The Hidden Link Between Your Gut Issues and Endometriosis | Dr. Jill Ingenito

24:53We get bad information. We know we've got to get second opinions. We're navigating more stuff and we're losing time. We're losing time with our family, time feeling well, time just living our lifetime, bringing our talents into the world. And it is so challenging because I often think if I didn't know what I knew, where would I end up? And I have so many female colleagues that are just like, how does the average patient do this when we know what we go through, but we have the knowledge to know that someone's wrong? I don't know. I really don't. I sincerely struggle with this in my own personal life.

25:30And especially advocating for like my children and what they need. And I hear it all the time. I get thousands of DMs like this doctor said this. And I honestly don't know. Like I think one of the best things you can do is bring an advocate with you. Because sometimes that person can kind of rephrase what you've said. And, you know, a lot of times I've had significant others stand up and be like, this is like ruining our life. Yeah. Like she can't work. she's missing school. She's never going to get into college. Like, I think when they kind of stand up and make those statements, it's really like, I'm like, okay, I believe you.

26:02And I think people come in very defensive talking, you know, and I'm like, well, no, when you're here, like, my first thing is I need you to basically talk me out of endometriosis because a lot of what I'm seeing is chronic pain and a lot of it is endo. So I'm kind of listening to your story thinking you need to tell a story that doesn't tell me it's endometriosis. And so a lot of people come and with like these advocates. And so I'm like, I'm safe. I believe you. Yeah, but it is something that I think a lot of doctors, so they won't say this on camera, but they don't want to work with women who have chronic pain because they say they're mean, they're reactive, they're mean to my front desk staff.

26:37And the thing that I'm always like, you have to stand back and you have to think about this isn't your average patient that you just go into this visit with. There has to be a setup ahead of time of like, Like, we know that this has been a struggle for you. We understand that you've been with providers who are not going to listen. This is how we're going to do things different so that you're held and you're supported and that you are in partnership with us. And it's that, you know, I am in a position where I teach doctors at medical conferences. And so when I teach people this, I mean, I get messages from doctors who are like, oh my God, like 180 on my patients.

27:13You have to set up the expectation for the person. Sometimes it's even on your schedule so that they understand. Otherwise, I've heard this phrase so many times from women just in general, is going to the gynecologist is preparing for war. You need to get your shield. You need to be ready to battle because they're going to gaslight you. They're going to dismiss you. They're going to try to force you on a medication you don't want. And this is how women as a whole start to feel. So especially when you're a chronic pelvic pain patient who's seen 10 doctors who've done that to you, that expectation is kind of there.

27:47And I think, you know, for patients who are listening, I always want people to know that, like, you've got to give a doctor another chance. Like, don't judge them before you get there. But also, not everything should fall on the patient's shoulders, right? To speak the doctor's language, to make sure you're holding the doctor's ego in mind so that they don't get upset with you. Like, it's a lot for one patient. It is quite a bit. I feel for that's why I try to come in with just I try to come in with a very very limited ego listening and kind of helping you where you're at and one of the things that I always ask people is like what's the one thing you need to leave my office today with you know and sometimes they say strange things like okay we can accomplish that and other times I can't accomplish their goal I'm like I'm gonna be completely honest that's not a we're not gonna accomplish that goal here and to be honest most of them have very realistic goals and it's like can you tell me if you think this is endometriosis.

28:38What would you do next? How much do you think medical trauma is contributing to mental health issues among women with endometriosis and maybe even perpetuating pain? I think a decent amount because if you have constantly like going in with a shield like you explained, that's hard. I mean, I feel that like anxiety sometimes when I have to go in and advocate for my child. It's just a lot and it's a lot of stress. And so if there's just someone there to meet you, like to take all that off. Like, I believe you. I think this is endo. Like you don't need to, like, this isn't, you know, not in a court case.

29:13I believe you. But I think that leads to a lot of anxiety, which is where I say like every single touch that you have can just bring more and more anxiety to the table. And the more doctors you see that dismiss you, I think it's just a cycle. I do think it lends to a lot of mental health issues for patients with chronic chronic pain. And I think the chronic pain already disposes you to anxiety and depression and those things, self-doubt. Yeah. Yeah. I had a guest on a link to his episode, Justin Janoska, and he works with a lot of women who have autoimmune conditions. And he talks about how medical trauma is so difficult.

29:54It's such an obstacle for people to be able to actually fully heal because they have to partner with these doctors, but they are in an abusive relationship sometimes with their practitioner in the way that they're being treated. And so they can't really heal because of resources, because of insurance, because of all of these things, because every time they have to meet with that provider who they need, they're bringing up more trauma, more injury, more wounds. Yeah, I think at least in the U.S. health system, I think it's a bit broken. And I think the doctors are also really limited, like for a lot of us are really limited on time.

30:31Some people have the grace of two hours for their consult, but a lot of us are really limited on time. And I think that that is at the detriment of the patient, especially when you have a chronic condition. Why do you feel that endometriosis is notoriously so hard to diagnose? and it is not just patients struggling to get diagnosed, but providers believing that like this is some rare condition. So why is it so hard to get the diagnosis? I think it comes back to the training that we get. I think there's a significant lack of training for chronic pelvic pain and endometriosis and they just don't know.

31:09So I think the doctor not being knowledgeable or whoever you see not being knowledgeable and they're coming, they get kind of defensive if they're like, I don't know what's going on. Like you're supposed to get better on the pill and your ultrasound was normal. I think it's just like a lack of education on our part.

31:28Most OBGYNs have to unlearn what they learned in med school and residency to know how to properly take care of these women. So I think this goes back to like a lack of education in this space in medical training. And at the same time, I think we also lack really good non-invasive tests to be able to say this is endometriosis. I mean, it's one of those conditions where to make the diagnosis, you pretty much have to have confirmatory surgery. So we don't have a good tool. There's no good tools, and there's a lot of people who do not know about endometriosis. So I think in the future, what would be great is just some dedicated training for those wanting to do chronic pelvic pain and endometriosis, and then also, you know, just having a good test that's not so invasive.

32:12I want to talk about imaging because people will say my transvaginal ultrasound was clear my MRI was clear and then you know they operated and there was stage four endo this was my experience I had a um I had an MRI so I had a pre-novo MRI which is full body MRI they so full disclosure they were like we'll comp you the MRI if you post this online so got it done they're like huh we see what looks like adenomyosis we also see what looks like endometriosis but we are not diagnostic we cannot do that you need a follow-up yeah i go get a follow-up mri and well first i go see a doctor who tells me um this is why you should take your advocate everybody because in the room he was telling me that adenomyosis is just a new trendy diagnosis doesn't have any bearing on fertility there's nothing that can be done about endometriosis my husband was in the room with me and he's like, I listen to you talk about gaslighting all the time.

33:07I just didn't think I would ever witness it. And he's like, and then you didn't say anything back. I was like, oh, because we already broke up. Like he didn't know I was, we were divorced. Papers were served. Like it was already over the second he started that. There was no point in me wasting energy because I was like, see you never again. Endometriosis doesn't always show up the way people expect it to. And too many women are left managing symptoms without a full evaluation of what is actually happening. Endoglobal specializes in complex endometriosis care, including advanced imaging review, multidisciplinary evaluation, and excision-focused surgical planning.

33:45You deserve a team trained to recognize the full scope of this disease. To learn more or schedule a consultation, visit drbrighton.com slash endoglobal. That's d-r-b-r-i-g-h-t-e-n.com slash e-n-d-o-g-l-o-b-a-l. So I get an MRI and the radiologist is like, there's nothing there. It's totally clear. I get the MRI and I'm like, no, but like I can see the adenomyosis in my own uterus and I don't read MRIs for a living. I'm like, read it again. He gets mad at me. He tells my primary care doctor that I'm just seeking attention basically. And like, you know, just trying to look for something that's not even there.

34:30I was like, oh really? Let me serve this MRI up to a radiologist who actually reads endo. And lo and behold, get a whole Enzian score. They're like, yep, there's, it is everywhere. So I tell this story because who reads your studies matters. Anyone can do a transvaginal ultrasound, not anybody can see endometriosis on a transvaginal ultrasound. So talk to us about the utility of imaging, and then we're going to get deeper in helping people navigate this. Sure. So I always tell people the basic rule for imaging is just to tell me who I need to invite to your party at your endometriosis surgery.

35:09And it can be, I think, in the future, imaging can be used vastly different, right? As we get better people to read them and better people doing the ultrasounds to look for endometriosis on an ultrasound. But for the vast majority of pelvic ultrasounds that get done, I tell people, if I tell you it's normal, I always write in there, that does not mean you'd not have endometriosis. It just means probably you don't have an endometrioma based on our imaging that we're doing. So I'm saying we're looking for endometriosis, but we're probably not going to find it on the ultrasound. If I see an endometrioma, that already upstages you to stage three, stage four.

35:44I also say with the MRI. So I see this a lot. It is 100 % what comes down to who reads it, the radiologist or yourself. And again, another gap. Gynecologists are not radiologists. Like we're not trained to read our own. You have to seek that education outside of your already crazy busy life. So that can sometimes be a challenge. Again, another thing, MRI. If they don't see anything in your MRI, doesn't mean you don't have endometriosis. It just means maybe the colorectal surgeon does not need to be invited to your party. The urologist does not need to be invited to your party. I can probably go in and start and see what I can handle on my own.

36:21Certainly always want to have the availability of those other surgeons at your tip, but I don't need to plan in advance. Okay, so-and-so needs to be available on this day for colorectal surgery. So-and-so needs to be available on this day for urology. So it's really for me where I work, it's like, I just need to know who needs to come to your party. The other thing I can tell people is I can see basically an endometrioma and adenomyosis. Those are two other things that can be really, really big keys. And a lot of times they won't come right out and say it, but there's several signs for adenomyosis.

36:47So that also helps, I think, patients to understand that basically we're looking for these very specific things and it's used for surgical planning. For people listening, adenomyosis and adenomyosis, they're the same condition we're talking about. In Mexico, everyone calls it adenomyosis. Also in Canada. and I was saying adenomyosis forever. There was a big debate I got into with people and they convinced me to say adeno, but I want people who are listening just to know it's the same term, even though we said it a little bit differently. So why does it matter that we know who needs to be at the surgery first?

