Hello everyone and welcome back. ⁓ I’m super excited for a bunch of reasons that I will be sharing shortly to have Dr. Shanti Mohling here with us. Welcome Dr. Mohling.

Shanti Mohling, MD (01:10)

Thank you so much. It’s an honor to be here, Ginger.

Ginger Garner PT, DPT (01:14)

Yeah, I have just been really excited to welcome you to the podcast since I saw you were on the agenda at Endosummit last year for talking about the gut microbiome, which is one of my favorite topics. y’all are in for a real treat. I want to brag a little bit and do a bit of a bio before we kick everything off. So let me do that first. Here we go.

Dr. Shanti Mohling is a board certified fellowship trained gynecologist and gynecologic surgeon. She joined Northwest Endo in May of 2021 and brings her outstanding talents in endometriosis care, gynecologic surgery and biomechanics. to the practice, Dr. Mohling is committed to, of course, providing world-class surgical care to women with complex surgical issues, including endo.

and also chronic pelvic pain because they overlap so much as well as heavy bleeding, fibroids, pelvic organ prolapse, and incontinence, what we call in pelvic PT all the things. Dr. Mohling focuses on minimally invasive surgical techniques for all surgeries, which is incredibly important and we’ll probably touch on that a bit.

She has great experience and knowledge in the biomechanical aspect of pelvic pain and dysfunction, which is a very unique ⁓ part of who she is and what she does. So you have to listen to the entire thing. Because you may not know that she’s a former massage therapist in pre-med years. And that gives her such an interesting, unique, deep appreciation for the role that the musculoskeletal system plays in perpetual pelvic pain.

which is in pelvic PT, that’s our jam. ⁓ You might guess she’s a very ⁓ in-demand speaker and educator on this topic. ⁓ And so what I want to focus on is ⁓ you’re speaking all over the place. You just got back from India, speaking over there. ⁓ You’re just, doing so many different things. So the two topics that I’m just going to kick things off with and we’ll kind of break them down from here.

is nerve-sparing surgery and why that’s so important and also why the gut microbiome is so important and previously historically just overlooked, kind of as endo was and has been as a disease as a whole. So welcome.

Shanti Mohling, MD (03:54)

Thank you. Thank you so much.

Ginger Garner PT, DPT (03:56)

Yeah.

All right, right out of the gate. I don’t know that most listeners will appreciate. ⁓ Now, they’re going to have heard and listen to so listeners, if you have not listened to the previous surgical podcasts talking about why ablation is not a solution for surgery, that excision surgery is the gold standard, please go back and listen to that because this is like an intermediate to advanced topic discussion here, what we’re about to dig into.

So I think that our listener may not be able to or may want more information on what nerve-sparing surgery is for endo. What does it entail? How does it differ from traditional excision surgery?

Shanti Mohling, MD (04:40)

So I think partly it’s important to realize that it’s kind of in vogue now to say you do nerve-sparing surgery. And I think even before I learned what that was, I was instinctively doing that because clearly you don’t want to be cutting important nerves, whether they’re motor nerves or sensory nerves, ⁓ and particularly in the pelvis. These nerves that all of this endometriosis and inflammation

Ginger Garner PT, DPT (05:00)

Mm-hmm.

Shanti Mohling, MD (05:10)

are adjacent to, those nerves control our bowel function, they control our bladder function, holding our bladder, releasing our bladder, feeling the urge to use our bladder, they also control our sexual function and being able to lubricate, for example. ⁓ nerve-sparing surgery can include everything from minor

disease like early stage one or two disease where you’re removing peritoneum and lateralizing the nerves separating the nerves from the disease tissue that you’re removing as much as possible. It can also be involved when you are

doing hysterectomy, for example. I’ve seen patients over the years who say, you I have since my surgery, I just don’t lubricate as well. Well, that was probably because that inferior hypogastric branch to the vagina got cut at the time of hysterectomy. Super easy to do if you’re not thinking about it. You know, I’m sure I’ve done it myself, especially in the past when I didn’t have the luxury of

such incredible visualization that today’s laparoscopic equipment affords us. ⁓ So nerve sparing, think really this concept got coined and maybe initiated by Marcello Ciccheroni, a surgeon in Verona who really has spearheaded the concept of nerve sparing surgery for the bowel and

really understanding that pelvic anatomy so well that as you’re excising bowel disease, you are lateralizing or separating the nerve tissue from the bowel so as not to injure it. There’s some aspects where some nerves are going to get injured no matter what, and sometimes they are already injured by the disease state itself.

Ginger Garner PT, DPT (07:09)

True, yeah.

Shanti Mohling, MD (07:11)

What we’re trying to do then is get the disease off. Can you save some of the nerve? Is it going to regenerate? Nerve regeneration is very slow. It takes a year or two to really regenerate ⁓ full bowel function, for example, after a complete low anterior resection of the bowel. Even if you’re doing nerve-sparing techniques, you’re not going to fully recover for

Ginger Garner PT, DPT (07:25)

Yeah.

Right.

Shanti Mohling, MD (07:40)

a year or so. So that is that a start to answer your question?

Ginger Garner PT, DPT (07:44)

It, yeah, it

definitely is because from the full spectrum, if we take, if we step back and take the 40,000 foot view in, which is I think what patients often want to hear. They wanna hear if they’ve been through the surgery and they don’t have full function yet and they walk into my office, for example, or any pelvic PT that specializes in endo, they’re like two hands in the air, what’s going on?

How long can I expect this to happen? When will it get better? And so that’s a really important point that you made that it could be one to two years, but the good thing is it’s good and bad. Yeah, exactly. The bad news is it’s one to two years. The good news is it’s one to two years. You have time. You have time to heal and recover and regain full function. And so I think that’s overarchingly a good sign, even though patients will be

Shanti Mohling, MD (08:21)

He has a good chance of recovering. Yeah, exactly.

Yeah.

Ginger Garner PT, DPT (08:38)

initially frustrated when they come in. I’m like, no, no, no, we have time. What do you see as the nerves that are most commonly impacted in deep infiltrating endo? And just give me an example. I know you have multiple cases to pull from of how you approach protecting those during surgery when you come up on that where the lesions are just everywhere.

Shanti Mohling, MD (08:42)

Yeah, yeah, absolutely.

Yeah. So what’s interesting is that I think sometimes you’ve got direct impact on the nerve, right? Or so I don’t yet, although I am training to do the full neuro-paleurology work, but you can have nerves like the sciatic nerve with endo directly on that nerve, right? And it’s a big enough nerve that you can kind of cut the disease off of it, right?

Ginger Garner PT, DPT (09:29)

Mm-hmm.

