number of patients that either at the time or just in general, it's very, very difficult for them to have vaginal intercourse without significant pain. And I hope this is the right thing that I say to them, but I remind them that intimacy is beyond vaginal intercourse and there's things in a relationship that you can do that are satisfying for both sides. You know what I'm saying, right?

Dr Dubinsky:

You're 100% right. I mean, that is similar conversation. Again, I've seen that because I'm seeing patients in my pregnancy clinic as well who are trying to get pregnant, but have painful intercourse, for example. So having that discussion as well. So you're 100% right. There's the intimacy and the sexual quality of life, which is a little bit different than what do I do when I have vaginismus or pain with sex and I'm trying to get pregnant. So there's a lot of that conversation that also is happening. So I agree with you. I think we're not equipped per se, like you said, and don't have necessarily the resources for all of our patients to address it. So I think referring them or they'll be connected, hopefully many of them with their gynecologist, they are definitely our best resource to be able to support our patients.

Dr Cross:

I wanted to ask you two health maintenance questions. One involves screening for cervical cancer. So our guidelines in IBD pretty consistently say that patients on immune suppression, regardless of which immune suppressant you're on or which advanced therapy you're on, that you should get an annual pap smear. But it seems like now that the guidelines are much more nuanced based on HPV testing and other things and stage in life.

Dr Dubinsky:

That is correct.

Dr Cross:

Do you even try to address that at all? I just basically push it off to the OB/GYN and say whatever they say you should do. Just tell them the meds you're on.

Dr Dubinsky:

I sort of say similar. And I think it's like there's even nuances like after 3 normal pap smears, you can go back to every 3 years, you can follow the guidance. So as you noted, it always changes. But my patients, and you probably have the same, is that they'll say, "I'd rather err on the side of caution.” But if they've had colposcopies in the past, you know that they're going very often and the gyne's going to guide them on that because there are guidelines on if you have a need for colposcopy for recurrent abnormal pap smears, for example, they'll have a different protocol. So I think you're right, I think that protocols are changing, but again, it's going to come down to that personalized risk of that patient and working with our gynecologist. And our gynes understand that they'll probably err more that they're on immunosuppression more than we would in a sense. Taking thiopurines and probably out of the mix because that is definitively due to its impact on lymphocytes and viral replication. I mean, that's how people used to be worried about EBV with thiopurines. I'm like, "I think you forgot about HPV as well. We forgot." I would have patients coming to me and they would have a history of colposcopy, multiple abnormal pap smears, and they're still on thiopurines. And I'm like, "Has anyone actually said that the reason..." They're on combo, right? There's not a ton of monos, but let's just say, and no one has removed the combination because they didn't have maybe skin cancer yet, because everyone's focused on skin cancer risk or lymphoma risk. But I'm like, "There's another important thing to talk to patients and realize with women that recurrent abnormal pap smears, please, thiopurines are a problem."

But I think they're going to err more on that they're on immunosuppressant even when they're on vedolizumab or a 23 is when I'm going to guess. The rumor on the street is these are all immune suppressants. That's how our patients are also coming to us and saying, "Well, is my immune system impacted? And I was told I'm on an immune suppressant." You hear a lot of that word. So probably their primaries and maybe their gynes are having that discussion with them as well.

Dr Cross:

And are you guys doing anal cancer screening at Sinai?

Dr Dubinsky:

We are recommending to our patients, but I wouldn't say that it's routine that everybody is recommending it as a routine. I don't know. Where do you land on that?

Dr Cross:

Well, I had 2patients that developed anal cancer that really sort of, it was very upsetting that they developed an anal cancer sort of on my watch. So for patients that have high-risk HPV-related complications, perianal disease that are 45 and over, we're starting to do anal paps. Now, how good anal paps are is not clear, but I think at least doing a perianal exam and digital rectal on years are not having a colonoscopy or a pouchoscopy, whatever, unless their OB - GYN is actually doing a bimanual and doing that, then I think it's a reasonable thing to consider. Whether it's right, I'm not quite sure yet, but I think more to come maybe in the future with that. For all the issues we talked about— this is the last question before the fun question. Does it impact your choice of treatment about what you're going to give them for their IBD?

Dr Dubinsky:

In terms of what?

Dr Cross:

Sexual health.

Dr Dubinsky:

Yeah. We were talking about whether or not, or you were asking me around whether or not there's a particular treatment strategy. I would say the following, that I think it's more so that we underestimate the impact of the disease on the burden of our patients' lives. And so I would venture to say that the answer should be whatever gets our patient into remission so that they could actually live their best life, I think would be my answer. I think one of the questions that STRIDE III is in play and is being sort of socialized, the votes are in, and one of the questions is to focus more in STRIDE as a target is these PROs and sexual health and urgency and other things. So I think the recommendation will probably be to, if your patient has active disease and they have all of the other symptoms, then you want to optimize the treatment.

The question that you're asking also I think is if a patient has luminal disease that's under control, would that impact your treatment strategy or what would you do next in a patient who has these continued impacts on their quality of life? Which is where I was getting into that I think that's where our behavioral health scientists and pelvic floor therapy, that's why I was like, I don't know. It would help me say I need to step up my game, but I'm not sure I would per se choose one therapy over the other at the moment.

Dr Cross:

And I 100% know you're going to agree with this. This is just another reason 40% of people are wearing a protective undergarment because they're concerned about leakage, difficulties with intimacy, dyspareunia, you do not have to earn an advanced therapy. Most patients with Crohn's should be on an advanced therapy across the entire United States. That's clear, and it's probably only a quarter to a third that are actually getting them. So this is just one more reason your patients should be on an advanced therapy.

Dr Dubinsky:

100%. That's exactly right. We don't ask what matters to the patients, therefore we think, oh, you have mild. That's what I was getting to about the rectum. It's like, ah, you only have rectal. If you need to use suppositories, whatever. Did we go one step further and ask how much that's impacting their overall quality of life? That's disease severity. It's the burden of disease. And that concept of switching and earning, like you said, because what? You need to earn it because you actually develop a stricture? Too late. Earn it because you now have a fistula. Yoo late. It's the same concept that we're not approaching the holistic treat to target, shall I say, and we're focused much more on mucosal healing or number of stools.

Dr Cross:

All right, Marla, what's your fun fact? Tell us something about yourself that we wouldn't know, maybe even that I wouldn't

Dr Dubinsky:

Know. Do you know that I'm a golfer?

Dr Cross:

I did not know that.

Dr Dubinsky:

Okay. So yes, I wouldn't say Nancy Lopez. I wouldn't say ready for the PGA Tour, but I decided to take it up during COVID. I kind of wanted a reason to go outside and be able to do something as I was thinking about what can I do as I age? Is there a sport? Because I don't know if you know this, but you know my brother played professional hockey, so I grew up in a very athletic home, myself as well, that it just looking for something to keep myself active and being outside. So yes, I took up golf and I'm happy to play golf with anybody at any time. Dave Rubin is excited to see me on the golf course. I golfed with Corey Siegel. He was impressed. He was actually good too. He was impressed. So yes, I'm open to playing with anybody, but yes, I took up golf and I'm excited about improvement.

Dr Cross:

I think I need to take some lessons before I play golf with you. Marla, this has been great. I think the listeners are going to really like this. Just for the listeners, this is IBD Drive Time, the official podcast of the IBD Network. Marla, hope to have you back soon.

Dr Dubinsky:

Thank you for having me.