37:27That's important so that the initial surgery that you have can be as complete as possible. So we want that first surgery in an ideal world to be a complete excision, which sometimes mean that our skills might be limited in what we can do and you know what you can do. And so you might need a colorectal surgeon to be able to help you take down some adhesions from the colon or take down endometriosis from the surface. You might need a urologist to place stents. You might need to help have them dissect out the ureter. It depends on your skill sets and what you know. But again, you know, if you're looking at cutting out part of a ureter, you're going to want a urologist to be able to sew that back together.

38:07So it can grow in all these tricky places. And always the first rule is first do no harm. So that's kind of my guiding principle. But we want to try to get a complete wide excision on your first go. And what happens if those people are not there? So let's say you go to someone, general gynecologist, who's like, oh, I can excise endo. They get in there. They're like, oh my God, it's all over your bowel. It's all over your bladder. Maybe it's like all over your diaphragm. Like we're finding it all these places. What are they going to typically do? That is variable. That is very, any number of things could be done in that scenario.

38:41Nothing could be done, which I also don't think like, again, we don't have a good non-invasive test available worldwide. So if someone goes in and says you have really bad endometriosis, that's still like an x-ray or an MRI. That's still a really good piece of information for you to leave and then be able to find someone, hey, here's my pictures. Can you help me get this disaster sorted out? So I still think that's a good way to at least know. I think the one thing that really I would hope was not done is ablation, but it is still done. The thing with that is if we're ablating these lesions is just burying them and it makes them harder to cut out.

39:23That's probably the hardest thing is for gynecologists to understand that when you do burn it, just pick a few places to burn. Then when we go to cut it out, that inflammatory process has pushed those lesions deeper into the tissue, which makes it harder for them to get out and you're at higher risk for complications. So you may end up with all these areas that are difficult to excise because of what was done. Yeah. And then what was the second part of your question? I was just asking, like, let's say you've got endo, you've got bowel nodules. You need a colorectal specialist there, but they're not there because your doctor didn't plan ahead.

39:54they didn't do the imaging, they didn't even know, because there's a lot who don't even know that you could do imaging. What are they typically going to do to sew you back up and tell you, let's do this again? So in those situations, and I've been in that situation myself early on in my career, where there isn't always a colorectal surgeon involved, or the colorectal surgeon comes in and said, this is going to be major for her. This is going to be probably a colostomy, probably temporary. But then I think that's something that somebody needs to know in advance. So if you have an excision, and yes, there's bowel nodules, I think the most important thing to do is take a lot of really close-up pictures.

40:29Same thing with the diaphragm. Sometimes I don't have a cardiothoracic surgeon available. Okay, but I've taken an insane amount of photos. I know who to send you to. This person can talk to you about your procedure. So I do think that, yes, it's ideal to have everybody, and you know exactly what's going to happen, and you have the perfect excision. But that's just not life. Like, it's just not. It's not the reality. I think you excise what you can, take a lot of good photos, and then you have those people at your disposal. Yes, you may need to have a bowel surgery. Yes, you may need to see a cardiothoracic surgeon.

40:57So getting them in touch. But I also think that's not the worst thing because do you really want to have this huge bowel surgery that you had no idea about and then have some big complication? Like you want to know. You want to be prepared for something. So I think that's the reality for a lot of people who are doing endometriosis excisions is they might see stuff that's outside of their scope. The surgeon may not have access to the specialist they need that day, but you don't want them doing something crazy that they're not trained to do or having, you know, it's just a disaster for complications.

41:29Do you feel like imaging, though, can make you better prepared and reduce the risk of maybe needing additional surgeries because you have the possibility of being able to see more, visualize more, and prepare the patient? Yes, I think sometimes a preoperative MRI can definitely help with that. And that's really where I use it quite a lot. but um it's wrong sometimes it's just wrong yeah and so you have to be prepared for that situation where it's wrong well and that's the other thing for people to know is that there's also the quality of the mri machine right in the facility that you're at and if you're rural and you're and it's old hospital like we don't really know like if you're going to get a quality image um then there's some people who will do gel MRIs and some who will not.

42:12I opted for a repeat gel MRI because I did have lesions on my bowels. And I was like, fill me up and let's make sure because if I have to like have a resection of my colon, like I need to know that I need to mentally prepare for that. And I need to have all the information possible going in. And thankfully it was just, we have to shave it off your bowels, which was horrific to recover from. So let me just say that like, just because they shaved off your bowels doesn't mean that it's a cakewalk, but it's certainly easier than a resection. And when you consider, you know, women have jobs, they have families, they have obligations, like this is a lot to mentally prepare for.

42:52Yes, it is a lot to mentally prepare for, which is why, you know, if you get into a situation where you don't think you can handle it and you know that the patients are planning to take, from a standard excision, maybe a week off of work. So for you to do something crazy like shave off the bowel when she's not prepared for that, then it might mean another surgery. But you want the right people doing your excision. You don't want someone just, okay, well, I'm in here and I can take this off. You really want somebody who's qualified. Yeah. And that was part of my Selectic My team is that I asked the question.

43:24I think it's an important question to ask is like, what happens if this is outside the pelvis, if this is invasive in another organ, what do we do? And their answer was, we bring in the best specialist. We try to predict that ahead of time and bring in the best specialist to make sure they handle it. And for people listening, you're always looking for that level of humility that I can't do everything. Here's what I'm really good at. But when it comes to the line, I find the person who can do it better. Right. Yes. Having that humility to know what your limits are is huge. And it's okay to be like, this is outside of my scope.

44:05But again, coming back to first, do no harm. The patient now has information. And for the vast majority of patients that I see who ask that question, I'm like, I don't see anything that suggests we need a colorectal surgeon there. If there's a small lesion, yes, the colorectal surgeon can probably take that off from a surface level. But if it's going to involve resection, I want you to have a full-on conversation with them. And again, most patients are fine with that because they've been trying to get the diagnosis for 10 years. So it's like if they can at least find and get some relief and they can decide down the road, okay, yeah, I don't want to have these bowel lesions resected, then they can have a discussion and they can know what they're up against.

44:40Yeah. Yeah. As opposed to like their first endometriosis surgery being something they didn't plan for the recovery. I talked with a neuropelviologist and endometriosis excision specialist, Dr. Nucelo, and I will link to that episode. And he said, you know, because we can't always see what is going on in there, I try to go basically worst case scenario with things of like, okay, let's say the endometrioma is this size. Like, at that point, do I have your permission to make a clinical call, remove the ovary? How often is that kind of conversation happening, you think? I mean, obviously, it's happening with you, but, you know, how often are patients getting that kind of informed consent?

45:24I don't think that they are getting that informed consent with the times. For my patients, I do kind of walk them through worst-case scenario mode and kind of see where they stand. And some people will say, I don't want you to take my ovary. Okay, I'll just take it again, and we'll sew it back together. And there might be the tiniest piece of ovary left, but the ovaries are crazy. So it might be able to regrow and do its own thing. But I leave it up to you because, you know, it's your body. You should have your own autonomy. I think that if you don't do a lot of endometriosis, you don't know what worst case scenario is.

45:59So then you can't counsel your patients on, this is the worst case scenario train. How do you want to get off of it if I get into this situation? And I do find it's different for everybody, you know, especially that comes into a situation with like the fallopian tubes. Like, okay, your fallopian tube is not functioning. It's not working. Would you want your fallopian tube removed? Because you're going to have one then. So everyone's a little bit different. Some people will. I just think you need to walk down that conversation with a patient. That's not happening a lot for people who don't do a lot of endometriosis, unfortunately.

46:28Well, that brings up a really good point because you brought up ablation earlier. There are people who call themselves endometriosis experts, and yet they're still practicing ablation. how did and i actually when i asked my audience for questions about endometriosis what are your questions there were still so many people asking like when should be ablation be considered my doctor's recommending ablation and i'm like why is ablation still a conversation like this shouldn't be a conversation so there are people who they think they're endometriosis experts but they're offering ablation they're not doing excision surgery they don't do any imaging um they don't even do this informed consent.

47:05How can somebody wade through that? Like, what are like some of the boxes to check? Like you were someone, you weren't taught endometriosis. You went and learned it on your own. What were the hoops that you feel like you went through that checked the boxes for you to be like, I now feel confident in my approach? Sure. One basic question you can always ask, do you do ablation or do excision? And if you're finding a mixed, if you're finding an uncomfortable response to that question, then you're probably in the wrong place. That's probably the one box that you can check. I think for me, the boxes that I had to check to kind of get to that point were watching excisions, learning the excisions from the best in the country, watching a lot of videos, hearing them speak, hearing them talk, and also understanding like, you know, the big world that chronic pelvic pain is.

47:58It's a huge bucket of all kinds of things. And you have to understand a lot of how our system interplays and so how different organ systems are affected by this. But you have to be interested. It has to come from the inside. I think that if you, and I don't know how to standardize the experts. I don't know. I don't know how that will fix that problem. I think we face that in a lot of different areas of medicine. Like you're an ADHD expert, but really are you? um it's so true well you have like it's not just endometriosis that's where sometimes i feel like we get kind of down these rabbit holes i'm like it's like this in all areas of medicine like you have to that was someone's i would never claim even myself to be an expert like i do endometriosis here's how i do it like i'm not saying i'm an expert like but here's how i do it i'm gonna call you an expert because when we put the average guy and we put you next to them, your knowledge base, experience, and technical surgical skills are far above that.

49:00And I think that's what it takes to be an expert. And that you, when people are like, yes, I'm an expert and I'm continually learning, that's a real expert. That is somebody who's like, okay, like I know what I know, but I also know there's a whole lot we don't even know. And that is someone that I'm like, look for that person, especially if you bring them studies and they're like, I love this. I didn't know about this. I want to learn about this. Oh, that's a good doctor right there. Yeah. Just that level of vulnerability and just humanity. If your endometriosis pain is still ruining your life, something was missed.

