What happens when Endometriosis & Age aren't the final word on Fertility: Julia's story + Expert Insights, Part II

This week, we hear the rest of Julia's story. More endo, a bit older, a shorter menstrual cycle, a medical community that was suggesting the pregnancy was unlikely again.

But Julia story should remind us to never bet against mother nature.

I'm also including the insights of a functional nutrition and integrative women's health expert who focuses on endometriosis.

Endometriosis is one of those topics that highlight how some areas of women's health have been historically. Let's say under researched. And if you go digging for those topics in the broad category of pregnancy, you will find more questions than answers. Because of that, I've started a new show called Making Sense of Pregnancy and which I interview scientists doing cutting edge work right now on a variety of topics to do with pregnancy. That may well change the way we manage and understand pregnancy both now and in the future.

We pick up where we left off last time, Julia and her husband are trying to get pregnant with their second child and have run into endometriosis as an obstacle again. And the idea of IVF surfaces...

To find Making Sense of Pregnancy--What Experts Want you to Know About Your Body:  https://podcasts.apple.com/nz/podcast/making-sense-of-pregnancy-what-experts-want-you-to/id1779600854

Transcript

[00:00:00] 

Welcome to what you didn't expect in fertility, pregnancy and birth.

How we think and feel about this enormous transition often lives in the gap between what we expected and what we actually experienced. This cap exists in part because of how we tend to talk about and portray these events are all kinds of media. In a one dimensional way. Everything was amazing. But it's more often the case that there are beautiful things that happen. 

And at the same time, really challenging things that happen. This show shares, true experiences, both the easy parts and the difficult parts and how we manage what we didn't expect. The intense things that can happen in the course of this transition can impact how you see yourself, how you see your partner and how you parent. The better we understand what happened to us, the better we can manage, all the things that follow I'm your host, Paula communica. 

I'm a writer and an economist and the mother of two girls. And I met many, many challenges in this process. None of which I expected. This week, we hear the rest of Julia's [00:01:00] story. More endo, a bit older, a shorter menstrual cycle. Uh, medical community that was suggesting the pregnancy was unlikely again. But Julia story, it should remind us to never bet against mother nature. I'm also including the insights of a functional nutrition and integrative women's health expert.

Who focuses on endometriosis. Endometriosis is one of those topics that highlight how some areas of women's health have been historically. Let's say under researched. And if you go digging for those topics in the broad category of pregnancy, You will find more questions than answers. Because of that, I've started a new show called making sense of pregnancy and which I interview scientists doing cutting edge work right now on a variety of topics to do with pregnancy. That may well change the way we manage and understand pregnancy both now and in the future. I'll include a link to the show, making sense of pregnancy in the show notes. [00:02:00] We pick up where we left off last time, Julia and her husband are trying to get pregnant with their second child and I've run into endometriosis as an obstacle again. And the idea of IVF services.

More endo, a bit older, a shorter menstrual cycle, a medical community that was suggesting that pregnancy was unlikely again. But today's guest's story should remind us to never bet against mother nature. I'm also including the insights of a functional nutrition and integrative women's health expert Transcribed The founder and CEO of Women's Health Initiative, who focuses on endometriosis.

Women's health, especially around fertility and pregnancy has not historically gotten the attention. It deserves. I've started a new podcast called making sense of pregnancy in which I'm tracking the impressive progress. That's been made more recently in these areas. You can catch my new show. Making sense of pregnancy on apple podcasts and Spotify, and wherever you get your podcasts, I'll leave a [00:03:00] link in the show notes.

Let's get to this inspiring story. 

We talked about it and at the time my husband was really in favor of pursuing IVF, which we were told had a, we had about a 20%, uh, shot.

at a baby with IVF. And I sat with that idea for a while. And I have friends for whom IVF has been extraordinary, who have beautiful families. I have, I have absolutely, uh, I, I champion it. I think if it's the right choice for you, it is a fabulous choice. It was not the right choice for me. Um, I had a lot of anxiety.

I've had some hormonal imbalance in the past and I just didn't feel, uh, I didn't feel good about making that choice for my, for my own health. And I already had one child. that I needed to be present for. And so I decided not to do that. Uh, and it was an extremely challenging time in my marriage. I think my partner, my husband felt at the time that I was kind of, that it was, it was sort of my way or the highway in a certain sense.

[00:04:00] And, and, and it was being my body, it was, and that was very hard for him. Uh, to feel he had, uh, no agency and, uh, also hard for me to feel that my body was somehow secondary or not, or my feelings around my body were not valid because they, they negated something for him. Uh, it felt like to him and, uh, and so we let it go.