Shanti Mohling, MD (09:29)

some of

our nerves are branches that are smaller and some of those will get injured. And maybe to some degree when you’re removing endometriosis and you’ve got these little fibers, maybe that’s part of why pain gets better because you actually cut some of those sensory nerves that were attached to endometriosis. ⁓ So I would say that the most commonly

Ginger Garner PT, DPT (09:48)

Mm-hmm.

Shanti Mohling, MD (09:56)

directly affected nerves are going to be the inferior hypogastric nerves, right? With branches to the bowel, to the vagina, to the uterus, to the bladder. And so as I am working my way down from the pelvic brim down deep into the pelvis and excising disease or doing peritonectomy, my technique really is to get into the retroperitoneum and begin to get that peritoneum gently

separated from not only the nerves, but the ureter, all of the vessels that lie and live in that retroperitoneal area, but the nerves included. So I think part of the technique that’s so effective is not just to cut the tissue off, but as I’m removing that peritoneal disease, I’m bluntly lateralizing, gently pushing the nerves.

away from the tissue I’m going to remove, right? And then sometimes that’s really stuck and you do need to use a little ⁓ maybe some cold cutting and sometimes even a little bit of monopolar energy to separate that tissue from dense fibrosis. And I don’t think I’ve had to fully cut through like the larger branches of the inferior hypogastric.

Ginger Garner PT, DPT (10:56)

Thank

Shanti Mohling, MD (11:18)

very many times, but there are a few times where there’s just so much fibrosis, the disease is already so infiltrated, the nerve, that that dysfunction already occurs. And fortunately, we have two sides, right? So if the bladder still gets information from the left side and the right side is boxed because of fibrotic disease, you might give it chance actually to then, ⁓

a heal if you can get enough of that fibrosis off. The other thing that’s interesting is sometimes I’ll do a superficial layer of the endo removed and I’ll send a second layer that’ll still have endometriosis on pathology. Sometimes the deeper layer, say I’m on the bowel, say I’m on the sidewall or uterus sacral, is just fibrosis and not endo. Usually I’m a fan of removing most of the fibrosis too. But when I do see, on the rectum,

Ginger Garner PT, DPT (11:49)

Yeah.

Shanti Mohling, MD (12:16)

some fibrotic tissues that the pathologist says there is no endo here. I think, okay, sometimes if you get all the endo and you leave a little bit of fibrosis on a nerve, it may be able to heal now that you’ve taken this big inflammatory amount of tissue out of the picture, right? So when you’re talking about nerve function, it’s a real balance and art as a surgeon, like, what am I leaving behind and why?

Ginger Garner PT, DPT (12:30)

True, yeah. Yeah.

Shanti Mohling, MD (12:45)

Right? I had to talk. There it is.

Ginger Garner PT, DPT (12:46)

Mm-hmm, that’s such a ⁓

brilliant, nuanced ⁓ way to describe it. So taking that, let’s take that inferior hypogastric nerve just a little bit further. What kinds of outcomes and symptom improvements, because I think that’s probably the question on most listeners’ minds are, what would I feel if that was happening to that particular nerve? How if, yeah.

Shanti Mohling, MD (13:08)

Yeah, so it might be harder to pee,

right? You’re like sitting there, it’s, might have to strain to pee, right? It might be ⁓ chronic constipation. It might be vaginal dryness.

And if you really like really destroyed both inferior hypergastric, you might not be able to pee at all. You know, so some really radical cancer surgeries. ⁓ I don’t think I’ve ever had a patient with that inability to void after surgery long term.

Ginger Garner PT, DPT (13:33)

Yeah.

Yeah,

it’s, you know, when, so the kind of the fallout from time of them having to strain or feel constipated, et cetera, then turns into the whole musculoskeletal issue that you can certainly appreciate with your very diverse background of then there being pelvic floor dysfunction or pulling in obturator internus dysfunction or other things that then they could mistake for.

and I’ve had this happen so many times in patients, a hip labral tear. So it looks like hip pain, it looks like a hip cartilage issue, or it looks like lower abdominal quadrant pain when in fact it was a psoas issue or a pelvic floor problem.

Shanti Mohling, MD (14:29)

Absolutely. Yes. Thank you, doctor. Absolutely. So often overlooked, right? Yeah. Yeah. And I think about someone with just massive endometriosis or even stage one or two endometriosis, but debilitating pain, they’re keeping that gate closed down below. They are clamped down. They are not letting in through the vagina. Everything is clamped down.

Ginger Garner PT, DPT (14:31)

Ha ha.

Yeah.

Yeah, yeah, and so that

⁓ definitely.

Shanti Mohling, MD (14:56)

Sometimes we’re really post-surgery, some patients we have to really work with physical therapy to unwind that.

Ginger Garner PT, DPT (15:03)

Yeah, that’s a super important point because patients will come in and I think they often think, which is it’s not to blame anyone at all. It’s just that you as a surgeon has, you have such this heavy burden of clearing someone with endo and helping them. And then we have our own set of issues and burdens in PT. And so no one really tells the patient.

just because you had excision surgery doesn’t mean your musculoskeletal issues will magically resolve post-op. Your psoas didn’t get a memo. Like, you know.

Shanti Mohling, MD (15:38)

Absolutely.

No, and we forget

that patients often are so deconditioned by the time they come in the door that if they’re coming in with a cane, they’re probably gonna leave surgery with a cane too, initially. Although that being said, I just saw this absolutely adorable patient for post-op. She came in 10 weeks post-op. We really wanted to check back in with her.

Ginger Garner PT, DPT (15:49)

Yeah. Yeah.

Yeah. Yeah.

Shanti Mohling, MD (16:08)

When I first saw her, she was so constricted and really couldn’t move well and in so much pain, super slender, beautiful young woman. She felt this tethering in her body and went to so many providers who just really thought she needed to get physical therapy only and or stretch more, yoga more, whatever. So she had literally.

Ginger Garner PT, DPT (16:28)

Mm-hmm. Mm-hmm.

Shanti Mohling, MD (16:32)

a loop of transverse colon and rectosigmoid colon tethered together right at the place where she had pain. Now that was also involving the abdominal wall. She had abdominal wall endo along with the bowel endo, abdominal wall endo removed. She comes in today 10 weeks later and she’s just like, you’re a different person, she can move.

Ginger Garner PT, DPT (16:58)

Yeah. Yeah.

Shanti Mohling, MD (17:01)

I do think that there are times when just surgically removing something frees someone up enough that they can move. But sometimes if it’s set in too long, then you definitely are unwinding the clock a long way.

Ginger Garner PT, DPT (17:09)

Definitely.

