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General Session II - Types of Endometriosis Based on Multi-Organ Involvement

General Session II - Types of Endometriosis Based on Multi-Organ Involvement

Endometriosis 2023:
Global Patient Symposium
Together for Tomorrow
March 18-19, 2023 - Einhorn Auditorium, Lenox Hill Hospital, NYC

So I thank them for, uh, willing to basically start the conversation. They're gonna be speaking for you, so, um, without, you have to believe me. I know. Uh, cheesy Castro, Donna Jones and Adriana Penon. Okay. All right. So, um, one of you, she, why don't you start, I know Siji is from Florida, right? Okay. She will, she will tell her story in briefly how, when her symptoms started, what kind of ordeal she went through, I guess. Right. And overall, how did you, how are you feeling today? What, what was it that was challenging for you overall? All right.

Hi everyone. My name is CG Castro, and like Dr. Sein said, I'm from Florida. Um, I wrote a little speech. I wanna just start by saying it's an honor to be here today. Um, thank you, Dr. Sukin and Carolyn from Endo found for inviting me. So, here's my note. Dear fellow warriors, I wanna share my story about paddling endometriosis. For most of my life, it has been a long and painful journey with countless visits to doctors and hospitals, trying to find answers for my painful periods that were sometimes hemorrhagic and sometimes would just go on for months. Debilitating crams, vomiting, diarrhea, recurrent miscarriages, and infertility.

It all started with an I U d. I had one inserted in 2013, of which my body expelled. I had it inserted due to a period that just lingered for months. During the ultrasound to find the I u d, they found a mass in my left ovary, the chocolate cyst. I had never heard that word before. We scheduled the surgery to remove the mass on January 30th, 2014. And I'll never forget that day because that was the day I was diagnosed with stage four endometriosis. I was terrified, shocked, and downright ignorant. I had no idea what that meant for me, or, or that it was the answer to my years of suffering. And after being diagnosed with stage four endo, I underwent multiple surgeries that only provided temporary relief. Endometriosis is not just a painful condition. It also significantly my life caused pain and fertility and hemorrhagic periods, while also attacking other organs in my body, my colon, my rectum, appendix, bladder, ureters, abdomen. As a result, I experienced symptoms similar to irritable bowel syndrome, chronic constipation, painful urination, and these symptoms were so severe that they caused me to miss out on my life. In my children's lives, this disease impacted my whole family. I logged every single period in a tracker app for over a decade.

Excuse me. I would schedule activities around ovulation in the first three days of my period, knowing I would be completely bedridden those days. The pain was often so unbearable that I completely disa I was completely disabled and unable to walk. Endometriosis affects every aspect of our lives, from personal relationships to our professional careers. This past November, I was hospitalized. I was experiencing excruciating belly pain. It was severe cramping in my abdomen in lower back, and I was feeling like my belly was about to explode. It was so distended. I, um, my husband was away on business, so I called my mom. I was home alone with the kids, called my mom to come over. Then I called my husband to let him know what was going on, and then I called an ambulance. And when I reached the er, by the time I reached the er, my husband had reached the airport trying to find a ke catch a flight home.

I kept telling the hospital staff that I was a stage four endo patient, but no one would listen. I was admitted as a GI patient. This was the 11th of November. My husband, the love of my life, my hero arrived at the hospital by 8:00 AM the next morning. So on the 9th of November, I had a saline hyster rectum, and an endometrial biopsy after hemorrhaging on and off since October 5th. Um, during this 48 hour period, a little over 48 hour period since that procedure, I started hemorrhaging. During that time, I called my gynecologist's office multiple times to let them know that I was hemorrhaging. They told me to go to the ER once I was admitted, I kept calling them, um, letting them know I was admitted as gi I'm an endo patient. Can someone, a doctor on call come see me. Um, a week later, someone came and slipped me a sample of, or Alyssa, the hospital's solution was to give me morphine when the painful episodes appeared.

