Welcome back everyone to the vocal pelvic floor. This is your host, Dr. Ginger Garner. So this season, we’ve been talking about all things endometriosis, expert excision, advocacy, and pelvic physical therapy and therapy in general, including mental health. But today I want to pull back the curtain a little bit and share how I professionally, personally approach treating endo. What optimal care ⁓ should include, why it takes more than surgery to heal. I’ll walk you through the pillars of integrative medicine, of pelvic physical therapy, the way that I use it every day in practice. And in the next episode, which will be the final episode, I’m gonna answer your questions directly because your voice belongs in this conversation too.

So let’s get started.

Let me just frame out for you for a minute, because usually I have a guest and today I am the guest. You got me? ⁓ Season four has been all about ⁓ endo top to bottom, right? We have focused on excision, advocacy, ⁓ therapy care that includes mental health, PT, OT, et cetera.

This episode is kind of a blueprint for what optimal care should look like. It’s to normalize. Let’s normalize the frustration that many listeners have faced with fragmented or dismissive care. And so I want to start there first.

If you’ve been diagnosed with depression, anxiety, or any other mental health issue, right, but chiefly it would be generalized anxiety disorder or, you know, depressive disorder, could it be that you’re actually fine and you’re having a normal reaction to being dismissed? To feel anxiety or frustration over chronically being dismissed since your time of, ⁓ know, first time that you have pain to the time of diagnosis is somewhere around 10 years. For me, it was 36 years, right? Could it be that you actually don’t have anxiety or depression? You actually have a medical condition. You have endometriosis, right? That does not make you anxious. It does not make you depressed.

Not that if you do have that, it’s some kind of inherent weakness. No, it’s not. We live on a planet that’s quite stressful. So we’re all going to have it at some point, right? And we all need mental health care. ⁓ Like a lot, right? Let’s normalize that. You go to your PCP for your annual checkup. You should also be doing a mental health checkup, just like you should be doing a physical therapy checkup every year, just to make sure everything is humming along nicely. No pun intended.

So I just want to normalize the frustration first that you’re feeling and it is far beyond frustration. It is anger. It could be flat out rage. Think about what anger really is. And I can’t attribute this quote to anyone in specific, but I read this somewhere and I am just kind of paraphrasing it and kind of shifting it into my own interpretation. ⁓ Grief that has sat unattended for so long becomes anger. So identify it for what it is. Too many times if you go in and you are frustrated, what’s gonna happen in your appointment? Or you get even more dismissed. she’s just angry. She’s just fill in the blank. So that requires us to do a couple of things, right? If you’re someone with endometriosis, then you’ve got to control that piece of things too. And what do you do to yourself? You gaslight yourself.

I was just angry, that was inappropriate. No, actually, you should be angry. And since we can swear on this podcast, you should be fucking pissed. You should be pissed, rightfully so. If you’ve been ignored for that long, and the papers, the statistics, the research clearly shows, if a woman walks into the ER, if a woman has cancer, if a woman is having a heart attack, what happens? She’s going to have delayed care?

Even for diagnosed cancer, she will still have delayed care of the onset of treatments. Something that should be obvious. someone has cancer. Let’s start treatment. wait a second, you’re female. Somewhere in the gray area, their treatments are delayed. Perhaps because the diagnosis is delayed, we don’t know, but women are ignored.

So let’s just normalize that, okay? Yes, you probably have felt dismissed and if you feel dismissed, you’re probably right, trust yourself. If you feel like you have been medically gaslit, you’re probably right. There is a hefty amount of medical misogyny that still exists. ⁓ When are we gonna root this out? When are we going to end it? I don’t know, I’m not sure, but…this is just a drop in the well, a grain of sand on the seashore, if you will, to try and empower you with the knowledge that you need to no longer be medically gaslit. That’s the point.

And if I sound a little bit fiery or passionate, you’re damn right I am because I see women every day come into my office and sit down and have the same story as the previous person that just sat down. She tells me the same story. What did it start with? Painful periods. I went to the doctor, tried to put me on birth control. They said periods are gonna be painful. It’s being a woman, get used to it. And it goes on and on and on.

I have to get up in the middle of the night, change my tampon and a super plus pad four times and my clothes and I just sleep on the other side of the bed. It’s a mess. It looks like an, you know, an ax murderer – have to take days off from work because they can’t stand or walk because the pain is so bad. There have been cases of women actually dying from a lack of care due to endometriosis, due to the scarring, due to the adhesions. The cases are out there.

So if we normalize the frustration that you are feeling, the anger that you are feeling, the desperation that you are feeling, the hopelessness that you’re feeling, then you no longer have to gaslight yourself. It’s okay to feel that way. Just let it out. Press pause, have a cry, scream, yell, stop your car, whatever you’re doing listening to this, and just let that out. That’s important.