49:38This disease is complex and without specialized evaluation, it's easy to manage symptoms without addressing the full scope of endometriosis. Endoglobal focuses specifically on advanced imaging review and excision planning, and they offer affordable options, including a complimentary consultation to evaluate your case and determine whether surgery is appropriate for you. You do not have to guess on your next step. Visit drbrighton.com slash endoglobal to book your complimentary consult today. That's D-R-B-R-I-G-H-T-E-N.com slash E-N-D-O-G-L-O-B-A-L. I think there definitely just are people who train and they have this ego.

50:30And I don't know, I don't know if you'll ever be able to like tease that out of the people you just have to. And I think that also comes from like being a patient yourself too, is understanding like who's in front of you, being the patient. They might not know everything, but if you can at least tease that out, like, okay, this person's admitting they don't know what the heck they're talking about and they can get me to the next person. Yeah. So we need more doctors like that who are just like, this is where I have to say like, I don't know. And here's what I would do. What do you think in gynecology like breeds that ego and makes it where we don't have doctors who are more vulnerable, more humble about that?

51:11Because I have my theories, but I would like to hear yours. I mean, residency, you're pushed to the limits in so many different ways and you have to prove yourself. I mean, I think there's a lot of just, you got to prove you're the best. And then if you can prove you're the best, you're the best. It's not always like a happy, you know, growth mindset type of environment. It's very like, it can be very cutthroat, to be honest. I just don't think that that was ever emphasized. I don't even think I ever saw a doctor in my training be like, admit to a patient they didn't know what they were doing or admit that they may not have the knowledge.

51:58I think we're all kind of coming out, especially as young doctors, we're not sure if we believe in ourself. We're not sure if we can do it. And then we just like put on this facade like, oh, I can do this. Like I can. So I think there's just not an acknowledgement of the vulnerability that goes into working with humans. Yeah. Yeah. So I agree with that piece. And I think that because it's women's health and women's medicine is kind of always seen as the lesser, that within medicine as a whole, right? There's like, I am like the orthopedic surgeon and you're just a gynecologist who couldn't make it into a surgical residency.

52:37So that's why you're a gynecologist. And I think that also because the field is predominantly women, there is medical misogyny, which translates to patients and to providers. And I think there's a lot of women who are like, I have to put on the strong front. I have to be like, I have to fight for my place. And that is something that I think, again, it's not about the individual. It's so easy as patients to like get mad and hate the person in front of you, which is the doctor, and not actually understand what has gone into creating that person. And we've got a whole upstream issue. We've got ACOG who could care less about endometriosis.

53:19They're like, why care about endometriosis? We can make IVF, like doctors, so profitable. You don't have to say that. I will say that because I would love ACOG to prove me wrong. I'm really challenging them because it's what I ultimately want is them to care about endometriosis, but we see like the way that you just said residency. And so much of this paradigm is it works against the provider and it's the patient who ultimately gets home. Yeah. That's 100 % what it is. I want to talk about, we're going to go more into surgery because my audience has tons of surgical questions. However, there are people who can't yet afford surgery.

53:58They can't get surgery. Maybe they don't need surgery. Who should they be thinking about having as part of their care team, right? Because the surgeon is always one part. So I don't do surgery. When I work with someone who's endometriosis, I'm like, we got to find you a good surgeon. Whether you need them or not right now, we don't know. But we want them there already when we need them, not like, oh, God, we have to scramble and find someone because we needed them yesterday. So surgeon, definitely a core part of the team, and we want to get their professional opinion. Who else should be on the team?

54:29Good question. So the way that I think there's a few handful of clinics are set up is that it's a chronic pelvic pain clinic. And so for me, I'm managing all facets of chronic pelvic pain. It could be interstitial cystitis. It could be pelvic floor muscle dysfunction. It could be a vascular disorder. And I'm also a surgeon, but I don't think there's a lot of people out there that manage chronic pelvic pain and do endometriosis surgery. So I do feel like if you can find somebody who does all chronic pelvic pain and also does endometriosis surgery, that would be great. But if you can't, you want somebody who does a lot of chronic pelvic pain that can do non-surgical management of pain, then you have your endometriosis surgeon, for sure, a pelvic floor physical therapist.

55:23And then I also would argue somebody who has an interest in urological conditions, colorectal, and vascular disorders. But this is like a dream team. I mean, these are just not the realities that you have. But if you have somebody, you know, if you're in a small town or you're in an area that doesn't really have access to surgeons, then you just want somebody who has a good understanding of all the different things that can cause chronic pelvic pain and can hopefully try to get you to those subspecialists. But I think that's one of the bigger issues. And I've been approached on this. It's like, why don't you just start a chronic pelvic pain clinic and you could do endometriosis surgery and you can have a variety of nurse practitioners like doing the medical management.

56:07But I still like all facets of the chronic pelvic pain management because I do get a lot of people who are like, I don't want surgery. Like I'm in school. I'm like going to school to maternity. I don't have time for this. So, you know, if they can get relief to the point where they can function and live their life, like that's great. Well, and it's an important thing because as you said at the top of this, you were like, you got to talk me out of endometriosis because I see so much of it. And yet we can see things like women get, you know, IBS diagnosis, interstitial cystitis diagnosis, like they're getting all of these other diagnoses, which can ultimately be related to endo, like these things can be connected.

56:43So I do think it's important to have that understanding. How do you feel about having like a dietician or nutritionist on the team? That would be great. You're like, oh my God, somebody make this happen. But this isn't like, I feel like this is not the reality. At least in my world, it's not the reality of medicine. I mean, the chronic pelvic pain specialist has to be able to say, you know, here's where, yes, you can see a dietician. You know, you can see an exercise physiologist. You can see all these people. So yes, having those people. But I don't think the average gynecologist, if they're even interested in endometriosis, has access or would be able to kind of connect people.

57:20Yeah. Well, I think also there's people listening that they just know they're going to have to do this themselves. They're going to have to put together their own team. You know, before we started recording, I was talking to you about a psychologist that we're having dinner with tonight who helps a lot of chronic pelvic pain, especially endometriosis patients. That's another thing I think is missing. Anytime a woman has pain, we know depression, anxiety, suicidal ideation, like these things begin to skyrocket. Having mental health is so important. And just because you excise it doesn't mean the body doesn't remember, the nerve pain patterns aren't there, or that like somebody doesn't also have a grief of loss of organs and tissue or the years that, you know, went by without help.

58:04Mm-hmm. So the way I do my consults is kind of addressing all of those things, right? Looking at the endometriosis and components, but also looking at mental health and central sensitization, other urological things, GI issues. So I kind of systems-based all of it and try to see what pieces also go with the endometriosis because endometriosis does not travel alone. alone. A lot of times it comes with a variety of different things. So you have to kind of not be so narrow focused and look at all the systems and how it's playing out for someone. Yeah. When you talk about central sensitization, that's going to be new for some people.

58:41Can you explain that? Sure. Central sensitization is the way I like to describe it is somebody could be touching your hand and it just feels like in a normal functioning nerve that your touch is being perceived by your brain. But for people with central sensitization, an actual touch can feel like they're pinching that area with a sharp stabbing knife. So our nerves have remodeled. And now when we get any type of sensation to that area or to that nerve, it's sending out, oh my gosh, danger, danger, you're being pinched. Whereas you might just, someone might be trying to just touch your hand. So those nerves have remodeled.

59:18And that happens over time and endometriosis and other pain conditions. It's just important to be aware of that nerve remodeling and how, you know, you may need to address that. How does someone know that's happened and how would you address it? So good question. There's some scoring that you can do. There's a few different types of scoring systems that you can do to determine a central sensitization component. But this can happen sometimes when you've had an excision, right? And you still have some of that residual pain. So like if the bowel, for example, is like moving in the area where you had an excision, you can still kind of feel that area and it may just be moving by as whereas you're feeling that same, the nerve is triggering that same endometriosis pain response.

1:00:00So I think you only really tease that out over time and after you've had a chance to have an excision, that's kind of something that comes down the line. And let's say you have an excision and this persists? Do you have therapies, ways that you can address that? Sure. So I think the main thing with central sensation for me, at least, is understanding what it is, anti-inflammatory responses that we can try, pelvic floor physical therapy, and sometimes a nerve modulating medication can be really valuable. And that can be a little bit of trial and error. So if somebody gets a good response with one of those nerve modulators for central sensation, you're like...

1:00:39There's some component here. Yeah. And I would assume this is a situation where keeping your journal, keeping your diary is really helpful. Yes. So if somebody, one of the questions that came up over my audience is that people are like, is surgery always necessary? Is it the only way to manage endometriosis? No. Okay. So what else can people be doing outside of surgery? We talked about pelvic floor physical therapy. Yes. So pelvic floor physical therapy. and then I think that the number one thing you can do is find a progesterone that you don't have too many side effects on and that could take some time that will stop all the bleeding so if you can't afford surgery you don't have access to surgery you don't have time for surgery a lot of times doing pelvic floor physical therapy combined with a progesterone is enough and a lot of people come to see me and they're like I want surgery on surgery I'm like great we have like a three six month wait so I'll put you on that in the meantime would you like to live your life yes okay let's do pelvic floor PT and let's put you on some progesterone that doesn't have too many side effects and I will tell you there's a fair number that come back for their pre-operative visit and they're like I'm fine and I gotta do this so when you say progesterone are you talking about progestin based like either one okay we gotta just find something that works for you and a lot of times for a large majority we are using like north or north endrone or medroxy progesterone and that will work for some but I do find in endometriosis patients that they're more sensitive the side effects of those medications.

1:02:06And so it can be tricky. So sometimes I'm going to the compounding pharmacy and using more progesterone-based therapies or getting creative, but some way that stops the bleeding altogether with some concoction, that is the way to go. Yeah. So firstly, I will link to the episode on progesterone intolerance for people because I talk about the difference between progesterone and progestin. endometriosis patients, neurodivergent patients, women who have PMDD tend to be much more sensitive to progestins, have more adverse side effects, and be told, no, it couldn't be happening. There's no causation in the research that birth control could shift your mood.

1:02:49The other thing we see is there's a big crossover in all those conditions. So there was a really interesting study that neurodivergent women, specifically autism and ADHD, are more likely to be diagnosed with endometriosis. And if you have endometriosis, you're more likely to be diagnosed with these conditions. And that to me, I'm like, is very interesting, especially when you consider the high rate of PMDD these women are experiencing. So I appreciate you saying like, we try to find what works for them because sometimes, I mean, I'm someone, I keep like, I try to gaslight myself that progestin will work.