He traveled a lot. I worked a lot. I spent time with our daughter. We kind of found our way back to each other. And then fast forwarding to the spring of 2020, where we all, we all know what happened in the spring of 2020. And my little family of three left the city, um, as we were privileged to be able to do and spent time in a, in a country house for about seven months.

And a couple of months into that time, my daughter started talking about wanting to have a baby. I very famously, she and I had a conversation. She was just about to turn four and she said, [00:05:00] mama, I want, A baby, baby sister. You know, you never know, but she said, how could we get one? And I said, well, you know, some people have a baby that the daddy has to give, put something inside of the mommy.

I sort of got like about it. Um, I tried to be clear without being too detailed because she, she wouldn't have been interested anyway. And, and there was a pause and she looked at me and she said, so you and daddy would have to do something together. He gives you something? And I said, yes. And she said, I just don't see that happening.

And I went, oh, well, you never know. And I went, there are other ways, you know, maybe some people adopt a baby. And then for days after we talked about adoption, she wandered around the house, like slapping her hands together and rubbing them together, going, now we've just got to find that baby. We've got to find that baby.

How are we going to do it? Where will it be? And looking around. And so, My husband and I, in some ways, [00:06:00] because she was so deeply keen, started talking about adopting a child. In the midst of that time, I mean, I haven't really told this story lined up this way before, it's a bit of a saga I'm discovering. In the midst of that time, I discovered that I have, uh, one of the Lynch Syndrome disorders, which basically means that I have several cancers that I am genetically predisposed to.

I have a genetic, um, anomaly. My mother has it. Um, my brother does not and I do as well as my mom and it comes with up to 48 percent chance of uterine cancer. Um, and a 30 some odd chance of colon cancer. There's some gnarly ones in there, but the uterine cancer issue was particularly concerning to me because of my endometriosis, right?

Uterine cancer is actually cancer of the uterine tissue. It's cancer of endometrial tissue and so given that mine grows all over my body, that felt like a problem. 

And that feels I received 

the [00:07:00] diagnosis. It felt really threatening. It felt like, why, why roll the dice in that way? Why? And when, when this is a part of my body that I can potentially just remove, um, and remove, therefore remove the threat or largely so.

So I started to plan for a hysterectomy. And, uh, I currently, you know, I was at this time I was 40 the summer before I was turning 41 and my, my menstrual cycle was only 22 days long. My one fallopian tube was occluded. I was starting to have more severe pain again, uh, with each cycle. And I thought, well, you know, maybe, maybe better to, to let this go now.

Let's send the old girl. off into the sunset for a little party or something. So I was in the midst of making that plan and starting to identify, you know, with COVID, when were they going to start elective surgeries? What, who did I want to do this? And talking to my OBGYN who I like and like and trust.

And in the midst of that, I missed my period. And I thought that's weird because I have [00:08:00] my periods come close together, but they don't, I don't tend to initially I had done a lot of head standing in my yoga practice. And I'm also an intermittent yoga teacher. So I've been teaching inversion practice that week.

And I was like, well, sometimes when I'm upside down a lot, it can alter my menstrual cycle a little. It must just be head standing. And then my period still didn't come. And like four days, I just never miss, I never miss it. It's never, it's never been a skipped. I've never, I've never been a woman who skips her period.

And so four days in, I thought, gosh, maybe it's stress. It's been a hard year, pandemic, you know, maybe it's perimenopause, maybe I'm just going into menopause early, and then two nights later, I woke up at three in the morning, and I thought, God, I want a bowl of cereal. And I, and I went, what? And I lay in bed, and I thought to myself, Is it possible that I could be pregnant?

And I did the math, and listen, I don't know about your house, but the pandemic was not a sexy [00:09:00] time, you know? I was like, it was not, it was not like, wasn't like, woohoo! Let's get it on! No, there was really like one opportunity that time, and it happened to fall, Technically, after I should have ovulated, even on my shortened cycle, but I did the math and I was like, well, I guess conceivably it's possible, but come on how it's so unlikely.

And so I didn't even tell I didn't tell my husband I was like, I can't open up this can of worms. Again, I can't, I can't, the pain that we went, I can't do it, we won't survive it. And there's nowhere for us to go. We can't like there's no track together. And so, I made up a story about needing plastic bins.