And I’ll get into why it’s important in a minute. It’s not just important for mental health. It’s important for your physical health if you have endo. Because if you bottle that up and you keep that in, yes, it will explode in other ways. Could it make your pain experience worse? Yes, it could. Because of hormone, cortisol disruption, a number of things, right?

So let’s dig down. Let’s talk about the foundations. What do we do first? Well, we get early intervention. So if you’re listening to this and you’re a woman who has endo and you have a daughter and she’s having problems, get her to the nearest expert endo excision surgeon. Not, and I cannot emphasize this enough, not your local OB-GYN with confidence, okay, you don’t have to look very far to realize or to go see many practitioners to realize the vast majority of them, majority of them, including OB-GYNs have no education about endo whatsoever, or they will tell you it’s just a disease of the uterus or the ovaries. No, no, no, no, no, no.

So save yourself a copay, deductible, whatever it is that the expense is going to be, the time, the humiliation, more frustration, and go directly to an endo excision expert. I’ll talk a little bit more about that in a second. But I don’t want you to get misinformation. I don’t want you to get told that you could just go on birth control, it’s fine, or just go on any of the few drugs that are available that…supposedly treat but do not treat endo. And then have more problems down the road, like osteoporosis. Okay, so we need to get rid of the barriers to timely diagnosis. The average years to diagnosis, as we know, is around 10. It can be even longer. There’s gender bias, there’s medical gas gaslighting. Excision surgery is the gold standard. And if this is the only episode that you listen to in the entire series, I’m going to try and kind of distill the wisdom from the entire endometriosis season into this little episode here. So bear with me.

So first truth bomb, okay, mic drop, excision surgery is the gold standard, period. Not ablation. And what an expert actually means is not someone who has just trained in MIGs, minimally invasive gynecologic surgery. No. They need to have studied with someone who is actually an endometriosis excision surgeon. And the ones that have are definitely upfront about that. They will tell you where they… who they studied with and for how long and what they learned and they are very grateful for that. It’s very humbling. Endo-excision surgeons are amazing people, humble people. They know how difficult the surgery is. They know the care with which they must approach it. And they know that early intervention is absolutely necessary. And they also know that our professional organizations are decades behind in what they’re recommending, equating ablation to excision. That’s a hard, fast no, a furious no. Ablation is not excision. Okay, so we all take a deep breath.

Who are your endo experts? Okay, who are your endo excision surgical experts in this country, in the United States and beyond? The best place for you to start, it is not the only place for you to start, but I’m not gonna go through the entire list right now. The most reliable one, the oldest one, the one that is vetted the best is going to be Nancy’s Nook. We’ll put the link to that in the show notes. Don’t worry about writing it down.

Nancy Peterson has done an incredible, amazing ⁓ superhero lioness type job of curating this information for the world, for everyone with endo. So if you are needing a surgeon, now it does not include therapists, you’ll have to find that a different way. And I can help with that. But for surgeons, go there first. Does it mean every surgeon on the list is going to be the best of the best of the best?

Well, of course not. That’s impossible, right? But if you’re wanting a second, a third, and fourth opinion from other people who know, myself being one of them, and there are many others who also know, please reach out. Please reach out to us on that list and we will help direct you to the best of the best. Now, the last point I wanna make about the foundation of endometriosis, know, accurate diagnosis and expert surgery. Beyond excision is that excision surgery is foundational, but it is not the only pillar and it is not going to be the cure-all, right? Now, could it be possible that you have a one and done? You have one surgery and then you’re done and you never have to have another one again? Totally, that is possible. That’s the goal. That’s why they train for so long and dedicate their entire practices only to endo. Now,

Dr. Liu’s podcast, if you want to go back, LIU, if you want to go back and hear her, she gives you the red flags for surgeons, what you should shop for and what you should absolutely ditch if you come across. And one of the things I’ll just pull out of that episode, that little nugget of wisdom is that if you go to an OBGYN and there’s still an OB, not just GYN, no, that’s a no. Okay, that’s not your surgeon. If you go to a GYN who’s no longer delivering babies, okay.

