The Hidden Link Between Your Gut Issues and Endometriosis | Dr. Jill Ingenito

Jill Ingenito: [00:00:00] The biggest thing is when you have pain with bowel movements, especially around your cycle, that is a huge thing in endometriosis. And so I think any pain that you notice is worse with bowel movements around your cycle. That can be bowel endometriosis. The medical management of endometriosis requires an insane amount of creativity.

You can't always out outsmart your endometriosis if it's there. 

Dr. Brighten: I've heard this phrase so many times from women going to the gynecologist is preparing for war. You need to get your shield. You need to be ready to battle because they're gonna gaslight you, they're gonna dismiss you, they're gonna try to force you on a medication you don't want.

Jill Ingenito: I think there's a significant lack of training for chronic pelvic pain and endometriosis. They just don't know the doctor not being knowledgeable and they get kind of defensive if they're like, I dunno what's going on. You're supposed to get better on the pill. And I think it's just like a lack of education on our part.

Narrator: Dr. Jill and Genito is on a mission to change how we treat and talk about pelvic pain. A Denver-based specialist in endometriosis and chronic pelvic pain. She blends evidence-based medicine with fierce patient advocacy 

Narrator 2: using her platform at Dr. Pelvic [00:01:00] Pain due to empower women with knowledge, compassion, and real solutions.

Dr. Brighten: When we think of misinformation, the problem is not the rise of influencers. It's not the reach of influencers, it's not influencers at all. It is doctors who have neglected women who have created this gap and who have forced patients to go outside of the medical community to look for advice 

Jill Ingenito: most. So what I've learned is from Instagram and watching my own podcasts, I started treating more PMDD.

I think I saw some real about treating PMDD more with the hormone replacement therapy type meds. And I have seen such drastic results as opposed to doing things like putting people on the birth control pill. But that ain't gonna be enough if somebody has. 

Dr. Brighten: Welcome to the Dr. Brighten Show, where we burn the BS in women's health to the ground.

I'm your host, Dr. Jolene Brighten, and if you've ever been dismissed, told your symptoms are normal or just in your head or been told just to deal with it, this show is for you. And if while listening to this, you decide you like this kind of content, I invite you [00:02:00] to head over to dr Brighten.com where you'll find free guides, twice weekly podcast releases, and a ton of resources to support you on your journey.

Let's dive in. So many women, if not all women have heard that painful periods are completely normal. How can someone differentiate between what normal period cramps are and what is something like endometriosis? Sure. 

Jill Ingenito: I think one of the most important things is starting with just your basic over the counter ibuprofen or nonsteroidal anti-inflammatory, and if that really doesn't cut it in terms of helping with your cramps or your pain, then that's a red flag that something could be.

Off. Mm-hmm. And that for me is a red flag for endometriosis. The other thing is that if you're having more than really bad cramps, you're having pain outside of your menstrual cycles, that's also a big red flag. Mm-hmm. Certainly if there's any family that has endometriosis and you're kind [00:03:00] of seeing the history repeat itself, I would say more than likely it's endometriosis.

Dr. Brighten: When you say pain outside of the period. Mm-hmm. What are we talking about specifically? Because the pelvis has a lot going on. There's more than a uterus there, and so sometimes people are like, oh, is it IBS and do I just have gas 

Jill Ingenito: cramps? I would say anything that you think doesn't seem right is probably worth talking to your doctor about.

Um, pain with ovulation, that's a big one too that I think. A lot of people dismiss as just a normal part of cycling, but pain with ovulation is another big one. Um, and any consistent like patterns that you can find, different times of the month with bowel movements, urinating, that kind of thing. I think those are all kind of red flags for me.

Dr. Brighten: What I'm hearing from you is that you should listen to your body mm-hmm. And trust your intuition. 

Jill Ingenito: Mm-hmm. That's a big one. 

Dr. Brighten: So you brought up the bowel movements. Mm-hmm. What about bowel movements points towards 

Jill Ingenito: endometriosis? The biggest thing is when you [00:04:00] have pain with bowel movements, especially around your cycle, that is a huge, huge, huge thing in endometriosis.

And so I think any pain that you notice is worse with bowel movements around your cycle that can be. Bowel endometriosis. 

Dr. Brighten: Okay. What's bowel endometriosis for people who are like, I haven't heard this before. 

Jill Ingenito: Endometriosis that grows onto the bowel. So small intestine, large intestine. Usually seen in more advanced disease stage three or four endometriosis where those lesions have implanted.

Mm-hmm. Throughout the bowel. 

Dr. Brighten: I, there was just someone I got a comment from, uh, this week and she had said to me. I look back now and I realize that before I even got my period, mm-hmm. All of my digestive issues were linked to endometriosis. And she said it wasn't just bowel, but I had upset stomach. I was being diagnosed at nine years old of them saying like, oh, we think that you have reflux.

Like, and she said, after I had my excision surgery, which was decades later, all of the digestive symptoms resolved. What's 

Jill Ingenito: going on there? [00:05:00] So I think that speaks to the prostaglandins and just the effects that it has on your gut. Mm-hmm. Um, and so that inflammatory process can cause all of those things that you just mentioned.

I just had a similar patient who had like. Decades of nausea only to find out that after excision her pain, or sorry, her nausea went away. So, uh, I think a lot of it is a bit retrospective and everyone's a little bit different. I think we'll know in the future as, as more people come out with these stories and as we get some more studies out there, that potentially there's a lot more that we can see even before the onset of periods.

Dr. Brighten: Mm-hmm. 

Jill Ingenito: So I think, um, that's not usually the most common thing, but I definitely have seen people who have unrelenting nausea that can't release. Get that to go away until they have surgery. 

Dr. Brighten: Yeah. When this person commented into me, it raised my eyebrows because I had chronic mm-hmm. Gastrointestinal symptoms.

Mm-hmm. Like starting very young. Mm-hmm. And I was later found to have h pylori. They were like, oh, that's, that's the cause of everything. But even after that, they were like, oh, you're just gonna stay on proton pump inhibitors for the [00:06:00] rest of your life. Like, this is just the way it is. And I look back at all of that and I'm like, oh, little flares from the body that it possibly could have been connected.

Mm-hmm. You said prostaglandins, not everyone knows what that term is. Can you explain what prostaglandins are and why they're involved with this pain, this nausea, and these 

Jill Ingenito: bowel problems? Yeah. So prostaglandins are an inflammatory substance that can cause things not to work properly, is basically what it is.

And those prostaglandins are released in endometriosis and that kind of sets off this inflammatory cascade that causes other parts of your body not to work properly. 

Dr. Brighten: The prostaglandins. They're not always all bad. So we know prostaglandins are important for women being able to deliver a baby. They're important.

They're part of how we shed the uterine lining once a month, but they can go wrong in endometriosis. So what's going on there? Are you saying the lesions themselves are making prostaglandins? 

Jill Ingenito: So yes, some of the lesions will make some prostaglandins and those can be at just higher levels than you would normally see with your normal processes like labor and delivery [00:07:00] and having your period endometrial lining shedding.

So I think that there's just a higher level of. Prostaglandins that cause a lot of inflammatory problems. 