Yeah,

I think that, ⁓ you know, and I can chime in on my own experience because I had bowel endo and then I had ⁓ the bowel tethered to the sidewall and kinked on itself. Yes, and so ⁓ there for me, I was one of those people, too, where I’m like, ⁓ you know, I can I can stand, I can digest food for the first time.

Shanti Mohling, MD (17:30)

so this is very familiar to you. Yeah.

Wow.

Ginger Garner PT, DPT (17:44)

I don’t have to randomly take a knee on a sidewalk walking the dog because of digestion being absolutely hindered. ⁓ So it was profound, very profound. It was night and day. And then you will have the, and that’s where, you know, we try to distinguish between what should be post-op relief, right? And what is a deeply ingrained motor pattern. I had the benefit as a PT of already knowing what the motor patterns

Shanti Mohling, MD (17:50)

Yeah. Wow. Yeah. Yes.

Ginger Garner PT, DPT (18:14)

and timing should be on what muscles should fire when. So I had fixed all that before, so I didn’t have the post-op pain still the same. I had post-op, okay, no pain, like zero pain. Everything’s great, right? So I think that to encourage the listener too, that if you are having some lingering pain post-op, it could simply be timing and motor patterning, a muscle that just needs to…

They have the reset button pushed, you know, to, yeah.

Shanti Mohling, MD (18:45)

Yeah. And again,

also that going, bringing back full circle that nerves are the slowest to grow and repair and it can take a year. And it’s funny, I was an expert witness in a case of a sciatic nerve injury and that was probably from positioning and I was flying to give testimony and

Ginger Garner PT, DPT (18:52)

Yeah.

Shanti Mohling, MD (19:07)

oddly enough, the person sitting next to me was a nerve researcher. And he starts talking to me about how nerves are so slow to grow and that even the sciatic nerve can repair, but it slowly, very, very slowly heals. It can take a year or two. And I was like, thank you for that information. It’s just what I needed to hear. Yeah.

Ginger Garner PT, DPT (19:12)

Ha

Yeah, totally. Yeah, there is

hope. is hope. Patience and hope. So a mix of patience and hope. So what do you think some of the biggest challenges are in teaching or spreading awareness about nerve-sparing techniques among surgeons?

Shanti Mohling, MD (19:34)

Totally.

Well, I mean, in some ways, think the bigger challenge is teaching them to do excision, getting them to recognize that it helps. ⁓ I think it’s so much about technique. It’s so much about technique and understanding anatomy and really.

Ginger Garner PT, DPT (19:53)

True, Number one, excision, not ablation.

Shanti Mohling, MD (20:05)

being aware that you also need to take the tissue off those areas, right? So I think anatomical awareness for sure, number one. But I was reviewing a video recently and they did a great low anterior resection of the colon, but they left all this sidewall disease overlying the hypogasterics. And so like,

Okay, they have the ability to deal with a nodule, but don’t have the awareness that that sidewall disease is contributing to the problem and that that person is going to have residual pain, undoubtedly, right? I think that all of these conferences and seminars and ⁓ when I teach for intuitive, I try to emphasize this that

you can very safely be near the nerve and that it just takes more time. It’s not going to do a 30 minute surgery. You’re going to be tediously moving this disease off and at least getting all the endo. If you maybe leave a little fibrosis on a nerve, that may be in the best interest of the patient long-term, but that taking one’s time and just being so very

Ginger Garner PT, DPT (21:28)

Yeah. You kind of answered my next question.

Shanti Mohling, MD (21:33)

very delicate to get that disease off.

Ginger Garner PT, DPT (21:37)

think you’re reading my mind. Because I had a question related to this and you just like went right into it and answered it. It was a question related to when endo infiltrates a nerve, direct like the pudendal nerve or something like that. Is it possible, is removal possible or what happens at that point? You mentioned maybe leaving some fibrosis in order to…

Shanti Mohling, MD (21:44)

Tell me.

Ginger Garner PT, DPT (22:05)

you know, of balance out taking the endo, but maybe not taking the fibrosis. Can you describe like that decision making process?

Shanti Mohling, MD (22:14)

Yeah, I think it’s the same as it’s really similar to removing extrinsic disease from a ureter. Right. And so if the structure itself is healthy and you are comfortable removing the disease and getting up close and personal with the structure.

Ginger Garner PT, DPT (22:22)

Okay.

Shanti Mohling, MD (22:41)

and also have the techniques to spread, to cut carefully, you can remove this disease from anything, right? Like it’s terrifying the first time that you take it off the peritoneum diaphragm over the heart, you know, and you’re just like, my God, but you can do it, right? You just have to go slowly and take your time and remember that things have nerves that are gonna jump. so…

Ginger Garner PT, DPT (22:59)

Yeah.

Shanti Mohling, MD (23:10)

Particularly if you use energy near a nerve, it’s going to jump and you have a greater risk of injuring it, right? So ⁓ sometimes you’re using less energy and you’re very carefully cutting disease off, right?

Ginger Garner PT, DPT (23:24)

Yeah, so what should patients, like what’s the takeaway message before we shift into our next topic? What’s the takeaway message? I think we’ve touched on it a little bit, like patience is one, keep the hope because it could be two years, but also be patient because it could take two years. Are there risks? What do you kind of take patients through when considering that a nerve is involved like I’ve had.

patients come in, clearly the sciatic nerve is involved, they’re getting pain, it’s going past the knee, it’s going into the foot, they’re having regular things happen. So when you have that presentation of someone coming in and they clearly have nerve-related pain, ⁓ how do you walk them through that in terms of preparing them for what comes and what kind of therapies they may do after?

Shanti Mohling, MD (24:09)

Okay,

so that’s a really good topic to bring up. So I really believe that when there’s sciatic pain, it’s not necessarily endo on the nerve. That when you have motor dysfunction, you probably have endo on the nerve. And then if you have that radiating pain, it’s usually nearby endo that is creating a referred pain. And that you can remove the endo really more safely.

But when you have true motor dysfunction, like a foot dropper or leg drag, then you really need one of very few specialists to remove that disease. So, so often I will remove uterus sacral disease or deep peritoneal pocket disease and the back pain gets better, right? Even though I haven’t been really directly on the nerve,

Ginger Garner PT, DPT (24:51)

That’s a very good point, yeah.

Shanti Mohling, MD (25:08)

that referral deep referred pain is creating and mimicking some of the same ⁓ patterns as a pinched sciatic nerve, for example. But I think when the disease is really on the nerve, you’re going to have like on a pudendal or on the sciatic nerve, you’re going to have more, ⁓ well, particularly with the sciatic, you’re going to have motor dysfunction.