1:03:22And then I'm just like this angry crying mess and it doesn't work. But because I have adenomyosis, I now have started taking progesterone during like the last seven days of my cycle just to be like, I just want a little buffer so that, you know, and at this point, like my progesterone levels are still good. So for people listening, I tested them. Progesterone looks fine, but the indication is not based on my levels. It's based on, I don't really want that tissue to grow and I would like to never have a hysterectomy. I like my body parts. I also don't like surgery. No offense. I don't like surgery.

1:03:57No offense taken. I think it's just you have to be really creative with your physician or your nurse practitioner. And that's the one thing that's hard to teach gynecologists. You got to get real creative with people. Yes, it could be I need birth control, and I need a birth control pill, but that ain't going to be enough if somebody has endometriosis for the large majority. And so sometimes you're adding in a bioidentical progesterone or progestin, something else on top of it. So it just, the medical management of endometriosis requires an insane amount of creativity. And so that's what I've learned just from other providers in my group, like, oh, you did this in combination with this progesterone, this worked well, she's not bleeding on this.

1:04:36So whatever it takes. Well, I was going to ask you because at the top of this, you were saying these tissues respond differently to hormones. Can you talk about progesterone resistance that can happen with these tissues? Yeah. So, I mean, over time, I think there are patients that I have that respond really well. Like they can get an IUD and they have a Mirena or another progesterone IUD and they respond well and they don't bleed and you're just everyone's clapping. Like it's great. You love it when it's easy. Yeah, that can be easy. But for a lot of women, that just is not enough, right? So we've got to up our game.

1:05:08So if someone comes to see me to have an IUD, they're still bleeding. We have to add some progesterone to the mix because we need to get to your point. We're not bleeding. So for some women who want to go the more birth control route, that's going to be a Mirena IUD and an Exponon or two Exponons or a Mirena and some progesterone or a bioidentical progesterone and the birth control pill. So you can't just rely on one thing, which is definitely something that's not taught to gynecologists. And there's no research. There's none. You know, there's absolutely zero about combining these different methods to find something that has the least amount of side effects where people aren't bleeding.

1:05:43and you're going outside the box right a lot of times when I'm on vacation for example then someone will say oh you were doing this and I'm like that's what we're doing is she okay yes it's working so yeah you have to get creative you have to be a little bold you have to do things that other gynecologists aren't going to do because it's often the case where there's just that progesterone resistance and the normal standard things are not going to work I love that you said there's not the research there. So we have to get creative because we'll hear providers say, you can't do that because there's no research to back this up.

1:06:17There's no research. And then, you know, you'll also hear from the general public who are like, well, that's not FDA approved. I'm like, oh girl, I can tell you how much stuff we do. That's not FDA approved, like many medications we're using in women's health. But I think it's important that we do look at the individual. And And I always, you know, I've had people say like, oh, you're rebellious and say different things like that because I'm with you on that. Like you have to get creative. But the way I always see it is that this individual has a finite amount of time on this planet and I'm not going to wait around for two decades for a research study to validate what they're saying is true about their body and what's working for them.

1:06:56Yeah. For me, it was learning from someone else who was doing this and like reading through their notes and seeing those patients and be like, oh, she did this progesterone and this progesterone that made the patient stop bleeding and she got better. She did two Nexplanons and that patient, you know, so a lot of what I do is pretty creative with the, what I have available to me commercially and just finding different combinations. But I would say there's, you know, patients ask me like, well, I don't see any studies on like dual use as an Nexplanon. I'm like, there are none. They don't exist. But, you know, and then people come to us and they're like, oh, we should do the research.

1:07:29I'm like, I don't have time right now. I just don't have time. It is so true. I hear that. There's been so many practitioners on this podcast who are like, and people ask me to do the research. And I'm like, people will say that to me too. And I don't think people understand the time and the money it takes to do a study. And clinicians are great at participating in the research study, not so great at designing and orchestrating the whole thing, because it really takes somebody just dedicated to that. And it is something that I wish we could be doing more studies, but it's not that easy. And even if you do do a study, if it's not double-blind randomized control trial, people are like, that's not good enough.

1:08:12And you're like, we have to start somewhere, right? We have to start somewhere in building evidence and making a case sometimes to get the funding to actually do the research. I mean, research is just not my forte. So someone comes with a research project and like, okay, it's a really great idea. Let's take it to this person and see if they can help us. But yeah, it needs a whole team. I mean, in the groups, the private groups that I've worked with where they've done successful research studies, like they have a whole squad. Yeah. It's not like the clinician that's running that. There is like a whole squad of researchers and I don't have that available to me.

1:08:47Yeah. What I haven't heard you say is Lupron. I mean, you can use Lupron. I mean, that's another thing in the toolbox that we can use. I don't use a lot of it because I really do find like if I do, you know, Northendrone and Prometrium or like the IUD and Provera, like combining things, I don't find myself having to do a lot of Lupron. The only time I'll do it, and I try not to do it before an excision because it can make the surgery just a little bit more challenging in terms of the scarring that it causes. Well, first of all, people hate Lupron. But second of all, we hate Lupron. They don't feel well.

1:09:21So I'm like, oh, it's good. And if somebody wants to do it, I'll do it. I'll do it with hormone replacement therapy at the same time. Yeah. But I usually use it in a situation where we're talking about like, you know, stage four disease that we excise as much as possible. The patient's still having a lot of pain. She doesn't want to have another surgery. She wants to try Lupron. Okay. Sounds good. But how long do you use it? I mean, I'll use it up to two years if someone can make it that long. But I don't know. It's hard. It's a hard medication to take. Yeah. So I've explained it to people. Like everybody's like, oh, perimenopause is the worst.

1:09:51I'm like, try going. just like within two weeks, you drop into the worst phase of perimenopause immediately, and it doesn't go away. Like it just gets worse. But you're doing ad back therapy. Yeah, I'll do that. With bioidentical hormones. Yeah. Yeah. No one's, I mean, in my experience, no one is tolerating Lupron without the bioidentical hormones. It's just not happening. But there's providers not doing it. Oh, for sure. I seriously, when I look at the brain research of the outcomes of like post hysterectomy, a woman losing her hormones, going without those for years at a time, 30 % reduction in her cognitive health compared to her cohort who didn't lose her hormones.

1:10:30I'm like, this is criminal. It has to be done with ad back. And I did Lupron and I did a tiny dose of like ad back of an estradiol patch. I'm in a place where I can prescribe for myself. And I did that. And that was just to take away the hot flashes because I was like, I cannot live like this. In retrospect, I'm like, my brain was struggling so hard. I should have done more. And then I did progesterone as well at night to be able to sleep and to also keep my sanity. But that also wasn't enough. I was like, seriously, that's when I discovered like saffron is amazing for mood. It's so necessary, but it's a very, very hard medication.

1:11:08But some 20-somethings, they're being told like, this is it. Like, this is the best. or we'll wait until it's really bad to have surgery. And as somebody who had surgery in their early 40s, I'm like, damn, I wish I had surgery in my 20s. That would have been so much easier to come back from. Yeah, definitely. It's easier to come back when you're younger. Lupron is just a challenge, I find. I can't get a lot of takers unless... I do sometimes use it where we've done an excision. The patient has bowel lesions, diaphragmatic lesions. They're not in a place where they can have these big surgeries.

1:11:38They don't have access to those specialists. That's when I'll try Lupron. Why does Lupron make the surgical outcomes worse? The fibrosis that it develops in those lesions, so as it starts to kind of like kill it off, so to speak, it just ends up creating this like scar, you know, just very similar to like if you have surgery and you have a scar. It creates this scar that's just, it's difficult to dissect out. You can't get the normal planes that you would get, which is what you want to get to. You want to get to the normal planes and the anatomy to know that the endometriosis is gone. But when that fibrosis is there, you're like, where is the end?

1:12:12Where is the normal anatomy here? That makes it challenging. When someone uses Lupron for two years and then has excision surgery, can there be worse outcomes? Can it be more difficult to recover from? In my experience, it's harder to excise. Okay. And it puts you at a little bit, I think, of course, in other states, I think it puts a little bit higher risk of complications, especially when it's like around your ureter. So that can make it more challenging to dissect the ureter out safely. because of that scarring and fibrosis that happens from Lupron. Yeah. And I wonder for the patients who are listening, who are like, I had what I was told was complete excision surgery, but pain has persisted and they would have a history of Lupron use.

1:12:55Could there be something related to that? There could be. There definitely could be something related to that nerve remodeling. If you don't get good relief from an excision, that's kind of a basket of things that it could be. So it could be that it's not endometriosis. It's the whole picture, right? There could be a vascular disorder. There could be a bladder condition, a bowel condition. There could be a lot of other things that need to be looked at. So that is not, I wouldn't say Lupron, I would go to like my first thing like, oh yeah, Lupron, that's definitely what it is. I want to go back and be like, okay, wait, let's see what, tell me more about your pain right now so I can kind of see, is there something else here in your picture besides just endometriosis?

1:13:32Because a lot of times there is. yeah well i think that's important for people to hear is that lupron is one consideration but i really appreciate because i think that it's really easy for us to like kind of get like our experience our bias and just be like i say this all the time with lupron so it's just lupron and it's like you're saying it could be lupron and i need to do my due diligence and ask more questions yeah yeah definitely so what other kinds of things could be going on if somebody so one person wrote me and they said, I had excision surgery and a hysterectomy 10 years ago, and I still get menstrual cramps.

1:14:07That could be a couple of things. It would depend on if the ovaries are present or not, but that could be pelvic floor. I mean, the two biggest things that I see that get missed is underestimating how painful pelvic floor muscle dysfunction is. And number two is vascular disorders. I think there's a wide, if endometriosis is largely unrecognized, but pelvic venous disorders are even large, even a bigger basket that are unrecognized. So in that situation, I'm usually having someone see an interventional rheologist who can do a good job evaluating for pelvic congestion and seeing if there's a role there.