Dr. Brighten: Yeah, I can, I just like highlight what you just said there because women with endometriosis will say, I'm having cramps and pain. That's like being in labor. Mm-hmm. And doctors will say to them, no, you're being dramatic.

But if you have lesions, which could be anywhere in the body making prostaglandins, which are causing these contractions in labor, it's totally conceivable. Would you agree that? Agree, you could have period cramps that are comparable to being 

Jill Ingenito: in labor? Agree. That is, um, the time that I, the couple times that I experienced labeler, I would say, if that's what you're experiencing.

Yes. It's definitely a prostaglandin process. 

Dr. Brighten: Do you have endometriosis yourself? I 

Jill Ingenito: do not have endometriosis myself. I get that question a lot. I do not, uh, I think I've just learned a lot about it over the last 15 years for my patients. So I get that question. People think I have it too. 

Dr. Brighten: No, I just [00:08:00] was curious because, um, the, so I have had two unmedicated births and I remember the, the pain as a teenager, but also the pain after my third egg retrieval.

And I was like, oh my God. Like I want, I didn't, but I kind of could have taken an epidural during labor, but like the endometriosis pain, I'm like, sign me up for an epidural. Like, that's like how intense it was. So that's why I was just curious 'cause you're like, I've been in labor a couple of times.

Jill Ingenito: Mm-hmm. Yes. That is that It's an intense one. 

Dr. Brighten: Yeah. 

Jill Ingenito: Intense pain. So. 

Dr. Brighten: With these lesions, there's this idea that has been perpetuated for a long time, that it's just the endometrial lining that has been spread via retrograde menstruation. What do you wish people actually understood in terms of the current research of what it tells us about endometriosis?

Jill Ingenito: Uh, I think that the biggest things, we see it a lot of times from birth. Those lesions are present and we don't really know why. And you're born with them. [00:09:00] Uh, I think there's also a lot of research now coming out, um, about retrograde menstruation that I think that was probably just the way they understood it however long ago.

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Uh, the best that they could. And I don't know what we're gonna know in the future about it, but I think that was the best way they could conceptualize like how this was, and then that theory just kept going and going. But the newer research Yeah. Shows that it might be present in female fetuses or male fetuses in rare circumstances, and that those lesions develop as you go through.

Puberty and start to develop. 

Dr. Brighten: Yeah. Yeah. And you see the, the retrograde menstruation was also born out of the idea that it's just the endometrial lining. Mm-hmm. But these lesions are distinct from what our uterus is doing month after month. They've kind of got their own agenda. Can you explain why these lesions are different?

Jill Ingenito: Yes. So these lesions respond differently to. Things like prostaglandin, estrogen, progesterone respond differently to hormones. A lot of times if we use [00:10:00] medications to treat endometriosis, we don't always, we can treat the endometrial lining, but we don't always get the same response from the endometriosis lesions.

Um, they just have a different way of behaving than the endometriosis or the endometrium in the uterus. And so that's really where I see. The struggle is a lot of times we're using medications and we're using those medications. We're expecting the same response that the endometrium would have. And at endometriosis we're just not getting those results.

We can't quite get those lesions to respond like we would. 

Dr. Brighten: When you say medications, what medications are you talking? Different 

Jill Ingenito: hormonal medications, different anti-inflammatories, really anything that you can do to treat endometriosis. I feel like you're, like any drug, it's all bets are off. I mean it, we use like the endometrium.

Okay, this works on the endometrium, this works for this process that's based on the endometrial lining in hopes that'll help us with the endometriosis type lesions. But I just don't find that it's always as successful. I think medications work a lot better once you've had an excision, uh, as opposed to beforehand 'cause they're just not responding.

Dr. Brighten: Mm-hmm. So. [00:11:00] Is this why so many gynecologists believe that the birth control pill is like a gold standard treatment for endometriosis? 'cause they're like endometrium. It works on that. Therefore it would work on a lesion. Even though we see so many patients report that it's not enough. There's certainly some people get some relief from it, but by far the majority of women that I've spoken with, that I've seen as patients that I, you know, even myself, are like, no, it's, it's not actually addressing what's going on for me.

Jill Ingenito: So in, in training, in medical school, school and residency, I would say there's a significant lack of focus on endometriosis. I mean, I think probably less than 5% of my training was focused on endometriosis. Um, there's just so much that you have to get through. I don't think in four years, at least in the United States, that we have enough time to actually focus on.

Endometriosis and chronic pelvic pain. Everything that I learned that I do now, I learned after my residency and I kind of had to unlearn [00:12:00] what I learned. Mm-hmm. Right. So the basic things that I learned were ablation and the birth control pill, and there really wasn't time, or there wasn't anybody focusing on that in the training.

So I think there's just such a wide variety of. Information and procedures and safety and just things that we have to take in in those four years. And a lot of it does have to become repetitive, right? Like doing deliveries. Like you need to be able to do those in the middle of the night and you need to be able to back to back and still function and keep people safe and healthy.

That, I think endometriosis is just not a priority in training. It's just not. So I don't, even if someone has gotten that far a gynecologist to say, this isn't working because the endometrium doesn't work like endometriosis lesions, that would be novel thinking, but that is not an idea that's presented.

Dr. Brighten: Yeah. 

Jill Ingenito: Um, but yeah. 

Dr. Brighten: I know it's, it cracks me up when I get attacked by gynecologists online. When I'm talking about doing imaging, I'm talking about anything that is accepted by endometriosis surgeons, [00:13:00] people who actually specialize in it. And these gynecologists come with such ego about how they know so much more.

And I'm like, and I see how the, for me, I'm like, okay, I get where you're coming from and I can understand this. And I think because I, I am a medical professional, but I see when these interactions help how happen with patients and how angry patients get. But also how so many more patients who have endometriosis know this condition, the disease and the research better than their gynecologist for sure.

But they're absolutely dismissed and gaslit about it. Yeah. 

Jill Ingenito: That's a huge problem. The training and the education does not exist. Mm-hmm. I think I can remember like. All of the laparoscopies that we did for endometriosis, either just looking or bleeding. Never. I don't think I did an entire excision the entire time I was a resident.

Oh 

Dr. Brighten: my 

Jill Ingenito: gosh. Um, I've been out for about 15 years, but still, I mean, these are your, like middle aged gynecologists, like serving the [00:14:00] population. Mm-hmm. Um, and I think again, it was just pretty much birth control pills and then use 'em continuously to see if that helps. Yeah. So I don't think many people take the time to learn about endometriosis on their own, um, let alone chronic pelvic pain.

I think. Um, and that's because the education's just lacking. The, really has to come from the gynecologist wanting to know more about it, wanting to help their patients, which is kind of what happened in my situation was like, what is going on with these, these women? And like, how are we gonna help them get better?

We can't just keep doing the same things that we've been doing, so. Yep, you're right. That's exactly where we stand is the patients often know more and are more educated. But I think if we get more education and more of a focus on endometriosis, at least for a part of the training, I mean even like couple months with a chronic pain specialist would be helpful.

Dr. Brighten: Yeah. I also think, and I, and I believe this to be true, and other people I've had on the podcast say the same thing, is that there's too [00:15:00] much of an expectation on gynecologists for what their scope is like. It's just far too much to expect that you are an expert in pregnancy, in delivery. Mm-hmm. In managing someone postpartum.