I was like, I need to buy bins. I need to go buy bins. And he said, you know, it's the middle of a pandemic. Can't you just order those on Amazon? And I was like, no, no, I need to see them. I need to go to, I need to go to Staples to see the bins. [00:10:00] I got in our little car and I drove to Staples and I bought some gin I didn't need and then I pocketed a home pregnancy test.

And, uh, I purchased, I should say, I didn't steal it, but I took home a home pregnancy test. And, um, just to be clear. And I got home and I woke up at like 5am for a bowl of cereal and to pee. And lo and behold, it showed up positive. And I looked at it and I thought, well, you know, it's going to be a chemical pregnancy, it's going to be ectopic, there's, there's just no way, but I did at that time share with my son, I said, you know, I woke him up, I poked him, he sleeps with, he sleeps with earplugs, and earplugs, and a face mask, he sleeps like he's at a spa.

And so I let you have to jab him hard to get him to wake up. So I'm shaking him and he pulls the mask off and he takes the things out of his ears and he looks at me like, what is your problem? What? And I said, I have to [00:11:00] tell you something. And he looked at me like, what could you possibly have to say at 515 in the morning?

And I said, I'm pregnant. And he just started laughing hysterically. And then he looked at me and he said, shut up.

And we started and we just sat there staring at each other for a few minutes. And then we decided we would tell no one because it was probably not viable. We drove into. New York City and had had kind of done all of our requisite testing and quarantining on a way to see our, our, our respective parents, uh, so that our, our daughter could see her grandparents for the first time in a while.

And I was dropped off at my doctor's office secretly so that I could be checked. And lo and behold, I, my, my OB even said, she said, you know, she said, the odds of this being viable are very low. And I said, listen, I know. I, I know. And she said, we're talking needle in a haystack low. And I said, I know, I know [00:12:00] I'm not, no one's getting their hopes up here.

And she said, wait, let me ask you a question because it's confusing, you know, 

you have all these issues that should stymie your ability to get pregnant, all those things. This little guy, this little zygote has made it past all those barriers. So why do we think the pregnancy won't last? 

Well we didn't know yet that he has, because there are two ways in which the pregnancy could have shown up positive and been non viable, right?

Initially the pregnancy could have been ectopic, it could have been outside the uterus, which given the state of my fallopian tube was, was not unlikely necessarily. And it could have been chemical, which given my age was also a possibility. So until we did the ultrasound to check and see that there was actually somebody cooking in there, there were still, there were still a couple of variables that left it uncertain.

So I didn't know what a chemical pregnancy was and had to look it up. According to the Cleveland Clinic, it's basically a pregnancy that ends before five weeks. An embryo forms and might even embed in the uterine [00:13:00] lining, sending out its beacon of HCG, the hormone that indicates a pregnancy is present on a home kit.

But for whatever reason, The embryo stops growing and ends in a miscarriage. It's referred to as chemical because the HCG was the only sign of its existence. It's too early to see it on an ultrasound. You may be more likely to run into one of these types of pregnancies if you're doing IVF, because you're being monitored so closely.

I wonder if your, um, serial test is also a factor here. Would a chemical pregnancy make you have. 

I don't know. I don't know. You know, that's an interesting, that's an interesting question. And to be honest, in those early days of the pregnancy, I was so convinced that it was on, that it was not going to be viable, that I didn't, I didn't question, I didn't look to the positive because I was so, I think, afraid of having my heart broken by it.

So I didn't, I just didn't even entertain it. I was like, well, There's no way this is unlikely, whatever. And [00:14:00] I was, I was wrong, right? So we did the vaginal ultrasound and it showed a very healthy, uh, early embryo sort of little, little sack of baby and a little sack of placenta embedded very healthfully in the uterine wall.

And my, uh, OBGYN looked at me and she smiled and she said, this is it. She said, if you can, you can come back in two weeks and we'll check the heartbeat. She said, but this looks really good so far. She said, and if we hear a heartbeat in two weeks, chances are in April, you'll have a baby. Wow. And this baby is someone who really wanted to be here.

And I said, yeah. So two weeks later we checked, there was in fact a heartbeat and off I went into the pregnancy. Now, since you asked about the first pregnancy, I will say that the second pregnancy, my expectation had been that it would be very similar. I was like, Oh, I'm going to feel peaceful. I'm going to feel grounded and good.

My body's going to feel good. I felt [00:15:00] like, like shit on a stick. I felt really bad for the whole pregnancy. I felt miserable. I felt conflicted and I felt anxious and I felt tired. And I, I had kind of gotten into a space where I was peaceful as the mother of one child. And who am I to look, look a miracle, look at a miracle in the eye and say, I don't, you know, You really messed up my life here, baby.