1:14:45And then also making sure people are doing pelvic floor PT with a good PT. So I have like a couple of places where I'll send you. And then there's a few places where I'm like, you got to have pelvic floor PTs that are very versed in endometriosis and pelvic floor. Yeah. This episode is brought to you by State Farm. You know, those friends who support your preference for podcasts over music on road trips, that's the energy State Farm brings to insurance. With over 19 ,000 local agents, they help you find the coverage that fits your needs. so you can spend less time worrying about insurance and more time enjoying the ride.

1:15:21Download the State Farm app or go online at statefarm.com. Like a good neighbor, State Farm is there. I agree with the endometriosis component. And after my excision surgery, I've been doing pelvic PT for like nine months now. But then I had to have knee surgery. So that's off the table. I was like, I need a three-month break from that. I do PT for my knee. but uh the trigger points that i didn't even know i had and i will say that i feel like because i was seeing her first before the excision surgery but after the excision surgery it's like the layers of the onion started to come off and now the lesions were removed we were able to get deeper and i'm just like i you know i was making a joke to her because i had this really painful like causing my legs to bounce trigger point and i was like i'm pretty sure that's like when I fell in the monkey bars or, you know, the stairs when I like the people on YouTube can see me straddle and fell when I was like nine.

1:16:19I'm pretty sure it's like way back then. Like, that's how like deep this feels is that it's like it's been with you for decades right now. So I think it is really important to consider the pelvic floor physical therapy piece. What is pelvic congestion syndrome for patients, people listening who don't know? So pelvic congestion syndrome is going to be, there's a number of different diagnoses that fall under that bucket. But it's basically the veins in your pelvis are not returning blood to your heart like they should. And so blood is pooling in different areas, and that can cause pain. And so I think there's a lot of pelvic pain that's caused by pelvic congestion syndrome that we haven't really acknowledged.

1:17:00And I think as somebody who trained as a gynecologist, what we're taught is that pelvic congestion syndrome is very commonly seen on imaging, but it's not clinically significant. And I don't think that is correct. I think that that's what we're taught. But I think the more we see some of these newer therapies coming out from interventional rheologists like iliac vein stenting and some other venous therapies and people getting relief, I think we need to pay attention because I think that that's even a larger area that hasn't been acknowledged. What are the symptoms of pelvic congestion syndrome?

1:17:36They can be all the same symptoms of endometriosis. That's the problem. So that's where I say, like, if you don't get, if you get some relief with your excision and you don't get complete, okay, have we really looked at pelvic floor and is there a vascular cause as well? And I think one of the things, you know, it can be pain outside of your cycles. It can be heaviness or pressure. But a lot of times it is a very similar overlap of symptoms. So while I think endometriosis is like this thing that's getting up and moving, I think we also have to acknowledge that there's other things that can cause your pain.

1:18:07So if you get an excision, you're not better. You've got to have somebody who can dig deeper. Yeah. And the two most common things that I see contributing to pain are going to be the pelvic floor and the vascular disorders and pelvic congestion. What if someone's seeing varicose veins, spider veins in their legs? Could that point that we've got pelvic congestion issues? Same thing with swelling. a lot of POTS patients. So people have POTS symptoms or even just orthostatic tachycardia syndrome, which is where your heart rate races when you go to stand up. So I think that can also be a big sign.

1:18:40Like when I see someone who's had an excision, a good excision, and they have POTS and their legs are swollen, varicosities, and like we have to get you to see a vascular interleague neurologist. POTS, ADHD, autism, EMDD, endometriosis all also go together. So as you bring this up. I'm just like, there's you guys in the comments, you can, if you're popping off light bulb moments, I want to, I want you to definitely let us know. Cause I think you just connected a lot for a lot of people. And I think POTS gets ignored a lot or it gets relegated to just, this is just a cardiovascular issue. You need to see the cardiologist without considering that like the nervous system's involved.

1:19:18And now you're like your entire pelvis vascular system could be involved as well. Yeah. I mean, this is only something I've just started learning about from experts in the area. And I saw one speak at a conference who happened to live like down the street from me. So I spent a couple of days like working with her. You're like coffee. I'll make coffee every day. Teach me about POTS. It's shocking though, like just spending a very short period of time with this group, learning how many pelvic pain patients they see who've had good excisions, who still have pain. And then it really ends up being some type of constriction in their pelvic vessels and they get better with stenting and other types of therapy.

1:19:56So I think we're going to learn more about that in the future. They're doing some studies. Some other people are doing some studies that are going to be coming out, but it's largely been taught to the gynecologist that pelvic congestion syndrome may be seen on imaging and it doesn't have any symptoms, but I think that it actually probably does. Yeah. Stenting. You've said it twice. People don't know what that is. Break it down. So a stent is basically like a long kind of tubular structure that you can put in a vein. Like if you have nutcracker syndrome or May Therner, these are different vascular or venous issues.

1:20:26That can open up the vein and keep it open instead of having the vein constricted. So it opens the vein. It keeps it open. Blood flow can get through the pelvis, back to your heart, back to your brain. So you don't feel like, you know, have POT symptoms or a lot of the pelvic pain can go away once we've relieved that constriction in the vein and opened it up. Why is there constriction in the vein? Like what is going on there? So sometimes it can be from anatomical, just anatomical variations. They're more common than you would think. And other times it can be from endometriosis and from scarring and from adhesions.

1:20:57Yeah. So those are kind of... Interesting. So what are you doing? So someone's having an endometriosis workup. What are you doing to check for pelvic congestion syndrome, which everybody listening will acknowledge has a big bucket, right? is a bucket. And there's lots of other things that can be diagnosed specifically within that bucket. But you see someone with endo and they tip you off. They say, I have POTS as well. What do you do to work that up? Are you doing imaging? So in that situation, it's really important to listen to the patient. Like, what is the quality of the pain? Is there a heaviness?

1:21:30Especially if anybody describes a heaviness to their pain, I'm like, with the combination of POTS, especially if I see some lower extremity swelling, I'm like, do you want to do your excision first or do you want to see an interventional radiologist first to see if there's a way we can treat that? And everyone's a little bit different. Some patients have just like the classic pain during their periods, but if anyone's having pain during their periods and outside of their periods, the two biggest things I'm thinking are pelvic floor and a venous congestion. So pain outside the period and a heaviness are two of the biggest things.

1:22:01And then POTS, that would be another big one where I'm like, we really got to have you see someone. And the problem with these venous disorders is that the protocol in the MRI has to be correct and that a lot of times the radiologist isn't even looking for it and they just completely miss it. So while you might have an MRI that said it's totally normal, it could be wrong. It really has to be looked at by somebody who does a lot of vascular pelvic pain. So we talked about you need a radiologist who actually gets endometriosis, who's been trained in it, can look for that. Pelvic congestion syndrome, you need a radiologist that specializes that, I think that's so important for women to hear because just like women are told your blood work is normal, but you have all these symptoms, you also might be told, oh yeah, well, your imaging is normal and it's not.

1:22:47You have to have that expert read it. How do people find that expert though? Because that's the thing. I mean, people ask me and I'm like, well, I know a lot of people. I know a lot of people. I called my friends. I was like, who's the radiologist I need to send this to? But I'm like, how does the average person, because the way it flows in the United States is that when you order it, it goes to the radiologist. We can actually say, I want to get it over to this radiologist. But if your doctor doesn't know who to get it to, what can a patient do? You're like, I have no answer. I don't have an answer.

1:23:17This is like a hot topic for me mentally that I'm trying to kind of uncover. There's a couple people in the United States that I know are doing this work and are doing it right. And so I just have to send it to them to have them take a look. Can you name drop them? Oh, sure. So Brooke Spencer and her team at the Minimally Invasive Procedure Center in Highlands Ranch, Colorado, and then Dr. Hutchins, which I can't remember where she's located, but she is online. She's also doing a lot of this work as well. And so I just don't think there's a lot of intervention radiologists that are interested in the pelvic pain patient and helping them, right?

1:23:57And from what I understand from these people who are doing these procedures, like the iliac vein stenting is, even if you get to the point where they're like, yeah, you need an iliac vein stent that can help with your pelvic pain, they're not placing the stents always correctly. So this is like a bucket of, I don't even know what to do at this point. For my patients, I send them to this group. I say they look at the imaging, they determine what the issue is, and they put in a stent. And that's why if you saw my post recently, like I took an entire day off to go learn from these people because I felt like it was that important, like as important as endometriosis to find out what they're doing, how they're doing it, how it can help people.

1:24:36Does pregnancy put you at risk for pelvis? Yes. Okay. I didn't even get the question out. Yeah. Pregnancy can put you at risk for pelvic congestion, but I have seen a few patients actually who have not been pregnant and who've had it. Yeah. Yeah. And sometimes your doctor can see it. I've been looking more and more for it when I do my scopes, when I do my excisions. I've been looking more and more for it. And you can tell like the vessels are just really dilated and tortuous and kind of twist and turn, kind of like a varicose vein in your pelvis. If I see any of that and the patient has symptoms after her excision, I'm like, I got to get you over to these people.

1:25:06Yeah. For them to take a look at an MRI and then determine if you're a candidate for a stent. Yeah. Is there anything that patients can be doing outside of surgical intervention for this? No, because it's like a constriction. I mean, there probably is. I don't know. But we're talking about a very narrow couple millimeters where a vein is supposed to be, you know, wide open and patent. Like, I don't know how to correct this to this without a surgery or a stent. Yeah. So it's like, I don't. Yeah. I wonder, like, I also wonder if, like, there's something going on with the nervous system of, like, what about potentially, like, nutritionally, you know, we know, like, bioflavonoids, vitamin C is like really good for veins.