Ginger Garner PT, DPT (25:36)

Yeah. And so for the listener, with that motor dysfunction, it would be difficult to walk. It would be difficult to do your ADLs because your muscles aren’t working the way you want them to versus them you feeling a sensation like hot, cold, numbness, stinging, know, ⁓ tingling, that kind of thing, which means it could be near, but it’s how you’re feeling instead of the foot literally dropping and you not being able to walk the way you want.

Shanti Mohling, MD (25:42)

Yeah.

Exactly.

Ginger Garner PT, DPT (26:06)

And so when it’s the latter and there is motor involvement, then yeah, and if you are in the Pacific Northwest, okay, listeners, know who to go see for that because that is an urgent issue. You can’t just let that go, right? yeah. Okay, so here is a topic that I have been very,

Shanti Mohling, MD (26:24)

Yeah, exactly.

Ginger Garner PT, DPT (26:34)

just super curious, to say super curious is not even the right phrase. It really isn’t. It’s like a little obsessed, maybe a more accurate phrase. When you’re talking about the gut microbiome, the first research that I heard and read about was back in the early 2000s, like 2010 or so, about the gut microbiome and the implications for C. difficile in infants when they’re like,

know, breastfeeding, you know, ⁓ or vaginal birth versus C-section and just the colonization of the gut microbiome and how mode of birth and how much, you know, ⁓ meat you ate that may have, ⁓ you know, hormones in it or otherwise could skew the positive bacteria or the good bacteria that you have. So, you know, fast forward ⁓ in a couple of decades here and, you know, the gut microbiome is everywhere. Everyone knows something.

about the gut microbiome in some way, hopefully. But here’s, I think where we’ll walk away currently saying the phrase that we love in healthcare and medicine, which is more research is needed. And I think that for this topic, that could not be more true. But can you just brief us, because I loved your lecture last year at Endosummit on the gut microbiome.

Can you just kind of give us the 40,000 foot view or a little closer in on the relationship between endometriosis and gut dysbiosis or microbiome appearances and imbalances if, you so to speak.

Shanti Mohling, MD (28:12)

Yeah,

so let me start with what my research was that I did when I was starting to get interested in this, and then how that led me to thinking more about the relationship between a healthy gut, flora, and endo-belly and well-being, right? So ⁓ it starts with… ⁓

a decade ago learning about celiac disease and learning that there was this molecule, this ⁓ called zonulin, which holds the tight junctions together in the lining of the small intestine. When a person who’s genetically predisposed, so this is really important, like with endo, we have genetic predisposition, we know this. With celiac disease, have

a genetic predisposition. And then you’ve got an environmental component and you’ve got your gut, right? So the environmental component is what’s going in and this is going to be gluten, right? And then the tight junctions start to release to get an uptick in zonulin. And then in those cells, the cells then are separated enough that anything going through the gut

doesn’t get screened as well, and you get antigens and negative maybe bacteria into the bloodstream, you get this massive immune response because 80 % of our immune system lives on the other side of this gut lining, right? So you get a huge immune response and then you get full-blown celiac flare disease, right? So the same thing, it turns out, happens with type 1 diabetes.

Zonulin goes up, leaky gut, exposure of things, and you get autoimmune mediated disease. Same thing happens with, interestingly, MS or spondylosing, I can’t remember what it’s called, but other diseases as well. So I wondered, is endo anything like this, right? And so is there some relationship with endo? And I will honestly say that

Ginger Garner PT, DPT (30:24)

Yeah, yeah.

Shanti Mohling, MD (30:37)

At this point in time, over a decade ago, when I was thinking about it, I was thinking that maybe retrograde menstruation was a thing. And I don’t think it’s as much of a thing, but I think it’s a little bit of a thing. I think mostly it’s embryologic origin.

But ⁓ when I wondered, is leaky gut at all related to development of endometriosis symptoms, or is it also related to endo belly and inflammation and the gut difficulties that so many of our patients face? So leaky gut is also called impaired intestinal permeability. And this occurs in a lot of disease states, in fact, not just celiac disease.

or the ones I mentioned. So I did a small pilot study and I got a grant from the Endometriosis Foundation and enough to pay for a bunch of test kits from, I think, North Carolina is where they can from the lab there. I painstakingly got enough patients to do my pilot study. I did a power analysis and so it was statistically significant. ⁓

Ginger Garner PT, DPT (31:35)

Go well.

Shanti Mohling, MD (31:51)

I had controls who were all negative for intestinal permeability impairment. had patients with pain and no endo, and they were negative. And half my patients with endometriosis had impaired intestinal permeability. Now, the thing about leaky gut is that it’s ⁓ not a static state, right? So if you have it, you probably have it more often, but sometimes someone could

really be like avoiding their non-steroidal anti-inflammatories, which by the way give us leaky gut. And what do we give all of our kids who have period pain? We give them NSAIDs. probably also birth control pills might also play a role. So someone might be eating really well, they’re trying to control their symptoms, they’re not taking ibuprofen, they’re not on hormone therapy, and their gut’s looking better even though they already have endo. So they wouldn’t show up positive on my test. So.

⁓ I had a hard time recruiting patients because you had to collect your urine for six hours, which is the old fashioned way to really reliably see if someone has impaired permeability. You drink a sugar solution with mannitol and lactulose, and lactulose should not show up in the urine because it’s a large molecule, which is why it works to help someone ⁓ have bowel movement. If it gets into the blood,

it gets into the urine and that’s how you do a urine collection and you can see if someone has intestinal impaired permeability. So it did show that there was an association. I don’t know if it’s causal. I don’t know if endo causes this or something about endo happens because we have intestinal permeability. We have no idea. But what we do know is that intestinal permeability when it’s impaired

is also related to a dysfunctional a dysfunctional microbiome because all this bad stuff can flow in, right? And we can’t control it because we have a leaky gut. So ⁓ some of the other things that we know about the microbiome is that a really healthy microbiome keeps our whole functioning of our whole system intact, including our hormonal function.

And so there’s a beautiful study and since I’m not having my slides prepared, I can’t quote exactly who did the study, it’s ⁓ looking at ovarian cancer and patients with ovarian cancer ⁓ had more dysbiosis and also had certain bacteria that reconjugates estrogen metabolites, making them reabsorbed, elevating estrogen levels in the system, increasing ⁓

Ginger Garner PT, DPT (34:32)

you

Ooh. Yeah, yeah.

Shanti Mohling, MD (34:46)

predisposition to breast cancer. Sorry, breast cancer is what it was, not ovarian cancer. So we are learning all these bits and pieces about how the microbiome affects our general function, our hormonal balance, our mood. I mean, it’s rather endless, actually.

Ginger Garner PT, DPT (34:48)

Yeah, definitely. Yeah.