But he, but I felt conflicted. I felt like I, the time had passed and I had moved on and I was doing all of these other things I didn't want to go back into the, the sort of deep absorption of new babyhood. And I really cherished and still cherish the deep relationship my daughter and I have. And I was like, I don't, I don't know that I want.

A triad here. I really like that we are a duo, that we are a dyad. That's important to me. There's something right about it. And, and then I had a series of pregnancy complications. I had unexplained bleeding [00:16:00] at around 11 weeks, turned out to be something called a subchorionic hematoma, which is basically just a pocket of blood inside the uterus that's It lets itself out and it's, it is often not threatening to the baby.

It doesn't always resolve, but it required almost six weeks of bed rest. Now having listened to another of your podcasts, I know that bed rest can go on for a whole lot longer, but which I shudder to think about, to be honest, but it just kind of everything added to this feeling of unease and anxiety that I had when we did, um, an ultrasound.

Uh, in the midst of all of the bleeding, the baby was, was doing actual little back flips. And so he was fine. He was imperturbable. Good to be oblivious. He was just an unflappable little, yeah, really just swimming around. What's this other liquid? Who cares? And so I spent six weeks on bed rest and, or pelvic rest, I guess they call it now.

So I could do light movements, but really it was meant to stay. And then it resolved and I did [00:17:00] ultimately have a home birth with the second baby. We talked a lot because of COVID initially, we talked about what the different, Issues were in a hospital birth setting. And so, um, my OBGYN who had delivered my first, she was actually, she no longer delivers babies, but she said, you know, listen, if you were a person who chose to have a home birth, I might be willing to make a special guest appearance.

Wow. Come on over. So, so we found a midwife that I, that we really responded to that also knew my doctor. We worked with the doula that the three of them all knew each other. And so when the day came, it was sort of like the inverse of the first pregnancy and birth. The pregnancy with my first was so easy and the birth was such a challenge.

And with the second baby, The birth, the pregnancy was so challenging and so filled with anxiety and doubt and fear and concern and confusion, the sort of reinvention of myself as [00:18:00] mother of two as opposed to mother of one, which doesn't feel like a profound change on paper, but it's in my body. It felt enormous.

It felt like I was being asked to dimensionalize in a new way that I didn't even know existed and, um, and didn't feel I had the capacity. Just didn't know how to do it, but the birth itself was beautiful. The birth, I went into labor at like five in the morning and it was slow and gentle, gentle enough that three hours later, I walked my daughter to school and we would stop every eight or nine minutes and I'd have a contraction and then we'd keep going.

And she knew that my mom was coming and that if my mom picked her up at school, It was baby day. And so we, we said, okay, I gave her a big hug. So fine. I said, I don't know if it's baby day yet, but if it's baby day, you'll see Mark, we call my mom, Mark, you'll see Mark at the end of school. Instead of me. And apparently when my, because my mother arrived just in time [00:19:00] to pick her up at school, my mom arrived and she got there and, and Esme was about 30 feet away coming out the front doors of the school and saw my mother and shouted at the top of her lungs, it's baby day!

That's appropriate. Yeah, why not? But this, and it just, it was a truly gentle labor. So I labored. On my own, my husband was there and then he was setting up the birthing pool and kind of doing all of the, he was doing all of the things that, that I was ultimately so grateful that he did. He was making sure that everything was set up for us and safe and we had just moved so he was putting up curtains so I didn't have to give birth to all of Manhattan Avenue.

And um, he was getting everything ready. And I was sort of like, curtains or tickets, curtains or tickets. Yeah, really? Um, you didn't know we were going to be your neighbors. Welcome. But, um, and I kept having this experience. Where I would feel the baby drop and I would be like, Oh, [00:20:00] this is when I threw up last time.

This is when my body didn't know what to do last time. But this baby was positioned differently. I was older. I had done it before. And this time I knew how to let go into the birth process and kind of lean toward it as opposed to pushing against it. So we, I think it was about 15 hours of labor start to finish and, uh, two hours of really active into transition and then 15 minutes of pushing and he came out in the water happy and peaceful and ready to go.

Um, and, uh, yeah, it was a remarkable, and there was this moment where my doula and my doctor and my midwife were all there and there were two, the midwife had two assistants. So I was surrounded by five women. And there was this chorus around me. The contraction would come and I would just hear the word breeze and they were all like echoing, like a little chorus around me to breathe, [00:21:00] breathe the baby down, breathe the baby down.