It had been a week since I had been there, and I missed my first born seventh, my seventh birthday. It was hard. I was there for pain management, nothing more. GI cleared me through endoscopy and a colonoscopy, and I was at a dead end. I was blinded by pain or drugged to sleep, no longer capable of advocating for myself, not that anyone was listening to me. Anyway, my husband was desperate for a solution. So Miguel took it upon himself to start calling endometriosis centers and doctors all over the country. And that is when we found Dr. Skd and Dr. Chu. In January, I underwent a massive excision surgery in a partial hysterectomy. My life has been unrecognizable and unbelievable to, unbelievable to me since I wake up every morning expecting to feel pain when my feet hit the ground. And I'm surprised that I don't. Instead,

Instead, I wake up feeling reinvigorated, almost kind of high on life. I'm pain free. I can do everything that I love. I play with my children. I can pick up my baby. It's just two. I can take long walks. I can travel to New York. I can practice yoga, garden, and cook. I feel like a completely different person than I have Dr. Sukin and Dr. Chu to thank for that. Their research and expertise at endometriosis has given me a piece of myself back that I never knew I had missed. I can finally say that I feel like a woman. I feel energized, confident, and even sexy in a way. I feel like I've been giving a new body, one that works. I know this journey can be lonely. But today I know. I want you to know that you're not alone. I'm your ally.

Thank you. Well, I, I didn't want her to cry. She's getting there. So please, please delete this section, the surgeon part. I, this is not about our practice. I really want to emphasize that the please understand the elements in her life. Stage four hospitals, not diagnosing IUDs, years, years, years. And in the end, getting radical treatment at the age of Duana. Dul your age.

39. I'm almost 39.

39. So typical in how many may I ask? I just want to have a feeling of the crowd. How many had similar experience his whatever, or multiple hospitalization. Oh my God, the whole crowd is going like that. How many had IUDs and not, did not do well with it? There's quite a few. IUDs are good when it works, but doesn't work all the time. Who wants to take next?

I guess I'll go cuz I think that, yes, I may not, uh, be able to hold myself together. <laugh>, I didn't expect to get emotional. I'm Dana Jones. I'll start with my story earlier than you started with yours at 12. Um, from my first period, it was debilitating pain. Um, those early years would be throwing up. Um, I'd have to come home from school. Um, in about the age of maybe 14, I think I went to the gynecologist with my mom and the only treatment at that point was getting on birth control and taking naproxen, which I would do days before. They would first tell me to take it as soon as you feel the pain. Then they said, well, no, it needs to be in your bloodstream longer, so take it even like a week before your period starts. I did all that similar to you.

Just excruciating pain, bloating, to almost the point my belly would look, you know, almost three months pregnant. Um, through my twenties. I was an avid volleyball player. I played volleyball in college and I remember I would see my, uh, sort of my game schedule and then like, look at the, oh no, I'm gonna have my period for this game or that game. And, um, just trying to live your life. Almost trying to become comfortable that you're just gonna be in chronic pain all the time. Around the age of, uh, I think I was 34 at the time, it was 2014. I actually was working here in the city. I live in Westchester. So I got up, commuted, took the train and subway. And I remember calling my mom and saying, I am so exhausted. I feel like I could literally sit down on the city street.

I'm like, I'm huffing and puffing. It was October. I said, I'm sweating. I'm like, maybe I'm getting the flu. Started to feel like a pain in between my shoulder blades. That was just getting more and more intense. Um, I commute all the way back to Westchester and luckily my internist could see me that day. I'm expecting the flu. She puts the pulse ox on my finger and that should be around like, you know, 98, a hundred minus like 92. So she says, let's just do an EKG and let's do a chest x-ray. So off I go to do that. And she rushes down from radiology, from her office to radiology that my right lung had collapsed. 40%. I had never heard of that. Um, happening. It's called a spontaneous pneumothorax or so I thought at the time, um, naively I think they're gonna maybe put something down my throat.

I have no idea that when I get to the emergency room, they're gonna tape me down to the bed. I'm taped like this, cutting through the side of my body while I'm awake to insert a chest tube. I've never felt pain like that. I've also had two knee surgeries from volleyball. I've never felt anything like that. Very traumatic experience. Um, unfortunately the ER doctor did not put it incorrectly. So by that evening, the chest tube had fallen out. Um, and, but through this adversity, I had met a wonderful, uh, thoracic surgeon, Dr. Sta Rolos, who I called Dr. Stav. And he said, look, hopefully this is just a fluke thing. It's just happened one time, like a sprained ankle and this is a blip on your radar and you can continue to live a wonderful life. Almost to a year later. 2015, I'm now 35 at that time, I'm like, oh no, I feel all the symptoms coming back.