And then you also have to be an expert in chronic pelvic pain in hormone therapy management. I mean, we know they gynecologists are also not competent in hormone therapy management. They are good at birth control pills, which they, I always laugh 'cause when they're like, no, we're hormone experts. And I'm like.

Knowing the pill is not, it's helpful, but it's not a hormone expert. And I think it, it's hurting women. Mm-hmm. And I think that this is not an individual doctor problem. This is at a bigger, at the root of it is that medicine is like, meh. It's a woman, just toss it all in this bucket. Mm-hmm. And there really should be subspecialties beyond just general ob gyn.

What do you think? 

Jill Ingenito: I agree, and I think most of us find that as we start to work with [00:16:00] women, like in the process of their career, as you start to work with women, you kind of see like, okay. I feel like I connect with this. I feel like I'm interested in this. I feel like I can help this person here. But yeah, I mean, it's all, and it's, it's, it's like you're drinking out of a fire hose when you like a resident, like it's insanity.

Um, and you're working, you know, ridiculous hours. Like you can barely take it in. And we're also like, we're learning oncology. Mm-hmm. So this just such a broad field. And I've always thought that like, obstetrics should be a different residency than gynecology. And it shouldn't even be the same. But let alone like the things that you see in gynecology, I mean, there is no real good training on hormone replacement therapy.

Most of what I've learned is from Instagram and watching my own podcasts and like TikTok, I mean, honestly, like I started treating like more PMDD, I think I saw some reel about treating PMDD more with the hormone replacement therapy type meds. Mm-hmm. And I have seen such, such drastic results as opposed to doing things like.

Just [00:17:00] putting people on the birth control pill. I mean, so it's just a little bit of trial and error and it's a little bit learning about it. Um, and for me that kind of came from just having all these patients that, you know, have had endometriosis, how all these surgeries are in surgical menopause, um, and learning more about hormone replacement therapy.

Dr. Brighten: I appreciate your refreshing honesty. It, it truly is refreshing because I think sometimes as doctors like there's this like fake it till you make it right. Kind of mantra where it's like I have to always front as I'm the expert, but until we actually say like, these are deficits in my training, we can't.

Fix those things or start to improve our own education. I mean, I was, so, my education, we did, I've been prescribing, uh, hormone therapy for over a dozen years now. Um, and I'm so grateful because in my rotations my, um, attending was in perimenopause. So she's like, you better learn this. You better know this.

Um, and we were actually taught all of that. And I learning only in the [00:18:00] last few years that gynecologists weren't taught about hormones at all. Really. It made so much sense of how often I got a gynecologist being like, you are gonna give her cancer and kill her if you give her hormone therapy. And I'm like, in the case of PMDD, she may take her own life if we don't come in with interventions.

Like there is always a risk and benefit conversation. And while you are scared, 'cause the Women's Health Initiative definitely scared everybody. Like there's nuance. To this conversation, I wanna talk more about like guiding patients through like how to find a provider. But in this conversation, something I'm curious about is what inspired you?

What made you go down this road of chronic pelvic 

Jill Ingenito: pain and endometriosis? Sure. I'm grateful. Like to work in an organization that's a large group and um, we had one chronic pain specialist for this very large group, this very large population of patients. And in that I found myself like sending a lot of patients to her, which is what happens to me now.

But there are a ton of gynecologists who just are not interested in this [00:19:00] or don't know what to do beyond getting an ultrasound and starting somebody on the pill. And so for me, I was referring someone to this specialist who had six, nine month wait lists. Oh wow. Yeah. Right. And then I was kind of found in this pickle.

I was in this middle of it where I have like six to nine months to try to help somebody. So, um. And I just felt like there was really a huge gap. Uh, and I felt like this was a population that could really use some help. So that's kind of, I just was like, I, these people need help. Um, I think a lot of people can do a lot of basic things in OB GN, but I was like, I, I think that I really could make a difference here mm-hmm.

In helping others and managing chronic pain. So it was something that was interesting. It combined both medical and kind of surgical, um, therapies. And so I just took an interest in it and started going to the conferences and learning from her. Mm-hmm. And. That was it. 

Dr. Brighten: Yeah. 

Jill Ingenito: So I just, I felt like there was just such a significant need.

Dr. Brighten: Mm-hmm. It 

Jill Ingenito: was also nice for me because I was, to be honest, learning something new about five years after I [00:20:00] finished my residency. So it kind of felt like learning something new. Yeah. And I saw people getting better, and so I just felt like, why are these people waiting six to nine months, you know? 

Dr. Brighten: Yeah.

And I really appreciate it. As somebody in the endometriosis community, I appreciate you seeing the needs stepping up. Um, especially, you know, six to nine months there's gonna be women listening to this. I know women in Canada are waiting like two years, like there's a global issue in endometriosis and people not getting relevant care.

And it is something that I had somebody reach out from the Netherlands and they're like, can you come and speak here and talk to doctors about this because they think just the pill or do ablation and like, we're not getting the care we need. So with that said, what's the first step someone should take if they suspect endometriosis?

Like first thing, someone's listening to this, they're like, oh, this pain's not normal, this bleeding's not normal. Like this is not normal. What should I do? Good question. I think. 

Jill Ingenito: Keeping a diary, obviously, of those symptoms and going in with a diary, especially if you've got three to six [00:21:00] months of data to bring forth, it's hard for me to say what the next best step.

'cause I would say go see a doctor. But I think I'm really cautious because if you see the wrong person and you end up getting dismissed or somebody who doesn't know what they're talking about, then it all, you internalize all of it. Mm-hmm. And then it becomes this big thing mentally where you're like, I'm fine.

This is, this is normal. They said it's fine. So it's just hard because I feel like that first touch, maybe even then, you're brave enough to get a second opinion, especially if you're really young, maybe you don't even know to advocate for a second opinion. Yeah. So, I mean, I feel like you've got to find someone who has an interest in endometriosis, but how you find that person, I, it's, it's challenging.

Um, I think if you have a family member that can advocate for you, I think that's really important to bring them to that doctor's appointment. And then persistence. Like I really think [00:22:00] that if you feel like you have endometriosis and you're getting an answer from a doctor that doesn't sound right or just sounds like they don't know what they're talking about, I would just say, is there anybody else you could send me to?

Um, but it's hard because I feel like a lot of these first touches are kind of when things can go really downhill. 

Dr. Brighten: Yeah. 

Jill Ingenito: You know, and then they see the doctor. The doctor has a limited amount of time. They order an ultrasound, recommend the pill, and you've never talk to them again. Mm-hmm. So it's tough. I feel like, you know, it's a lot that way with a lot of medical conditions.

You can't just walk into anyone's office. Yeah. You've gotta have done your research, which is a lot of work. It's so much work. 

Dr. Brighten: Yeah. Especially when you are in pain. Yeah. And this is something that I think about all the time because you know, you've probably had your own experiences. I talk so often to female colleagues.