Shanti Mohling, MD (35:11)

Our digestion, of course, is part of it. mean, that’s the real tube that we’re dealing with. But it definitely has an impact on all the systems of our body. So how do we get a healthy microbiome? Well, one, yes, if we’re born by C-section, we’re off right at the get-go. We don’t have quite as good of luck. If we’re not breastfed,

Ginger Garner PT, DPT (35:13)

Yeah.

Shanti Mohling, MD (35:37)

We’re not getting all those immune globulins and a lot of those natural bacterias from our mothers. So there’s another hit. If we grow up in a very sterile environment where we’re not having organic vegetables, which have some nice little micro bacteria that are good for us from the farm, then we’re not getting all those nutrients that we need. So. ⁓

What do we do if we had all those hits at the beginning and then we had plus a ton of antibiotics because we had kidney infections as a baby or whatever we had? We’re we’re we’re behind the eight ball and we need to work to improve, right? So things that you can do are just generally avoid sugar and processed foods and and make sure you’re a very wide variety of fruits and vegetables are going to augment and not radiated ones, right? So probably organic.

fruits and vegetables, a wide variety will help bolster a microbiome. I’ve also recently become a fan of bovine colostrum. And I feel like, so the reason, here’s the reason. I, you know, you mentioned that I went to India and I spoke in India and I went to a travel clinic beforehand and I was given bovine colostrum to take.

Ginger Garner PT, DPT (36:51)

Yes.

Shanti Mohling, MD (36:59)

to prevent travelers’ diarrhea, which is studied and actually is a known thing, that it helps prevent travelers’ diarrhea. And I have a history also. I was born in India and then I was there 40 years ago in my 20s and got Shigella and amoebic dysentery. I terribly sick. And this time around, I did not get sick at all. In fact, I felt fabulous and I was taking bovine colostrum before every meal.

Ginger Garner PT, DPT (37:19)

Wow. Wow. Yeah.

So the mechanism is if it’s diversifying commensal bacteria or, yeah, yeah. ⁓

Shanti Mohling, MD (37:31)

Yeah, protective bacteria, which is what we need. So, and perhaps the immune globulins. I think that there, it’s really interesting. I wish that if I were in an academic institution, I would be like, yes, we need to study this. But ⁓ I came home and I started reading about it and it can heal the gut from overuse of non-steroidals. And it’s used by athletes ⁓ for ⁓ muscle recovery.

Ginger Garner PT, DPT (37:33)

Yeah.

That is fascinating.

Yeah.

Shanti Mohling, MD (38:01)

And so I think it’s intriguing to me, can this help with the microbiome? And maybe it can. And it’s also really harmless unless you have a true lactose intolerance or allergy to milk, then you probably shouldn’t use it.

Ginger Garner PT, DPT (38:19)

Yeah.

Oh my gosh, okay, I have 52 questions. I was trying to add them up in my head as I went along, but.

Shanti Mohling, MD (38:24)

Yeah. ⁓

Wait, let me add one more thing. I want to be really clear that fixing your microbiome does not make endo go away. It would be wonderful if it did. We could be so happy. But I think even if you had a perfect microbiome growing up, I think if you have all the seeds of embryologic development or misdevelopment and the deposits left from the diaphragm all the way down,

Ginger Garner PT, DPT (38:37)

Yeah, we wish it did, but unfortunately, yeah.

Shanti Mohling, MD (39:00)

No amount of changing our microbiome later is going to help if you don’t get the disease removed. But I do think that a lot of the gut issues that go hand in hand, some of which we may be creating by giving so many NSAIDs and birth control pills to all these kids, might be benefited by really addressing that gut and getting it healthy. It for sure is going to help some of the symptoms and it’s going to be important in recovery.

Ginger Garner PT, DPT (39:04)

Yep. Yep.

Yeah, absolutely. I think I might be a poster child for what you just said. Okay, so I was ⁓ vaginal birth, breastfed. ⁓ My mother has endo, lots of female family members had endo, never properly treated, unfortunately. That was decades and decades and decades ago. ⁓ So their treatment was hysterectomy, which we’ve said a billion times on the podcast, is not, doesn’t.

It’s not a cure for endometriosis. It’s not even necessarily a treatment for endometriosis at all. ⁓ But yeah, I had that good beginning, but with the genetic history. And then I went on into my profession and did what I did and studied Ayurvedic medicine and got a certification in that and studied yoga and all the nervous system regulation that you do. And then I got board certified in lifestyle medicine. So I studied the gut microbiome. And I think in a way it allowed me to

it mitigated it because I was looking at estrogen metabolism. I was looking at the gut microbiome and trying to optimize that. it did mitigate the disease process, but never stopped it. So eventually, I had to have excision, right? In spite of all of those things, it allowed me to live to a certain degree until my body was like, you’ve done everything you can do. There is nothing else you can do. You have to get excision. And it was very clear.

Shanti Mohling, MD (40:44)

Right, right.

Ginger Garner PT, DPT (40:57)

⁓ at that moment, when I arrived at that moment. ⁓ And of course other things are found too, like when your bowel is kinked on itself, well that’ll give you problems on a random day, on a random Tuesday. But yet that last point is so important that we want to manage all of those things. It’s certainly from the very yogic integrative medicine, lifestyle medicine side of what I do,

in pelvic PT, it’s paramount because I would not want them to come out of surgery with you, for example, and then just say, whatever you eat is fine. Right, the excision has taken care of it, I’m gonna do some internal pelvic floor and needle a quadratus in an internal ⁓ obturator and then you’re on your way. ⁓ So my questions kind of lie in that. In that…

Shanti Mohling, MD (41:34)

Right.

Ginger Garner PT, DPT (41:51)

So I’m tracking some of these labs for patients. I’m looking at whether zonulin is an issue, intestinal permeability. I’m looking at their stool tests. So my first question would be, what do you think the ideal follow-up lab to track the gut microbiome is? Because some of us who are integrative and lifestyle medicine oriented in PT are doing that. And we see really low levels of

You know the commensal positive bacteria, so it’s very homogeneous like they don’t have diversity at all

Shanti Mohling, MD (42:26)

You’re seeing that across the board in your patients? Yeah, that’s really interesting.

Ginger Garner PT, DPT (42:29)

Yeah, I’m seeing that a lot.

Yeah, and patients. I just got two back this past week. I’m like, oh, goodness, you know, I’m seeing the same thing. I’m seeing higher levels of opportunistic bacteria.

Shanti Mohling, MD (42:41)

Yeah, that’s so interesting. So you’re doing a stool study on your patients. I think that’s fantastic. I should be doing this too. I mean, I’m so focused on getting people in the door for surgery, doing that. But I love that you’re doing this. Absolutely. And so I think that the key is how do we really get that microbiome to diversify and to improve

Ginger Garner PT, DPT (42:45)

Yeah.

you’ve got one or two things to do. You’re real so busy.

