Endometriosis, HRT, and Menopause: Expert Answers on Surgery, IVF & What Really Helps | Dr. Melissa McHale

25:13It was like, I'm having all these anxieties. He's like, let's get on a phone call right now. He got on like three phone calls with me before my surgery, which another friend of mine who's an endometriosis surgeon, she's like, yeah, before I went through my surgery, like I had a panic attack on the OR table. Like I was like, she's like, that's totally normal. But then Dr. Ana Sierra was like, I reached out to her and I was like, I just need you there. Like, I just need the nerve specialist in the room with me, even though nothing is showing nerve involvement on the off chance that it happens. I need to know going into this, that like you are there and you've got my back.

25:46And I think knowing what I know, I know how to ask for these things, but other patients don't. And that's where hearing you say, like, your doctor needs to say, like, this is who will be there. Who's going to help out? Like, and your doctor's completely prepared for it. Helps ease the patient's anxiety, but it also ensures that they get the best outcome. No, totally. And, and I think that just brings back to the doctor should treat you like a colleague, right? There's no, there's no instance in which, right? Like they, they took your concern seriously. Nobody said to you, that's not going to happen.

26:21Right? No, that's not an appropriate answer. That's the kind of thing that makes a patient more anxious, right? If you give patients information, I think information really makes us feel in control of a situation, right? Because then you're making choices about your body based on the best information. You know, I very frequently get asked, you know, am I going to need an ostomy? Again, don't say, nah, you're not going to, don't worry about it. What's an ostomy for people who don't know? Sure. We do them, usually they're temporary in endometriosis surgery where we either pull up a loop of small bowel or large bowel and the stool empties into a bag for a period of time so that the intestines can heal after surgery.

27:03It's really uncommon in endometriosis surgery in most places. I think it happens a lot more in Australia. Interesting. So, and so, you know, people talk, it's one of those things that gets talked about a lot on the internet. And so people often ask me, am I going to need, am I going to need an ostomy? Yeah. And instead of saying no, you say the circumstances in which a patient having surgery like yours needs an ostomy are if there's an ultra low infiltrating endometriosis nodule, right? Like within five centimeters or less of the anus. or if, you know, there's a complication, right? Something, you know, something like a leak happens and then we have to have to reoperate later and that intestine needs time to heal, right?

27:47These are both really uncommon scenarios. And we can also say to the patient, like, I've imaged your entire rectal wall from your anus to five centimeters up. I don't see anything. So it would, you know, nothing's impossible, but it'd be extremely unlikely in a situation like yours for you to need an ostomy. I've never personally seen it, right? And when you can say that to a patient, I think it gives them a lot of reassurance because they can tell that instead of just dismissing them, nah, you don't need that. You thought about it. You were like, here are the reasons I can reassure you that in my experience, that's really unlikely to happen to you.

28:25I want to go back into adenomyosis because you mentioned that this shows up later in a woman's life and it does progressively get worse in most cases in perimenopause through menopause. If you can explain what's going on there, why does it get worse? And is birth control and hysterectomy the only options? Sure. This is one of those things where it really depends on the person, right? Some people it's bad early and it stays bad. Some people it progresses quickly. Some people it doesn't, right? And this is something that I think a lot of doctors struggle with when they see a patient with adeno and the patient says, you know, is this going to get much worse before I go through menopause?

29:07Because, you know, for some patients who have adenomyosis after menopause, it's better. Not everyone, but many. And so, you know, and unfortunately the answer is like I don't have a crystal ball, right? Like yours could progress a lot. It could progress slowly. I'm not sure, right? But at the end of the day, I think, you know, the treatments for adenomyosis are really challenging, right? And this is one of those things, again, imaging is really important because in some cases, if the adeno is focal or it's concentrated to some parts of the uterus, that can be surgically managed, right? And so it's not always a situation where it's like, adeno, nothing to do, right?

29:46But in most cases, it is that diffuse adeno that doesn't have a surgical intervention. And in those cases, the most important things are to really sort of drill down on what are the symptoms, right? Some patients who I see with adeno, their predominant complaint is actually heavy bleeding, right? And that is something where, okay, if your primary complaint is heavy bleeding and hormonal management isn't working for you, tranexamic acid is a great option for you, right? It's a non-hormonal treatment that decreases bleeding and has a very, very favorable side effect profile, right? And so why not offer that to patients as opposed to just saying like, well, if you don't want the birth control, you have to have a hysterectomy at the end, right?

30:27Like, come on, think about what the symptom is and how to address it. At the end of the day, some people have both the heavy bleeding and that, you know, I call it the hot bowling ball feeling. Like at the end of the day, a lot of my patients just talk about this heavy, throbbing, hot bowling ball in their pelvis. And that is something where unfortunately we are really limited in terms of treatment options. You know, hormonal management does work for some women and hysterectomy is, you know, unfortunately the other option for a lot of people. I saw a study and I'm not going to quote the statistic perfectly.

31:01However, I remember my jaw dropping that the estimate was that I believe it was more than 60 % of hysterectomies in the United States weren't actually warranted. So they were not medically necessary and the patients were not receiving an informed consent. So there's women who are like, when I bring this up, they're like, women have a right to have a hysterectomy. Absolutely. It's your body. If you want to undergo this surgical procedure, then that is your choice. However, it was that the patients actually didn't get informed consent. They didn't get treatment options. Their doctor was pushing them into surgery.

31:39Why are we seeing that happen so often? That's a hard question to answer because I get tripped up often on medically necessary. Because who defines medically necessary, right? I find particularly with endometriosis, right? Like if something's causing pain, in my opinion, it's medically necessary, right? If you want it done to your body, it's medically necessary. And so, you know, I'm not sure who it is deciding, right, if the indication was pain. Did they feel it wasn't medically necessary? Because like, or like if a woman's heavy bleeding wasn't so bad that she needed a transfusion, is it medically necessary?

32:21Well, like, yeah, if she can't like live her life for two days a month because she can't leave her house because her bleeding is so heavy, like, you know, that to me, that's medically necessary. And so I, you know, I struggle to sort of make heads or tails of that particular statistic. But at the end of the day, I think the counseling is what's most important, right? And I, you know, I really sort of try to drill down with patients exactly like why are you here and exactly what do we need to do to fix it? Because sometimes like, you know, on an ultrasound, if touching someone's adenomyosis, adenomyotic uterus with, you know, very gently with the ultrasound probe, if they're like, yep, that right there, like you have low level reproduced the pain that brought me into my office.