So they’re not delivering babies and they’re just a GYN and they say that they can handle it, but they’re doing ablation? No. If you go to a surgeon, a GYN, and they’ve done a MIGS fellowship and they haven’t trained with someone who is a legend, a forerunner ⁓ in excision surgery, I would also be highly wary of that. Yeah, that’s a no. And if you’re going to a GYN who says they can do excision, you know, has studied with someone or whatever and is not on the Nancy’s Nook List, again, look at it with skepticism. So moving on, past excision, all right? So you know what the gold standard is, you know a little bit about choosing your right surgeon, ⁓ you know how not to get gaslit, right? And that is to trust yourself. Your pain is real, your symptoms are real. And just because medicine hasn’t caught up with the female experience yet does not mean that your symptoms aren’t real. So trust yourself. So let’s talk a little bit about the pelvic floor and whole body physical therapy. Many people think physical therapy is just looking at orthopedics. It’s not, it’s not. And then if they understand orthopedic physical therapy, they think it’s only about ortho and not about the whole body. You’re just looking at joints, right? Or muscle length or good Lord, just like…strength and flexibility, right? Okay, no, it’s not about that either. Yes, it includes that, but it’s not just about that. I want you to start thinking of physical therapy as a primary care provider. You have a PCP that might be a nurse practitioner, right? Who has a master’s degree. I want you to think of PT as a primary care provider. We are doctorally prepared. Okay? So think of your PT as your primary care provider.

Now, how do you find a good one? Well, there isn’t a list of like, endo-expert PTs. You can do your Google searches. You can go on Academy of Pelvic Health for the American Physical Therapy Association and you will find a laundry list of people, many of them, I’m on that list as well, that will say they’re endo-experts, okay, that say, yes, this is what we specialize in. You want to gravitate towards those people. ⁓ Pelvic Guru has a find a therapist ⁓ finder and you can go to their website and also look up pelvic floor PTs and OTs who specialize in endometriosis. That, we’ll put those in the show notes, those links in the show notes as well. That’s the places you can start to find a qualified PT. So the role of pelvic PT is to do a whole body assessment. If you go to a pelvic PT and they’re only doing an internal pelvic exam, no, that’s a red flag. Either that’s all they learn to do and they’re not – they don’t have enough experience ⁓ or they’re absolutely ignoring everything else that needs to be addressed and they don’t really specialize ⁓ in the pelvic floor or endo really. So they’re gonna do ⁓ what you wanna look for is someone who’s going to do a full blown assessment and I’m gonna give you many, many categories in just a second. They will do things like manual therapy that could manual therapy includes dry needling and other modalities. ⁓ It also includes things like electrical stimulation because sometimes you cannot get muscles to fire on their own. And some of these muscles are deep and can only be reached with your hand internally or with quite a long needle internally. And you want someone well-trained in both and those modalities, okay, of manual therapies, you know, electrophysiological agents and stimulation, et cetera, and dry needling to be able to handle the complex cases of endometriosis. Okay. They’re gonna do things that you might think of that are obvious. Breathing work, scar immobilization, ⁓ movement retraining. Those are all things you might expect. But what are the pillars of care that I use as an endometriosis specialist? First of all, I wanna help women and I’m going to use functional, integrative and lifestyle medicine. I affectionately call it film for short.

So I use film to manage these pillars. These are critical pillars. None of them can be ignored. And you need someone who has postdoctoral training in all of these areas. First, estrogen, hormone management. This is not prescribing hormones or birth control, that kind of thing. And that’s what we think of. Oh, I can only go to an MD or a nurse practitioner or a DO who can prescribe hormones. That’s what she’s talking about. No.

We’re talking about mitigating estrogen at its source, how your body is actually processing, how it’s actually being metabolized by your system, which includes how it’s excreted through the bowel and bladder, which is very much in the scope of pelvic physical therapy. So the very first discussion we’re going to have is what’s going on with your estrogen levels? That also requires a discussion of progesterone levels and maybe even testosterone because if those are not in check as well, then anything that I do as a physical therapist is really not gonna matter. So that’s the first stop. If they’re not having a discussion about hormones and looking at labs for you, that’s a problem, okay? So make sure that they can do that. Second thing that they need to be looking at is inflammation mitigation and management. I just had someone, a lab just come back. We were measuring systemic inflammation.

I’d referred her for that lab and that lab came back and it was way too high. How effective do you think my role in orthopedic and pelvic health management is going to be if they’ve got unmitigated inflammation in their bloodstream and their body? It’s not gonna be effective at all. Their pain is going to persist. If they’ve got poor estrogen metabolism or an imbalance between estrogen progesterone⁓ or their testosterone is absolutely tanked because they were in birth control for a very long time, ⁓ their pain’s gonna persist. It’s gonna continue. So we’ve got estrogen and inflammation mitigation. You’ve got immunomodulation. What’s happening with your immune system? It is, one of the theories is that endometriosis can be fueled by a lack of proper immune system functioning or modulation. What does that mean?

It means if you get sick often, if you’re incredibly fatigued all the time, if no one has actually ever addressed that, then maybe there is an immune system issue going on and that is actually exacerbating or making the endometriosis worse.