The pain in my shoulder blades, shortness of breath. I text dr. Staff cuz we're on text basis now. And, um, my lung had collapsed again, this time it was down 50%. So I rush to the er and he does a procedure there called a pleis where they go in and make scar tissue inside of your body. And my right lung is glued into place from about 2015. At, at that time he says, you know, I do, I practice with Dr. Seskin. Um, have you ever been told you have endometriosis? And I said, no, I've never been told that I've had vaginal ultrasounds. I have had painful periods, I have had a lot of bleeding. I've been on birth control pretty much almost all my life, but I've never been diagnosed with that. Um, around that time I had just recently gotten married. We were trying to have a baby and it was not happening.

Um, I had done two rounds of ivf, they were not successful. Um, and in 2019, I actually came for the first time to see Dr. Seskin at my, uh, thoracic surgeon's, um, recommendation. Um, we did talk about surgery that day, but at the time my lung was not hurting. And the idea of having more chest tubes and the months it takes to really heal from a procedure, get your energy back and get back to work and all of that stuff, I just couldn't wrap my brain around it. I also had, my brother at the time had just been diagnosed with, um, a glioblastoma, which is brain cancer. So it just family-wise wasn't the time. I also, at that point since I desperately wanted to be a mom, couldn't even think about potentially maybe having to have a hysterectomy. Um, so I said to myself after that appointment, I remember I went out and I just cried.

I was so overwhelmed. I had had all this test, major surgeries and um, I said, I'm not gonna do it now, but if it happens again, I'm just gonna decide to do it. So I made it. Um, so at, I also was getting a divorce around 2019 as well. So I had made it another almost three years in December of last year, I was on a work trip in Dallas and the symptoms started coming back and I was like, oh no, I was boarding a flight home and I knew my lung was collapsed, but I wanted to get home. So I did that anyway, I flew home and ended up in the er and um, the ER doctor as well as Dr. Staff who I had been texting, said, you really need to go see Dr. Seskin. Essentially what had happened is the right, the upper part of my lung was working from where the pleis had glued in, but the collapse happened on the bottom and the, um, on the bottom and around the sides of my back.

Um, I was terrified. I think in every appointment I was crying with all the physicians that I had to meet because it's a multi, um, multi sur a lot of, so surgeons are present for the surgery. Um, and just the idea of having to have another procedure was very overwhelming. Um, I had surgery on January 9th, I'm sorry, January 6th, um, with Dr. Seskin and Dr. Chu and Dr. Alden as well. And um, essentially a lot of the pictures you could see when I came back from my follow up, it looked like spiderweb, essentially in my diaphragm. Um, there were a lot of holes and what was happening was air was just flowing through my chest, um, and causing that pressure to collapse my lung. Um, similar to you, even though I'm healing from surgery, I remember the first day waking up and trying to like stand and I thought, oh my god, my uterus is not hurting.

<laugh>. Um, I had lived with chronic pain for so long, um, at times only having maybe five days out of 30 that I didn't feel pain. I had pain in ovulation pain after my period. Um, and so that was an amazing feeling. And also from surgery, as soon as they closed the holes inside of my body, my lung just popped up. That's what the surgeon told my mom. The lung just went pop and came back up. So thank God I actually didn't have to get another chest tube. That was part of why I didn't wanna do surgery in 2019. So it was so grateful that I didn't have to get another chest tube. And since then I'm breathing normally. Um, I don't have any chronic pain that I always had. The bloating is significantly better, so I'm just also to you very grateful. Um, it's just unfortunate to have to have gone through so many procedures. Oftentimes doctors just writing it off. Oh, it's just painful periods. Lot of women have it, um, with no real options in terms of how to make this better. So thank you also for the opportunity.

Thank you. Well, this is a fascinating story because it really gives you a glimpse of thank God it is very, it is not, it's a very rare aspect of the disease. Not everybody, but, but we do have experience with this type of disease and it really keeps me going. It's so fascinating. Why would there be air in the lung when the lung itself doesn't let the air out? Where is that air coming from? Anybody knows how does the air get into her lung? Not from her on par? Yes ma'am.

Yes, I'm, I'm very interested cause I have this too, so I wanna know

Here, hold on. Speak. Yeah, go ahead.

Sorry. Yes, I wanna know the answer too because the same with her. I have this experience too. So whatever she's saying, it's like, it's my experience. So I wanna know why there is an air in the lung because of this cap. Is this what they call catamenial pneumothorax?