33:16That's one of those things where like if your uterus hurts, at the end of the day, the most likely way to give you relief is to remove it. Right? Hey, Chicago. Class it up with Crocs. You know back to school is coming in fast. So why wait to find your new fave footwear? Step into a local Crocs store and step into your new look. Try it. Style it. Make it yours. Because the right pair doesn't just show up. It shows off. First day fits, handled. Walk out ready for whatever's next. Visit your nearest Crocs store today. but that like, it's not, it's not in my body, it's in your body. Right. And so you're the one who should be making the decision about how much is this symptom affecting your life.

34:05Right. And so I will tell you like, here are your options, right? Here are your hormonal options. Here are your non-hormonal medical options, which are unfortunately very limited. And then here are your surgical options. And, and that's, that's what you have. I'm not telling you, you have to pick any of them, right? You have to decide what's right for you. Yeah. Well, I think that's, that's really what the issue of the study was pointing out is that it wasn't the doctor saying, I need you to decide what's best for you. It could have been a situation where you had a fibroid and they're like, well, it's easier to stick out the uterus.

34:39You have endometriosis. And we know there's a lot of doctors out there promising to, you know, take away your period pain by having a hysterectomy. And it's like, well, yeah, now you don't have a period, but that doesn't mean the pain's gone away. You brought up hormones. I want to talk about this because there's new research showing that estrogen only, HRT, has nearly tripled the risk of ovarian cancer in women with endometriosis. So the question is, why is unopposed estrogen still being prescribed in endometriosis patients? And what should women be asking their doctors for instead? I'm going to lead with, I am not the expert in this.

35:21Okay. And I really like to stay in my lane on this. And truthfully, when I have patients who need complex or long-term HRT management, I don't do it myself. Because there are a lot of people who have really great expertise in this. And I happen to have access to a couple of them in my area. And so it's really, you know, and this is one of those things where, again, I really believe in doing what's best for the patient, which is why, like, you wouldn't want them doing your endosurgery, but at the same time, like, you don't want me doing this management for you going forward. That said, I think we just need more data.

36:00And that's, and of course, that's hard, right? Because you never want to be the person who's like, here I am participating in the acquisition of data. Like, we'll see what happens, right? You know, we do, you know, from the women's health study, we do know that there are significant risks that, you know, are associated with the progesterone component of... The progestin component. Yes, you are right. You're right. The progestin component. But they did report it as progesterone. But once you get into the methods, it's like, no, that was progestin, which is, you know, I think the slippery slope that we've fallen into in medicine overall.

36:37Like a woman says, I had adverse mood symptoms when I was on the birth control pill. The doctor says, well, clearly you can't do progesterone. And yet it was the progestin that's more closely linked to that. It's been very interesting to see as studies come out, how much estrogen got a bad rap for everything progestin actually did. Yeah. I mean, again, I think this is one of those things where we need more data, right? We can't just keep reanalyzing the same data from the women's health study over and over. And it's a great study. We learned a lot, but we just need more information, right? And at the end of the day also, I think I'm hopeful that we're also going to do a lot more to assess a woman's baseline risk for things when we're making these decisions, right?

37:19Some people are really high risk for breast and ovarian cancer. Some people are really low risk for breast and ovarian cancer. We don't stratify when we're making these recommendations. And so I think we have a really long way to go in how to get this right. Yeah. So the study, what was interesting is they found when you combine estrogen and progesterone, then there was no risk of ovarian cancer compared to anyone else. But it's about the endometrioma. And that's something that when my audience is like, why did you decide to have these excision surgeries? I'm like, well, I had bilateral endometriomas.

37:55The risk of ovarian cancer goes up slightly. However, I want to be on estrogen hormone replacement therapy in the future. and I would rather have an excision surgery at 43 than 53 because unfortunately it was the age, it's harder to recover from surgeries. But that was part of my decision making as well is that I know that I want to have my brain health and my heart health and my bone health and not lose my mind. I did Lupron for two months. So I already have a insight into a window of like how freaking bad it's going to be to go cold turkey without estrogen. And so that was part of my decision process as well, is knowing I had endometriomas and knowing that if I do HRT, that because of that predisposition, that might increase my risk of ovarian cancer.

38:46However, what often happens is that the doctor took your uterus, you know, once upon a time. Can't even be the same doctor that is doing your HRT. And they'll say, well, because you don't have a uterus, therefore you don't need progesterone. But in endometriosis patients, that's a very different situation. Progesterone isn't just about protecting uterine lining. Also, I would argue that like progesterone is also good for your mental health and it has a lot of other benefits as well, but it's that unopposed estrogen. And I think about it like at no other point in a woman's life would we ever be okay giving unopposed estrogen knowing she had endometriosis.

39:24I think, again, the issue in terms of assessing someone's risk for these things, again, the landscape is changing so fast that we haven't caught up to understanding it, right? At this point, we know, for example, 60 to 80 % of ovarian cancer start in the fallopian tubes, right? And so, of course, like your baseline ovarian risk, you want to talk about something that changes it significantly, is whether or not you had a salpingectomy, either if you had a hist at the time of the hist, right? What is that for people who don't know? I'm sorry, a hysterectomy. And a salpingectomy is removal of the fallopian tubes, right?

40:02They have one job. They don't have a hormonal function. All they are is a highway from the ovary to the uterus. As far as we know right now, because it's very interesting to like, I feel like the fallopian tubes are kind of like the appendix of Once Upon a Time where we're like, it doesn't do anything like it or it's got like one job, although I think we thought even less of the appendix in the in the past. But I just bring it up because women who have their tubes removed, there is actually entire groups talking about the hormonal hell that follows that and like all of the symptoms that they're having.

40:37And so it just makes me wonder what we'll know hopefully in our lifetime about are they doing anything else? Like, you know, how are they involved with the microbiome of the reproductive tract? Like there's big question marks around this. I think I would be much more concerned about the technique of the salpingectomy because everything's very close together, right? And the blood supply is important. And, of course, the ovary does have a lot of collateral blood supply. And so depending on how the salpingectomy was done, your ovaries may well just be in shock because if they previously were getting a lot of blood supply from those same vessels that the surgeon took during the surgery, then the ovaries may take more time to recover from that.