Yeah.

Shanti Mohling, MD (43:10)

the balance of your health supporting bacteria. And ⁓ it’s, yeah.

Ginger Garner PT, DPT (43:11)

Yeah.

Yeah, so if I use,

for, and here’s one, let me add one layer of complexity onto this because so many women have bowel endo. So let’s just say they also have low good bacteria and a negative opportunistic bacteria, two high levels of that. Maybe they have pathogens on top of it and they have bowel endo. What do we know? I think this is a future research question of what,

What do lesions on the bowel, what does it do? What does it do? It took me 36 years to finally get surgery. What were those lesions doing the entire time? Was it the reason why an individual, like I see patients who just can’t shake Candida, like they always have that. So that’s one thing I wanted to throw in there too, because with bowel endo, it seems like it complicates it even further.

Shanti Mohling, MD (44:10)

Interesting. So let’s break, because that was a lot of questions at once. So let’s take the question of what does the bowel endo do? So what’s interesting is that most of the time the bowel endo is not inside the bowel. Right? And the leaky gut part is usually in the small intestine where we don’t usually see endo. Right? So the whole

Ginger Garner PT, DPT (44:15)

Yeah, sorry.

Yeah.

It’s going to be like shaved, like external.

Yeah, Yeah.

Shanti Mohling, MD (44:40)

immune function and the gult, that layer, is actually more associated with the small intestine, which isn’t really where we’re having the disease state. I feel like they are slightly separate issues, and yet they go hand in hand. They’re associated somehow. Almost all endometriosis,

Ginger Garner PT, DPT (44:49)

True, yeah.

Okay.

Yeah, yeah.

Shanti Mohling, MD (45:10)

of the bowel is extrinsic, right? So you’ve got the lumen and the disease is starting on the outside. And occasionally you’re going to have cyclic bleeding that is actually from a lesion working its way all the way through, right? And we see this, I’ve shown pictures of mucosa with endo coming out of it. But most of the time that lesion is starting on the outside, working its way to the inside, but it’s impacting

the nerves of the bowel probably, and probably thereby also the motility of the bowel. But I sometimes see this very similar symptoms in patients who have nodules on the utero sacral ligaments and not even touching the bowel, but they still have this bowel pain and dysfunction and constipation chronically and

and irritable bowel-like symptoms. I think that truly, you can have an ileus. An ileus, for those listening who don’t know, is where the bowels just sort of shut down and don’t work. you have peritonitis from a ruptured appendix, for example, your bowels will just go to sleep and not function for a minute, for a day or two or five. So I believe truly that the peritoneal fluid in someone who has endometriosis is pretty much toxic.

Ginger Garner PT, DPT (46:35)

Hmm.

Shanti Mohling, MD (46:36)

to the bowel. And so the bowels are always in a mild state of ileus. They’re kind of in a state of dysfunction and not really functioning well, right? And this may be separate from SIBO or from this intestinal permeability picture, but it’s not as though the gut is leaking into the body wall, into the body fluid, right? It’s leaking into the bloodstream, creating systemic inflammation.

Ginger Garner PT, DPT (47:04)

Mm-hmm.

Shanti Mohling, MD (47:05)

Is that and we don’t know is are people with endo having leaky gut because they have taken so many NSAIDs in their lives that they’ve just destroyed the lining of their gut, right? Or is there some other genetic association? We don’t know the answer, but

Ginger Garner PT, DPT (47:14)

Yeah. Yep.

Yeah,

would tracking, and this is more of a research question, I think, would tracking calprotectin as a measure of inflammation in the gut be ⁓ an indicator of whether or not, versus something like HSCRP where we’re looking at systemic inflammation versus inflammation directly in the gut, would that be beneficial in the long run? Yeah.

Shanti Mohling, MD (47:46)

Yeah, I don’t know.

I think that following maybe CRP and inflammation markers, ⁓ and then maybe a six month, if you’re doing a very aggressive probiotic therapy, maybe try this bovine colostrum. I mean, if a calf doesn’t get it, it basically can’t survive, right? It’s so important. ⁓ By the way, if you choose a product of bovine colostrum, make sure it’s a product that makes it calf first so that the calves don’t die.

Ginger Garner PT, DPT (48:07)

Yeah.

good point. Yeah.

Shanti Mohling, MD (48:20)

Yeah,

so, ⁓ and the products will state whether they make that important or not. But the tools really are avoiding the bad things. So alcohol, non-steroidal anti-inflammatories, probably birth control, ⁓ and increasing the foods that really support a healthy gut. And then that may also mean

probiotics, but it’s hard to know what’s the good one. You have to probably choose really reputable brands and ⁓ prebiotics, so foods that your body has to break down in a meaningful way. And then I think maybe it’s an interesting idea, checking ⁓ six months later, repeating a stool study. And also maybe those markers of inflammation could be valid.

Ginger Garner PT, DPT (48:59)

Mm-hmm.

Yeah. Yeah.

Yeah,

you know, I’ve been tracking it.

Shanti Mohling, MD (49:17)

I mean, you’re way outside the box. This is not mainstream medicine at all. And yet,

mainstream medicine has not done a whole lot for endo, so we know this. We have to be out of the box.

Ginger Garner PT, DPT (49:26)

Yeah,

we kind of have to be outside the box. Well, I tracked it on myself, of course, ⁓ just because I had symptoms way before I had my diagnosis. So I was tracking it for a long time. of course, being post-op and everybody that listens to the podcast knows I had endo. So it’s like no surprise ⁓ that I would be tracking these things post-op. But it makes me intensely curious about the future of research in the gut microbiome for endo because

There’s all these questions that we have brought up just in the context of this conversation. Should we, can we, how long should we be tracking ⁓ women post-op with a stool test to see if their gut microbiome diversifies? Does the endobelly resolve? ⁓ Does peristalsis and motility feel fine to them now? it restored? ⁓ And do they have enough energy to…

Shanti Mohling, MD (50:21)

Right. Yeah.

So I think the answer is this, that if someone is still having symptoms of their gut problems after reputable excision surgery, and whether they had this resection or a low anterior resection or whatever was done to remove actual bowel disease,

Ginger Garner PT, DPT (50:25)

get through their day.

That’s a key phrase. Yeah.

Yeah.

Shanti Mohling, MD (50:50)

and also adjacent disease creating an inflammatory environment. ⁓ If they aren’t progressively getting better, then they probably should work with a functional provider who is gonna check their stool microbiome. I think that’s really reasonable because we do also have to think about other ways which the gut is making us feel unwell. It may be at this point beyond endo.