We get gaslit. Being a doctor doesn't protect you from getting gaslit. No. We get bad information, we know we've gotta get second opinions, we're navigating more stuff [00:23:00] and we're losing time. Mm-hmm. We're losing time with our family time feeling well, time just living our life time. Bringing our talents into the world.

And it is so challenging because I often think if I didn't know what I knew, where would I end up? And I have so many female colleagues that are just like, how does the average patient do this? When we know what we go through? But we have the knowledge to know that someone's wrong. Mm-hmm. I dunno, 

Jill Ingenito: I, I really dunno.

I sincerely struggle with this in my own personal life. Um. Especially advocating for like my children and what they need. And I know I hear it all the time. I get thousands of dms like, this doctor said this. And I, I honestly don't know. Like I think one of the best things you can do is bring an advocate with you.

'cause sometimes that person can kind of rephrase what you've said and be, you know, a lot of times I've had significant others stand up and be like, this is like ruining her life. Yeah. Like she can't work. She's missing school, she's never gonna get into college. Like I [00:24:00] think when they kind of stand up and make those statements, it's really like, I'm like, okay, I like, I believe you.

Yeah. And I think people come in very defensive talking, you know, and I'm like, well, no, when you're here, like, my first thing is I need you to basically talk me out of endometriosis. 'cause a lot of what I'm seeing is chronic pain and a lot of it is endo. So I'm kind of listening to your story thinking you need to tell a story that doesn't tell me it's endometriosis.

And so a lot of people come in with like, these advocates and, and so I'm like, I, I'm safe. I believe you. 

Dr. Brighten: Yeah. But it is something that, um, I think a lot of doctors, so they won't say this on camera, but they don't wanna work with women who have chronic pain because they say they're mean, they're reactive.

They're mean to my front desk staff. And the thing that I'm always like, you have to stand back and you have to think about this isn't your average patient that you just go into this visit with. There has to be a setup ahead of time of like, we know. That this has ha been a struggle for you. We understand that you've been with providers who are not going to listen.

This is how we're gonna do things different so that you're [00:25:00] held and you're supported and that you are in partnership with us. And it's that, you know, I I, I am in a position where I teach doctors at medical conferences. And so when I teach people this, I mean, I get messages from doctors who are like, oh my God, like 180 on my patients.

I'm like, yeah, you have to like set up the expectation mm-hmm. For the person sometimes is even on your schedule so that they understand otherwise, you know, I've heard this phrase so many times from women just in general is going to, the gynecologist is preparing for war. You need to get your shield, you need to be ready to battle because they're gonna gaslight you, they're gonna dismiss you.

They're gonna give, they're gonna try to force you on a medication you don't want. And this is how women as a whole start to feel. So, especially when you're a chronic pelvic pain patient who've seen 10 doctors who've done that to you, that expectation is kind of there. And I think. You know, for patients who are listening, I'm always, I always want people to know that like, you've gotta give a doctor another chance.

Like, don't judge them before you get there. But also, not [00:26:00] everything should fall on the patient's shoulders. Right. To speak the doctor's language, to make sure you're holding the doctor's ego in mind so that they don't get upset with you. Like, it's a lot for one patient. 

Jill Ingenito: It is quite a bit, I feel for, that's why I try to come in with just, I try to come in with a very, very limited ego listening and kind of helping you where you're at.

And one of the things that I always ask people is like, what's the one thing you need to leave? Mm-hmm. That my office today with, you know? And sometimes they say strange things. I'm like, okay, we can accomplish that. And other times I can't accomplish their goal. I'm like, I'm be completely honest. That's not a, we're not gonna able to accomplish that goal here.

And to be honest, most of 'em have very realistic goals. And it's like, can you tell me if you think this is endometriosis? Yeah. What would you do next? 

Dr. Brighten: How much do you think medical trauma is contributing to mental health issues among women with endometriosis and maybe even perpetuating pain? Uh, 

Jill Ingenito: I think a decent amount because if you have constantly like going in with a shield like you explained, uh, that's hard.

I [00:27:00] mean, I feel that like anxiety sometimes when I have to go in and advocate for my child. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: It's just a lot and it's a lot of stress. And so if there's just someone there to meet you, like to take all that off, like, I believe you, I think this is endo. Like, you don't need to, like, this isn't, you know, not in a court case.

I believe you. Yeah. But I think that leads to a lot of anxiety, which is where I say like, every single touch that you have can just bring more and more anxiety to the table. And the more more doctors you see that dismiss you, I think. It's just, it's just an A cycle. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: I do think it lends to a lot of mental health issues for patients with chronic, chronic pain, and I think those chronic pain already disposes you to anxiety and depression and those things.

Self-doubt. 

Dr. Brighten: Yeah. Yeah, I had a guest on a link to his episode, Justin Janka, and he works with, um, a lot of women who have autoimmune conditions and he talks about how medical trauma is so difficult. It, it's such an, uh, an obstacle for people to be able to [00:28:00] actually fully heal because they're, they have to partner with these doctors, but they are in a abusive relationship sometimes with their practitioner in the way that they're being treated.

And so they can't really heal because of resources, because of insurance, because of all of these things. Because every time they have to meet with that provider, they need, they're like bringing up more trauma, more injury, more wounds. 

Jill Ingenito: Mm-hmm. Yeah. I think at least in the US health system, I think it's a bit broken.

I think the doctors are also really limited, like for a lot of us are really limited on time. Some people have the grace of two hours for their consult, but a lot of us are really limited on time and I think that that. Is at the detriment of the patient, especially when you have a chronic condition.

Dr. Brighten: Mm-hmm. 

Jill Ingenito: So 

Dr. Brighten: why do you feel that endometriosis is notoriously so hard to diagnose? And it is not just patients struggling to get diagnosed, but providers believing that like this, like this is some [00:29:00] rare condition. So why is it so hard to get the diagnosis? 

Jill Ingenito: I think it comes back to the training that we get.

I think there's a significant lack of training for chronic pelvic pain and endometriosis and they just don't know. So I think the doctor not being knowledgeable or whoever you see, not being knowledgeable and they're coming, they get kind of defensive if they're like, I don't, I don't know what, I dunno what's going on.

Like, you're supposed to get better on the pill and your ultrasound was normal. I think it's just like a lack of education on our part. Um, most OBGYNs. Have to unlearn what they learned in med school and residency to know how to properly take care of these women. So I think this all goes back to like a lack of education in this space, in medical training.

And at the, at the same time, I think we also lack really good non-invasive tests to be able to say this is endometriosis. I mean, it's one of those conditions where to make the diagnosis, you pretty much have to have confirmatory surgery. So we don't have a good tool, [00:30:00] there's no good tools and there's a lot of people who do not know about endometriosis.

Mm-hmm. I think in the future what would would be great is just some dedicated training for those wanting to do chronic pelvic pain and endometriosis. And then also, you know, just having a good test that's not so invasive. 

Dr. Brighten: I wanna talk about imaging because people will say, my transvaginal ultrasound was clear.

My MRI was clear. And then, you know, they operated and there was stage four endo. This was my experience. I had a um, I had an MRI, so I had a pre novo, MRI, which is full body MRI. They, so full disclosure, they were like, we'll comp you the MRI if you post this online. So got it done. They're like, huh? We see what looks like the end miosis.