1:25:48But, you know, as I, as I spot all this off, I'm like, I, other than something that vasodilates you, right? Like, I mean, I, I, I'm not an expert in pelvic congestion syndrome. So, you know, one question I have is that like, are there medications for vasodilators that might be helpful? I think it just has to be, and this would be a great person actually to have on your podcast. Yeah. Okay. Okay. either dr hutchins or dr spencer and they can talk more about it and talk more eloquently about it than i am but i can't i also was thinking that same question i was there was like is there any way i can help these people without yeah opening up the vessel and i mean other than temporary your legs up the wall every night right and yeah but like for some of them it's just an anatomical thing yeah that has to be corrected yeah so it's a difficult place to be in and it's also something that like you know i bring on surgeons on the podcast and we talk about surgery and then we often try to talk about things outside of surgery as well but sometimes surgery is just you know the only answer is what I just went through with my knee I'm like no can we do anything else right they're like no there's literally tissue lodged in your knee joint you got to get it out I'm like great okay right it's the same thing like with endometriosis right you know you can try medical things but if you're not getting better like I can't remove them there's no medicine to remove them.

1:27:07Yeah. So one question that came up as you bring it back to endometriosis, somebody asked, okay, so can endometriosis stay minimal your whole life or is it always going to grow? Is it always going to keep, you know, being problematic? Is it something that like I have to worry about it moving into my organs? I just think it's, I've seen such wide variety. I would say yes, sometimes it can just stay very minimal. And it kind of depends. That's hard to say because sometimes then they end up going on birth control, right? For contraception, just straight contraception, they need birth control. So like, did it stay minimal because that person was on contraception?

1:27:46But then there's some people who have endometriosis very early on where, you know, even them being on contraception, it doesn't matter. It just spreads like wildfire. So I don't know. Yeah. For some people, you just stay kind of this like a minimal stage one, two anti-inflammatory, but I don't think that's true. I don't think there's like an overarching statement. Usually once I see the endometriosis, I can kind of say, okay, this, once you've excised it, like, I don't think this is going to grow back because it's more like surface level. But that deep infiltrating stuff, I'm like. Yeah. Well, I think it's also important, you know, as I frame this question is I never want women, firstly, you never caused your endometriosis and secondly nothing you did personally like was like the deal breaker of like making your endometriosis like the worst thing ever and there's a lot I think especially now it's become very political about like this personal responsibility in health care and yet what gets left out of that conversation is the environmental impacts that you do not have control over so when you've got forever chemicals coming through in your water like you might clean up all your makeup to have it as, you know, endocrine disrupting free as possible, but maybe your water supply, maybe you live near farmland, like there's all of these variables within the environment that also can influence your health and the development of chronic disease.

1:29:06And so while I think it's important and I always want to empower people to take as much control as they can over their life, I think it's also important that we recognize that you can live your absolute best life and try your best. And sometimes life just hands you variables that you didn't see coming and you could have never controlled. Yeah. And that's a hard conversation to have with patients. Yeah. Just understanding that some of this is out of your control. Oh, totally. I want to control everything. Yeah. And they do too. I mean, right? Like they do too, because it feels like something you can control.

1:29:37But, you know, I mean, it's the same thing. Like I, my son has ADHD and like, I feel like my husband and I will constantly go back and forth. Like we can control this. Like we can fix this. Like we'll get them in the right sports. We'll put them on the right meds, like right therapies. But like, sometimes we're just like, this is outside of our control. Yeah. And I feel that same way with endometriosis. Like I'm like, this is, you can do all these things and it could still be an issue. So please don't, you know, keep searching for like the perfect supplement or, you know, the perfect exercise routine.

1:30:09Like some of it is just out of your control. Yeah. And there's, you know, I think it's really hard when a patient's like, I haven't touched sugar in like 10 years. And I like, you know, don't stay a plate. And they, they, they look back and they're like, I did everything perfectly and I didn't get to live my life. And yet this still happened. And I think that's hard. And sometimes we have to recognize that like, there is an experience in this life to have as well. And within wellness culture, I think that perfectionism is something that becomes this gold standard. And, and I'm, I'm integrative.

1:30:43I'm always like, I want everything. I want every single tool at our disposal because whatever you need is what we want to use. I'm a buffet. Like I don't eat at buffets because of, you know, foodborne illness. But when it comes to medicine, I'm like, give me the buffet and let's pick and choose what we want to put on your plate and what your plate can actually handle. And I think, you know, sometimes, you know, we have to just look at things and say, like you, you may be thinking, wow, I ended up in surgery anyways, but what you're not actually seeing is that how much worse would this surgery have been?

1:31:16How much harder would the recovery time been? Like you don't realize that like everything that you put in was positive towards the outcome here. And that like not all of us are going to avoid a medication or avoid a surgery our entire life, but living that life to the best of your ability is going to influence those outcomes. I mean, you're going to reduce medication side effects in some instances. Right. I think that it's important to go through that, like discovering what works well in your wellness journey and also pairing that with what we have available to us, like surgically and medically.

1:31:48It's not either or. Yeah. And I think I've had these conversations where women will say, like, I'm doing all this stuff. Like, do you think I can still avoid an excision? I'm like, we can try. Like, we can try to keep you out of the OR. Like, whatever you want to do. But just sometimes we have to, it involves all the things. So, you know, you can't always outsmart your endometriosis if it's there. You sometimes have to use the tools available. That is such a good song by right there. You can't always outsmart your endometriosis. So I'm like, yeah, I think we all need to hear that. You did talk about reoccurrence.

1:32:26How can somebody reduce their risk of recurring after excision? Yeah. So during the excision, it's important to get, like I was saying, to those normal planes in the anatomy where the clear spaces are. So if we can get those wide margins, we know anatomically and things are back together. What I do in my practice is I say there's no bleeding after excision. None. How you want to do this, it's entirely up to you. Here's the 500 things that you could do in combination, but there needs to be no bleeding whatsoever. And I find that those patients have less recurrences in my practice. I don't know that that's true for everyone, but like some of the combinations that I use, like they're not studied.

1:33:08So you're saying no cycling? None. Okay. But I still have found that in really deep infiltrating endometriosis that I can't, nothing that I can do medically. It's just like, we don't have this. This medicine does not exist on this planet yet. So there are some cases where no matter what, even if I don't cycle people and I go back in there and they have a recurrence, I'm like, it is what it is. At this point in 2025, here's where we're at. Yeah. Well, I want to ask you though, because there's women who get excision surgery with the goal of getting pregnant. Yes. I don't put them on anything. Okay.

1:33:39Yeah. So that would be the exception is right. We're trying to get pregnant. Okay. We want to try to get pregnant in those first six months immediately following your excision. Like we need to be ready to go. Infertility evaluation needs to be complete. We need to have normal semen analysis. Everything needs to be in order because right after the excision, we have about six months. So for those gals, no. Why is it six months? I think after about six months is when they see those lesions kind of start to regrow and more inflammation starts to build to the point where it can interfere with pregnancy.

1:34:09Yeah. And there was a study that came out recently, and I can't think exactly what it is, but it basically showed after like six months, you should get them in the hands of an infertility specialist. But also like, I always tell patients like, do you want to do this for another six months? I mean, it's up to you. You can keep going, but the chances are less and less. Yeah. As you get between six and 12 months. So. Yeah. I mean, that's hard to hear, but I think it's also important to hear. And I've had other fertility specialists on the podcast that are like, we try within three to six months for her to get pregnant like post-excision surgery.

1:34:41And then I know it also differs if like the uterus was involved at all. And like if you had to shave anything off the uterus or maybe there was, you know, a focal adenomyosis and you had to remove that piece. So it starts to get really tricky, which is why I think it's really important to highlight what you said, which is that getting that fertility consult and making sure you have that player on the team. So we talked about the team already, but if you're wanting to get pregnant, that brings in a new team player. And I think that there's obviously some people who do all of it, and those people are even smarter than I am.

1:35:15But yes, you want to have everything. And sometimes that means having an egg retrieval before you have your endometriosis surgery, and sometimes it means after. So working with them to try to make the goal what it is. Yeah. But excision alone can increase chances of conception by up to 40%. So if you want to try that, I think it's worth a six-month trial. But after that, you need to get a lupine infertility specialist. Yeah, no. And for people listening, it also depends on your age as well of all of these considerations. And it was something that when I was faced with, you know, my endometriosis surgeon was like, okay, you know, let me give you a little algorithm of what your AMH is.

1:35:55And if your AMH is less than one, you need to do an egg retrieval before you have excision surgery. And my endometriosis surgeon ended up being like over two. And I was like, lies. No, like rerun that. And then it was over two again. And I was like, okay, like 40 something years old. This is okay. Like I'll take it. Yay. However, I opted to do the retrieval first because I knew it was going to blow up my lesions. I knew that it was going to be provocative. Right. And it did. I mean, sure enough, they were like, yes. And we saw lots more. And I'm like, yeah, because all of that estrogen stimulation.

1:36:32So I ended up just going that route just for that reason that I was like, every little bugger that exists, I want you to see it. And of course, so people say you have to wait a period of time for it because you get very inflamed during an egg retrieval and you have to wait a period of time for the inflammation to go down. But it showed me that, I mean, that was really a definitive for me where I'm like, everyone with endometriosis needs to understand IVF makes endometriosis worse because it absolutely does. We do not talk about it. And I was managing my endometriosis naturally really well, living pain-free, third egg retrieval, thought I was dying.

1:37:08Like three weeks later, I was like, I think I'm dying. Like something is so, so wrong in here. And I didn't know I had endo yet. And then I had a fatty endometrioma. I'm like, that makes so much sense now. Yeah, that's hard. I really find that to be a challenging place for women who have to go through egg retrievals. I think it really is like, you really got to look at your life and be like, what am I going to be able to tolerate in this period of time? I think we have to be honest with endometriosis patients. I think there's too many reproductive endocrinologists who aren't looking for endometriosis.

1:37:39And when things get really bad, I woke up from my egg retrieval crying and they were like, we need to get you more meds. And I was like, there was that nurse at Yale who was smuggling all the fentanyl. And I was like, did someone steal the pain meds? Because I'm feeling everything. They immediately were like, we have to do transvaginal ultrasound, like something's wrong. And they were like, your entire cavity is just inflamed. And I'm like, yeah. And nobody ever thought to say endometriosis to me. So I share this story with everybody because if I had to go through it, then it's a great teachable moment that hopefully I can prevent someone else from going through it.