Fun fact, if you didn’t know, one of the other reasons that we need to mitigate estrogen impact on the body, which can be both good and bad, is because endometriosis makes its own estrogen. And that’s a big ouch point. That’s another big mic drop. Endometriosis making its own estrogen means that if you’re not looking at the forms in which estrogen comes into your body is or is synthesized, aromatized by your body, then again, nothing that we do in physical therapy is going to matter. So we want to get immune system, optimally humming along, inflammation under control, estrogen metabolism under control, nervous system regulation. This is a huge one. So if I have a lab that comes back and says that a 24 hour cortisol panel and they’ve been feeling stressed and they’re not sleeping well and they get panic attacks, they may even be getting perimenopausal symptoms like hot flashes or night sweats and maybe they’re cycling, they’re still a young female and they’re cycling. Those are all red flags that point towards nervous system dysregulation, probably chronic activation of the HPA axis, the hypothalamic pituitary adrenal axis, and we need to get that under control. I use integrative medicine to do it. I also use lifestyle medicine to do that and sometimes functional medicine as well.

But the point is the nervous system is at the root of how we’re going to manage that pain and the frustration and the long-term stress. Next up on the path of intervention that I use is gut health. Gut health is a deep well and it is admittedly one, just like immune function, that we do not fully understand. So if someone tells you, ⁓ know, gut health is simple, just…take a fistful of supplements, these supplements every day and everything will be fine, then that is a gross oversimplification. It really does take a team effort here. That may be a combination of referral for labs. It could be a referral to a nutritionist, could mean a referral to an allergist as well, to be able to identify food triggers. Food can be healing, it can be medicine, but it can also create inflammation. And when…endo thrives on inflammation, what do we have to do? We have to pull back and get really linear and look, take a lean look at nutrition. What are you eating? What are you putting in your body every day?

So that’s just the tip of the iceberg for looking at gut health. But I have also helped patients successfully manage endometriosis pain and symptoms through doing these things, even before they go into surgery. Does it mean surgery doesn’t need to be done? No, not necessarily. Can some women kind of get away with not doing excision? Yes, totally. That is sometimes true. I think that I would have to credit my use of functional, integrative, and lifestyle medicine with being part of the delay in my diagnosis. Was that a good thing? Yeah, it was. I was able to maintain that ⁓ fertility. I was able to actually obtain and get to the point where I did have three kids, three awesome babies, ⁓ because of using that system of medicine, functional, integrative, and lifestyle medicine.

But eventually, those lesions are unrelenting and they do need to be removed, just like a cancer. It’s not cancer, but it acts like that. So once you do remove that, then yes, your functional integrative and lifestyle medicine and all these pillars of care, and take note, I haven’t even got to the pelvic therapy side of things yet, ⁓ those will help you stay out of the OR, okay, where you may not need another surgery because you are mitigating all of the things that would cause it to ⁓ be flared or exacerbated again.

We hope that all the endo is gotten by surgery, but we never know if there are cells left there that could grow again. So what do we do? We use film to try and tamp all that down so that even if the cells are there, maybe they don’t thrive. Maybe they don’t grow. Maybe they don’t cause you pain. Maybe they don’t obstruct a bowel, right? And then the last pillar is pelvic therapy. I’m going to say pelvic PT specifically. Yes, there are pelvic OTs. But I have said this in quite a few other interviews and podcasts. Pelvic OTs are awesome, fantastic. When you’re talking about endometriosis, however, there’s an extra element. You need to also be trained in orthopedics. I spent, well, I’ve spent my entire career, 30 years in orthopedics. And the first half of that was dedicated to only orthopedics. That was my bread and butter. That’s what I did all the time. Neck pain, jaw pain, shoulder pain, knee pain, whatever, hip pain, particularly back pain. And then I added pelvic health.

And I do think you need both. unless your prac, I say prac for short for practitioner, unless your prac has both PT , ortho and pelvic, then you’re probably going to end up with a pelvic PT when it comes to endometriosis. Now for other things, postpartum, et cetera, maybe, maybe not, you know, ⁓ but again, interview them, right? Most specialists ⁓ will give you that time if they truly specialize in endo. They will usually give you a free consult. Okay, 10 minute discussion, 15 minute, whatever. So look for people who will do that for you. And then finally you have this whole pelvic and ortho physical therapy component. So that gives us, let me go back through them again. We’ve got estrogen, inflammation, immune function, nervous system, gut health, and pelvic and orthopedic PT. That’s six pillars, okay.

And when you get down to pelvic PT, let me just be clear, okay? Pelvic PT is more than kegels, all right? When do I ever use kegels in an isolated way? I don’t even use that word. ⁓ I don’t. I don’t. I don’t use them in an isolated way. Why? Well, because do I just send someone to the gym to do bicep curls and then say, okay, your upper body’s fit? No, we don’t. That is entirely ineffective.

So if you go to an OBGYN and they say, you don’t need pelvic PT after you had a baby, just do Kegels. BS. No, there’s so much that we have to look at. And you shouldn’t be using those in isolation anyway. 