We also see what looks like endometriosis, but we are not diagnostic. We cannot do that. You need a follow up? Yeah. I go get a follow up MRI, well, first I go see a doctor who tells me, um, this is why you should take your advocate, everybody. 'cause in the room, he was telling me that a [00:31:00] mosis is just a new trendy diagnosis.

It doesn't have any bearing on fertility. There's nothing that can be done about endometriosis. My husband was in the room with me and he's like, I listen to you talk about gaslighting all the time. I just didn't think I would ever witness it. And he's like, and then you didn't say anything back. I was like, oh.

'cause we already broke up. Like he didn't know I was, we, we were divorced. Papers were served like it was already over the second he started that, there was no point in me wasting energy. 'cause I was like, see you never again. So I get an MRI and the radiologist is like, there's nothing there. It's totally clear.

I get the MR MRI and I'm like, no, but like I can see the Aden Myosis in my own uterus and I don't read MRIs for a living. Sure. I'm like, read it again. He gets mad at me. He tells my primary care doctor that I'm just seeking attention basically, and like, you know, just trying to look for something that's not even there.

I was like, oh, really? Let me serve this MRI up to a radiologist who actually reads zendo and lo and behold, get a whole ENION score. They're like, yep, there's, it is everywhere. So I tell this story [00:32:00] because. Who reads your studies mm-hmm. Matters. Anyone can do a transvaginal ultrasound. Not anybody can see endometriosis on a transvaginal ultrasound.

So talk to us about the utility of imaging and then we're gonna get deeper in like helping people navigate this. Sure. 

Jill Ingenito: So I always tell people the basic role for imaging is just to tell me who I need to invite to your party at your endometriosis surgery. Mm-hmm. Okay. And it can be, I think in the future, imaging can be used vastly different.

Right? As we get better people to read them and better people doing the ultrasounds to look for endometriosis on an ultrasound. But for the vast majority of pelvic ultrasounds that get done, I tell you, well if it's, if I tell you it's normal, I always write in there, that does not mean you'd not have endometriosis.

Mm-hmm. It just means probably you don't have an endometrioma. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Based on our imaging that we're doing. So I'm saying we're looking for endometriosis. But we're probably not gonna find it on the ultrasound if I see an endometrium that already upstage you to stage [00:33:00] three, stage four. I also say with the MRI, so I see this a lot and it is a hundred percent what comes down to who reads it, the radiologist or yourself.

And again, another, another gap Gynecologists are not radiologists. Like, we're not trained to read our ultrasound. You have to seek that education outside of your already crazy, busy life. So that can sometimes be a challenge. Um, again, another thing MRI, if they don't see anything in your MR mri, doesn't mean you don't have endometriosis.

It just means maybe the colorectal surgeon does not need to be invited to your party. The urologist does not need to be invited to your party. I can probably go in and start. See what I can handle on my own. Um, certainly, always, always wanna have the availability of those other surgeons at your tip, but I don't need to plan in advance.

Okay. So and so needs to be available on this day for colorectal surgery. So and so needs to be available on this day for urology. So it's really for me where I work, it's like I just need to know who needs to come to your party. The other thing I can tell people is I can see basically an endometrioma and adenomyosis.

Those are two other things that can be really, really big [00:34:00] keys and a lot of times they won't come right out and say it, but there's several signs for adenomyosis. So that also helps I think patients to um, understand that basically we're looking for these very specific things and it's used for surgical planning.

Dr. Brighten: Mm-hmm. For people listening, adenomyosis and adenomyosis, they're the same condition we're talking about in Mexico. Everyone calls it adenomyosis. Aosis also in Canada. Um, and I was saying adenomyosis forever. There was a big debate I got into with people and they convinced me to say adeno. But I want people who were listening just to know it's the same term even though we said it a little bit differently.

Um, so why does it matter that we know who needs to be at the surgery first? 

Jill Ingenito: That's 

Dr. Brighten: important so 

Jill Ingenito: that the initial surgery that you have can be as complete as possible. So we want that first surgery in an ideal world to be a complete excision, which sometimes mean that our skills might be limited in [00:35:00] what we can do.

And you know what you can do. And so you might need a colorectal surgeon to be able to help you take down some adhesions from the colon or take down endometriosis from the surface. Um. You might need a urologist to place stents, you might need to help have them dissect out the ureter. It depends on your skill sets and what you know.

Mm-hmm. 

Dr. Brighten: But 

Jill Ingenito: again, you know, if you're looking at cutting out part of a ureter, you're gonna want a urologist be able to sew that back together so it can grow in all these tricky places. And always the first rule is first do no harm. So that's kind of my guiding principle. But we wanna try to get a complete wide excision on your first go.

Dr. Brighten: And what happens if those people are not there? So let's say you go to someone, general gynecologist who's like, oh, I can excise endo. They get in there, they're like, oh my God, it's all over your bowel. It's all over your bladder. Um, maybe it's like all over your diaphragm like it we're finding in all these places.

What are they gonna typically do 

Jill Ingenito: that is variable? That is very, any number of things could be done in that scenario. Nothing could be done. Which I also don't [00:36:00] think, like, again, we don't have a good non-invasive test available worldwide, so mm-hmm. If someone goes in and says, you have really bad endometriosis, that's still like an X-ray or an M mri, that's still a really good piece of information for you to leave and then be able to find someone, Hey, here's my pictures.

Can you help me get this disaster sorted out? 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Um, so I still think that's a good way to at least know. Uh, I think the one thing that really I would hope was not done as ablation, but it is, it is still done. The thing with that is if we're ablating these lesions is, is just bearing them and it makes them harder to cut out.

That's probably the hardest thing is for gynecologists to understand that when you do burn it, just pick a few places to burn, then we go to cut it out. That inflammatory process has. Push those lesions deeper into the tissue, which makes it harder for them to get out and you're at higher risk for complications.

Mm-hmm. So you may end up with all these areas that are difficult to excise because of what was done. 

Dr. Brighten: Yeah. 

Jill Ingenito: [00:37:00] Um, and then what was the second part of your question? Sorry. 

Dr. Brighten: So just asking, like let's say you, let's say you've got Endo, you've got bowel nodules, you need a colorectal specialist there, but they're not there 'cause your doctor didn't plan ahead, they didn't do the imaging.

They didn't even know, 'cause there's a lot who don't even know that you could do imaging. What are they typically gonna do to sew you back up and tell you, 

Jill Ingenito: let's do this again? So in those situations that I've been in that situation myself early on in my career where there isn't always a colorectal surgeon involved.

Yeah. Or the colorectal surgeon comes in and said, this is gonna be major for her. This is gonna be. Probably a colostomy, probably temporary. Mm-hmm. But then I think that's someone that, something that somebody needs to know in advance. So if you have an excision, and yes, there's bowel nodules, I think the most important thing to do is take a lot of really closeup pictures.

Same thing with the diaphragm. Sometimes I don't have a colorectal or co cardiothoracic surgeon available. Okay. But I've taken an insane amount of photos. I know who to send you to. This person can talk to you about your procedure, so, mm-hmm. I do think that yes, it's ideal to have everybody and you know [00:38:00] exactly what's gonna happen and you have the perfect excision, but that's just not life.

