Episode 46: Why Endometriosis Is Still Mismanaged & How We Can Do Better as Clinicians w Heather Guidone

Heather Guidone joins us to help work through all of the noise surrounding endometrosis. 

She the Program Director of the Center for Endometriosis Care and a Board Certified professional health Advocate. She has focused on 'bench to beltway to bedside' efforts in endometriosis research funding and facilitation, legislation and policy reform, education, advocacy and activism, patient-centric care, and more for over thirty years; importantly, she is also someone who has struggled with the disease. 

What we will discuss: 

-Why the "retrograde menstruation" theory falls short

-Why birth control, pregnancy, and hysterectomy aren't  cures

-The key differences between ablation and excision surgery

-Why diagnosis requires skilled listening, imaging, and sometimes biopsy

-How trauma, chronic stress, and nervous system dysregulation can influence symptoms

-The critical role of patient autonomy, informed consent, and individualized care

-How to find a skilled excision surgeon and what questions to ask

-Non-surgical ways to manage endo symptoms (like PT, stress regulation, and nutrition)

Timeline:

00:00 Introduction to Endometriosis Mismanagement

00:28 Meet Heather Guidon: Advocate and Expert

00:59 Debunking Myths: Retrograde Menstruation and More

03:55 Understanding Endometriosis: Beyond Painful Periods

13:03 The Role of Trauma and Stress in Endometriosis

15:09 Patient-Centric Care and Informed Consent

28:18 Diagnosis and Treatment Options

40:05 Understanding Excision and Ablation

42:31 Challenges in Accessing Quality Care

46:09 Questions to Ask Your Provider

49:16 The Importance of Compassionate Care

54:05 Surgical and Non-Surgical Treatments

59:27 The Role of Hormonal Treatments

01:07:01 Endometriosis: A Multifactorial Approach

01:09:35 How to Reach Out for Help

01:13:40 Conclusion and Final Thoughts

You can learn more about Heather at:

https://www.centerforendo.com/

Workshop:

The “Woo Woo” Explained: How Energetics, Fascia, Lymph, and the Nervous System Impact Movement for Rehab Professionals

Dont worry, it will be recorded and sent to you if you can't make it live.

📅 May 6th, 2025

⏰ 6PM CST/ 4PM PST / 7PM EST

📍On zoom (will be recorded)

You can learn more and sign up here. I hope you can join us! 

If you are a health or movement professional and want to stay in touch with future episodes, webinars, courses, events and more. Subscribe to my email list here

I’ll see you in a week!

Transcript

0:56

Welcome back to TMI talk with Dr. Mary. Today we're gonna be talking about why endometriosis is still mismanaged and what we can do as clinicians to help better serve our clients so that way we can get them the results that they need. Maybe it's just not. Pt, maybe it's not just chiropractic care. Maybe they actually need surgery, maybe they need an endometriosis specialist. But oftentimes there's so much misinformation out there that it can be even confusing as clinicians to even know where to send our clients. So today I am so excited because I brought on Heather Guidon, who is the program director of the Center for Endometriosis Care and a board certified professional health advocate. She is focused on. The bench to beltway to bedside efforts and endometriosis, research funding facilitation legislation, policy reform, education advocacy and activism, patient-centric care, and more over 30 years. More importantly, she's also someone who has struggled with the disease. In this episode, we're gonna go over why retrograde menstruation Theory falls short. Why birth control, pregnancy and hysterectomies aren't the answer, the key differences between ablation and excision surgeries. Why diagnosis requires skilled listening, imaging and sometimes biopsy how trauma, chronic stress, and the nervous system dysregulation can influence symptoms. The critical role of patient autonomy, informed consent and individualized care, and how to find a skilled excision surgeon and what questions to ask. Also, we review non-surgical ways to manage endometriosis. Such as physical therapy, nutrition, and stress management. So I hope you enjoyed this episode. Now we're gonna get to it. Welcome back to TMI talk with Dr. Mary where we dive into non-traditional forms of health that were once labeled as taboo or dismissed as Woo. I'm your host, Dr. Mary. I'm an orthopedic and pelvic floor physical therapist who helps health. Movement and rehab professionals integrate whole body healing by blending the nervous system into traditional biomechanics to maximize patient outcomes. I use a non-traditional approach that has helped thousands of people address the deeper roots of health that often get overlooked in conventional western training. And now we are gonna be starting our next episode.

Audio Only - All Participants-1: 3:17

Well, welcome to the show, Heather. I'm happy to have you here. Thank you so much. I'm such a huge fan. It's such a privilege and an honor and a pleasure. Thank you for having me. Oh, I feel the same about you and like we were just saying before, don't be on your best behavior. No, no behavior here today except Ill behavior. We're gonna get in good trouble. Before we jumped on here, we were talking about humor and dark humor and how it's all healing and laughter, and I truly feel it is the best medicine. Like when you feel like shit it like you can laugh. you have to be able to poke funny yourself. You have to be able to take those vulnerable moments and not make light of it. You wanna show yourself grace, but you have to be able to take those moments and really just say, what else is there? You know it, what else can I do? I have to laugh to keep from crying sometimes. I just have to, and I know so many people like that. Oh yeah. So much. I do think, yeah, like you were saying, there's a balance. Between, giving yourself the space to feel and be sad and emotions, but also there's a point of humor can be, I used it for many years to deflect and like just be like, oh, I'm fine. I'm fine, everything's fine. But now I use it as a healing tool. So it's interesting to look at it that way. And so you've reclaimed that power. I love it. Yeah. Yeah. So well, let's just go ahead and jump right in and Yes, all things Endo, TMI. Let's do it. Yes. Endo, TMI. I love it. Yeah, can you explain to everybody why endometriosis is more than a painful period? I feel like there's just so much misinformation around here, and I'd love for them to hear it from you. Absolutely. Yeah. For far too long this disease has really been reduced to a reproductive disorder. It's been framed as a menstrual disease. It's constantly talked about as quote unquote just a bad period. It's just killer cramps. It's just backwards, menstruation, all of these things that really reduce it. And take away from the magnitude of what it really is, which is a systemic chronic inflammatory disease. The tissue that comprises the lesions of endometriosis. Yes, they're somewhat similar to the endometrium, which is where it gets its name from, but there's so many biomolecular differences between the lesions of endometriosis and the normal or native endometrium. It's different tissue. It behaves differently. It acts differently in the body, and it's been found in virtually every organ system in the body. It's not just a reproductive disease of the ovaries or found on the surface of the uterus or in the rectal vaginal area. It has been found in the lungs. It's been found. In the sciatic, it has been found in the brain. Rarely it's been found in folks assigned male at birth. You name it, it has affected the body. Fetal autopsy has revealed endometriosis. It has been found everywhere in everybody. Now of course, obviously it goes without saying. Yes, it predominantly impacts those assigned female at birth. Many people with a uterus, but not just those with a uterus, you can be post hysterectomy. You may not be menstruated for whatever reason you may be in menopause. Endometriosis can still affect you. And I know we'll probably talk a little bit about, the different phases and so forth. But if we wanna just talk pure definition, the most simplistic way to put it is a disease that is comprised of tissue, somewhat resembling the endometrium, but distinctly different. And it causes a host of issues if you've ever suffered from endometriosis, it is way more than painful periods. It is pain apart from periods. It can be terrible GI symptoms. It could be organ dysfunction, it could be a collapsed lung. It could be ureter or kidney or bladder dysfunction or pain or issues with that. There is a fertility component just as there may be a menstrual component, but again, that's part and parcel of other symptoms. Things that you might not even think about. Chronic inflammation, fatigue, neuropathic pain painful sex.