So pelvic PT should be about restoring function, nervous system regulation, quality of life. If you’re postpartum, can you lift that kid? If you’re post-op, you know, endo-excision, again, can you lift that kid? Carry the groceries in? Can you twist in that weird way to get that thing that you need to get or clean behind the toilet or whatever it is that you need to do or do your job? ⁓ Especially if you’re in a service field, you’re teaching, you’re a police officer, you’re a therapist like I am or in healthcare. Your jobs are demanding, lives are demanding and it takes quite a bit to be able to get back to that point. So that’s the whole point is to help you get back and fully recover to doing what you wanna do. So what should PT be doing? What should pelvic PT be doing? A complete orthopedic screening. I’m talking head to toe. Now I teach continuing education on what I call the three diaphragm approach or the voice to pelvic floor for short. Hence the vocal pelvic floor podcast. Why do I think that’s critically important? Because of the vagus nerve. That’s number one. The vagus nerve the fascial system connects these three diaphragms and neurologically in other ways as well. But it connects these three systems. And unless someone is evaluating your orophacial diaphragm, respiratory diaphragm and pelvic floor, as well as the extremities, they’re not getting a full picture for what you need. So they’re gonna do a complete orthopedic three diaphragm assessment of the vocal diaphragm and pelvic diaphragm – all three of those. They’re going to, I want to make sure that they assess the hip specifically too.

The reason is if you go back and you listen to the episode on hypermobility, ⁓ that was incredibly important because endo and hypermobility go together. Ehlers-Danlos syndrome, whether it is or isn’t that, or generalized hypermobility, ⁓ POTS, Postural Orthostatic Tachycardia Syndrome, endo and hypermobility of the system go together. This is not just talking about hypermobility of your joints.

This could be vascular hypermobility. It could be just connective tissue hypermobility. It does not have to be joint hypermobility. So if you go to someone and you’re like, feel my joint, like my SI joint or my hip might be coming out of place, they might literally laugh at you and say, oh, that’s impossible. It can’t come out of place. No, it can. It can sublux. It can slip around if you have those type of disorders.

Why is that important? Because they need to be measuring also for hip dysplasia, for joint hypermobility, tissue hypermobility, vascular hypermobility, which may mean you get dizzy, you get lightheaded. Your blood pressure or your heart rate do weird things when you try to go from lying down to standing up. If that’s happening to you and you have endo, there’s treatment for that. You don’t just have to live with that. Okay? They should look at fascial planes.

They should ask you to bring in functional movements. What can you do? What can you not do? What bothers you? If it’s picking up that car seat or trying to unload the bike off the back of your trailer, ⁓ what is it that you’re trying to do that you cannot do? I want to hear about those functional movements so that I can look at them and then I’m usually going to image them using ultrasound imaging in real time to see if the motor patterns are correct. And if they’re not, we will.

press the reset button, okay? We will retrain those and I will show you in real time what that looks like when the muscles aren’t firing correctly and together we’ll fix it. They should be doing, of course, an internal pelvic exam. That could be intravaginal, it could be interectal. Yes, that’s internal. That is a conversation that you have with your therapist. You know, talk to… ⁓ that person and make sure that you understand the parameters of what they’re evaluating. When I’m evaluating that stuff, ⁓ I give you a model to look at. And every muscle that I am on internally, I will say, here’s where I am. How does that feel? And I’ll talk about why that’s important in just a minute when we go to the whole pain discussion. 

I use ultrasound imaging as I ⁓ mentioned there. ⁓many, many practices are not going to have that. It is very expensive to have in practice. It also takes quite a few years to become proficient with that. It is relatively new technology that we have available to us in musculoskeletal imaging, especially in lumbopelvic imaging and physical therapy. So you want to look for someone who has that. If you don’t have someone who has that in your region,

I do take out of state, out of country cases on a regular basis because it is a specialty. ⁓ You got to really love it to really want to focus in on this. So if you need to be seen, we can work you in to see that. And then I can send you happily back to your therapist to continue on because some things are a little bit trickier to assess. They should also do lifestyle screening.

Lifestyle and screening should include nutrition, physical activity, stress management, endocrine and environmental disruptors. That means xenoestrogens are fake estrogens that are coming into your body. Either you’re eating them, you’re putting them on your skin with self-care products. I mean, y’all, I’m from the South, so I say that a lot. Y’all, just eliminating those xenoestrogen can…Xenoestrogens can make a huge difference in your endo journey and battle. So we talk about that. We talk about healthy relationships. Do you have supportive healthy relationships? I cannot tell you the number of stories that I know and experiences and some of my own experience where if you don’t have the right support or you’re worse, you’re in an abusive environment, it is going to get worse. It is going to make everything worse. Managing the gut microbiome, immunomodulation, your immune system, hormone regulation, cortisol, all of it is gonna be made so much harder. So we need to talk about resources. How are you going to tap the resources you need? Who needs to go with you to that surgery? Who needs to go with you to that appointment? I’m happy to meet with people and do consults to tell you exactly what questions you need to ask so that you don’t get gaslit.