Right? Yeah, I mean, you have your endo totally removed and yet you still have this gut issue. What do you need to do?

Ginger Garner PT, DPT (51:29)

Yeah, I’ve also seen patients like on a similar but separate note, like when we have ruled out like, ⁓ you know, the gut microbiome is looking good and digestion is looking good, but they’re still having abdominal wall pain that feels similar to their endopain before. I’ve actually done ultrasound imaging in the clinic and looked at fascial gliding. So like my fascial pain syndrome and seen that.

They have no gliding of the internal oblique and the transverse abdominis and everything is kind of stuck down because there’s been no visceral, general visceral motility. It’s like everything’s still guarding. Their hip flexors are still guarding. The abdominal wall is still guarded. And maybe that’s just a conscious motor pattern.

Shanti Mohling, MD (52:13)

What do do for them?

Ginger Garner PT, DPT (52:15)

goodness, I’ve done a number of things. Sometimes I’ll send them home with something really simple like cupping instead of massage work where we would compress the fascia. We do decompression and so I’ll do have them and they can do that themselves. I can teach them in one session and then they’re off and on their way. Sometimes it’s actually motor repatterning because they’re recruiting. They’ve used the internal oblique to stabilize everything for so long because they had no availability of the pelvic floor.

or the deep hip rotators to really support them because if they tried, it would flare everything, that they use all the superficial muscles, so the rectus and the internal oblique overfire, and then they end up with neural symptoms that they wouldn’t have if their motor patterning was corrected. So I just do real-time imaging and have them breathe different ways and move different ways until all of it is freed up. And then sometimes I’ll have to do visceral.

⁓ mobilization and scar mobilization and scar needling and things like that, but it’s generally always a good outcome. They have more freedom of movement and less pain. Yeah.

Shanti Mohling, MD (53:22)

awesome.

Ginger Garner PT, DPT (53:26)

my gosh, this gut microbiome conversation is so good. ⁓ I think I so many equally ⁓ curious questions when you did your presentation at EndoSummit and I was just so glad to see someone talking about the gut microbiome and endometriosis because I think…

there are so many research questions that can be answered. And I’m not at an academic institution either. I’m just clinically practicing every day. hey, ⁓ if you’re listening to this and you do research in endo I have questions. Dr. Mohling you have tons and tons of questions. I’m sure that would be wonderful research questions to pursue because I think both of us probably ⁓ do realize this. Doing research is hard work. It’s so hard.

Shanti Mohling, MD (54:15)

Yes.

Half the patients I enrolled just would not do the six hour urine collection. Like, hello. You know, it’s like, don’t complain about there not being enough research if you aren’t going to want to participate.

Ginger Garner PT, DPT (54:21)

It’s, yeah, it’s a lot on the… Yeah.

Participate,

yeah, so it’s tough for the patients. And then you’ve got urine testing and stool testing, all the things that aren’t fun for anybody to do. But if we had some of these research questions answered, we would understand more about endo and the gut microbiome and how it would impact us. Like imagine if we had a protocol a few years from now of.

at six months post-op or three months post-op, we do these tests. We look at the microbiome, we see whether or not there’s diversity there and get people back up on their feet even quicker. I think it’s really fantastic.

Shanti Mohling, MD (55:07)

I love it. Yeah.

Ginger Garner PT, DPT (55:09)

Yeah.

my gosh. So one question, I know we’re we got to go because we could just keep talking about this forever. But are you focusing now? I know you’re just like a brilliant surgeon. So, y’all, she doesn’t have time to do this other research. She’s like saving nerves and lives over here. But how do you currently integrate like any ⁓

Shanti Mohling, MD (55:28)

Thank you.

Ginger Garner PT, DPT (55:37)

microbiome testing or is that down the line? They end up with an integrative practitioner or if they were in my office or someone like that ⁓ in terms of microbiome testing or probiotics or other gut-focused therapies for endo.

Shanti Mohling, MD (55:56)

So in Portland, we’re lucky we have a naturopathic school. We have so many acupuncturists and naturopaths and people who really want a functional approach. And some of them really think what I do is archaic and you should never be cutting this disease out, but that’s okay. If you then can address the functional aspect, that’s wonderful. Go for it. So pretty much, ⁓ I know some practitioners, some surgeons,

Ginger Garner PT, DPT (56:01)

That’s right. Yeah.

Yeah.

Shanti Mohling, MD (56:24)

There’s a couple who insist that someone do a full six months of cleaning up their diet and so forth ahead of surgery. I don’t do that. One, I want to see all that disease. I don’t want any of it to be at all like suppressed. In fact, I don’t want someone on Lupron either. And sometimes, ⁓ or any GNRH analog for that reason, but sometimes disease is so extensive that…

Ginger Garner PT, DPT (56:37)

Minimized, yeah. Yeah, yeah.

Shanti Mohling, MD (56:51)

nothing’s going to suppress it. But anyway, once I do the excision, when I meet for post-op, we do a few things. One, we review their video so they can see exactly what their disease was and 90 plus percent of the time, it’s exactly where they kind of thought that it was going to be, right?

Ginger Garner PT, DPT (57:12)

Yeah.

Shanti Mohling, MD (57:12)

that’s exactly where it was tethered and I couldn’t move from that. And it was like, yes, exactly. It’s exactly there. And you see it on your video. And it really is, it’s so impactful to healing, to understand what was removed from your body and how it related to the pain that you had experienced for years. Then,

⁓ We always go over a plan which is often designed to dietary plan. It’s a general form that I created that Really is designed to get someone to eat more fruits and vegetables. I sound like a broken record ⁓ and and Really to avoid processed foods to how they make their can make their own broth and so forth like and what supplements I find valuable which are usually antioxidant or anti-inflammatory supplements

Ginger Garner PT, DPT (57:47)

Yeah.

Fantastic.

Shanti Mohling, MD (58:02)

I also don’t think someone has to take a supplement every single day. You can take a supplement four days a week. It’s still affecting your general system in a positive way. then resources if they need them to follow up with a functional provider. I don’t really have the ability in my practice to follow through with all that. Maybe someday I’ll figure out a way to do that and I would love to.

Ginger Garner PT, DPT (58:08)

Yeah.

Shanti Mohling, MD (58:27)

I think what I would do is for those patients who continue to have gut dysfunction three months after surgery, I would initiate a protocol of testing and it might include intestinal permeability testing because that’s pretty easy to do. If you’re in pain and you know it’s for your benefit, do that testing. You’re gonna collect six hours. A stool test, like you discussed.

Ginger Garner PT, DPT (58:42)

Yeah.

You’ll do it.