Audio Only - All Participants: 7:40

Gastrointestinal problems, collapsed lung in the cases of thoracic endometriosis painful sex, body wide inflammation, things you might not think of, poor sleep quality, fatigue, loss of productivity. A host of symptoms and in different organs and different body parts can really be attributed to endometriosis pain and symptomology. So it's very far reaching, far distant from the pelvis, far outside the reproductive organs, and far and apart from menstruation. Yeah, as for those of you listening, I have endometriosis and it's something that I've been managing and have under control currently, but you also have had it yourself. That was your big part of your story as well. And so we can speak from experience how the amount of gaslighting, the amount of misinformation, the amount of just dismissiveness, I don't think people are, at least for me, I don't think they intentionally do it. I just think that there's just so much lack of information. And then you saying too, that people assigned male at birth or are experiencing this as well. So what do you think, there's so many theories behind endometriosis and one of the leading ones that I've seen is how it's retrograde menstruation, but What are you you all seeing All almost 90 percent of menstruators experience some level of retrograde menstruation. Not all 90 percent of them are going to develop endometriosis. It doesn't explain endometriosis in CIS men even though that's a very small study sample. There's only a handful in the literature, but they exist. And it's not just men who have been on hormones for prostate cancer. It's men who have never had cancer, never been on hormone therapy. So while small, and of course, obviously, it predominantly impacts those born with a uterus. It retrograde still doesn't explain endometriosis in all people who are affected. They have found it in fetal autopsy. There is some link to it. Retrograde neonatal bleeding. But again, we can't really necessarily align that with adult endometriosis. We look at teenage, pre monarchal, and adolescent endometriosis. Those who've never menstruated, they have the disease. Sometimes it's a different, more aggressive form even than adults. So retrograde definitely has a place in endometriosis in terms of, historical origins. It simply cannot explain the disease in all bodies, and that is something that Samson himself acknowledged throughout his career. He said, I acknowledge that this is really one of many therapies. And at the end of his career, he said, it's less important to me whether I'm right versus finding progressive knowledge on the disease. So he acknowledged it even through it. His work that this is just one of many as we've evolved as our knowledge has grown organically and through research, we begun looking at things like. Embryogenesis. Are you born with it? Is it a perfect storm of multiple factors? Inflammatory, immune components, genetics, epigenetics, stem cells. In our opinion, in our center's opinion, we are probably born with it. It is probably triggered by a multitude of factors and or mechanisms. But the reality is there is not a single theory that explains all endometriosis in all of those affected. We have a long way to go and we have a long way to go. Can you explain who Samson is for people listening? Cause I'm also like to let people know, like I break things down a little bit too. So retrograde menstruation is basically instead of, or a majority of the menstrual flow coming through the cervix and out through the vagina, it's going. Into the abdominal cavity. Yeah. John Sampson was a preeminent gynecologist. He gets maligned quite a bit. He takes a lot of heat for his theories, but he really did have a very big role in, in helping endometriosis evolve both research wise. And in terms of awareness. So in 1927, nobody was really countering his theories and his work because nobody knew, nobody knew how to counter it, except for a couple of folks who said you're wrong. He believed was that menstrual effluent would back up through the tubes, shower out amongst the pelvis, all over the ovaries, and voila, you have endometriosis. That would work if it could explain endometriosis in all bodies, which it can't, and that would work if natives Slash normal endometrium and endometriosis lesions were identical, but they're not. So we know there has to be other reasons in addition to, apart from and or instead of just Samson's theory his is the most enduring because we don't have that much research to combat it. We are definitely getting there. There are so many wonderful scientists. So many wonderful researchers really doing the yeoman's share of work on the pathogenesis of the disease and really helping us better understand it, what its origins look like, where it came from, why some people get it, some people don't so you know, I have hope that we will have definite progress in our lifetime, for sure. Yeah, I think for me, I didn't realize so much of my chronic fatigue was also related to it. The back pain, the painful periods, the painful sex. And for me, what I've realized is a lot of it was being estrogen dominant, since endometriosis is estrogen dominant. And progesterone resistant, just for that added extra bonus. Yeah, I'd love to chat with you more about like that, but then also insulin resistance and how much that was affecting. So when I managed my diet and my stress levels, sure, that made a massive difference. I do see a high correlation with people with endometriosis and unprocessed trauma or childhood trauma. Do you see a lot of that in your clinic? Not as much as you would expect given the body of research that indicates we should. There's definitely a component but that may just be a population bias. Totally. Yeah, that's what I was asking you. If we are to believe the evidence based literature, which seems to think everybody with endometriosis has been sexually or physically abused or has some sort of trauma, then you would expect every single one of our patients to have some form of trauma. And certainly there are as a human race, we're just going to encounter that. Right? Yeah, we're all going to be not as much as you would expect. Okay. Given what the literature tells us we should be, maybe that's because patients are not more forthcoming. I just, we don't see that kind of link that says up, this is definitive. But it's there. It's in the background. We do see physical anomalies. Uterine didelphys, if they're born with a heart shaped uterus or they have an obstructive outflow, you would expect to see maybe endometriosis in those patients. And we do. But again, that's a very small part of the population. So it really just depends. Yeah. Yeah. I didn't, for me, I'm 38 now and I, it's just more of being in that chronic fight or flight. And once I started working on that and not knowing that I was in that fight or flight all the time. So I would have put on your thing that I don't have history of trauma, but I didn't know that even just. Something that doesn't seem like trauma to somebody else could be traumatic to me in those, that inner dialogue of just not knowing that you're under fight or flight all the time. But I also don't like to, the thing that I don't like about the trauma movement and like really diving in is it doesn't explain. Everything right. It's almost like this. it's like the gasoline on top of what's actually happening, right? And I think that's why it's so important, as practitioners, as centers, as healers, as physicians, as nurses, all healthcare workers, we really have to come from a place of trauma informed care. And that has been a more recent movement versus what has been historically done. In the past, we've had such paternalistic medicine. We have, the overarching patriarchal model of health care where I am the doctor. I know best. We didn't really deliver those patient centric shared decision making biopsychosocial model health care. We just said you have a female disease. We want you to get pregnant and then have a hysterectomy and go about your business. Whereas now patients are so educated and so smart and they're so well attuned with their bodies and such experts on their own lived experience and often the only expert in the room. They're pushing back against that. So the care has really evolved into a shared decision making model where that trauma component is being thought about in advance. There's deliberate and a more judicious model of care, I think. Oh, yeah, I actually just did a post on this how it is not hierarchy, like evidence based medicine is the patient, the clinician's experience and research. So it doesn't matter if you're the physician and the client and the patient. Isn't resonant. What you're saying is not resonating. So how can we meet them where they're at? So maybe they need more of a traditional like Western approach, right? Or