And then we’re gonna talk about sleep science, okay, sleep hygiene. There’s some specifics for that and visceral mobilization. Visceral mobilization kind of goes into the scar piece of that, but I’ll talk about the whole pain side of that in just a second. So that’s what physical therapy should look like. Those are the pillars, okay? That’s in a nutshell what I do ⁓ in my personal practice, scope of practice as a physical therapist.

So how do I intervene? Like if I am assessing all these things, it’s a lot. It’s a lot to assess. And I hope that sheds some light on the depth of which your therapist should be your primary care provider when it comes to endo. So how do I treat? Well, we look at nutrition, we look at gut health, we reduce inflammation, we support good healthy hormone metabolism and levels. ⁓ We look at the microbiome connection. Sometimes the… ⁓ even the vulvovaginal microbiome and the estrobulum ⁓ or the estrogen and gut microbiome are intertwined. We have to look at that as well. ⁓ Mind-body practices. My first book was Medical Therapeutic Yoga. I wrote that almost a decade ago now and it’s still in print. ⁓

if you’re interested in it, but the point is I use a ton of yoga. That is what brought me into kind of the passion of looking at women’s and pelvic health in general is yoga as the container for it. So I use yoga, I’m trained in yoga, I’m trained in Pilates. ⁓ Can you find someone to help you do yoga and Pilates to help manage pain? Yes, there’s so many fantastic people that are doing that. It would be helpful if they focus on women’s health specifically.

But I also work with yoga teachers and Pilates teachers and instructors who understand the concepts. And I can just send them a note and say, hey, will you work with my patient on this? ⁓ Especially if they don’t have access to me all the time. We can’t do everything, right? I also use mindfulness, meditation, and breath work. Usually ⁓ with the breath work, I’ll do that under imaging in the clinic.

For lifestyle medicine, I kind of listed all the things that I will work on there, but we’ll do sleep intervention, stress reduction, movement that is usually mindful, usually yoga or Pilates based, sometimes dance based, and then kind of relational intervention and support. And then I frame this as building your resilient foundation for your long-term wellbeing. Cause y’all at the end of the day, it’s about longevity, right? You want to live to 90, like my goal, I’m going to be, I want to do headstands at 90, 95. There’s no reason why I can’t. I also teach them in medical therapeutic yoga to be non-weight bearing. So I’m not putting weight on my head. It’s all arm strength. So what are your goals? What do you want to do at 90? What do you want to do at 95? And that’s the goal is to help you reach that, to help you have high quality of life because too many women, although they live longer than men,

Too many women spend the last 15 years of living longer than men in really poor health, really poor health, but we don’t have to, that’s changing. That’s changing as there’s less medical gaslighting and less medical misogyny and more people listening to and believing women and trusting women. So let’s talk a little bit about pain science. Now, pain science is a deep well, but I wanna start off by saying this.

I’m not going to tell you that you’re just centrally sensitized and that you can meditate your way out of this. Okay, I’m not gonna tell you that. That’s BS. Now could, can meditation and mindfulness help you manage pain? If your brain got smudged a little and is perceiving pain a little bit further than the actual, away from the actual problem, yeah, it can. But with endometriosis, ⁓ I have seen so many patients with endometriosis, not one of them, not one of them was just this whole concept of just being centrally sensitized where, you’re just sensitive to pain and the pain’s not real. It’s just your brain perceiving pain because you’ve been in pain for so long, that’s all your brain can perceive anymore. Can that happen? Yeah, it can happen. Have I seen someone fully just centrally sensitized?

That means their brain can’t even correctly perceive pain anymore? No. Women know their bodies. And when they come in and they sit down and they say that hurts there, one thing that I have seen is that a woman comes in, has a seat and says, ⁓ I have back pain. It feels like it’s coming through my abdomen. Yeah, your body, your peripheral nervous system, your central nervous system.

has a hard time distinguishing back pain from visceral pain, that abdominal kind of gut pain. And so it can feel the same. And I think sometimes that gets mislabeled as central sensitization. And then they’re put in the go to pain management category. Or you just need to have a glass of wine and relax. Or you’re just hysterical, you just need to breathe, it’ll be fine, you’re not really in that much pain but because you can have both lesions and adhesions in that whole abdominal cavity area, and the endo can extend back towards the sacrum, into the sacral nerves, or the sacral plexus as we call it. It can go down your leg and feel like sciatica. I don’t want you to ignore any of those pain patterns, but what I do want you to do, if you are my patient, right, is to write them down. Write it down, do a body map.