Shanti Mohling, MD (58:54)

and test for SIBO probably and then adjust accordingly as best that we can. But I want to reemphasize just as an anecdote that there are bacteria in dysbiosis that themselves produce the enzyme that makes you reuptake your estrogen, elevating estrogen, which drives endo. I think that’s one tiny example of this.

Ginger Garner PT, DPT (59:02)

Yeah.

huge.

Shanti Mohling, MD (59:22)

massive burden of bacteria within our bodies that create the functioning. And if we have an overload of dysfunctional bacteria, it will create disease, not just end-up.

Ginger Garner PT, DPT (59:32)

Mm-hmm.

Yeah, and then add to that if they have constipation on top of it so that the way we eliminate, yeah, it’s just like the bathtub plug is full and it’s overflowing and the estrogen has to go somewhere and endo is rubbing its hands together like, yeah, we’re gonna get some good stuff out of this because, yeah, because it can’t eliminate it. I think.

Shanti Mohling, MD (59:40)

Yeah, it’s all just festering in there.

Yes, madness. Yeah, want some more estrogen. That’s great. Yeah, and I mean,

in balance, I’m a fan of estrogen. know, at my age, I’m like, ⁓ give me some estrogen. Absolutely. But right, so, and testosterone, we didn’t even touch on that. But yeah.

Ginger Garner PT, DPT (1:00:03)

yeah, yeah. Me too. Yeah, yeah.

I know, I spend a lot of time educating patients about that. So I think that’s a really important point that if you are listening, you have endo, you think you have endo, and your providers aren’t talking about these topics.

You might not be settling on the proper provider yet because all of these things are essential to basically mitigating and managing, you know, endo for the rest of your life, particularly post-op because yes, while we, you know, you can be as certain as possible that you’ve gotten all of the endo, we don’t want to create the conditions for anything that could be there to grow, right? And so all of these lifestyle medicine pieces and integrative medicine because of everything that it can offer us in terms of

stress management, stress has to do with systemic inflammation, it has to do with hormone management or not, are really critical pieces of the puzzle that kind of add up to make the whole thing come together and give you the really good outcomes that you want.

Shanti Mohling, MD (1:01:13)

Well said.

Ginger Garner PT, DPT (1:01:13)

All right,

yeah, Dr. Shanti Mohling thank you so much for, yeah, for your brilliance and your passion. And the first time I heard you talk, I just wanted to like, this is a big Southern term, I just wanted to hug your neck. I was like, my God, she’s doing, she’s doing the Lord’s work out here, ⁓ my gosh. Talking about these things, because I think it’s what will give us that long term.

Shanti Mohling, MD (1:01:16)

Thank you, Dr. Ginger Garner.

Ginger Garner PT, DPT (1:01:43)

know, good outcomes in addition to the brilliant surgery you’re already doing. And that to me is like, throw your arms around the world, holistic, truly patient-centered care that is the future of endo. So just want to thank you for that.

Shanti Mohling, MD (1:01:56)

⁓ thank you. Thank you for the work you’re doing. And I love this functional medicine approach that you’re doing with checking these labs and trying to understand why someone’s still having gut dysfunction. And really, you’re going to the limit for your folks there. I appreciate that so much. That inspires me.

Ginger Garner PT, DPT (1:02:16)

Thanks. feel like,

oh, well, thank you. You know, I feel like if I could, if that helps them 10%, 20%, that’s the difference between them sitting on the sofa on a weekend or walking the dog or playing with their kids outside or whatever it is that makes their life meaningful. And so to me, I just can’t imagine not throwing the whole kitchen sink at it to try and make it as good as possible.

So two questions I had left, pretty short questions actually. One is the easy one, where can people find you? And two is what gives you hope in the current landscape or the future landscape of endometriosis care?

Shanti Mohling, MD (1:03:00)

⁓ So people can find me here in Portland and I can be found on my social media at Shanti Mohling MD. I usually post on Instagram, sometimes a little bit on Facebook and I have a budding YouTube which I need to be working on but there’s a few things on there. Anyway, I…

Ginger Garner PT, DPT (1:03:22)

Right. Yeah.

Shanti Mohling, MD (1:03:27)

I also am found at Northwest Endometriosis and Pelvic Surgery here in Portland with Dr. Nick Fogelson and we’re at www.nwenedometriosis.com.

Ginger Garner PT, DPT (1:03:40)

And if you haven’t listened to his podcast, please go back and listen to that.

Shanti Mohling, MD (1:03:43)

Speaking of

his podcast, we just recorded one because we are, ⁓ he hasn’t been doing it for a long time and we just are resurrecting it. And our ⁓ first one is going to be probably published May 1st and that’s on iTunes. I think it’s endometriosis podcast.

Ginger Garner PT, DPT (1:03:48)

yay!

then

Fantastic.

Okay, Endometriosis podcast. Okay, guys, gals, all the people. I just say folks usually and y’all. my gosh. Y’all, you can say y’all too. Yeah. All right, well that actually, yeah, that gives me so much hope you guys are resurrecting that podcast. That’s fantastic. And ⁓ so what gives you hope in the…

Shanti Mohling, MD (1:04:09)

Right. I lived in Tennessee, you know, for five years. So I can say, I can say y’all and folks. Yeah.

So

you know, I do some teaching for Intuitive, the company that makes the robot, and they reach out to me frequently as the endometriosis robot contact person when doctors want to deepen their skills and they want to have me proctor them or meet with them how they can learn to excise endo. And of course I also am a…

speaker through AGL and have taught there. But when individuals really want to learn it and they’re reaching out and they are already in practice, they can’t afford to go back and do a fellowship and they really want to push their own envelope and not just burn things and they want to excise it, they are reaching out and there is a way in which I am able to actually.

assist in their becoming excision surgeons themselves. So that’s really what we need. We really don’t have very many people who devote to this. So it gives me hope that there are people who want to.

Ginger Garner PT, DPT (1:05:27)

Yeah.

Yeah, that does. It gives me hope too. And all of the patients that come in and all the comments that you see or that I see on Instagram or on YouTube or any of a number of places where they’re just like, where can I go? Or they’ve unfortunately already been to half a dozen people and want to know. yeah, that gives me a lot of hope as well.

Shanti Mohling, MD (1:05:54)

Yeah, and also hearing some of your work, that gives me hope as well. Thank you. That’s great. It does. It does.

Ginger Garner PT, DPT (1:05:57)

⁓ well, thank you. It takes a village.

Yeah, it takes a village for sure. Thank you so much.

Shanti Mohling, MD (1:06:05)

Thank you. Have a wonderful evening. Yeah, thanks.

Ginger Garner PT, DPT (1:06:07)

You too.