maybe somebody over here wants to avoid surgery because they have more Eastern beliefs, but they're open to Western and I'm all about blending. I'm like, we need to be blending the two because there's so much shame. There's so much shame around oh going and getting maybe say, if we're talking about the spine, getting an injection in your spine or being on medication for endometriosis, but then still, doing your inner work to understand your traumas and your stressors and then diet, right? There's not this cohesive, there's just that I, and. It's an or and I'm like, no, it's a yes. And it's a plus, it's a plus, and I think that's really important because there is a lot of shaming. There's a lot of med shaming. There's a lot of hysterectomy shaming. There's a lot of surgical shaming. There's just shaming everybody for everything. And I always say. I don't care if you hang upside down by your toes like a bat and eat kale in the moonlight. If it helps you, do it. Right? everybody wants so much black and white about this disease and its treatments. And there is not one size fits all model. It's a gamut of things. We can try surgery. Excision surgery is a great and huge and surgical cornerstone. It's important, but there are other medical knowledge systems that can play into someone's well being. I might do really well with therapy and surgery and go about my business. Somebody else may want to do acupuncture and no surgery and watchful waiting. Somebody else might want to do medical therapy and suppression because it helps them go back to work and take care of their home and their family and that's great. Somebody else might be doing all of those things. Someone else might only be eating a gluten free diet. Awesome. Does it help you do it? But we've got to get away from that finger pointing and that shaming that, if I don't have surgery, I'm failing myself. If I do have surgery and my pain comes back, then I've failed you. If I didn't eat the right food, I'm not doing it right. If I didn't, take this pill, then I'm in the wrong. Or if I did take this pill, I'm in the wrong. Enough of that. There are multiple adjuncts that play into the multidisciplinary management of this disease. People need to find what works for them. And it needs to resonate and align with their beliefs, their outcome goals, what they're looking for long term. Their affordability, because let's face it, insurance covers nothing, and even when it does, it's still unattainable. There is a lot that goes into managing this, and it has to be up to the person. The best we want to do, as advocates and centers and providers, we have to make the education available. We have to let them be able to make their own informed decisions, and we need to be high supporters of that. Even if it's not something we agree with, if it's not the direction we would go, if it's not something we're capable of offering, that doesn't mean it might not help. Now, that's very different from selling 5, 000 coaching platforms to unsuspecting people on the internet. there has to be a balance. There has to be legitimacy. There has to be some evidence behind the therapy. You cannot just hang a shingle up on the world wide web one day and say, you're an endo coach and you are selling flower seeds that need to be added to this diamond water and you're going to cure your endo. We can't have that. But I think having legitimate different medical systems and different belief systems play into a full adjunctive care. That's where the answers lie. But at the end of the day, it's your decision. It's my decision. It's that patient's decision. And we need to support them. No, I 100 percent agree. I think my concern with medications and surgery is that, especially with hysterectomies, I've had so many clients that told that was their only option. And then now they're, dealing with the side effects from having that and feeling oh, I didn't know there were other options or being put on. I didn't know it wasn't a cure. Yeah, and then they're put on birth control and sometimes put on estrogen birth control when they need more progesterone. And so they're just like, wait, I didn't know, I don't even know what birth control I'm on. and my whole thing is I just want people to know all of the things. Yes. Hard. Cause this is still evolving. Right. Right. To just be jumped into a hysterectomy is Oh, like it's not your first choice, and I say that to people all the time I'm just going to have a hysterectomy and an oophorectomy and I'm going to be better because that's what my doctor said. Your doctor is operating from a place of outdated information coming from a time when it was believed that this is a menstrual disease, therefore. If we take out the source of menstruation, we're going to cure the patient and that's, decades old And there's multiple reasons for this. First of all, it doesn't originate from the uterus in most cases, right? I think it's safe to say We're born with this disease outside the uterus by very definition. Endometriosis exists outside the uterus. You're taking out an organ unless you have adenomyosis, which we can talk about the uterus is typically not affected by endometriosis. So now you've left disease. right? And you've taken out a uterus and maybe you've taken those ovaries too. And maybe they needed to come out for you. Maybe for you, that's the right answer. I had a hysterectomy and oophorectomy. I am hollow. I have nothing. For me, that was the right answer. I had multiple gynecopathologies in addition to my endometriosis. But for somebody who's 22 years old, hasn't made any decisions about, Family building down the road doesn't really, hasn't really tried anything else. Hysterectomy is not your go to. And it's not a cure. That's an outdated notion. But yeah there's many reasons for that. But my point is that is the often go to still and that is the case and somebody goes into that and they choose that by all means, but a lot of times in my experience, they don't have all the information and they regret it and then they're thrown into menopause if they take their ovaries out to, and they're like, I didn't know. I don't know. Nobody told me. And that's, I'm not going to use the word malpractice, but I am going to confidently say that it's negligent, right? I am going to say that it's negligent because there's something called the sacred construct of informed consent. And you have to tell your patient this is your expected outcomes. These are your expected pros. These are the benefits. These are the cons. And if you're simply telling them you're cured by taking my ovaries out, you have not informed me. And that is negligent. Yeah. Yeah. I'm often confused on how people are still not looking into this and then making massive treatments. From a clinician or surgical standpoint without knowing the body of evidence and talking to people like yourself and people that are true, like in the trenches researching this and knowing what's coming out in the research. And it's evolving and there's so much each year. I'm like, Oh, what we learned last year is even outdated than this year. And each six months ago, yeah, it's just constantly evolving. And you have to stay on top of that as a clinician, you've got to stay abreast. And that's why when we talk about, certifying formally and institutionally certifying a subspecialist in endometriosis, that would make a difference because right now anybody can say they're an endospecialist. You want somebody who only focuses on this disease, who keeps abreast of the literature, who is in the trenches, like you say, who is at the events, at the conferences, learning from and teaching their colleagues different tips, tricks, techniques, technologies, devices, products, all of those things that go into the part and parcel. Of making sure that you're treating this disease the best way you can for all of your patients. You have to have an armamentarium To treat all of your patients because not every patient is one and done. Not every patient is one size fits all and i'm not going to hysterectomy shame again. I'm not a hysterectomy patient myself. For me, it was the right answer for someone else. It may be the right answer. Maybe your ovaries are so damaged that they had to come out. That's a decision between you and your physician. But if your physician is presenting it to you as well, we've got to take them out. We have no choice. I want to get a second opinion. I want to have somebody else look at that. That might be able to say, maybe we could do something else. Maybe there is a way. You know some other treatment. Yeah, and my whole thing is anti shaming So like the whole thing about if you did get a hysterectomy because of this I'm not shaming anybody Oh, it's more of I just want people having informed consent before we want you to know we're here to support you Yeah, we're gonna cheerlead you all the