1:38:16But I want to ask about endometriomas as I brought it up. So a big question is, is ovary removal ever necessary or should the goal always be to preserve them? Eczema is unpredictable, but you can flare less with Epglyss, a once-monthly treatment for moderate to severe eczema. After an initial four-month or longer dosing phase, about four in 10 people taking Epglyss achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing. Epglyss, LibriKizumab, LBKZ, a 250 milligram per two milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema.

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1:39:27I think it depends on you. Depends on what your goals are. If we're looking to do an aggressive excision and surgery and you're young, yes, let's try to keep those ovaries. Let's quantify young, okay? So what are we talking about here? Is it like, if you're under 45, let's try to keep them. If you're over 45 and what size of endometrioma, we might want to remove them. I mean, I always try to go in to say like, let's try to keep the ovary. Okay. I like this. Okay. So like, let's try to keep the ovary. Like, let's just try and see what happens. You know, sometimes, and it's not a lot, but sometimes it is more challenging to get to those normal planes when you're doing like an endometriosis surgery on the ovary.

1:40:12So sometimes it is challenging to get to that restoration, that normal planes to like get you as much wide excision as possible. Yeah. And I just kind of go with, yeah, we can probably, I mean, there's very few situations where I feel like the ovaries need to go unless you want them to go. Like there's definitely people who are like, it all must go. Yeah. That's the end. Okay. I like that you give women the choice. Yeah. I'm not your mom. Like you decide what you want to do. If you want me to say that ovary and there's like two millimeters of it left, fine. Is there a certain age though where you're like, okay, let me ask, is there a certain size of an endometrioma that makes you think, oh, I probably can't preserve this ovary?

1:40:48Let's start there. I don't have a cutoff. Okay. You just try no matter what. Just try. Okay. I like it. I'm a fan. Yeah. I don't have a certain size. I mean, I guess if it's like 20 centimeters or something and there's zero, you can find no anatomical ovarian cortex, then maybe. Okay. um but i don't have a cutoff and do you have an age where you're like you know at this age it's probably okay if we if we take an ovary like when you're consulting someone i and i leave it up to them okay um i would say probably over 50 i don't know that you know that would kind of be there's some evidence to kind of say over 50 if you're going to be doing that surgery do you really want to keep the whole ovary but if you want to it's fine i give you the choice yes i want to keep it over.

1:41:34Okay, we'll do it again to try to save it. It may end up like a tiny remnant, but probably under 50 is kind of where they say ovary removal. It might just be easier to do it that way. And for people listening, the average age of menopause is 51. So your ovaries have already stopped at that point. And for some people, you might be in perimenopause at 45 and it's like, well, you're going on HRT anyways. And this ovary might not be the healthiest. Yeah. It's just an individual conversation. Do you want it removed? Do you not want it removed? How do you want this to go? And does the concern for having ovarian cancer ever come into play?

1:42:13Oh, yeah. I mean, I tell them if they have a family has ovarian cancer, I would just take it out if it's me. But a lot of times I find what patients say is, if you think I'm going to be out of pain and it's not worth saving, then go ahead and take it. But, you know, if it's so intertwined, then I would rather get to the normal tissue planes than kind of keep it. So it's individual. And I haven't found a real, like, strict cutoff for people. I just kind of give them the choice. Okay. And then when it comes to hysterectomy, this is something that there are still doctors. I'm going to pull a book out of this Southern playbook of Bless Them that say hysterectomy can cure endometriosis.

1:42:54Can we please talk about that? Yeah. That said a lot. I think that it can help quite a bit if you have adenomyosis, which tends to run with endometriosis. And so I think it can help. But if you don't do it with an excision, I just don't see how anything's making sense there. I think that comes from a place of, again, people not knowing what to do. Like, I don't know how to help this patient, but I can do a hysterectomy. And maybe that'll help a little bit. It might. It might help with the adenomyosis. But I think, again, that comes from that line of thinking I've never heard taught in training ever.

1:43:34Wait, so you were never taught that a hysterectomy cures endo, but yet we've got like a little like cage of parrots on the Internet who are just spouting that over and over and over. I think it's because people don't know what to do. Okay, okay. Which, you know, to their credit, what you are saying, and I think this is important to dissect out here, is that you're saying they are just trying to help. They're trying to help and they think this might help. But why is it that a hysterectomy without excision is not going to help? So the endometriosis still lives. The actual disease is still living in the peritoneum or that space all around the pelvis.

1:44:12So you've not removed any of it at all. So, you know, it's kind of like leaving a big mass behind. You've left the big mass behind, but you've taken out the uterus. It's not going to help. But this is not stuff that I'm telling you is taught in training. Like this idea. And again, I think where I've seen patients come to me where they've had a hysterectomy, that had ovaries removed because you have an endometriosis excision. Honestly, the gynecologist is not trying to be a jerk. I think that they legit did not know how to help this person. And there are some people that get better who have chronic pelvic pain who have a hysterectomy.

1:44:47But I have seen a lot of people with all of it removed and they're like, I'm still in pain. Yeah. And there's also been celebrities who have touted like having endometriosis. And so I just decided to get my uterus removed. And it's like this hysterectomy is like this women's rights thing that like starts to come up. And then I think it's like when Angelina Jolie had her like double mastectomy. And then suddenly I had patients who were like, should I get a double mastectomy? I'm like, why are you listening to Angelina Jolie about like medical advice? And I think we saw that in, I think it was like the last seven years, several celebrities just talking about like, I had endometriosis, so I just got a hysterectomy.

1:45:24And I'm like, slow that down. like that was part of like a bigger conversation I'm hoping there was excision surgery in there but like that only perpetuates this myth that like just remove the baby container and like you're gonna be fine and what we've heard so far in this conversation is that like it doesn't only have to be endo like it can be so much more and the hysterectomy isn't just the one one-stop shop for women yeah the thing about it is is in the past I think maybe a generation, the older generation where that's what's happened. Like my mom had a hysterectomy. My aunt had a hysterectomy.

1:46:01My grandma had a hysterectomy. Okay. It was just like what was done. Like they're just like, got it all, take it all out. And I still actually find people coming to me like, just take it all out. I just want everything gone. I'm like, okay, I'm not going to just take everything out. We can take everything out. And here's what else I'm removing, okay, but are you taking out the uterus? Get out, take it out. So I think that we're kind of seeing some generational stuff come down there because that's what was done. If you had anything going on down here, it was like, take it out. Yeah. What's interesting is you say that.

1:46:35What comes up for me is that generationally, that was, are you done with children? Okay, just hysterectomy, take it all out. Our generation, because I'm assuming we're around the same age, was like, did you start menstruating? Just take the pill. Like, just take the pill. And so much of women's medicine is like, your lady parts, right, are the problem and not a, well, hmm, what might be going on? I look back at this and I'm like, when I had horrific periods that made me vomit, I missed school, like I bled with a heating pad on the ground for like seven days out of every single month. Like that was so clearly endometriosis, like so clearly.

1:47:13But like doctor after doctor, all I was told is just take the pill. The pill solves everything. The pill is like your best thing. and it didn't help. And I just went through like a decade of depression and pain of taking the pill. So I think like it really kind of comes on that bigger conversation of like, why do we just have one intervention and we call it good enough women, you should just be thankful and apply it to everybody. I don't know. Oh, come on. You don't have an answer. Come on. I know this keeps you up at night. I don't know. I mean, I think it was like the people who just taking everything out with their hysterectomies, like that's because there was the pill wasn't available.

1:47:49And then like the pill came on the, on the scene and then it was like, Ooh, you can like maybe not get pregnant if you don't want to get pregnant. Yes. We like that part of the pill, right? Like, Ooh, you know what I mean? So then as many people weren't having to have just take everything out. So it just kind of has shifted. And now we're seeing like more and more people who have been on the pill in the situation and they don't want to be on it anymore. And they find out, Oh my gosh, this is my reality without it. So, you know, I think that'll shift. I don't know. I don't know the answer to that one.

1:48:19Well, I think we're also seeing doctors like you, like you just like stepped on the scene on social media and you like ended up in my feet. I was like, this person's fantastic. You're like, I'm going to say this. I don't want this to be rude, but you are hilarious. You're far more hilarious in your videos than in an interview. And I know this is more high pressure situation. So I want everybody to go watch your videos. And I think they're going to be like, wait a minute, is this the same person? Yeah, you're always like dancing or rocking out or you got your daughter with you. And I'm just like, you're just such an awesome duo.

1:48:51But I think we're seeing more doctors. It's something that like, I want to pose this to because I have said to my husband, the problem is not when we think of medical misinformation, the problem is not the rise of influencers. It's not the reach of influencers. It's not influencers at all. It is doctors who have neglected women, who have created this gap, and who have forced patients to go outside of the medical community to look for advice. And the biggest thing that doctors can do is not, I think, calling out misinformation of like, this person's so stupid, is a really bad negative content, and it only reinforces in the people's minds who think doctors are the enemy, that they are combative and the enemy.

1:49:31But I think doctors coming online, educating more, being human is going to be the most powerful thing to rebuild trust, but also make it to where patients are like, I want to go back into the medical community. I want to go back to them for advice. What do you think? Yeah, I mean, that was one of the reasons I decided to do it because I debated it for a while and my patients would just come to me with a TikTok. like look at this TikTok and I'm like and I felt like I could do it better and more funny and yes I'm probably not as funny in person but um I'm also not people will always be like you're so funny can you like say a joke when I'm speaking on stage I'm like no I cannot no I absolutely cannot because there's an expectation yes so yeah I'm probably more funny and more funny online but I think that was one of the things that there was just so much negativity about doctors in the endometriosis space.

1:50:21I was like, yeah. And then I was like, I'm not doing this. I'm like, I am going to get eaten alive on Instagram and TikTok. I am going to just get eaten alive if I say things in a certain way. And part of that came from like, you have to be really careful with your language too, especially in this community. I found that, you know, sometimes when I, the way I want to say something like in life, right? Like if I just say it like this, it's not going to land well. So there's a little bit of finesse learning there, but that was one of the reasons I was trying to do it is like, listen, we're all not the enemy.

1:50:52Like, I usually do want to help people. Like, sure, I could have just stayed a gynecologist and like done all the like boring, you know, stuff. I didn't have to do any of this. It takes away from my time, my family, like all the things. But there are some of us who like actually do want to help. And I try to bring a little bit of humor to the space because I just feel like it can be sometimes very dark. Yeah. And yeah, I hope that that message gets out there that we're all not like that, that there are people who care. There's people who are interested in this. So. Yeah. Well, I think it's important.