I have a hypothesis for that. Nobody knows how that air gets there, but, so during the period, well I have, I have pictures of his. During the period, your uterus contracts about 70, the pressure inside the uterus is 70 mill millimeter mercury. That's your diastolic pressure. So that pressure constantly is pushing the blood draw out. So that's how period start, because uterus contracts, right during that time, if the, when the flow starts, there is connection with the internal organs, which is the pressure in the perial cavity is minus one to the mi plus three. So there is a incredible pressure gradient is likely that the way the Aires escape, the, the blood escapes backward, the air also comes in. We can't document that, but there's, it is almost soluble air. You can really picture the lung. The pressure inside the inter cavita flora is minus seven to 10.

So that holds the lung always attached. So it's constantly in breathing mode. So delaying itself has a vacuum of pressure from minus seven minus one to three here and 70 pushing from here, most likely because we've seen quite, we, we've done more than 50 cases like earths and about five to six of them, you cannot see a hole. But there is small membrane there that kinds are almost transparent. So what my hypothesis though, that membrane breaks during the period and closes up. That's probably why the, the word hysteria, imagine a woman out of very rare, but this is being obviously public, sees these doctors every month going short of red, like, I'm gonna die. I cannot breathe, I'm gonna die. So this like two days, she goes through that and she becomes well, and then starts doing her job and the next month comes, of course she becomes in the eyes of the ignorant doctors or at those, those times they were mimed as, uh, this is how the hysteria maybe developed. You never know. This is my humble theory, but there is a common

Ground. I think it's such a good point because what I would do is because you don't wanna walk around your life always being paranoid. I would wait till my lung was hurting so bad that I would be like, so, so sure before I would go to the doctor because almost every other month I would feel a lot of the symptoms.

So, so one, one interesting story I wanna share. So we had a patient, she was a gymnast and she had come with this problem. She would, well, you know what she would, she would do cartwheels upside down and get the air back to her abdomen so she could feel better. And she would say she would stay like that six hours, seven hours head down and she would feel perfect. That's very interesting. Go ahead ma'am. So

If it's the, uh, pressure on the peritoneum that, uh, you said, um,

Thank you.

So you said it's the pressure on the plutonium. I'm not so sure about it. So is the, uh, hyper ventilation gonna help like hyperinflation of the lungs? Like, um, when the patient have this negative pressure? Um, hyperventilation,

I think hyperventilation is due to anxiety of your, the difficulty of breathing. It's kind of feeds itself. Um,

Because it, sorry, but I'm just so interested with this because, um, even after the surgery, uh, of removal of the endometriosis, um, why during your period it still keep coming back. Sometimes it's not every month, but it's still, it's still coming.

What is

Coming? Um, the, the symptoms of um, you know, it's like same with you when you have the, I don't know if it's catamenial neumothorax, you will feel like the pneumo TOXs coming back. Do you have ever

Experienced that? Well, well there is, there is always a scar tissue there that scar tissue attaches to your liver and other, you know, diaphragm, central tendon get attached. You feel pain and this pain really radiates to your back, neck and even to ear like that. Usually it's on the right side. So that's one. And also it takes a while for the air to be reabsorbed there. So it's never complete pneumo pneumothorax, it's always partial. It takes a week or so to resolve and then they return on the next month that comes back again, then it increases gradually. Yeah.

So you don't really have to have a surgery for that. Like,

Well, it's a, of course there's no other way of treating it in case if it's coming every month and gradually getting worse, obviously if it's documented, there's no other way that than surgery to, to correct it. The idea is having the right team right set up. I mean, I, as you see, the, the problem here is there are multiple hospitalization. Nobody knows what's going on. I mean the, the, the recurrence of endometriosis is not the issue. The incomplete surgeries, batch surgeries and doctors generally not knowing this disease. And that's our, that's why we are here for, and that's why you are voicing your, your, uh, yourself and putting yourself to teach others here. Right? So I think we have to move on with your situation. So we cannot ignore you. <laugh>, tell me where you are coming from and if you want, uh, my name is

Hello. Okay. Um, my name is Adrian Pinon. I'm coming from New Jersey. Um, I first got my period at a young age around 10 years old. Um, I always had cramps by the age 13. 13. I, you know, experienced a lot of, um, I was diagnosed with dysmenorrhea, so I had diarrhea, vomiting, um, which is never fun for a 13 year old girl in high school. Um, so I missed probably like weeks and weeks of school. I was always out in bed, um, just missing everything that all my friends and my sisters were doing. Eventually I went to a gynecologist with my mom. I was prescribed birth control and basically on birth control for most of my life. All through, up until within the last year or two, um, I decided to come off, uh, on my own. Um, just thinking, you know, my doctor told me I'm getting closer to the age of 35.