41:17But I think, you know, at the end of the day, I'm not here to tell a patient what their experience is, of course, right? But I think that there are a lot of different variables into why that could be. But certainly I wouldn't want a woman to miss out on the opportunity to have her fallopian tubes removed if she's not going to use them. Because if you want to talk about an intervention that is, you know, that without removing the ovaries is most likely to impact her or decrease her ovarian cancer risk, it's that procedure, right? And I think a lot of endometriosis surgeons don't do a good job talking to patients about their fallopian tubes before surgery.

41:59The reason being, it's a really long conversation. Yeah. My every time, you know, and I have this conversation with every patient I take to the operating room, whether they want to get pregnant or they don't want to get pregnant or they don't know, is how am I going to handle your fallopian tubes in different scenarios, right? On the one hand, if you're not trying, if you know you never want to get pregnant, then you should be offered an what's called an opportunistic salpingectomy, which means we take your tubes out even though that's not the objective of the surgery, right? The reason I'm going in is not a tubal, but I will offer it to you if you'd like to have it done at the same time because that's your right.

42:38And then on the flip side, if you either are currently trying to get pregnant or you are planning to do so in the future, what if one of your fallopian tubes is really damaged from endometriosis? What if it's dilated? What if you have a hydrosalpinx? What if, you know, what if, what if, what if? If it's one tube, but the other one's fine. If it's both tubes, how do you want me to handle those scenarios? And of course, I counsel the patient like, this is what I recommend for these reasons. The alternatives are this. And what would you like me to do, right? And the patient, you know, again, I'm just here to give you information.

43:14You make the decision about what you want me to do during your surgery. And I think that a lot of surgeons don't do that because at the end of the day, it's a long conversation and it's pretty weighty. and often it's unnecessary, right? You know, the majority of the time when the tubes look totally normal on imaging, they're going to be totally normal when you get into the operating room. And what type of imaging are you doing ahead of time? So you know about the health of the tubes? Ultrasound or MRI. Not in HSG? Okay. No, because I can do that intraoperatively is one reason, but also, you know, HSG like tubal spasm can happen.

43:53Those kinds of things can happen. It's an invasive procedure. It's really unpleasant for the patient. And so, you know, I'm not, I'm not going to do it just so that I can sort of shorten that conversation with the patient, right? Like you shouldn't have to experience a painful procedure just so that I can like, you know, save 15 minutes going through all these different scenarios with you, right? That procedure is more than 15 minutes I had it done. Right. And it's, it's terrible, right? And so... I have to say that I think because I thought it was going to be so terrible, it wasn't as terrible.

44:28Okay. You know how that goes sometimes? Yeah, you build it up. You build it up. But also, like, I mean, they had me on, like, scopolamine. They were, like, they drugged me up for this procedure. I will say. So I had this done in Mexico. Their pain management is very good in women's health. Like, when I had to have an endometrial biopsy, and I was like, I'm going to be put under for this, right? And they're like, of course. Why wouldn't you be? And I'm like, well, let me tell you a story about the U.S. And my doctors were shocked. They're like, they do biopsies? Well, you're awake in the U.S.? I'm like, yeah, they do.

45:00It's not fun. So I'll say that, like, anyone listening, if you're like, my HSG was hell, and you're like, why was Dr. Brighton's fine? Drugs. I was medicated. And I think that was a big part of it. And I just, oh, so I had an entire team of women. And they were very, very much like, we're checking in. How are you? Let's do deep breathing together. Like it was a very pleasant experience from the perspective of my team being very invested in my comfort. Yeah. And I think that that's essential. And thankfully, we are seeing this change in the U.S., right? Like I have a list of providers in my office, like if someone wants an IUD or like needs any kind of procedure, of the people who will give them pain management during that office procedure.

45:47And so we are seeing that more and more in the U.S. And again, advocate for yourself. If your doctor doesn't do it, ask them who does. And if they say that they don't know, then go looking because there are, you know, increasingly more and more practices offering that. But back to that, the conversation about sort of fallopian tubes, right? Like I'm not going to put the patient through a procedure just to truncate that conversation. I'm just going to say, you know, if this is what I find, how would, you know, what would you like me to do? If this is what I find, what would you like me to do? And I think it's really important because no one can make that decision for you in the OR.

46:27And I say that to my patients like, look, I'm not comfortable with anyone consenting on your behalf to have a reproductive organ removed. And so the only scenarios in which I remove a reproductive organ without someone's consent would be like, you know, if it's sort of a life or death situation, right? Like surprise cancer or like surprise, you know, bleeding event that, you know, couldn't have been foreseen. This has not happened to me. But that's, you know, people ask me like, is there any scenario in which you're going to take my ovary out? Like, yes, I would do it to save your life. Those are the only, that's the only time that it's appropriate for me to do that without your consent.

47:04And I've seen this where women have a surgery, like an endometriosis surgery, and then their doctor wakes them up and says, your tubes are totally dilated and damaged. And, you know, I'm sorry, you're going to have to do IVF and you're going to have to have the tubes removed before you can do IVF. Right. And on the one hand, that patient is entitled to be mad at the doctor because they're still in the PACU from the surgery they just had and they're being signed up for another surgery because the doctor didn't talk to them about it. But on the flip side, if your doctor takes your tubes out without having asked you ahead of time and then just says, sorry, I had to take your tubes during your surgery, that's also not appropriate, right?

47:46Like it's, I think informed consent is growing with surgery, but it's challenging because your doctor has to have the time to do it. And so as doctors get squeezed with shorter and shorter appointments, you know, it's harder and harder to do the longer counseling. Yeah. I went through a punch list with my doctor and he also had, you know, fellows in his office, which was nice because they could, he could be like, I'm going to go through this stuff with you. And then I could have conversations with them as well. But I basically was like, I want to see the list of what we think's going. And then I want to, I want to make a list of what might be going.

48:25And then I want to make a list of like, holy shit, we didn't see that coming. like this, like, and, uh, and it sounds like, I just like, I'm so grateful that my team was like really patient with me because not all doctors are patient. And I get where they're like, you're being, you know, well, I would call it being hypervigilant. Maybe that would be like the worst term I would use, but they would be calling it hysterical. Like you're, you're going on, you know, above and beyond. And yet it's something that I'm like, I need to know this to mentally prepare for these things. And I think having the tubes on the list is a really important thing for patients listening to this to be like, okay, I go in and talk to them, right?