way to the OR if that's your choice. I'm here for that. I hope you feel better for life. I hope your days are pain free forever. Just know that we want you to have that information. That's why you're here. That's why people like me are here. That's why you see such a strong advocacy movement out there. We just want people to know because so many of us have walked that path. We work on that path. We're in the weeds. We're in the garden. We're pulling them up every day. We're seeing what's working, what's not. And I think it's important to democratize that knowledge and let it out. People be the bearers of that knowledge so that they can make the best decisions, I work across the women's health gamut quite a bit. Obviously, endometriosis is my focus. You don't see this dearth of information and this lack of consent. For various treatments in other diseases and disorders, particularly in women's health. You see very concerted movements to educate patients to make sure that the most cutting edge, no pun intended, technologies and information is being applied to care. you only see this. primarily in endometriosis and diseases like endometriosis, where there's a pelvic pain component or a taboo or a stigma attached to it which unfortunately endometriosis does. And that's very frustrating to me because it's as important, if not more so than any other quote unquote women's health. Condition disease disorder syndrome out there. So it frustrates me. The thing that frustrates me the most too, as a clinician is getting people diagnosed. Yeah. I know we can make assumptions, but the goal, would you say the gold standard is still a laparoscopy? I would not just a peek and shriek though, if we're going to do surgery at all, you should not be just opening up that patient and going, Oh, you gotta know, putting a little stitch in there, closing them up, sending them on their way, and now you're gonna keep them on birth control or GnRH analogs for the rest of their lives. No. If you are prepared to diagnose at the time of laparoscopy, be prepared to therapeutically remove it. through excision. Be prepared to send tissue samples to biopsy so that we have histopathology that confirms the diagnosis. No one should be doing diagnostic only laparoscopy anymore. that should become as antiquated as plague masks. Look and just close them back up. So basically a laparoscopy is they're going in surgically to assess the tissue, basically. And I like to break it down so they can understand and ask some of these questions. What are some non surgical ways to diagnose because I'd love to hear how what you all are doing and how I've been leading people to gauge hey, this might be something you want to look into treatment wise. I think the first thing that you have to do to diagnose anybody is listen to your patient. They will tell you everything that you need to know about this disease and all of their symptoms, but you have to listen and you have to listen to understand, not just reply. You want to understand the full scope of their narrative. Does it align with? Not necessarily a classical picture of endometriosis, but okay, now we're talking about sciatic pain. We're talking about leg pain. We're not talking about killer cramps. We're looking at spitting up blood once. That's not a classical type of symptom that you would learn in med school or think about when you talk about endos. So we want Sure, that you're listening to the patient and you should never count endometriosis out as a potential diagnosis, but then you really have to do a very methodical judicious work up your pelvic exam, your physical exam. These things matter. You may be able to palpate as a skilled G Y N nodules in the rectal vaginal septum. These are highly indicative. You've got to utilize imaging. I know imaging is just having this moment right now as if it's just suddenly been invented. The endo folks have been using imaging and endo care and diagnosis for, longer than I've been alive. Yes, we have some wonderful Emerging technologies now, and there's far better understanding of imaging appearances and so forth. So you've got to take advantage of that. MRIs, maybe you're doing a rectal gel protocol looking for endometriosis. Maybe you're doing a dynamic ultrasound. Maybe it's transvaginal. Maybe you're doing a cat scan, whatever your modality is, There are imaging techniques out there that should be playing into your diagnostic workup. Now you can rule endometriosis in with imaging if you know what you're looking for, you cannot rule it out. It is still not sensitive or specific enough to just look at a hundred patients who have endometriosis, confirmed a biopsy and know that all 100 of those patients had endo or have endo. So you do the dismissal of folks who say it stops here. The diagnostic journey stops here because I didn't see a no on your imaging. That's an injustice. They may have superficial endometriosis. They may have missed disease. They may have a typical disease that presents just as maybe some peritoneal Weird looking appearances, it may be very superficial. There may be things that you're not seeing, not recognizing, or not getting picked up. So the journey does not stop there with an absolute no. If you still continue to suspect it, maybe the patient doesn't want surgery, maybe they're too young, maybe they're medically fragile, maybe they just don't want it. What's your option? PT. Number one. Start looking into PT immediately. I will forever be the champion of PT and pelvic floor therapy. Maybe you want to do a combination of PT and medical therapy. Maybe you want to do oral contraceptives. Maybe we also suspect adenomyosis. So perhaps an IUD is an option for you. I don't know. Maybe that's the route you want to go. There are things you can do pre surgically and or if someone can't or does not want to have surgery. If we are talking histological gold standard diagnosis, you've got to have histology. You've got to have a sample of the tissue underneath the microscope. You've got to look at it. You've got to look for those glands, those stroma. Maybe it's a hemocyte or macrophages from a lesion. maybe we're ruling it out. Maybe that sample some surgeon took wasn't endo. Maybe it was something else. Maybe it was fibrosis. That, if you really want to differentiate and or confirm, you've got to have a biopsy. You do not get that through burning the lesion. You do not get that through just zapping it. If you are not using the laser or your tool to excise the disease and send it off to pathology, you're not going to have anything for pathology. So that's where excision would come into play. Yeah. The other thing too that I've been seeing in some research is how endometrial tissue can get stuck up in the posterior fornix of the vagina. So like the backside, for the people listening, like the backside behind the cervix. Have you seen that too? You have to explore and dissect all areas. You've got to look from below at the diaphragm. You've got to look down to the rectovaginal, the retroperitoneal areas. You've really got to move the rocks around and pick up the stones and look around. You've got to obviously of course, check the ovaries. Yes, that's a no brainer. You want to look at the backside of the uterus. You want to look everywhere, but you want to be looking in that scope. As far and as broad as you can because again, it may not be where you think it is. Maybe it was missed on your imaging mapping. Presurgically. You want to make sure that you're doing a very thorough investigation. The surgeons. I, yeah, it's not as good as the magnified camera, but a skilled surgeon's eye who treats just endometriosis all day long, they're going to see things other surgeons don't see. That just comes by rote. That just comes with doing a high volume of cases. They're going to know what to look for. Yeah. I think there's so many things. PTs, we can't do imaging yet. There are some PTs that will do ultrasound, but in general, the way that we look at it is going based on their symptoms of visceral mobility. How is their uterus moving? How are the ovaries moving? How's the bladder moving? How's their abdominal cavity moving from their intestines? Is there any stickiness in the tissue or lack of mobility? You can feel when there's Visceral restrictions, also pelvic floor tightness. you can get an excision and still have the pain because the pelvic floor muscles, you're still getting all of that visceral feedback, that feedback of pain. So we have to retrain those muscles, but that also, we've got the uterus sacral ligament. So the ligament that for people listening, that connects the uterus to the sacrum too, and that can tug and pull on the low back, even if there's no Endometrial tissue in that area. But it's really important to assess all of these things. And I, from a physical therapy standpoint, I tend to lean more towards