1:51:26I think the work that you're doing is really important. I made a joke the other day on social media because I explained like, hey, there's one theory of endometriosis where these stem cells that would have become a reproductive tract migrated during embryonic development. And I go through all of that and I made this joke. I'm like, there's a playbook of, I don't know if it's like set up, maybe somebody is like really smart with AI and just has it reflexively to comment, but you say something and it edges towards like endometriosis could be derived from endometrial tissue, right? And people are like, endometriosis is not the endometrial tissue.

1:52:04And I'm like, yeah, bro, that's what I said. Like, and I was talking and they're like, you said that it could have been. I'm like, okay, I know that embryonic development is kind of complicated. We don't get taught it. And even in just like saying that of like trying to acknowledge it, like I get that. They're like, what are you calling me dumb? I do understand this. And I'm like, I'm not saying that. Like I'm just saying that like maybe I could have done a better job and this is complex and confusing and like, and they're like, oh, so you think it's too complex for me to understand? And I'm like, oh, you woke up and chose to hate someone today and I'm not someone.

1:52:35I got to just, I love that. I got to just walk out of this conversation. And I think that's like what makes working with the endometriosis community and trying to support them so hard is, you know, there's one person who comes in and decides that like this pent up rage and anger, like they're going to offload it on you. And it can be really easy to like let that bog you down. And I always have to just go back and look at the comments. And like, I just had someone last night that she was asking me a question about like a hysterectomy. I was like, here's this podcast episode. And she's like, you've helped me through every stage of my life.

1:53:07She's like, you helped me when I was having period problems. You helped me when I wanted to get pregnant. You helped me postpartum. And she just went through. She's like, and I've never even met you. I've just seen you online. And I'm like, I'm going to hold on to that forever. And I'm going to put this up of like a total stranger on the internet has had every phase of her life affected by me. And so I say that to everybody listening and to you of like, keep showing up because odds are the person that you help the most is the person you never even hear from or knew they existed. Yeah. I mean, there's a lot of people online scrolling all the time and they can live in small towns in the middle of nowhere and you can help them.

1:53:45That is, I take those messages and I hold onto them super tightly too. I think another reason I wanted to come into this space is because I come to the table with, I'm just trying to educate, even though if you think my content does not speak to that, I'm just, it's fantastic. But a lot of people will be like, I think most, a lot of the influencers on in this space that are doctors, like trying to make money off of certain things, which is why I've gotten a lot of criticism. Like, what are you doing here? You're not trying to make any money. Like, why? What are you doing? I'm like, I'm just educating, right?

1:54:16I'm not selling you surgery. If you come to me, I make no money if I do your surgery or we sit there and we talk. Like, it's the same amount of cash. So I think a lot of people are looking at me like, well, you're just trying to sell surgery with yourself. I'm like, I only take a certain type of insurance. You can't see me anyway. So again, they might've just woke up and decided to hate someone. But it is, It can be challenging. I definitely have days where I look at my phone. I'm like, okay, not today. Yeah. Not today. Why am I doing this? I'm making no money. Yeah. Just educating. But I mean, it gives you opportunities.

1:54:47And I do get those occasional messages. Like I live in the middle of nowhere. Yeah. No one in this town even knows what endometriosis is. I think we all get that. I think there's just this idea that like you shouldn't be able to make money in something that's so personal to somebody. I own a supplement company and it's interesting to me that I actually don't get that much hate for it but there will often there will sometimes be like oh you just tried to sell me your supplements I'm like really because I just told you all the foods to eat for magnesium so I don't know like I always tell you to eat nutrition first but then I'll have people who are like um I didn't even know you had supplements and I wish I would known this because I just discovered it and it helped and it's something where you're like I'm you have to be comfortable in who you are and what your mission is and what you're really trying to do at the end of the day.

1:55:33And I think that's something that when I entered into my 40s and I've had like a really rough ride into my 40s of things happening that I was like, I know who I am. I know what my intentions are. I know what I showed up to do. And I know the history of my character speaks for itself. So someone may want to come online and paint me in a negative way. And people online tend to believe the first thing they hear, right? and never actually like look into somebody. Someone says like, oh, this doctor, like she's just a surgery mill. And so she just wants to make tons of money off that. There's going to be people that are like, oh, unfollow, you must be.

1:56:07And I'm like, it's sad to me that we are not teaching critical thinking in school. And it's something that I'm trying to do better with my kids. But also it's not my responsibility to prove my character to every single person that exists out there. Like my actions have spoken. I have been very public for a decade. And I think it's some point you just have to be comfortable with that of like people are going to judge me either way I've I've shown them who I am they can make their own decision yeah I mean I've even had uh there's a couple like content creators that do menopause that are really big into the menopause and like the hormone replacement therapy and I follow them and I've even gone into like large meetings with big groups of OBGYNs like just for a regular meeting and said hey I learned this from so-and-so online and they're like, what?

1:56:54You're quoting this doctor from online and that person has a supplement company, like obviously, you know, and I'm just, it's just. Like I think what doctors don't get taught. So my background is in nutrition science and I learned a lot about the supplement industry. And OB-GYN has no problem prescribing a prenatal, but what they don't realize is that there's a lot of contaminants in that prenatal and it doesn't actually even have what it says in it. And that was the big reason why I ever did my supplement company because I was like, I'm pregnant. I want it third-party tested. I want it heavy metal screened and I want to know what's in it.

1:57:28And I am going to contract with a pharmaceutical manufacturing facility. So it is at the pharmaceutical grade in doing that. And I think when people are like, oh, it's just a sub, like they're just trying to sell supplements. Like, yeah, there are supplements that I see on Amazon that I'm like, I know how much those ingredients cost, that's not in the bottle. I mean, I have met people at business conferences who are like, oh, we put rice powder in our supplement and sell it to people. And I'm like, what? And they're marketers from some other country who think this is totally okay. And I'm like, this is wild.

1:58:03And that's there. So when you meet doctors who have supplement companies, it's often because they're like, I need to take this. I need to control this because it's so wild out there. But it's this idea that like, you know, because there are some doctors who are like, oh, supplements are bad. There's no reason for a supplement ever. And then I'm like, well, what if someone has iron deficiency anemia? Oh, iron sulfate. Oh, the lowest quality iron so that they're constipated and they feel like hell. Or you could give glycinate, like highly absorbable, lower dose, going to raise their ferritin like faster.

1:58:30And you start getting into these conversations and you realize there's been no critical thinking. There's only been, I heard this thing from someone I respected. So therefore I just thought like, okay, this is just the way it is. But I know what you're talking about in the menopause space because I know some of these people because I remember them when they were like just stepping onto the space. And when they got popular is when other healthcare providers decided they were no longer a human. And that's a weird phenomenon that happens on social media is that once you have a certain number count, you no longer have to be treated as a human.

1:59:05For some reason, you can be dehumanized and hated on and it's somehow okay. I don't get down with that psychology. I'm always like, the thing is, is that you have kids. I think about this all the time. My kids will grow up and they will see the history of my legacy of what I did online. And I never want them to see that I taught them to be kind, not to be a bully and to treat people with respect while I went online and did the complete opposite. I'm like, no, no, no. That's what I'm like. That's what on my deathbed with like, I don't know, keep me one foot out of the grave. I don't know about this.

1:59:37Yeah, I mean, I had like no coaching in this space. I just was like, I'm just going to start somewhere. Right. I don't think a lot of people do. Like, and that's now people are like, well, you have$25 ,000. You need like someone to help you. And I do need help. But like, I don't know. I'm just kind of learning as I go and just trying to kind of go back to that same mission of like, I'm just trying to provide education in this space. Make patients like see that we're not all like this. Like, it doesn't need to be so much like hate against endometriosis, like doctors and OBGYNs. Well, gynecologists, man, people hate gynecologists.

2:00:05They hate gynecologists. It's crazy. Definitely have like welcomed in that hate by being really awful humans to other humans who are in pain. And I get that. But I think it's so important exactly what you said of like demonstrating that like it's not a whole field. It just happens to be that you've run into like some really unsavory ones. I mean, most of the gynecologists I know and I work with are really good people who want to help people. Like I don't come across like these people who show up every day and say like, I don't want to help these people. Yeah, I honestly think is that we don't know what to do.

2:00:39And so then their ego steps in and they're like, well, just get an ultrasound and take the pill. Yeah, your ultrasound's normal. Have a great day. So I think that a lot of the hate that's come for gynecologists is just speaks to the large gap in education, in the chronic pain and in the endometriosis space. People do not know what to do. I always say no one went to medical school because they didn't want to help. They absolutely wanted to help. And the other layer in that is that insurance ruins everything. It literally ruins everything. Insurance and the pharmaceutical company, they so wisely played the patients to say the doctor is the enemy.

2:01:13Well, they raked in all the profits but told the patient that the doctor is just money hungry, greedy, all of that. I'm like, that's literally pull back the statistics of where money flows. And it's not the reality of it. But these big corporations sure did play us all against each other. I want to ask you, so for someone who's newly diagnosed or still searching for answers, what's the most important thing you want them to know about living with endometriosis? I think that, well, I would say endometriosis will not or should not, it's not an automatic death sentence or life sentence. Like there are ways to help.

2:01:52Is it perfect? No. But there are ways to help. And I think a lot of people feel like a ton of relief once they know they have it. But then also they go into this next stage, which is like, how am I going to live with this? What am I going to do? My whole life, you know, it's going to change my career path and whether I have kids and all of this stuff. I think it comes with the diagnosis comes with a lot of questions about your life path. But I think the one thing would be, you know, there are things that can help. There are people out there that want to help you. it's just finding those people just feels like a little bit impossible of a health journey so you just have to be persistent and you have to have someone in your corner that can advocate for you and so and surrounding yourself with those people that's what I would say wow this has been such an insightful conversation and I'm gonna link to your social media so people can find you because you are funny okay you make learning fun I try I try Well, thank you so much.

2:02:47Thanks for having me.

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