49:03Because everybody's concerned. Like I don't want a bowel resection. Like that's, nobody wants to recover from that. Not a good time. Nobody wants a bowel resection. Yeah. And so I think there's like the big scaries and yet it's like, maybe you're not thinking about like, well, what about the tubes? You know, I was like, we please make sure you're going to check my diaphragm. Like even, even though everything looks like, just go peek up there, please look at my diaphragm. Like, and Even though I knew what, you know, what, what the plan was, I was like, I need to know you're going to check my peritoneum.

49:32Like, I just need to hear it. I need to hear that we're going through the list and that like all of these things are going to be checked because I never, ever want another surgery again if I can help it. Of course. Hey, Chicago, class it up with Crocs. You know, back to school is coming in fast. So why wait to find your new Fave footwear? Step into a local croc store and step into your new look. Try it. Style it. Make it yours. Because the right pair doesn't just show up. It shows off. First day fits, handled. Walk out ready for whatever's next. Visit your nearest croc store today. And I think that this is one of those things where, again, like information, like you are entitled to all of the information about your body.

50:18And so, you know, my OR team always teases me that I'm trying to win the Pulitzer in photogynecology because I take so many pictures in the OR. I mean, I walk out with a stack of pictures. Like, here are all of the before pictures, and then here are all of the after pictures. And my patients are entitled to that. But also, I think a lot of doctors hand a family member a stack of pictures and say, everything went well, I got it all the end. And then they just kind of walk away. And then the patient, you know, I see a lot of patients in my office who had a prior surgery. And, you know, very helpfully, they bring the pictures from their last surgery.

50:53And then they sort of say, like, can you tell me what's happening? Because no one ever told me what's happening in these pictures, right? And so I'm going through all the pictures of the old surgery. And so, you know, and this is one of those things where also, like, it's really hard to remember, right? I'm sure, you know, you remember and your family remember surgeries are a really overwhelming experience. And when you're in an experience like that, it's very, very hard to take like detailed mental notes of what's happening. And so when I bring that stack of pictures out, I sit down with my, you know, whoever came to the hospital with my patient and I say, take your phone out, take a video of me.

51:29And I take it and they take a video of me going through every single picture that I took saying, this is a picture of this. This is why I took this picture. You know, this is normal. This is not normal, blah, blah, blah, blah, blah. This is what I did after. Here's, you can see, here's the edges of the areas that I excised, whatever it is. Right. And I think then, you know, first of all, I don't contribute to like anybody's, you know, inter inter family drama of like, what did she say when they're waking up from surgery, but also, you know, you're entitled to have that information in a digestible way that you can keep, right?

52:05You need to have that information because you may, you may have questions about your surgery two years from now, five years from now. Again, you're living in your body for the rest of your life. You're going to take that surgery I did with you for the rest of your life. And so I think, you know, that's why like you've got that video. You can look back whenever you want about exactly what happened. And it's not just an op note that's written in medical jargon that no one who's not a doctor can possibly understand. Yeah. And pictures don't lie. I've read a lot of op notes where the op note says one thing and I look at the pictures and I'm like, that does not, that does not appear to be what's happening to me.

52:40Right. And so I think that that's really important is for people to have that information. Yeah. In Mexico, they're required to record the surgery and provide a patient with the video of the entire surgical procedure. And then in your post-op, they sit down and they go through the entire video. And I had my husband record because I was like, I want to be present for it. And then the moment I saw them like pop a black pearl out of my ovaries, which is an endometrioma, I was like, oh, I'm like, I'm not a squeamish person, but when it's your own body, I'm like, oh my goodness. So just for people listening, I say that because sometimes people are like, that's hardcore.

53:15I don't want to watch it. It's okay if you get squeamish, but get it, collect the data because you never know when you want to go back and revisit it. I want to talk about when it comes to endometriosis surgery, hysterectomy, tubal removal, all these surgical procedures, why can the wrong surgeon leave you worse than before? And what do we know about repeat and the necessity of repeat excision surgeries? So that is a really important question because we see this super commonly, especially in the U.S. Because, you know, increasingly you're seeing the specialists are all out of network or a lot of them are out of network or have very long wait times.

53:53And then you'll see a patient who is, you know, really suffering. And she says, you know, I can't afford it. I can't wait that long, whatever. And so I'm just going to have this like surgery with my local GYN now, and that'll like buy me some time before I can have the right surgery. And no surgery is better than bad surgery because... Say that again, because I think people need to hear that. No surgery is better than bad surgery because there's a number of different things that can happen during bad surgery that no surgeon can undo, right? If someone does nerve damage in your pelvis, no one can unring that bell, right?

54:35And a lot of people say like, well, it's okay because for a lot of the functions that are not like sensation or motor function, things like being able to hold your urine, being able to empty your bladder, things like that, you do have nerves on both sides. And so if you get damaged to one side, in theory, the other side still works, which is true. But if you had bad surgery on the side that actually like those nerves could have been preserved, and then you have invasive endo on the other side and the bad surgeon was like, well, I'm not going to touch that because I know I can't fix that. Then to actually get that out, suddenly you've gone from having collateral to having nothing, right?

55:15And that's when we really end up in trouble. Fibrosis is an enormous problem with endometriosis surgery, right? Because when you're doing it, you're really opening up all of these spaces that are below the peritoneum, that sort of protective plastic wrap that we have throughout the abdomen. When you get in there and you start doing things, you cause fibrosis and scarring. Just like if you've ever had a scar on your skin, you know that when it heals, it's not the same as it was before. The same thing does happen to a certain extent on the inside. When it's done right, we reduce that fibrosis. When it's done multiple times, that's your highest risk for having a lot of that fibrosis, which can entrap your nerves and do all kinds of things that are painful, right?

56:00Retroperitoneal fibrosis can cause pain. And that's a thing that, you know, it's hard, if not impossible, to undo that, depending on the level of fibrosis that someone has. And so we, you know, we really struggle with that. And the other thing is sometimes the worst, the worst patients to reoperate on are good surgeons who know nothing about endometriosis. That is my nightmare. Right? Like I'll see people, it's like, he's a great cancer surgeon, but he went in and he opened up all the spaces and then he left all the endometriosis there. Right? And it's great. Like, great. Now he made these like deep dissections and then like just seeded the endo into these deep dissections.

56:42It's so much harder. What does that mean, seed the endo? So, I mean, either they didn't remove it, so it's still there, but when it heals, it just gets tucked in, right? Or like an endometrioma gets sort of tucked into the sidewall because they didn't remove it completely. These kinds of things where it's now it's much deeper and much harder for me to go in there and dig it out, right? And similarly with that fibrosis, it makes it much harder for me to dissect the, you know, essential structures in a way like, okay, now I know these are over here. They're clear. They're safe. I can operate here and remove the endo.