endo when I treat these things. so say if somebody has like sciatica or like chronic back pain and they get a little bit better with Orthopedic therapy treatments. So like mobility to the lumbar spine, maybe dry needling mobilization strengthening mobility, all of the variety of things, but then still keeps coming back. Also to have them track it based on. Even if they're not menstruating, right, just even that luteal phase is when I tend to see them flare up as well with the spike in estrogen and progesterone time. So you'll see a lot of ovulation pain patients at that point, maybe middle schmertz is their only symptom, Which is not the norm, maybe for someone with endo, that's the only time that they find themselves in a flare. So yeah, I mean Those phases when you're getting your hands on, no pun intended, that can be really helpful for your patients for sure. Let's explain a little bit about excision versus ablation. years and years ago, this is interesting. I went in, so I was doing IVF. And they did a laparoscopy for me. And in that the surgeon apparently just did ablation on my ovaries. Cause apparently I had endometriosis and I woke up and he was like, Oh, I just burned that off. And I'm like, I didn't even know that. What? Yeah. Yeah. I felt like it was taken from me that this, to my knowledge, we didn't talk about that and it didn't help anything. I still had the symptoms after, but it was to my knowledge, the way it was told to me, it was, Oh, this is a little thing. No big deal. Duh duh. No big deal to them. I was like, Ooh, I don't feel good, but I didn't know at the time that I could advocate for myself. And on top of it, I felt my rights were Ooh, that doesn't feel good. No. And you're not the first person to say that. I hear that a lot. Just, across our community, writ large, like people don't feel, educated and informed. And I have more than one good friend who either had, their AMH significantly reduced as a result of ovarian surgery, or had their ovaries just taken not necessarily consented to. And, Not even from a family building perspective, but for someone like you and me when we were dealing with IVF and fertility issues that really matters. That's really significant, but it's also significant for the person who doesn't care about children. It's, you're not treating them. You're treating a human being and it's just so important. And I think too, what you brought up that kind of really resonates with me and makes me think more about this. And this is something we don't talk probably a lot about, it matters to be judicious. Even within excision shouldn't mean going in and just cutting everything out, that's not what it should be or is intended to be. Excision is really meant to be tissue sparing. And it's meant to leave healthy organs and healthy tissue behind. And, but I think even a subset of that. Someone who has said to us, fertility is my goal. I don't care if I still hurt as a result of residual disease, I need to build my family and then I'll deal with that. And that's something that has to be respected like a cardinal wish. And if that means leaving a little disease behind on the ovary to protect that ovary and protect the IMH, that's what's going to happen. It's the same thing as saying they left disease behind arbitrarily. That's saying your surgeon was very judicious because that was your goal. That was your outcome oriented goal. That's what we're trying to do for you. But then on the other hand, you have surgeons who left it behind because they couldn't remove it. So now you can't get pregnant because you left disease behind and they should have referred you out. So there's a real balance, even with an excision. To make sure that it is fully aligned with that patient's goals and what they want long term and what they're looking for as an outcome. Ablation. But can you, like people might not know what excision is. Sure. Yeah. So think of an iceberg, right? You have this giant iceberg. And you just shave the surface of the iceberg and you've got this nice smooth surface of the water. That's ablation. That's just burning in a way. We've burned the surface of the lesion. Now we have this nice clean surface. Then suddenly you look under the water. You've got this massive remaining iceberg excision is going in and you can use whatever tool you want. We happen to use the laser using your surgical tool to go in and resect. And remove the entire lesion that's taking out the entire iceberg, right? So now you've taken the disease. You've taken the lesion out by its roots, theoretically, anecdotally and also in the literature, we see that there are far lower persistence and recurrence rates when you remove the lesion versus when you burn it and obviously leave the roots behind. It's just like a tree. It's still there. It's gonna keep growing. That iceberg is still there. It's still got the base. So you want to make sure that you're removing and you're dissecting out all of the disease. So that would be excision. If you have to have surgery. That is the goal that you want is to have your surgeon cut out all disease from all affected areas. And it is possible. I know that folks like to say it was the worst case anybody's ever seen. It could not be removed from my ureter because X, Y, Z, or it couldn't be removed from my diaphragm because X, Y, Z, I guarantee you it can be removed. Most likely we do it every day. I have two surgeons that work five days a week, do 500 cases a year in the OR of diaphragmatic, lung and thoracic endometriosis, ureters, the most sensitive areas you could ever think. What you need to do is make sure you've got your team in that room. but how do people find. Surgeons like this. That's the rub, right? It's not so much a question of finding them because they're here. They're out there, centers like ours, we're out there. The problem is accessing them. And that's a real, that's one of the, if not the big. of this disease is that it's so undervalued in the recent reimbursement structure of our insurance system, and it's just so ignored by the institutional oversight boards that nobody's bothered to make it a subspecialty. We can't get out of our own way with the reimbursement structure. So everybody from a payers perspective is viewed as equal. So in other words. You've done two cases in your entire career. You are viewed the same as a surgeon who has done 10, 000 cases, right? So they're going to tell you, you don't need to go to that 10, 000 case surgeon. You can go to this surgeon that's done two cases because all diseases treated the same way are equal. I assure you they are not. And I can say that not because I work for one of the leading centers. I say that because I had 22 surgeries. Most of which were ablation. So it's the problem that we need to really be continuing our focus on and we have been for decades is trying to fix that access to care. It is a travesty. It is. really a violation of medical ethics that we are not making. quality standard care, equally accessible to all people with endometriosis. We can do it on piecemeal basis. We can do it on small scale. We can discount. We can do pro bono. But again, that's all small scale. We have been working for years across the landscape with legislators with medical organizations with medical educators trying to get the coding fixed so that endometriosis has. Proper reimbursement codes so that more people can take insurance, be in network, and everybody can access the care. So that's a hill I'm gonna die on. In fact, I'll probably die on the hill legitimately fighting for access to care because it's abysmal. I don't want people selling their homes to get care for endometriosis. That is a travesty, And what you're alluding to is most places are out of network, right? So they're not taking they have to be if they want to keep their doors open. These are not huge academic centers that are backed up by hospital systems. These are small. Private practices like ours. If we want to keep our door open so that we can continue to treat people. We are insurance friendly. We will jump through all of the hoops. We will do all of the appeals and the peer to peer. We will file all the paperwork, but we still process as an out of network provider and most of the other endo centers that are independent private practices do as well. It's just it's a fact of what it is. Okay. So I, what I'm trying to get is the people listening, like what they can take away to find, obviously we're going to talk about your facility and we can explain where you all are in Atlanta and, but also if somebody can't get to Atlanta, right. And or maybe you guys are, I'm assuming you're probably on that crazy wait list. No. Oh, cool. So Atlanta, eight weeks, depending on the type of case. Okay. Awesome. And, but so say they can't make it to Atlanta. So what are some questions that they can ask a provider? So say