Like, it's just not, it's not the reality. I think you excise what you can take a lot of good photos and then you have those people at your disposal. Yes. You may need to have a bowel surgery. Yes. You may need to see a cardiothoracic surgeon. Yeah. So getting them, um, in touch. But I also think that's not the worst thing because do you really wanna have this huge bowel surgery that you had no idea about and then have some big complication, like you wanna know?

Mm-hmm. You wanna be prepared for something. So I think that's the reality for a lot of people who are doing endometriosis excisions, is they might see stuff that's outside of their scope. The surgeon may not have access to the specialist they need that day, but you don't want them doing. Something crazy that they're not trained to do or having, you know, it's just a disaster for complications.

Dr. Brighten: Do you feel like imaging though, can make you better prepared and reduce the risk of maybe needing additional surgeries because you have the possibility of being able to see more, visualize more, and prepare the patient? 

Jill Ingenito: Yes. I think sometimes the preoperative MRI can definitely help with [00:39:00] that and that's really where I use it quite a lot.

Mm-hmm. But, um. It's wrong. Sometimes it's just wrong. Yeah. And so you have to be prepared for that situation where it's wrong. 

Dr. Brighten: Well, and that's the other thing for people to know, is that there's also the quality of the MRI machine, right. In the facility that you are at. And if you're rural and you're, and it's old hospital, like we, we don't really know, like if you're gonna get a quality image, um, then there's some people who will do gel MRIs and some who will not.

I opted for a repeat gel, MRI, because I did have lesions on my bowels and I was like. Fill me up and let's make sure, because if I have to like have a resection of my colon, like I need to know that I need to mentally prepare for that and I need to have all the information possible going in. And thankfully it was just, we have to shave it off your bowels, which was horrific to recover from.

So let me just say that like, just because they shaved off your bowels doesn't mean that it's a a, a cakewalk, but it's certainly easier [00:40:00] than a resection. And when you consider, you know, women have jobs, they have families, they have obligations like you, this is a lot to mentally prepare for. 

Jill Ingenito: Yes, it is a lot to men to prepare for, which is why, you know, if you get into a situation where you don't think you can handle it and you know what the patients are planning to take, you know, from a standard excision, maybe a week off of work.

So for you to do something crazy like, you know, shave off the bowel when she's not prepared for that, then it might mean another surgery. But you want the right people. Mm-hmm. Doing your excision. You don't want someone just, okay, well I'm in here and I can take this off. You really want. Somebody who's qualified.

Dr. Brighten: Yeah. 

Jill Ingenito: So, 

Dr. Brighten: yeah. And that was part of my selective, my team is that I asked the question, and I think it's a important question to ask, is like, what happens if this is outside the pelvis? If this is a, you know, invasive in another organ, like what do we do? And their answer was, we bring in the best specialists.

We try to predict that ahead of time and bring in the best specialists to make sure they handle it. [00:41:00] And, um, for people listening, you're always looking for that level of humility that I can't do everything. Mm-hmm. Here's what I'm really good at. But when it comes to the line, I, I find, I find the person who can do it better.

Jill Ingenito: Right. Having that humility to know what your limits are is huge. And it's okay to be like, this is outside of my scope, but I again, coming back to first do no harm. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Right. The patient now has the information and for the vast majority of patients that I see who ask that question, I'm like, I don't see anything that suggests we need a colorectal surgeon there.

If there's a small lesion, yes, the colorectal surgeon can probably take that off from a surface level, but if it's gonna involve resection, I want you to have a full on conversation with them. And again, most patients are fine with that because they've been trying to get the diagnosis for 10 years.

Mm-hmm. So it's like if they can at least find and get some relief and they can decide down the road, okay, yeah, I wanna have these bowel lesions resected, then they can have a discussion and they can know what they're up against. 

Dr. Brighten: Yeah. Yeah. 

Jill Ingenito: As opposed to like their first endometriosis surgery being.[00:42:00] 

Something they didn't plan for the recovery. Yeah. 

Dr. Brighten: I talked with, um, a neuropathologist, an endometriosis, uh, excision specialist, Dr. Celo. Um, and I will link to that episode and he said, you know, because we can't always see what is going on in there. I try to go basically worst case scenario mm-hmm. With things of like, okay, let's say the endometrioma is this size.

Like at that point, do I have your permission to make a clinical call? Yes. Remove the ovary. How often is that kind of conversation happening? You think? I mean obviously it's happening with you, but you know, how often are patients getting that kind of informed consent? 

Jill Ingenito: Uh, I don't, I don't think that they are getting that informed consent at the times.

Um, for my patients, I do kind of walk them through worst case scenario mode. Mm-hmm. And kind of see where they stand. And some people will say, I don't want you to take my ovary. Okay. I'll just take out all again and we'll swap back together. And there might be the tiniest piece of OV overlap. The ovaries are crazy, so it might be [00:43:00] able to regrow and do its own thing.

But I leave it up to you because you know it's your body. You should have your own autonomy. Um, I think that if you don't do a lot of endometriosis, you don't know what worst case scenario is, so then you can't counsel your patients on this is the worst case scenario, train. How do you wanna get off of it?

If I get into this situation, and I do find it's different for everybody, you know, especially that comes into a situation with like the fallopian tubes. Like, okay, your fallopian tube is, I. It's not functioning, it's not working. Would you want your fallopian tube removed? 'cause you're gonna have one then.

So everyone's a little bit different. Some people will. I just think you need to walk down that conversation with a patient. I just don't, that's not happening a lot for people who don't do a lot of endometriosis, unfortunately. 

Dr. Brighten: Well, that brings up a really good point because you brought up ablation earlier.

There are people who call themselves endometrioma. Experts, and yet they're still practicing ablation. How did, and I actually, when I asked my audience for questions about endometriosis, what are your questions? There [00:44:00] were still so many people asking like, when should be abl ablation be considered? My doctor's recommending ablation.

And I'm like, why is ablation still a conversation like this shouldn't be a conversation? So there are people who, they think they're endometriosis experts, but they're offering ablation. They're not doing excision surgery, they don't do any imaging. Um, they don't even do this informed consent. How can somebody wade through that?

Like what are like some of the boxes to check? Like you were someone, you weren't taught endometriosis, you went and learned it on your own. What were the, the hoops that you feel like you went through that checked the boxes for you to be like, I, I now feel confident in, in my approach? Sure. 

Jill Ingenito: One basic question you can always ask, do you do ablation or do excision?

Um, and if you're finding a, a mixed re, if you're finding an uncomfortable response to that question, then you're probably in the wrong place. Okay. Um, that's probably the, the one box that you can check. I think for me, the boxes that I had to check to [00:45:00] kind of get to that point, were watching excisions, learning the excisions from the best in the country, watching a lot of videos, um, hearing them speak, hearing them talk, and also understanding like, you know, the big world that chronic pelvic pain is, it's a huge bucket of all kinds of things.

And you have to understand a lot of how our system inter interplays and so how different organ systems are affected by this. Um, but you have to be interested. It has to come from the inside. I think that if you, and I don't know how to standardize the. Experts. I don't know. I don't know how that will fix that problem.