57:15And, you know, again, it's not just like it's harder for me. Like don't cry for me. I'm up to the challenge. But it's one of those things like it is more dangerous for you. Yeah, I was going to say, if it's harder for the surgeon, then it's harder on the patient too. Exactly. Exactly. That's the point I'm trying to make is it's not about, you know, how hard it is, right? It's about the more complex the surgery, the higher the risk of complications, regardless of who's doing the surgery. We all have complications. Every single surgeon who's doing high-volume endosurgery has complications because these surgeries are challenging, right?

57:52The anatomy is no longer where it's supposed to be, and endo has no respect for where it's supposed to be. I just whacked that microphone. That's fine. It's very endo of you. Endo, wham! Endo has no respect for where it's supposed to be. And so we really end up in these situations where like, we're going, we're going hither and yon to look for that. Please don't let some other doctor like make it, make it even harder, right? Don't, you don't want your endo to have like a teammate in getting it where it's not supposed to be. Totally. And the, the, the thing that you'll hear often is that doctors will say, and even you know, women will also say this as well, because that's, this is the truth to their experience is that excision surgery isn't going to take care of endo.

58:35It's just going to come back. You're going to have to have five or more surgeries. Like you'll hear these stories, but that really, from my understanding, and I know there was a recent study coming out showing that if your surgeon knows what they're doing, they are an endo specialist. It's, you're looking around like less than 5 % chance of recurrence. If they imaged first, they get in there, they get, they get everything that they can. Of course, we're not perfect because we're humans. But why do you think we're not talking enough about that endometriosis specialist exists in surgery and that that is the patient's best bet in managing their endometriosis?

59:16Yeah, I, that's an enormous problem. That data is still coming in, right? We're still collecting it, we're still learning a lot about recurrence, right? And the hardest recurrence is exceedingly hard to study because so many of the people who have been doing surgery for so long on endo are leaving it behind. So it's not recurrence, it's residual, right? And so our biggest challenge is differentiating recurrent and residual endo. But now we're starting to get series of patients who had what we know to be complete excision surgery, and the numbers are much lower, right? There's a range, 5%, 20%, 10%.

59:51We're seeing different numbers, but they are much, much lower than what we're seeing for all comers having endometriosis surgery. So we know that outcomes are much better. We know which types of recurrences are more common. Endometriomas, for example, right? Ovarian endo is the most common site for true recurrence. And so these are the kinds of information we're starting to get, and hopefully the basic science is going to catch up with us and help us figure out why. Like, why is that a place that we know recurrence is a significant risk, whereas other places it's not as high risk, right? Yeah.

1:00:27And then you were asking about why, I'm sorry, you were asking about why I think we let people do these surgeries when they have no idea what they're doing. Well, that's a really, I think everybody wants to know, like, why the hell is Rookie Hour fronting like they know what they're doing and cutting into women's bodies? But also just not like the respect that like endometriosis, excision surgeons, they specialize in it. It's their life. They exist. If this was any other kind of surgery going on, but something about it's a woman's body and it's endo, we just let anybody get in there. Yeah. And I think this is something, you know, this is sort of like my, one of my favorite soap boxes to climb onto.

1:01:07So like stop me when I get out of it. I think I already was on this soap box yesterday. But, you know, we know for certain types of complicated surgeries, people have better outcomes if the person doing the surgery does a high volume and has advanced training in that thing, right? And so, for example, with hospitals, when you apply for privileges at a hospital, you have to say, you know, okay, if I want to do this thing that's considered a subspecialty, I have to be able to demonstrate to you that I was trained to do it and I have a high enough volume of that procedures to have kept my skills up, right?

1:01:42So for example, if you want to do a suspension procedure for prolapse, you want to be putting meshes in people, that kind of thing. You have to be able to demonstrate somebody taught you how to do it and you do a high volume of it. The reasons being mesh complications are serious and people who do a lot of them have fewer mesh complications. And you're much less likely to have the surgery fail if the person doing it knows what they're doing, right? So a urogyne who does a high volume of them is less likely to have recurrent prolapse than somebody who doesn't do a high volume of this. This is why I like to say I don't mesh around.

1:02:21When I have a patient who needs like a suspension procedure, I say, fantastic, I have a wonderful urogyne colleague. We're going to coordinate. We're both going to be there in the OR. I will take out all of your endo and they will do your suspension. Right. But and same thing with GYN cancers. Right. I do not have privileges to operate on cervical cancer. There's a reason. I don't treat cervical cancer, so my outcomes will not be as good, right? And to that end, endometriosis should be that way, right? Why is it not, though? No one knows. I mean, I don't know. I think the real reason is, you know, gradually there's this erosion into general gynecology of like, okay, now you guys probably shouldn't be doing this because it is a subspecialty field.

1:03:05and okay, now you guys probably shouldn't be doing this because there are people who can do it better than you. And I think at the end of the day with endometriosis surgery, a lot of people feel like they can do it. And so they don't want that taken away from them. And obviously the skill of the surgeon, like this is something that's very variable. At the same time also, there are general gynecologists who really don't believe in what I do, right? There are people who believe like you should take out the endometriomas, you should take out the cysts. Like Easter bunny stuff over there. Like, I don't know why you're doing these big dissections and taking out all, you know, all these nodules and peritoneum.

1:03:42The patient's not going to feel better. So why are you doing this? And then we feel better. And then they're like, oh, that's just placebo. I mean, it's increasingly this is changing. This mentality is changing, but it's not changing fast enough. Right. And so I think really what we need is more data on people who are having high quality surgery to show that sure enough, if you have surgery with someone who has advanced training in this and does a high volume of this, your outcomes will be better, right? Because at the end of the day, you know, and this is like the sad truth about medicine in America, but a lot of it's about money, right?

1:04:18And your insurance company would rather pay for you to have surgery once than for you to have surgery annually, right? And so we have to demonstrate to them like, no, no, like there's value to what I do, right? I know there's value to what I do because I change people's lives by taking their pain away or helping them get pregnant or whatever I, you know, whatever it is that their goals are. But I think that, you know, unfortunately, corporate medicine needs to see that value in the form of a bottom line. Yeah. Well, and speaking of money, I want to talk about IVF because I saw you post on social media something that I have echoed a lot because of my own personal experience.