maybe they're in another country from all over the world that listened to this. Yeah. And so what are some questions like, I'm assuming like what you're saying is, okay, do they do excision or ablation? How many do they do a year? Yeah, absolutely. First you want to understand their philosophy on the disease. If this is someone who posits endometriosis as a purely menstrual slash reproductive disease and their interest is more in your procreative value versus your pain and quality of life and ability to have a fulfilling life. Thanks. sex life and go to work. Maybe that's not the right fit for you. Maybe you want to find somebody else who values you as a whole person and sits down and says, what do you want from your treatments? That would be my first sort of what to look for. Is this somebody who is a high supporter of your goals and outcomes and wants to help you. Is this somebody who is a less enthusiastic supporter who was like I'd really rather you get pregnant and then come back and see me or is this a low supporter who says no endo is a menstrual disease and it'll go away when you're in menopause and or I can offer you a hysterectomy. So I think you have to go through that hierarchy and see, do they align with your beliefs and your values? Do they, do you feel that they are, up on, on disease education? Do they share your patient? Your shared decision making model, right? Let's say that. So now let's say you have found them. What should you ask? And interestingly enough, we have a whole list of questions from our perspective on our website. If anybody wants to take a look, but it's things like how much of your practice is focused on endometriosis and or pain. How much to fertility, how much to minimally invasive gynecologic surgery generally, because Excision will fall under minimally invasive gynecologic surgery. Excision will fall under minimally invasive gyne surgery, but minimally invasive gyne surgery does not make you an endo expert either. So you have to parse that out a little bit and find out what's your volume. They say 10, 000, do something 10, 000 times before you're an expert. Have they done two cases? Have they done 12 cases? How many cases are you doing a year? What's your volume? Volume matters. Because as you keep doing things, you get better at it. And as you do more cases, you're exposed to that, the 12 percent of, extra pelvic cases that most people never see. You're being exposed to complications that a lesser skill set may not be ready to handle. You're being exposed to Various manifestations of the disease and how it presents and maybe a uterine anomaly that no one expected or some sort of obstruction over here on the left side. You need to have volume. Volume brings skill. More important than any of that. What's the compassion like? Where's the bedside manner? I don't want you to be the best surgeon on the planet. If you're going to treat me like shit, that's not going to work for me. I can't get care from somebody who has clear disdain for me as a patient but might be able to, treat my disease. That's just me. Other people may not care about it. For me, compassion goes a long way. I have a primary care physician who's been with me for 27 years. He can't do, Everything half the stuff he can't do. So what does he do? He refers me out and he's kind to me That's what I need in my life at this stage. So compassion, we know what is their compassion level? How are they prepared to treat my post op pain simple? Practical questions. I don't want to go into surgery and then wake up and find out I've had this six hour procedure And you're gonna give me some over the counter Tylenol that matters I want to know that my pain is adequately being managed I want to know that like I said the volume is there What is your team back up? If I'm calling the office on a Friday at eight o'clock, is someone going to answer me? I have an emergency. I want to know that I'm being cared for. Is there a continuity of care? A lot of the centers of expertise like ours. We, we are doing immediate and acute follow up for several months after surgery, but eventually you are going back to your maintaining physicians. That's the nature of our business. We're a subspecialty. We're not going to do your OB. We don't do any OB. We're not going to do your well woman type checkups. You are going to have to maintain your relationships with your regular medical team. We'll interact with them. We're happy to contribute to the continuity of care, but you need to have a plan in place, and you want to establish that up front. Am I your patient forever, or are you my surgeon, and I need to have other providers in my armamentarium? You want to make sure of that. You want to make sure that the hospital is good. It's great. Of course, you want your surgeon to have high marks, five gold stars across the board. Does the hospital suck? Do they have horrible, staff? Are they going to make my life miserable? Again, something to look into. I feel like these are so hard though, because you can look up reviews, at least all the hospitals in Austin are like. 3. 5 stars. But yeah, I think it's important to understand and look at all the things and like what works best for you. Like I'm okay with a surgeon, like you're like, I want a compassionate surgeon. I do like that. But if I have two options and I have somebody that's compassionate and they've done two surgeries and I have somebody that maybe is more direct and maybe their neuro, And they don't have as much of that, See, I lucked out. I got both. I got the really nice guy who couldn't do shit. Then I had a really awful guy who was a decent surgeon. But my main Surgeon. He was a gem among humans. He was compassionate and skilled. And I know not everybody can get to that. So they have to resonate, there has to be, there has to be a rapport. Yeah. Yeah. I'm like, if somebody is going to be direct with me and not an asshole and they're, they've done so right. It's different than being an asshole. For sure. You can be direct. I don't mind that at all. We want that TMI, right? Yes. I love the directness. I don't like the, I'm like, what's it's black and white. Like what? Tell me like, yeah, if you're going to belittle me, you're not the guy. That's different. But I will say, to add on, I know you had said you've had 22 surgeries. I'm sorry. You've had to go through all that. Thank you. Me too. But the goal is not to have 22 surgeries, just to clear up for people. Nobody should have multiple surgeries like this. Because you didn't get the answer sooner, and you were passed around the medical system. I was. And, people say it's minimally invasive, it's still fucking surgery, and it has a lasting impact on your body. It still starts at you, yeah. I am dealing in my mid to late 50s. With the impact of the poor care I had in my early and late teens up through and into my late twenties. And that matters there, there are disease and treatment impacts I'm dealing with 30, even 40 years later that I should not have to be dealing with. Then that's the reality for so many of us. Which is why I say, maybe you can't be one and done in a perfect world. That would be amazing and wonderful. I know it's not reality, but the idea is to go in as minimally invasive amount of times the least amount of times it should not be this is just how it's going to be for you. you're going to go from surgery to med to surgery. Cause that's not the answer. It's addressing the surgery when we remove it. And like you said, not everybody wants to have surgery. That's not a path that I. Personally like I said, mine was ablation that I was unaware occurred. And I was like, wow, that was not something I consented to, but here we are. But in that though, I've heard and seen That usually that initial surgery is you want to try to go in as minimal as possible, but usually that first time, if it's an excision, I've heard that's like the ideal, right? But then maybe the results aren't as great following. Would you say that's correct or no? I think it's a bit of both. I think that if, let's say you get a surgically naive patient, right? Maybe they're in their early twenties or late teens. They've never had surgery. They don't have a concrete diagnosis. They've definitely got all the hallmarks of endometriosis. That's somebody you can feel confident about taking back to surgery. When you get in there, you still should treat the disease as you would in any patient. You should still be excising from everywhere that it appears because not only are you preserving their fertility, which again, I don't want to focus on that as the end goal. Maybe they don't give a shit about having kids, but they should have that option, right? So you want to preserve their fertility, but you also want to remove the disease because it can be progressive in people. It doesn't always progress. Sometimes it's. stay