Do a body map of when you’re on your cycle, when you’re not on your cycle. If you’re perimenopausal, menopausal. Of course that doesn’t apply. Still bring me your body map. When is the pain worse? Because we wanna be able to determine where is that back pain coming from? Is it truly visceral? If it is, that’s part of what visceral mobilization and manipulation looks like. We do a visceral assessment. We do a ⁓ gastrointestinal, urological. ⁓you know, assessment, we do the pelvic floor assessment to determine where is that coming from.

And once we can do that, then we divide it into categories even further. Because you can, your body can react with trauma posturing. This is why trauma informed care is so important. Your body can react. And when I say trauma posture, this is what I mean. If you’ve been through trauma, and if you have endo, you have, okay, having endo is traumatic, being medically gas lit over it, and getting a delayed diagnosis is traumatic.

Surgery is traumatic, recovery is traumatic, right? Imagine, you don’t have to imagine. Think of the last time you were in a lot of pain or you saw someone in pain or you’re watching a movie and someone’s really upset. What do they do? They curl into a fetal position. They might actually rock back and forth on the floor, right? Do you know that that is actually reorganizing for the vagus nerve?

If your voice is stressed, in pain, distressed, your pelvic floor is also going to feel it. Your whole body is going to feel it. It is going to feel like that curled up fetal position where your hip flexors get tight, your back starts aching and feels like it’s maybe overstretched or there’s like a fist in your back. The gut starts hurting. It feels like you’re not digesting things well. You might get endo belly and feel bloated. You might get headaches and or a facial pain. Your voice might change.

You might have a hard time finding your voice. You might have vocal fatigue. All of those things come from the trauma of having endo. All of those things come from the vagus nerve. The vagus nerve controls your voice. It innervates your vocal cords. It also controls sexual function. It can control whether or not birth proceeds or stalls.

It controls a lot of things. Most of the information out of the vagus nerve comes from the gut up. It’s why it also impacts your gut microbiome. It’s also in control of cardiac function. That’s why the vagus nerve in Latin means the wandering nerve. It’s the longest nerve in the body. It’s the one that I go for the most when I’m actually treating things in a trauma-informed, culturally sensitive way. Because I understand how much you’ve been through.

So that means when it comes to nervous system care, we need to look at somatic therapies. Yoga is a beautiful way of somatic experiencing the body of, yes, you might identify some traumas. It’s why mental health is on my speed dial, right, for patients who need ⁓ processing.

It could be through hypnosis, could be through EMDR, it could be through internal family systems, it could be through cognitive behavioral therapy or dialectical behavioral ⁓ therapy, it could be through acceptance and commitment therapy or ACT. there’s a lot of ways to process trauma. So don’t be afraid of the mental health arm of this. But somatic experiencing is something that I use. ⁓to help people work through the hopelessness, despair, the trauma of what they’ve experienced, the pain of what they’ve experienced. So you ask yourself, a typical way of doing that is to slow down your breathing and thinking.

Where do your emotions get stuck in your body? Where do you feel them?

And you may say, I don’t know, I haven’t thought about that. Well, feel it now. If you’re driving, pull over. If you’re walking, stop. Sit on a park bench or just walk slowly. If you’re at home, go lie down, go sit down. Where do you feel emotional stress physically in your body? For some women, it’s the pelvic floor. For some, it’s the respiratory diaphragm. For some, it is in their head, neck, and shoulders, the orophacial area. For some, it’s the low back. For some, it’s their calves, their feet.

Maybe gripping in their hands, they don’t realize it. Holding their shoulders up, they don’t realize it. Digestion goes sideways. I want you to identify that. And then what I would do from there is take you through a series of yoga poses of mindfulness, of meditation, breathing, that helps you unlock that.

So you let go of that trauma so that you can somatically feel it inside your body and then move your way through it. That can help you not only regulate your nervous system, it reduces pain intensity and that’s scientifically supported.

I also use ultrasound imaging to connect your brain, reconnect your brain to the actual sensations in your body. So I promise you I’d come back around to that whole pain science thing again. One of the ways that we change that experience, and I’ll give you an example, is I was imaging a patient once, well not once, 100 times if I’ve done it once, and she was talking about something stressful.

And I was imaging the bladder and the pelvic floor. And when she got to that same topic of conversation that was a known stressor for her, without her feeling it until it was delayed, she did feel it, but not right away, without her knowledge, her pelvic floor clenched. It clenched a lot, not just a flicker. It clenched as if she was doing a maximum voluntary contraction of 100%. It was unmistakable and my eyes got wide and I looked at her and in the midst of me saying, can you feel that? Of course she was saying no and then she changed her answer in the midst of me talking to her. She was like, whoa, whoa, whoa, wait a second. my gosh, there it is. That’s the pain, that’s the pain. Now she had initially described that pain as a bum rod. Like it’s going right up her spine, right up her spine. And that’s back pain, right? It’s back pain, it’s tailbone pain. You’re thinking, what’s going on with the back pain? It was actually pelvic floor. That can be true with a lot of things.