1:04:59So let's talk about is IVF making endometriosis worse and could it be sabotaging your chances of actually getting pregnant without you knowing it? So this is a very controversial topic. And I will tell you, the endospecialists I know debate about this among themselves. Yeah. Okay. So this is not something where someone can give you a definitive yes or no answer, right? I think the things that we know right now are that it really depends on an individual case. Right. And so, you know, we do know for sure that when you give someone that stim, if they have endo in their body, it's going to flare.

1:05:42Their symptoms are going to get worse. So for people who don't know, the stim is doing FSH and LH injections that causes your body to produce its own estrogen. And you're trying to get, you're trying to, Dr. Amy, the egg whisperer, the way I love that she frames it, you're trying to save all of the eggs that are there. You have all these follicles, so you're trying to basically go on a rescue mission and get as many eggs as possible. That's a good way of thinking of it. Yeah, as you're saying, so the stims, the stimulation that's going on, that can flare your endo. Why is that? Because endo is hormonally responsive, right?

1:06:16So when you do that, like, you know, a lot of patients tell me, like, that experience was terrible, right? And that is true. It's absolutely true. This is one of those things where theoretically, if hormones cause endo that's there to progress or spread or sort of causes, you know, lesions that were previously microscopic to then become macroscopic, right? The theory is that, of course, that's possible. But at the end of the day, nobody has done like a, you know, laparoscopy, look at the lesions, leave them behind, do IVF, and then go back and look at the lesions and see if they look different, right?

1:06:53Because that would be awful for the patient. But it's happening to us all the time. Like you said, it's awful for the patient. And yet I think about how I went for retrieval, retrieval. By the third retrieval, I couldn't get out of bed for three weeks. And I was like, something is seriously wrong with me. And they were like, more NSAIDs and like more of this and that. And I was like, no, like it's not working. And so as you're saying, like it'd be horrible for the patient. And yet it's the reality right now. Oh, of course. I just mean we don't do a surgery to look as a surveillance and then do IVF and then just look again, right?

1:07:29Yeah, yeah. No, I would say imaging. I would advocate for imaging, not surgical procedures. But I just use that as an example to say, like, we can have these things that, like, scientifically, theoretically make sense. However, you know, we can't say definitively, right? And I try very hard to not make definitive statements when we don't fully know yet, right? Because I think that that's happened so long with endometriosis that people say like, oh, like it's retrograde menstruation, case closed. And then that like shuts down scientific thought about that issue for many, many years. And so when we don't really know, I think it's really important to keep an open mind, right?

1:08:14And because now, of course, like we're learning that obviously retrograde menstruation does not make sense for, you know, a lot of endometriosis cases. And so that can't possibly be the explanation, right? And obviously we know now that endo happens more than one way, right? And so you were asking about IVF. For example, when we do endosurgery and we take an endometrioma out of an incision, some people get endo in the incision. That's how we get abdominal wall endometriosis. It happens. Obviously, like that's not something that was laid down before she was born. It's surgically seeded. And so that both supports the endo has to happen more than one way.

1:08:55But it also supports the theory that if you do IVF, for example, someone has an endometrioma, and you're like, more IVF, more IVF. If you're poking an endometrioma with a needle, and then the needle's going in and out of the patient's body, you're going to be seeding endometriosis. And so, like, yes, we do see seeded endo from IVF. Is it necessarily going to happen? No, right? And plenty of cases it doesn't. And at the same time, also, knowing that risk doesn't mean it's the wrong answer, right? And again, this is extremely patient dependent. And I wish that, you know, and I hope someday we're going to have algorithms for, like, what is the right answer in terms of should we do surgery first?

1:09:39Should we do egg retrievals first, right? But I think there's so many factors. Does the patient have endometriomas? How old is she? What is her AMH? How many children does she want? Has she done a previous retrieval? Has she had a previous surgery? Like no two patients are alike, right? And so making that recommendation is very nuanced. And it also, a lot of it plays into what are her symptoms, right? I counsel a patient differently if she doesn't have symptoms, but, you know, she's like, I don't have symptoms. And, you know, a lot of people would say, well, you're just not asking the right questions.

1:10:14Maybe, but I do believe truly there are some women who don't have symptoms. I wish I knew why, but I don't. And for those patients, I'm going to counsel them differently than the patients who are like, yes, I've been miserable my whole life. And just now that I can't get pregnant is when I'm finally getting answers. Yeah. Right. For someone like the second scenario I just described, she needs to have surgery. It's just a question of when, right? And so that's something where, again, you're really, you're looking at all of these different factors so that you can help her achieve both her family goals and her own like health goals, right?

1:10:51You shouldn't be unable to take care of your newborn because you're in horrible pain trying to have a bowel movement, right? Like this is not the right scenario. And so we really need to think about the whole person. And this is why I bother the reproductive endocrinologists in my area constantly. Hello, here I am again, again. Dr. Cabrera and I sat down and we were talking about when to time doing another egg retrieval. And something that he had tried to institute here in Mexico is actually trying to develop an algorithm and then start collecting data on it so that it can be verified. And so he very much was like, yeah, right.

1:11:35And like, can we just everybody get on board with that? And what, you know, so if people are interested, like what he said to me is that 43 years old, if your AMH is less than one, we should definitely consider getting you in for another egg retrieval before doing the excision surgery. If your AMH is greater than one, we can go excision surgery, do ovarian PRP, and then go egg retrieval afterwards. My AMH at 43 ended up being 2.4. And I was like, I called the lab. I was like, you messed up. Are you sure? But, you know, it can fluctuate. Just so people know, AMH is like, it's not like a definitive number, right?

1:12:17And trends matter. So it's a lot more nuance to it. But with that, I elected, I was like, well, 2.4, we're looking at, you know, possibly 20 plus eggs, like, let's just do it. And I also decided I'm going to go through an egg retrieval because I do want to actually flare my endo before going into surgery because I want it to be apparent because I was afraid after three egg retrievals. When I woke up from that third one, I was in the most excruciating pain to where I was like, I don't think you gave me pain meds. Like I was crying and like, I wanted to scream. I was in so much pain. And they immediately were like, we have to do ultrasound.