static. Sometimes it regresses in terms of symptoms. Sometimes it progresses. So you want to be compassionately aggressive as possible. You want to get all of that disease out because you don't want them to have more surgery down the road. You don't want to have to keep cutting into someone. I see a lot. Surgeons, that's how they make their money. They want to keep you sick to keep coming back. No, they don't. First of all, it's a blow to their ego, right? Cause they're a surgeon. Second of all, no responsible ethical surgeon wants to continue cutting into a patient. Yeah, they're balancing, their skillset and giving the best possible care they can. The very first time because they know that it hurts a patient to undergo a procedure. They know that it's a potential risk of complication. They know that down the road, having additional procedures costs money for that patient. No self respecting ethical moral surgeon is just thinking of someone as, a cutting post that I could just continually get money from it. That's just not real. There's always going to be a monster in every profession, but a self respecting, skilled, compassionate, do no harm surgeon, they want to go in as minimally invasive the least amount of times. That's always the overarching goal. Of course. And from a pelvic floor PT side to just going in and making sure like anytime you have surgery, their scar tissue, right? It's our body's way to heal. And from a physical therapy perspective, it's getting the scars moving, getting the tissue that was excised moving as well when they're cleared for that. So that way we can prevent more of this. The tissue starting even the scar tissue starting to hold stuff down that can almost because you know, like endometrial tissue can also be very sticky, very fibrotic, you start to see a lot of frozen pelvis in untreated disease or someone like me who had frozen pelvis as a result of my adhesions from going in with no adhesion barrier, no post op PT, no prehab presurgical PT or any kind of measures, someone like me who didn't have the benefit of that a lot of the time that matters and it makes a difference in your outcome, but it also makes your job harder for you, I think too, right? Cause we don't want to send you a patient who's worse off after surgery. We want to send you somebody who's, going to be helped by the therapies. Yeah, it's just like we're saying, I think it's important for people to know that surgery will help remove the symptoms, but then also addressing why it happened is surgery, even something that you want, And then your post op, it's like when you go to get a total knee replacement, maybe that's too drastic, but if you get a knee surgery, right, you still have to recover your range of motion. You have to move the scar mobility. You have to get it moving the same thing for our visceral organs or internal organs. So especially in this case, like the uterus, the ovaries, the bowels, this tissue can stick to all those areas. And so getting Ovarian torsion you, you hope never to see that, of course. But these are all, real things. And I think that's why that multidisciplinary approach and those adjuncts are so critical. You can cut the disease out, and you should, if you are the right candidate for that. But, that's one part, that's one component. So what are some non, I'd love to hear your thoughts on the non surgical ways to treat this or to prevent after surgery. So what are some things you've seen? Obviously we talked about like physical therapy and stuff like that, but what about Yeah, I think that you can use all of them together with surgery or exclude the surgical component. That may be something like we talked about earlier, hormonal suppression. I don't think that I would necessarily recommend. a GnRH analog in someone who's not been diagnosed. I think that's a bit of a jump. That's more of a given the cost profile and the side effects and the tolerability. I think it's pretty fair to say that a GnRH analog family drug is going to be a second tier. And I don't think they should be used in undiagnosed patients because they're not. Approved for use in undiagnosed patients. That's a medication like lupron they're very powerful. They can be very effective They can also come with a host of side effects. So I would just say do your homework I would consider those second tier I think we seem more cost effective, better tolerated experiences in the general oral contraceptive family. Continuous oral contraceptives, they seem to be pretty, not by everybody. I'm not, no way am I inferring that, they're completely risk free, harm free, side effect free. I'm not saying that at all. But I'm saying generally accessible. Tolerated a lot of the time continuous oral contraceptives. If you don't want to go that route. Absolutely. Nobody says you have to Maybe you just want to treat the pain and we're talking about things like either Prescription medication for pain or we're talking about things like over the counter NSAIDs Maybe you want to take Tylenol. Maybe you want to take whatever and you know your preference that works for you over the counter My, but with the oral birth control stuff, I struggle with this because people are put a lot on estrogen birth control for this. And if this is an estrogen dominant, I've heard that the U S is one of the main places where we tend to put beyond estrogen birth control versus progesterone. It should be a combination therapy, but what I've seen though, is in this other thing, when somebody is on that for an Their whole lives, right? It affects so many different systems, and so when they wanna get off or it's not working anymore, it can be difficult. So I struggle with that as a type of long-term treatment. obviously, if somebody needs it and they need relief now and it works, great. But what do they do? You get what I'm saying? Yeah, and that's just it. You give them the education, you give them the information, you let them decide. If they cannot tolerate it or do not want to be on it. If they're like this is the greatest thing that ever happened to me. I love this drug. I'm never coming off it. That's great, too. As long as they know, like any other drug. Even Tylenol has risks and side effects, right? You want to make sure again, it comes down to informed consent and it comes down to the patient's choice. You have to give them that information to let them decide and let them know that these are the possibilities. let's put it all in a basket. Let's have you decide. I will support you. I will help however I can ask questions. I want to maintain our close relationship so I can see if you're having side effects, things like that. All of those things matter. So you want to have that conversation with your doctor. For sure. And maybe it'll be someone like me who says, look, I've had enough. I don't want to be on these. My, my breasts hurt. I'm bloated. I feel awful. I'm crying in the mall for no reason. Like the mall anyway. So that's probably not a fair sample, but Just Overwhelmed take me off. You have to respect that too. You can't say to them. It's either or Because it's never either or there's always something else Yes, and yeah, but I would say beyond and the evidence would support this if you've tried three Different kinds and you still don't feel better and you still feel like shit There's no reason to assume that a fourth medication is going to do you any good so I think that's a really Important conversation that you should be having with your doctor as well. At the end of the day, it's up to the patient You've got to let them decide but it's your job to give them that information You've got to be really honest about it. You cannot just hand them a Janssen and Janssen, brochure That's like people are dancing during their periods and everything is beautiful here in utopia No, I want to hear about. Do you have family history of clots? Have you been on pills before and had negative side effects? Do you know we might have a difficult time in five years taking you off of this? Have that conversation so that they feel empowered and emboldened in, in their choices. And if it's not something they want or cannot do, which is also the case so folks cannot be on it. Then again, we're talking about pain managing. I was always a crazy person on oral birth control. Like I, I'm crazy with or with Alice, so I can relate. I was not crying in the mall. I was crying Everywhere. Yeah. Everywhere it was. And they're hard. I've been on'em in years, but they're hard I think my hangup about it is that. So many people have just been told like, that's just it. Like it's this magic pill and it pisses me off when people say that. Cause I'm like, you're not informing people that, we have estrogen receptors on our brain too. So like when you start going off of these things, like I'm getting, I've been weaning off, I know it's not the same, but