I'm getting a higher risk for stroke and you know, if you can think about fertility, like now's a good time to start coming off of it, which I did. Um, and within probably a year I started getting really sick again. My cramps had come back, but this time, um, it was worse I guess because I forgot what it was like before. But, um, I started getting admitted to the ER on a monthly basis. Every month I just end up in the er, um, on my period. Uh, I eventually I asked them, I was like, is this related to my period? I think it might be? And they're like, no, it just looks like you have some infection. Um, we're gonna give you some antibiotics and everything and kind of just send you on your way. Uh, they did do a CAT scan. I found a growth on my, um, colon ccu and they said you should go see a colon doctor and get that checked.

So I went to a colon doctor. Um, she seemed unimpressed by the scan <laugh>. They, she didn't seem to be concerned. She just said, you can get a colonoscopy if you feel like it or not, it's up to you. So it was kind of just very dismissed from the very beginning. Um, ended up getting the colonoscopy. They found a polyp in there, still didn't do anything and just set me home again. I was in the ER again. The same thing kept showing up in my scans and they're like, this could be cancer. You need to see a doctor. So finally I went to another colorectal surgeon, had another colonoscopy within three months of the first one, um, where he removed the polyp. He said he didn't see anything unusual and that I should be fine. Um, what bothered me about these, all these experiences that I had a green folder of every medical instance I was going to.

And I was coming with these scans of this is what showed on the CAT scan. This is what was shown during my colonoscopy. And none of them even bothered to open it or to look at it. They were just like, Nope, I think I know what this is. I'm gonna treat it. Uh, er again, they found the growth again. I went back to him and I said, I'm very concerned. What can we do? And he said, well, let's just do one more colonoscopy. So third colonoscopy in probably six months or so, he just said, I found nothing. Everything looks fine and good. You're good to go. Um, <laugh>. So at that point I was um, just very frustrated. My mom started coming with me to doctor's appointments. We went to see a GI doctor. Um, I was experiencing at the time, I didn't know it, but it was endo belly after my period and I just had extreme tenderness.

No one could touch my stomach. Um, and I just was like, I don't know what this is. It is after my period. So I was thinking maybe this is something else. And she was more focused on actually my colon and my colonoscopies and I'm like, I don't need to. I've gotten all clear like, I need you to focus on my stomach. Um, we did tests for ibs, for everything. Everything came up negative. Um, eventually, I think it was Christmas Eve two years ago, I was in the ER again with severe side abdominal pain. They said my appendix looked inflamed. Possible you can get them removed if you wanted to. You know, my mom was like, I think you need to see a specialist. She found Dr. SK and his team. We went to, you know, we set up our appointment, we went and we looked and just the validation of like, yes, it's there.

Like it's visible even just like on the scan right there, like you have so much. It just explained everything that I was going through in that moment, you know, like the just random burst of nausea, the vomiting, the constipation, um, and uh, to the point where he is like, you need to see a colorectal surgeon as well. And it had basically just, um, embedded into part of my rectum and onto my colon and bowel. And so I had to have surgery to get part of my bowel removed. I had to get my colon, my appendix, like all of that partially removed as well with in terms of like everything else with the endometriosis and the next month or two, I just noticed a whole change in my life. Um, I'm still working on the bathroom part for the vow. People like that will always take some time, but at least it doesn't hurt to go to the bathroom anymore. Um, I have just more energy. I just feel like I have a part of my life back that I lost even from an early age of 12 years old that I missed out on.

Thank you. Thank you. I know the time is obviously moving fast, but, you know, thank you very much. Very heartful testimonials here. Again, uh, as much as so difficult for the patient, it's very difficult for surgical team to deal with these cases. These are extremely difficult cases. Takes I, I'm not sure, but how long did your surgery take? It was the last nine hours. Nine hours. Six. Six four. So any, anything at this stage takes long. But I, I wanna hear some reflections from the crowd. Uh, this there, there's a bowel case, there's, in every case there is delay. Again, the same scenario. Yes ma'am.