1:12:54Like something's wrong. It was incidental later that I had a full body MRI that was offered through ProNovo. They comped it. They were like, oh, make a post, do this thing. I was like, sign me up. I would definitely want that. And they were like, have what appears to be endometrioma. It looks like you have endometriosis, adenomyosis. We're not diagnostic. You need to go follow up. And I'm like, holy hell. And the IVF clinic I was with were like, oh yeah, we saw your endometriosis. we saw your adenomyosis. I'm like, why didn't you ever say anything to me? And they're like, it's, the bro man like broke up.

1:13:25We broke up so fast. He has like head spin because it's fun, because he was like, I know my, this is just the new trendy diagnosis, like ADHD and women all think they have it. And I was like, well, I have freaking ADHD. So like, you're also telling me this is not real. Like, yeah, um, we're over. See you later. I went to a different clinic. Like they've been like super fantastic. But I share these stories because if I had known then what I know now, it would have saved me so much pain, so much heartache. I would have been holding a baby in my arms so much earlier, most likely. And so I share this because I think it's important that we share our stories because if I'm further on the road ahead and I'm like, girl, there is a pothole and I can help you not fall in it.

1:14:06Like, why would I not do that? This happens so much in IVF clinics where endometriosis is very profitable for an IVF clinic. Private equity groups have been buying up IVF clinics and really it's how many cycles can you get her to go through. But what I want to talk about in this moment is that there's a consideration for egg quality. We know that endometriosis can negatively impact egg quality. and some women who know they have endo might be 32 thinking, well, I'll just be 38. And, or, you know, when I try, or my doctor said I can have IVF. There's different considerations, correct? There are.

1:14:46And this is one of those things that again, like it's very person dependent and, uh, you know, there are certain things that, you know, even the best doctor in the world does not have a crystal ball and does not have a magic wand, right? Like nobody can tell you how fertile you are, right? And so when I see someone who's, you know, 32 years old, and she's like, I know I want to have children, but I'm not ready now. And we know she has endo, okay, we have to be strategic about this, right? And I often tell people like, this is a question of priorities for you, right? And a lot of it, again, you're making decisions with information you don't have, right?

1:15:22Some of those people, if they went and tried to conceive right now, they would be pregnant, right? And other people, whether they tried, if they tried now, they wouldn't be successful. So if they wait another six years, certainly I don't expect their fertility to improve without intervention. And so it's really one of those things where you say to them, look, here's your AMH, here are your options, here's what I expect to be going on with your surgery. And again, another factor, for example, is do they have endometriomas, right? Are their ovaries accessible for retrieval? Some people have like a big, this gets into the types of endometriomas, right?

1:16:00For example, a type one endometrioma is smaller, but it's much more fibrotic. It's a lot harder to peel it out. A type two endometrioma is a lot easier to peel out, but they can get much bigger. If you have a big type two endometrioma and we can't even access that ovary, then that's obviously going to change your IVF outcome. And that's when we talk about, you know, whether it makes sense to have surgery first so that we can actually use that ovary during your IVF retrieval, right? And this is something where I think collaboration is really important. And there are, you know, I'm not here to knock IVF docs.

1:16:32I think they're great. And there's a lot of really good ones that I work with in my area. And very frequently, you know, whether they saw the patient first or I saw the patient first, we'll both see the patient and we'll get on the phone, right? Often with the patient there, right? Well, like one of us will call the other on speaker and be like, here's what I think, here's what I think, you know, and we sort of hash it out, the three of us, and say like, here's what the game plan should be in your case based on all of these different factors. I think that that's really important, right? Because again, we can't tell the patient, you know, if you have surgery first, then it will improve your egg quality by this much, but decrease your ovarian reserve by this much.

1:17:11And on the flip side, we can't say like, oh yeah, like I know that if you do a retrieval now, you're going to get however much. So we just have to talk about her individual factors and then how that impacts her outcome. Yeah. A daily pill to shut it all down. what should we know about the new endometriosis drug and should we be cautious about it? We're talking about my Fembre? Yes. Yeah. So, I mean, yes, 100 % we should be cautious about it. If for no other reason, then you can only take it for two years, right? But ignoring all of the other, in my opinion, large problems with this medication, if I could pick one that really bugs me, it's you can only take it for two years.

1:17:54So like, okay, you're 25 years old and someone's like, here, this is going to help you. You're going to feel great. Great. What happens in two years? What's the plan? Right? And so if your doctor can't tell you what the long-term plan is going to be, then like something's not right. Right? For something that's a chronic condition, a medication that maxes out at two years makes no sense, especially when that max is because of the health risks that it carries. Right. And, you know, ultimately like patients, patients don't tolerate these medications well. They really, the side effects are miserable.

1:18:33And let's talk about them. What are the side effects people should know about? I mean, the most common ones, of course, are the menopause ones we were talking about earlier when you were talking about your experience with Lupron, right? I'm not a nice person. That add back therapy, like it really doesn't mitigate those side effects enough for us to be able to say like, oh, you couldn't do Orlissa, but this is going to be totally different. Like, no, you're still going to have horrible mood side effects and you're still going to feel really tired and miserable and hot flashes and sleep disturbances and all the things, you know, people really don't feel well and the cure should not be worse than the disease.

1:19:08And the case can be made that those medications, the cure is indeed for some patients worse than the disease. The only scenario in which I have used one of those medications is when someone has a major life event that is less than three months away. And they're like, look, I'm getting married. And we picked our wedding date two and a half years ago. And my wedding's in three months. I can't have surgery between now and my wedding. And I'm in so much pain that like, is there anything we can do to try to control it now? And I say like, look, this is an option. You can see if it helps, right? You know, we can trial it now and you can see if you feel better enough that you think like, okay, this is the difference between being able to dance on your wedding day and not being able to dance on your wedding day.

1:19:56Let's do it. And then we plan for surgery after the major life event. Yeah. Right. Is it a perfect, is it a perfect fix? No, absolutely not. Right. But in my mind, like because of that time limit, it is that if someone has a short term, like limitation that they can't have surgery. That's the only scenario in which I have ever found it to be clinically useful for me. It doesn't work for everybody for that, but for some people, it can get them through that major life event. We're seeing more and more women online talking about how they don't trust their doctors. Reporting medical gaslighting is rampant in the endometriosis community.

1:20:41What do you think we do to move forward to rebuild patient trust? I mean, I think the doctors who are good, there's an expression in medicine of meeting people where they are, right? And I think 10 years ago, a lot of people were like, oh, those doctors on social media, like, you know, they can't be real doctors. And I think that now there's a big shift of doctors saying like, no, no, like you should have access to health information in a place that's accessible for you. Right. Like I, I'm not here to gatekeep health information from you. You shouldn't have to come see me in the office to be able to learn my opinion about how to treat something.