I think it, we face that in a lot of different areas of medicine. Like you're an A DH ADHD expert. Well, really are you? Um, it's so true. Well, you have like, it, it's not just endometriosis. That's where sometimes I feel like we get kind of down these rabbit holes. I'm like, it's like this in all areas of medicine.

Mm-hmm. Like you have to, now someone's, I would never claim even myself to be an expert like [00:46:00] I do endometriosis. Here's how I do it. Like I'm not saying I'm an expert, like, but here's how I do it. 

Dr. Brighten: I'm gonna call you an expert. Because when we put the average GYN and we put you next to them, your knowledge base experience and tech technical surgical skills are far above that.

And I think that's what it takes to be an expert and. That you, when people are like, yes, I'm an expert and I'm continually learning, that's a real expert. Yeah. That is somebody who's like, okay, like I know what I know, but I also know there's a whole lot we don't even know, and that is someone that I'm like, look for that person.

Yeah. Especially if you bring them studies and they're like, I love this. I didn't know about this. I wanna learn about this. Oh, that's a good doctor right there. 

Jill Ingenito: Yeah. Just that level of vulnerability and just humanity. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: I think there definitely just are people who train and they have this ego and I don't know.

I don't know if you're, I don't know if you'll ever be able to like tease that out of the people. You just have to, [00:47:00] and I think that also comes from like being a patient yourself too, is understanding like who's in front of you, being the patient. Might not know everything, but if you can at least tease that out, like, okay, this person's admitting they don't know what the heck they're talking about and they can get me to the next person.

Mm-hmm. Yeah. So, um, we need more doctors like that who are just like, this is where I, where I have to say like, I don't know, and here's what I would do. 

Dr. Brighten: What do you think in gynecology, like breeds that that ego and makes it, it makes it where we don't have doctors who are more vulnerable, more humble about that?

'cause I have my theories, but I would like to hear yours. I 

Jill Ingenito: mean, residency, you're pushed to the limits in so many different ways and you have to prove yourself. I mean, I think there's a lot of just, you gotta prove you're the best and then if you can prove you're the best, you're the best. Um, it's not always like a [00:48:00] happy, you know, growth mindset type of environment.

It's very like. It can be very cutthroat, to be honest. I just don't think that that was ever emphasized. I don't even think I ever saw a doctor in my training be like, admit to a patient they didn't know what they were doing. Mm-hmm. Or admit that they may not have the knowledge. I think we're all kind of coming out, especially as young doctors, we, we, we not sure if we believe in ourself, we're not sure if we can do it, and then we just like put on this facade like, oh, I can do this.

Like I can. Yeah. So I think. There's just not an acknowledgement of the vulnerability that goes into working with humans. 

Dr. Brighten: Yeah, so I, I agree with that piece and I think that because it's women's health and women's medicine is kind of always seen as the lesser that within medicine as a whole, right?

There's like, I am like the orthopedic surgeon and you are just a gynecologist who couldn't make it into a surgery surgical [00:49:00] residency. So that's why you're a gynecologist. And I think that also because the field is predominantly women, there is. Medical misogyny, which translates to patients and to providers.

And I think there's a lot of women who are like, I have to put on the strong front. I have to be like, I have to fight for my place. And that is something that I think, again, it's not about the individual. It's so easy as patients to like get mad and hate the person in front of you, which is the doctor and not actually understand what has gone into creating that person.

And we've got a whole upstream issue. We've got Egg Hog who could care less about endometriosis. They're like, why care about endometriosis? We can make IVF like doctors so profitable. You don't have to say that. I will say that. Um, because I would love ACOG to prove me wrong. Um, I'm really challenging them because it's what I ultimately want is them to care about endometriosis.

But we see like the [00:50:00] way that you just set residency and so much of this paradigm is it works against the provider. 

Jill Ingenito: Yeah. 

Dr. Brighten: And it's the patient who ultimately gets hooked. 

Jill Ingenito: Oh yeah. That's a hundred percent what it is 

Dr. Brighten: I wanna talk about, we're gonna go more into surgery 'cause my audience has tons of surgical questions.

Okay. However, there are people who can't yet afford surgery. They can't get surgery, maybe they don't need surgery. Who should they be thinking about having as part of their care team? Right? Because the surgeon is always one part. So I don't do surgery when I work with someone who's endometriosis. I'm like, we gotta find you a good surgeon whether you need them or not.

Right now we don't know. But we want them there already when we need them. Not like, oh God, we have to scramble and find someone 'cause we needed them yesterday. So surgeon definitely a core part of the team and we want to get their professional opinion. Who else should be on the team? 

Jill Ingenito: Hmm, good question.

So, uh, the way that. I think there's a few handful of [00:51:00] clinics are set up is that it's a chronic pelvic pain clinic. And so for me, I am managing all facets of chronic pelvic pain. It could be interstitial sitis, it could be pelvic floor muscle dysfunction, it could be a vascular disorder. So, um, and whether, and I'm also a surgeon, but I don't think there's a lot of people out there that.

Manage chronic pelvic pain and do endometriosis surgery. Mm-hmm. So I do feel like if you can find somebody who does all chronic pelvic pain and also does endometriosis surgery, that would be great. But if you can't, you want somebody who's does a lot of chronic pelvic pain that can do non-surgical management of pain.

Then you have your endometriosis surgeon for sure. A pelvic floor physical therapist. Um, and then I also would argue somebody, uh, who has an interest in urological conditions, colorectal and vascular disorders. But this is like a dream team. I mean, these are just not the realities [00:52:00] that you have. Yeah. But if you have somebody, you know, if you're in a small town or you're in an area that doesn't really have access to surgeons, then you just want somebody who has a good understanding of all the different things that can cause chronic pelvic pain and can hopefully try to get you to those subspecialists.

But I think that's one of. Bigger issues. And I've been approached on this. It's like, why don't you just start a chronic pelvic pain clinic and you could do endometriosis surgery and you can have a variety of nurse practitioners like doing the medical management. Um, but I still like all facets of the chronic pelvic pain management because I do get a lot of people who are like, I don't want surgery.

Like I'm in school. I'm like going to school to an attorney. I don't have time for this. Yeah. So, you know, if they can get relief to the point where they can function and live their life, like that's great. 

Dr. Brighten: Well, and it's an important thing because as you said at the top of this, you were like, you gotta talk me out of endometriosis.

'cause I see so much of it. And yet we can see things like women get, you know, IBS diagnosis, interstitial cystitis diagnosis, like they're getting all of these [00:53:00] other diagnoses, which can ultimately be related to endo. Mm-hmm. Like these things can be connected. So I do think it's important to have that understanding.

How do you feel about having like a dietician or a nutritionist on the team? That would be great. You're like, oh my God, somebody make this happen. But this isn't like the, 

Jill Ingenito: I feel like this is not the reality. At least in my world it's not. Mm-hmm. The reality of medicine. I mean, you, the chronic pelvic pain specialist has to be able to say, you know, here's where yes, you can see a dietician, you know, you can see an exercise physiologist, you can see all these, these people.

So yes, having those people, but I don't think the average gynecologist, if they're even interested in endometriosis, has access or would be able to kind of connect people. 