And, my husband had his hands on my back and, and it just, it felt. Like this sort of, it was almost like a meditation of strong sensation, moving this baby out of my body and the second child, a boy, or, you know, until he, until he determines otherwise, until he lets me know something else is the case.

And, , my daughter is dark. She hasn't, she has my, my eye color. They're now dark green and she has like dark, thick, curly hair and it's like intense. And my other child has strawberry blonde hair and crystal blue eyes and greets the world with like a, Hey, what's going on? Like, happy to be here. Thanks for inviting me to the party.

And um, Everyone wants a surfer. Good work. Listen. It's, it's great. I'm thrilled. He's, he's gonna, he's gonna get with a smile what she gets with a sledgehammer, you know, like good for him. Um, and um, good for her too. [00:22:00] Yes. He arrived and, and has been a little light beam ever since. He'll be one in April this year.

So I am now that he is almost one. I've been told in terms of my other conditions, um, You know, basically that I can nurse him for as long as I wish to, and we'll wait until I get a little closer to natural menopause. And then likely I will go ahead and have a direct in order to curb the likelihood of uterine cancer emerging on the later side.

And, um, in the meantime, I'm having biannual pelvic ultrasound and, and an annual colonoscopy, which is a real delight. And I'm just, you know, taking care to check in as much as I can with my body and do everything I can to keep it healthy. 

That's amazing. I don't know whether to say you should run out and [00:23:00] buy a lottery ticket or if your son is the lottery ticket.

Something's going on there. Some kind of magic though. And how does Esme like her brother? 

You know, I asked her the other night, we, we went out for our first mommy daughter dinner since the beginning of the pandemic, we went to a restaurant, which was a big deal, and she and I were sitting there by ourselves together, which we used to do all the time, and we never do now, and, uh, rarely, we were sitting there and she was eating her spaghetti and meatballs, and I, I looked at her, Mae Mae, call her Mae Mae, well, how is it having a brother?

What do you think about that? What is it like for you to be an older sibling? And, And there was a pause and she looked very thoughtful for a moment and I was like, oh, here it comes. She's going to send me something. And she said, mom, I like him. I was like, okay.

She does. She likes him. He lights up the world. The earth spins for her, for him. And [00:24:00] I think she really, is excited by the prospect of having a sort of a comrade in our compatriot. 

That's an amazing story to have all this success, despite kind of the predictions that you were given at the onset. 

Yeah, I mean, I think , my story is a real testament to, to not letting the barbarians get you down, right?

 If you have a sense that,, your journey is not over or not What you are being told that it must be, listen to that thing, right? It's that, that no path is preordained, despite what the medical field might like to say, largely, right? Because they don't want to get it wrong. And it's easier to say no than it is to say yes.

Yeah. . Managing expectations is a big 

game. 

So we talked in the beginning, before we started taping, about your writing about this. Did you want to talk a little bit about that? 

Yeah, sure. , it's very much all a work in progress right now. The pieces that I've published have largely [00:25:00] actually been tangentially related to my parenthood.

I write a lot right now about a whole different story. , in my life, I know I mentioned at the beginning that I was a caretaker for my father. And so , I've written a lot about the transformation in that relationship. My dad has had HIV and AIDS for a very, very long time. And I was his primary caretaker in the 90s from the time I was 18 for quite a while.

And he was very, very, very sick. So, , I've written a lot about my parenthood as reflected through the lens of having gone on that journey with him. And then I'm just starting to come back to some work about my own journey toward parenthood and fertility and what it was to decide to become a mother with the legacy of mental illness that exists in my family and also the physical challenges that presented themselves along the way.

Those are works in progress and forthcoming. 

Well, you can give me links to your website and I'll put them in the show notes so people can [00:26:00] find your writing. Okay. Yeah, I would love that. , thanks so much for coming on the show. Such a pleasure. Such a 

pleasure. I'm so happy to have this conversation.

Thanks again to Julia for sharing her story of overcoming. The process of becoming someone's parent requires so much flexibility, the ability to withstand physical challenges, and willingness to manage uncertainty. It's a miracle any of us are here. 

Thank you for listening, and if you like this episode, feel totally free to share it with friends, to like and subscribe. Thanks also to Dr.

Drummond. She and I had a longer conversation about endometriosis than is shared in the body of this episode. One thing I asked her is how people could potentially get a diagnosis more quickly, and I'm including her answer as a coda to this episode. So just after the music ends you can hear her answer.