1:21:24Right. And I'm a big believer that like, if you get to know a doctor through social media, through patient reviews, through whatever it is that they're doing, you know, speaking that they do locally, if doctors make themselves more accessible in that way to patients, the patients feel like, okay, this is someone I could gel with, right? Like I'm not the right doctor for every patient. And similarly, you know, someone else isn't the right doctor for a patient who may get along great with me, right? And I think we have to just accept that patients like are going to find the right doctor for them and embrace that, right?

1:21:59Like let patients get to know you, let them know your treatment philosophies and what kind of person you are, and then patients are going to trust you. I think people respond differently to different things, right? I'm very blunt with people, right? Like with my patients, I'm like, this is what I think. This is what I would do. Here are your alternatives. They may not be very good alternatives, but like, this is what I got, right? Some patients love that, but not every patient is going to love that. They should get to make that choice. In 2025, what do you wish endometriosis patients knew more?

1:22:34That's a hard one because... It's meant to be hard. It's okay. I know. Have I said that with every question that you've asked me today? No, no. You have not at all. That's a hard one. No, no. You ask good questions. This is... But the thing about this is endometriosis is such a unique disease in a lot of ways, but especially in the enormous variability in patient understanding of their condition, right? I find when people get like a diagnosis, like a cancer, right? They go and they learn everything they can possibly learn about that cancer, right? And so when someone comes in and says, I'm a breast cancer patient, you're not sitting down explaining to them what is breast cancer, right?

1:23:22But with endometriosis, there are some patients who have no idea they have it, they've never heard of it. And, you know, they hear the word, they don't understand what it means. And then there are patients who know more than 99.9 % of doctors about endometriosis, right? And that gap is, I think, what I would like to close in terms of what patients know about it, right? Like, it's not so, you know, so many patients are so well informed that like they talk about endometriosis and I'm like 10 out of 10, no notes for you. But for the other, like my, my wish is to get the other people to catch up more, right.

1:24:00To, to, to bring them along and educate other women about it. I mean, I was doing the math in my head and now I'm going to like betray how bad I am at mental math. But like, if you assume there's, I think there's about 50 ,000 OBGYNs in the U S the last time they surveyed them, like 60 % of them were women, right. That number is increasing now. You know, 85 % of OBGYN residents at least are women now. But say 60 % of practicing OBGYNs are women. So 30 ,000 OBGYNs are women. And then you assume, you know, 90 % of them lack a sort of baseline understanding of pelvic pain and endometriosis. and then you assume between 1 in 10 and 1 in 7 of these women have endometriosis, you're looking at somewhere between 2 ,700 and 4 ,000 something OBGYNs who are gaslighting themselves about their own endometriosis if they don't even know.

1:25:06That's so true. Like there are mathematically, there must be thousands of general OBGYNs all across America who like have endo and they see a patient and the patient's like, I can't go to work because of my period. And the OBGYN is like, girl, me too. We're unlucky. And you're like, ah. That does happen a lot. And you also see a lot of OBGYN saying like, well, I'm a fan of menstrual suppression. So I just recommend that I do that. And I recommend it to everyone. And I'm like, you don't get to be a fan of something and then decide, like, you're, what is this, the MLM of medicine? Like where you're like, I'm a fan.

1:25:48Hey girl, hey, like this works so great. So everybody just get on board and let's do it. It's like, well, wait a minute. Like what if the patient doesn't want to do that? Also, we don't have long-term data to understand when we put women through menstrual suppression from 14 to 44. Like we don't actually know. It's a huge question mark. Is it bad? We can't say. Is it maybe good? Possibly, but we really can't say. Yeah. And I think the transparency about a lack of data is important, right? Saying like, there's no known health risks now, right? We haven't seen any. If it works for you, that's great, right?

1:26:26There's risks to everything. And humans are terrible at calculating risk for anything, right? And statistically speaking, this is one of those things where, again, And when we give somebody numbers like this may slightly increase your risk of this type of cancer if you take this medication. And it's like, OK, compare that statistically to like how likely you are to get hit by a bus on your way to work. Right. Like humans really struggle with calculating these these relative risks. And I think as long as the patient has access to that information, that's what's most important. And no patient like no doctor should be making a recommendation based on their own personal experience.

1:27:01Right. But just like I wouldn't say, aha, I had one patient and she liked him like the Mirena. And so every patient forever will have a Mirena. You can't do that. Right. But it happens. It does. It does. But it shouldn't. Right. How do we close the gap? So you keep saying, you know, there's this information that patients need, information that doctors need. Like we have this big gap of information in a perfect world. your biggest wish can come true, how would you close the gap on endometriosis education? You know, I think educating people early, right? So I think if, you know, I know people try to reach out to like school nurses, for example, right?

1:27:41Health class. I think those kinds of things are really important. College campuses, places where young people are giving them access to this information. Happily, one of the places young people are is also like TikTok. And so So you see a lot of doctors who are on Instagram and on TikTok and talking about this kind of stuff. I think that that's how we start to bridge this gap. And I think it's a great movement. You know, patient education, patient advocacy is really coming from patients and from advocates. And I think the doctors who are getting on board with that are, I think it says a lot about them, right?

1:28:18When a doctor says like, yeah, like you lead the way. I'm here to support you. I'm here to give you like what information I have. I don't have all the answers, but like I want to be a resource for this. I think that speaks volumes about someone's sort of collaborative nature. When doctors are like, ah, TikTok, those are the doctors you really don't, you don't want to engage with those doctors. Totally, totally. Well, this has been a fantastic conversation. Anyone who wants to find you, we're going to put links to your social, to your clinic so that people can reach out. I really appreciate you taking the time to share your knowledge, your expertise, and for getting online and being just brutally honest about the state of endometriosis.

1:29:00It's super refreshing. Awesome. Thanks so much for having me. It's been fun. Class is now in session. And the UPS Store is here to help you ace arriving on campus. Our certified packing experts can pack everything you need, from desktops to decor. Plus, when you pack and ship with us, you get our exclusive pack and ship guarantee. Your items arrive safe or your money back. Restrictions and limitations apply. To get a 20 % off packing coupon and for full details, visit the upsstore.com slash packing. I see you. Avatar Fire and Ash is now streaming on Disney+. It's the film critics are calling the best Avatar yet.

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