it's. just made me think about, I've been weaning off my SSRI after being on it for 20 years, I was told it was safe. And now all of my hormones are all fucked up. but I was unaware that I was told it was safe to be on forever. And as I started waking up and started asking questions and learning more, so many of these other symptoms I had are contributing to that. And I, for me, it was that I didn't know. That this would be this hard because if that was the case and I knew there were other outlets I would have never gone on it, but it helped me Significantly manage anxiety for a long time, but it didn't help me with the root. And so that's just my hang up I think more with the birth control side and then also There's not a lot of blood testing to see like what if somebody already has So much estrogen already. And then we're getting more. Where am I? You don't. And I think you bring up a good point too. Are there comorbidities, which I know is so popular amongst, is there something that contra indicates or maybe it has the opposite effect on X condition that I also happen to suffer from. So it's definitely a nuanced conversation. And I'm not, I'm not somebody That likes to push medication per se it's there. It does help. It could help. It may help. It may also be horrible. Yeah. Yeah. I think, letting them have that dialogue, but it has to be an honest dialogue just as you would signing informed consent to go under the knife. Right. I think, and I'm not. coming at you for this. I'm just more of, no, I know we're just sharing our, of course, our mutual lack of success with pills, but injections. Yeah. But here's the thing. If somebody needs to go on it for a couple of years to just get things under control or whatever it is, basically what we're, in summary of a lot of what we're talking about is. Endometriosis is not a one size fits all. There's so many ways it can show up, right? A lot of times it's around the pelvis. Sometimes it can migrate up to the lungs or the brain. Those aren't as common. You guys probably see that a lot more because you're in the surgery center. But for us, that's a bit more rare. So I don't want people to super worry, I know. People are gonna start running around thinking they have endo of the brain. I think there's been maybe three cases in the entirety of the literature. The lung is more common than people would think, but again, outside the centers it's not. Or I should say inside the centers it's not. I would say it's important to know if you're having spontaneous lung collapsing, like that's one thing, but if you're not, but you're having all these other symptoms and you're not getting the answers, You should know about it. Yeah, you should know that this is something to consider. And like you're saying, it's multifactorial. There's not a one size fits all. It can happen. Definitely not. And watchful waiting is a thing. That's a treatment. Do nothing is a treatment. What is not a treatment is get pregnant and you don't want to. And even if you do, it's still not a treatment. You're not going to outlive this disease through menopause. That's not a thing. You may be symptom free. That is not the same like David Redwine used to say to me all the time. Absence of evidence is not evidence of absence. So being symptom free while it may be the goal doesn't mean you don't have endometriosis because you're managed well, you're managed well and you're in menopause. And also when we talk about the hormones, I want to make very clear. They treat the pain associated with endometriosis. They do not treat endometriosis. However, if you are in medical school or law school and you need to be pain free so you can function on your studies to be successful, and this is an option you want to try. Fantastic. You may have really good success with it, right? Or you may not. but you've done a great job on just being like, Hey, these are the options. These are the questions. No, for sure. Multi factorial approach, whatever you decide, as long as you've had all the information, you get to do that. I get just really passionate when people don't have the information. I'm like, do you know all these things or did they just present this? Cause just making sure that there's, you see the dancing tampon commercial. But there's just so many different things in that it's ever evolving. So even what we've maybe talked about six months ago, that stuff's changing as well. You're trying to be 100 percent. Trying to be patient with your health care team as they're staying on top of this as well And so what are some ways that people can reach out to you or learn more about? Your center and you so that way they know how to reach out. Yeah, definitely You know patients have come to us over the last 30 years from every corner of the world. We've got patients in Almost 80 countries now And they all tell the same story. They've been dismissed. No matter if you came from Kenya, or you came from Iceland to us, or you came from down the street, you have experienced something negative in association with your diagnosis. That has not changed. Since I came on the scene 35 years ago and was dealing with my own endometriosis. So our goal is to try to first listen to people. We will review their case reports for free if they want to see if they could possibly benefit from surgery. We will see them in the office. We will see them by telehealth. They are free to come. They do not need to be referred. They are free to come from any Place in the world. They can get in touch with us. Just go to center for endo. com E N D O. We have a ton of information there. There's, a library, a wealth of information on all things parents, caregivers, coaches other doctors, everybody could benefit from it. If there's somebody in their life that has, or thinks they have endo. Check out our website. We've got a literal ton of information there and we keep it updated. We change it as the evidence changes and knowledge evolves. We keep it current. Like I said, you can consult with Dr. Yenio and Dr. Cinervo. These are world class experts that have seen every manifestation of disease you can think of. I am not saying that we are miracle workers. We are not. They are human beings. They are, people who are skilled and highly adept at the art and science of care for the disease. But we have pretty good outcomes and a lot of satisfied patients. Awesome. Can I ask you like what the typical rate would be roughly so people can budget? Yeah. It really depends. we're hesitant to give out any kind of ballpark figure because somebody may come to us that has really good insurance and they'll pay 14, 000 or they may be somebody who has no insurance at all that we're going to work with and maybe they're going to pay 5, 000. There is a broad amount. It also matters what type of case if you're a joint case of a bowel resection stage 4 endometriosis and a thoracic case Clearly you're going to pay more because we have a team there's going to be joint surgeons involved You're paying them separately. That's going to cost more money. The hospital is separate from us, but in terms of our fee The most anyone would pay out of pocket is 21, 000 The most advanced case you could think with no insurance, no discount no financial aid from us whatsoever. We try to be creative in our solutions in terms of accepting care credit cards, things like that. And we try to work with everybody. That would be the absolute max of the worst scenarios. And insurance matters. The type of insurance you have, some of it pays really well, so we're able to collect a lower out of pocket cost Because your insurance is going to pay more and, we are able to work with them better. But folks can go to our cost and insurance page and, we go through the ringer with insurance. I, as somebody who does third level appeals after being denied for a patient twice, I can tell you, we go through the ringer, we have dedicated staff that's. All they do is fight with insurance for our patients. So we're going to try to help you however we can to keep your costs as low as possible. Awesome. Thank you so much, Heather. This was wonderful. This was fun. We could do this all day. I know. But we've got to work on our standup next. we're going to do a little standup. Peter Pern will be so proud of me. I'll come join you in stand up. He'll be so happy. It'll be our audience of two. Thank you. This was so enjoyable. I really appreciate it and keep doing the wonderful work you're doing. Please. We need you.

1:14:59

Thank you so much for listening to my podcast. It would be a huge help if you could subscribe and rate the podcast. It helps us reach more people and make a bigger impact. I would also love it if you could join my email list, which is LinkedIn, the caption for podcast updates, upcoming offers and events. You can also find me on TikTok, YouTube and Instagram at Dr. Mary pt. Thanks again.