Keep listening. We'll be back soon with another inspiring story. 

And remember to hear more about these miracles in newly uncovered details. Check [00:27:00] out. My new show, making sense of pregnancy. 

You can find it where you found this podcast on apple or Spotify. I'll leave a link in the show notes.

And now Dr. Drummond's tips on how you might be able to ferret out a diagnosis of endometriosis more quickly. 

Is there any advice you can give to women to help them get a diagnosis faster? Is there anything they can do to, to present more clearly to whoever they bring the issue to? 

Yeah, that's a great question. And I think it goes a little bit back to when you were talking about in this case, the woman had a vaginal ultrasound and it, and, and, and was found.

Here's the tricky part about that. That. If someone, if there is evidence of endometriosis on imaging, if someone actually can see it, that shows that that's a diagnosis of endometriosis. The problem is, is that not seeing it on imaging [00:28:00] does not rule it out. The only way to truly make a diagnosis of endometriosis is by a skilled laparoscopic surgery, which I highly recommend being done by a person who specializes in endometriosis or pelvic pain, or at least, , minimally minimally invasive gynecologic surgery.

So not your kind of OBGYN who, Sees, , three endosurgeries a month or a year, but someone who does this, this is their whole job because it's as complex as good cancer surgery. And so you want someone who really knows what they're looking for, because sometimes these lesions can be missed, especially if they're not in the most common places.

So back to your question about how to drive this diagnosis forward. So just because something is not seen on imaging, or there are no abnormal biomarkers, blood markers, things like that, doesn't mean a person [00:29:00] doesn't have endometriosis. So if you still have symptoms, keep pushing the issue. A few things that might be valuable to test in the blood work would be just chronic inflammation markers, things like CRP.

 But also, , CA 125, the markers of increased risk of ovarian cancer can be valuable. But really it's more of a symptomatic diagnosis. 

So if your story is It's something like, huh, the women in my family all said things like, welcome to womanhood, you have your period get used to it. It's going to be bad. , that's a red flag,, any history of infertility, especially because generations before didn't really talk about it.

in as comfortable a way, that's a red flag. Any, any other woman, you know, cousin and [00:30:00] sister, mother, grandmother, whoever had surgery for endometriosis or had early hysterectomy, that's a red flag. The challenge is, is that I've seen two things in the family history Story. One is that the family just didn't talk about it much there.

 There's a lot of shame around any kind of problem with menstrual health. So it was either not talked about, or it was normalized that everyone in his family has bad periods. Or I see kind of from , the sort of less conservative, will you say like progressive crunchier natural medicine moms, it, you might hear stories like, Oh, you know, this pain is part of the process of your body expelling the toxins or something like that.

Also not accurate, but a different take on it. So that kind of family history is a big red flag. Almost all of my patients, there's something in the family history. They just maybe didn't know about it. , and then the second thing is that [00:31:00] really intense periods that disrupted middle school, high school, trying to, play during the softball championships and just white knuckling the whole thing, being in the nurse's office, throwing up, passing out one, one of the doctors.

Who is a brilliant endosurgeon up in Massachusetts. He has the, he calls it kind of like the signal that someone probably has endo. If you ever found yourself sitting on a bathroom floor in a school with your chin on the toilet, just trying to cool down. That's a big red flag. , pain down the leg.

It's a big one because of the nerves involved, but also that vasovagal response, that kind of autonomic nervous system sweating, passing out, needing to lay down in the girl's bathroom, putting your head on a cold toilet or anything else. Those are all big red flags. And to me, there's no [00:32:00] reason that should happen.

So there are a few other things that can lead to that degree of discomfort, ovarian cysts, for example, which can be seen on ultrasound. So if that's not the issue, or if someone is treating that well with nutrition and supplementation, and they're still, you know, their hormone tests look normal and all of that.

That's where I'm really looking for that index of suspicion. And the final thing that tends to overlap is digestive issues. , So I certainly wouldn't, skate past that. So I think the faster we can educate these, , middle school health teachers, middle school nurses, that's where we're going to make inroads because that's.

where it first presents. And most of my patients get really good, you know, like this patient you're talking about at tolerating pain and powering through it. And they just stopped [00:33:00] bringing it up after a while. 

Yep. 

And that's the problem. So by the time they're old enough let's say they actually are seeing a gynecologist who even knows to look for this, which more and more of them do, but , you might be 22 years old and you've had it since you were 11, 12, you just forget about, you don't bring it up anymore.

Cause You know, it's been dismissed so many times.