Thank you. Can everyone hear me? Yes. Um, I know you said it's not about the surgeons, but I wanna thank you and Dr. Goldstein. Um, I've suffered from Catamenial, pneumothoraxes. I've had seven collapses and a bilateral pneumothorax. And I came to you guys with stage four endo and my life is so much better since, um, having been with you guys and having the surgery with you in 2021. Um, although I had a hysterectomy, you told me that it was the best thing and it would be the thing to save my life and it definitely did. So I thank you guys so much.

But for, for teaching purposes again, you had harmony, many, uh, how many endoscopies? Colonoscopies? We had three. I have a lady here who had 40 of them, probably 30 to 40. She's sitting right back. I know who she is. So even after menopause, these symptoms can sus be sustained and the diagnosis could be after 40 years, after 40 endoscopies. And even in the hands of best doctors, it's about the physicians and we have to train them and it's our response. It's the public responsible to put emphasis on this disease. That's why you are here for any other comments or, or any further up? Yes ma'am.

Hi, I'm Madeline. I, um, just wanna reiterate what Dr. Seskin says. I, I had, um, I was told I had IBS for 40 years and when I was 63, I, I read about Dr. Seskin and he said that I, even though I was almost 20 years past menopause, I had, um, 28 lesions. And, um, it explained and I, I went to all the best doctors in New York. I was fortunate to be able to do that, but nobody ever mentioned that it could be, you know, that, that it was on the bowel or they just thought I had this IBS issue and blew me off. And so I just wanna say never, it's never too late. I thought I was as old as patient. I don't know that I, that I am, but it's, it's never too late to, to keep, keep pushing for yourself, um, because you're just your own best a advocate. And I have him to thank for so many things.

So you were diagnosed how many years you were in? You can,

I was diagnosed at 63.

Thank you. That's a great interesting story. So there's a lot of women at the age group. Doesn't, doesn't, uh, they're not aware and they cannot do good e r t, either estrogen replacement because they're afraid to take their pain may resume. So certain there are so many things, everybody's so unique. So everybody's endometriosis is their endometriosis. Our job is, you know, in the end you don't treat, you treat the disease, but eventually you're treating the patient. Don't forget that, that's the way my, I like to think every patient that comes to us is our only patient, but realistically that's not the case. But at that time it should be an, that's why surgery is easier part for me. Even though it's 6, 7, 8 hours, the difficult thing is to to care. You lose contact with the patient and it's impossible. So that's why the structure should be different.

I'm hoping one day I dream that's gonna happen. The the setup, that's why it should be institutionalized. It can't be depending on one person or one group. That's so good. It's not about, again, I'm emphasized, it's not about me. These patients are generous. It's mentioning my name, but I am irrelevant. I'm gone tomorrow. You know. But this has to be learned and stay with the, with the culture. The way we treat our patients and the patients has to be fair too to doctors in a way that, you know, she had complication. Can I say that? She had pulmon, they called me at the middle. She didn't go get to that stage. I all, I didn't sleep that night, you know, and

I had a blood clot.

She has a blood clot too. <laugh>. So, I mean, you are in surgery 10 hours. It's not, it's not a game. So there is, these surgeries are highly 10%, one out of 10, there is complication. Every organ you touch there, it has inherent complication rate. So we put our neck for it and the system doesn't forgive us, actually. I mean we have our, you know, insurances, this, that, but that's not about it. But it's, you know, we also lose a lot from ourself as physicians if there's no, you know, there's physician burnout to, so I'm still around guys. Okay. There is a red flag swinging over there. That means we have one minute. Any other comments? Last comments? Don't be shy. Somebody has to make one comment. Okay. I guess you're gonna make it later. I'll, okay.

Caregiver's perspective, and I'm Dana's mom, um, to have seen her struggle since 12, do all the physical checkups, the gynecological checkups, do all the things that are recommended as a young woman is developing. Nobody until we met you said this is the answer. So I would say it's been hard for me to see her struggle and have five days out of 30 or 31 that she felt healthy. Um, to see her go through that whole IVF process and all the testing. Nobody ever said anything. And so it is when we walked into your office, met you and Dr. Chu, Leah and Holly, and your wonderful staff that life turned around for her. But for somebody who loves and cares about her, um, and to all the caregivers out there, you just have to be a really fierce advocate. And this is something that everybody that treats women ought to know about. It shouldn't be that you find out 30 years later after having suffered chronic pain. So thank you to you and your team.

Thank you. Well, I think this is gonna be the end of this, this presentation. I hope there was some energy transfer from here. Thank you very much, uh, for the speakers, thank you for the testimony.