So if you’re not aware of that, you can be if I use imaging because she saw it on the screen, she felt it in her body, and then she could connect the two and now she knows. Now she knows when the pelvic floor starts to do something involuntary, she knows what to do to bring it back down again because we immediately shifted gears into mindfulness and somatic experiencing for what the pelvic floor was like doing, which was like betraying her.

So I want you to separate your experience from your body for a second. Don’t blame you. You’re not doing this. Okay, the pelvic floor can kind of do what it wants on its own. So can the bladder, so can the bowel, so can your abs. So stop blaming yourself for things going sideways. Your body has been fighting a disease for so long. Of course it’s going to be traumatized and start clenching up without your permission. And it’s not your fault.

So once you begin to separate that out and go, I just have to retrain my body for the experience it has, instead of saying, I’m doing something wrong, I’m terrible, I suck, I don’t know how to exercise, I don’t know how to move, I’m hurting myself, no, no, you’re not. Your body’s doing that.

So that’s the importance of trauma-informed care. That’s how you might look at your pain experience and go, okay, my body’s gotten a little bit off and it had a right to, it had a right to get a little bit anxious because it’s been fighting this disease that it cannot fight and cure on its own without surgery. And that will help you shift your mental health towards that positivity of addressing your depression and anxiety is something that was a result of the disease. It’s not a weakness.

to seek out collaborative care with mental health professionals, to know that it’s important that someone believes you and trusts your story. Really, that’s at the end of the day. That’s all I need to hear someone’s story to know if I need to refer them to an endo-excision surgeon.

because there’s no diagnostic test that’s definitive for it. There’s no lab test that’s definitive for it. Only looking inside the body during surgery and identifying them with your eye, those lesions, is the gold standard right now. Maybe that will change in the future and we hope so, but currently right now, it isn’t. So I want to encourage you to be an advocate. Ask questions.

Know those red flags for finding the right surgeon. Find allies in care. If they’re not actually doing all the things that I just listed in physical therapy care, it’s not enough. I want you to have high standards for your care and nothing but high standards and anything less is not what you deserve. I also want you to define success beyond pain scores because I will be the first to tell you, ⁓ as a person living, with endometriosis, hopefully it’s gone now, but we don’t know, right?

Your endo care is a marathon. It’s not some sprint. ⁓ I’m not defining and I don’t want you to define your success by your pain score, okay? Because you could have a flare, but maybe it was that inflammatory meal, right? You ate. But hopefully in working with your therapist, you’ll be able to identify and you’ll know what those food triggers are. Or the fluid, sometimes it’s a cup of coffee is all it takes for a flare.

And for some people, can drink a gallon of coffee and it’s fine. So there is no endo diet, okay? It is a unique case-by-case basis. So look at it as, you know, just a slow, not crazy hard marathon, just that’s life. We’re gonna manage this. You’re gonna build a team to help you manage it with you, together. It’s not a dash to some finish line. All right?

I hope that talking about this has helped. I want you to feel empowered. I don’t want you to feel afraid. I want you to ditch that fear. Can we fully ditch fear? For example, I have a colleague and a friend right now who I’m coaching her through her endo experience. And she’s self-doubting. Do I really have endo? My gosh, what if I put my family under all this financial stress and the logistical stress of getting me to the surgeon and then I don’t have it?

Yes, we’re going to have those fears, but trust yourself.

If you have all of those signs and symptoms of endo, yeah, you probably do. And if you talk to excision surgeons and therapists like myself, they have never had someone come out of that surgery and not have it, you know, right? You’re gonna have some kind of family history, even if it’s not endo, it will be, my mom got an early hysterectomy or so did my grandmother or an aunt did. And, you know, it may have not been diagnosed as endo, but you’re going to have that history. You’re going to…

⁓ have those signs and symptoms that you can trust your experience, right? So I don’t want you to feel that fear and distrust of yourself. I want you to feel empowered and I want to invite you to give me ⁓ your questions, okay? Now that I’ve shared my framework, in the next episode, I’m gonna dive into your specific questions about surgery, pelvic floor care, integrative medicine, and daily life with Endo.

Hopefully you’ll have listened to this episode before the Q &A. ⁓ So I’m gonna give you a little bit of time to do that, to let me know what your questions are and I will answer them live. You will record the questions. You can write them in, but I would really, really love it if you would read your questions live. There’s an easy way to do it. You just click the link and record your question and I will answer as many of those as I can live on our final closing episode of this endometriosis season on the vocal pelvic floor.