Dr. Brighten: Yeah. Well I think also there's people listening that they just know they're gonna have to do this themselves. They're gonna have to put together their own team.

You know, before we started recording, I was talking to you about, um, a psychologist that we're having dinner with tonight who is, um, who helps a lot of chronic pelvic pain is special endometriosis patients. [00:54:00] That's another thing I think is missing. Anytime a woman has pain, we know. Depression, anxiety, suicidal ideation, like these things begin to skyrocket.

Having mental health is so important and just because you excise it doesn't mean the body doesn't remember the nerve. Pain patterns aren't there. Or that like somebody doesn't also have a grief of loss of organs and tissue or the years that, you know, went by without 

Jill Ingenito: help. Mm-hmm. So when, when the way I do my consults is kind of addressing all of those things, right?

Mm-hmm. Looking at the endometriosis and components, but also looking at mental health and central sensitization. Are there urological things, GI issues? So I kinda systems based all of it and try to see what pieces also go with the endometriosis. 'cause endometriosis does not travel alone. Mm-hmm. A lot of times it comes with a variety of different things.

So you have to kind of not be so narrow focused. Um. And look at all the systems and how it's playing out for, for someone. 

Dr. Brighten: Yeah. When you [00:55:00] talk about central sensitization, that's gonna be new for some people. Can you explain 

Jill Ingenito: that? Sure. Central sensitization is, the way I like to describe it is, you know, somebody could be touching your, your hand and it just feels like in a normal functioning nerve that your touch is being perceived by your brain.

But for people with central sensitization, an actual touch can feel like they're pinching that area with a sharp, stabbing knife. So our nerves have remodeled and now when we get any type of sensation to that area, that nerve it's sending out, oh my gosh. Danger. Danger. You're being pinched. Whereas you might just, someone might be trying to just touch your hand.

Dr. Brighten: Yeah. 

Jill Ingenito: So those nerves have remodeled and that happens over time at endometriosis and other pain conditions. Um, it's just important to be aware of that nerve remodeling and how, you know, you may need to address that. 

Dr. Brighten: How does someone know that's happened and how would you address it? 

Jill Ingenito: So, good question.

There's some scoring that you can do. There's a few different types of, of scoring [00:56:00] systems that you can do to determine an, uh, central sensitization component. But this can happen sometimes when you've had an excision, right? And you still have some of that residual pain. So like if the bowel, for example, is like moving in the area where you had an excision, you can still kind of feel that area and it may just be moving by as, whereas you're feeling that same, the nerve is triggering that same endometriosis pain response.

So, um, I think you've only really teased that out over time and after you've had, um, a chance to have an excision, that's kind of something that comes down, down the line. 

Dr. Brighten: Mm-hmm. And, and let's say you have an excision and this persists, do you have therapies, ways that you can 

Jill Ingenito: address that? Sure. So I think the main thing with central sensation, for me at least, is understanding what it is.

Anti-inflammatory responses that we can try. Pelvic floor physical therapy and sometimes nerve modulating medication can be really valuable. Mm-hmm. And that can be a little bit of trial and error, so Right. If somebody gets a good response with one of those nerve [00:57:00] modulators for central sensation, you're like, there's some component here.

Dr. Brighten: Yeah. And I would assume this is a situation we're keeping your journal, keeping your diary mm-hmm. Is really helpful. Mm-hmm. Yes. So if somebody, one of the questions that came up in my audience is that people are like, is surgery always necessary? Is it the only way to manage endometriosis? 

Jill Ingenito: No. 

Dr. Brighten: Okay. So what else can people be doing outside of surgery?

We talked about pelvic floor physical therapy. Yes. 

Jill Ingenito: So pelvic floor physical therapy. And then I think that the number one thing you can do is find a progesterone that you don't have too many side effects on. Mm-hmm. And that could take some time. That will stop all the bleeding. So if you can't afford surgery, you don't have access to surgery, you don't have time for surgery.

A lot of times doing pelvic floor physical therapy combined with a progesterone is enough. And a lot of people come to see me and they're like, I want surgery. I want surgery. I'm like, great. We have like a three, I'm a six month wait. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: So I'll put you on that in the meantime. Would you like to live your life?

Yes. Okay. Let's do pelvic floor PT and let's [00:58:00] put you on some progesterone that doesn't have too many side effects. And I will tell you there's a fair number that come back for their preoperative visit and they're like, I'm fine and I gotta do this. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: So 

Dr. Brighten: when you say progesterone mm-hmm. Are you talking about progestin based?

Jill Ingenito: Like either one. Okay. We gotta just find something that works for you. And a lot of times for a large majority, we are using like north or north syndrome or hydroxy progesterone, and that will work for some. But I do find in endometriosis patients that they're more sensitive to the side effects. Mm-hmm.

Of those medications. And so. It can be tricky. So sometimes I'm going to the compounding pharmacy. I'm using more progestin based therapies, um, or getting creative, but some way that stops the bleeding altogether with some concoction of that is the way. 

Dr. Brighten: Yeah. So firstly I will link to the episode on progesterone intolerance for people.

Um, 'cause they talk about the difference between progesterone and progestin endometriosis patients. Neurodivergent patients, women who have PMDD mm-hmm [00:59:00] tend to be much more sensitive to progestins, have more adverse side effects and be told no, it couldn't be happening. There's no causation in the research that birth control could shift your mood.

The other thing we see is there's a big crossover in all those conditions. So there was a really interesting study that neurodivergent women, specifically autism and A DHD are more likely to be diagnosed with endometriosis. And if you have endometriosis, you're more likely to be diagnosed with these conditions.

And that to me, I'm like, is very interesting, especially when you consider the high rate of PMDD these women are experiencing. So I appreciate you saying like, we try to find what works for them because sometimes, I mean, I'm someone. I keep, like, I try to gaslight myself that progestin will work, and then I'm just like this angry crying mess and it doesn't work.

But because I have adenomyosis, I now have started taking progesterone during like the last seven days of my cycle just to be like, I just want a little buffer. Mm-hmm. So that, you know. [01:00:00] And at this point, like my progesterone levels are still good. So for people listening, I tested them. Progesterone looks fine, but the indication is not based on my levels.

It's based on I don't really want that tissue to grow, and I would like to never have a hysterectomy. I like my body parts. I also don't like surgery. No offense, but no, I have none offense taken. I don't like surgery. 

Jill Ingenito: No offense taken. I think it's just you have to be really creative with your physician or your nurse practitioner.

Mm-hmm. And that's the one thing that's hard to teach gynecologists is like you gotta get real creative. Yeah. With people like. Yes, it could be I need birth control and I need a birth control pill, but that ain't gonna be enough if somebody has endometriosis for the ma, a large majority. Mm-hmm. And so sometimes you're adding in like a bioidentical progesterone or progestin something else on top of it.

So it just, the medical management of endometriosis requires an insane amount of creativity. 

Dr. Brighten: Yeah. And so 

Jill Ingenito: that's what I've learned, like just from other providers in my group. Like, oh, you did this in combination with this progesterone, this worked well. She's not bleeding on this. So whatever it [01:01:00] takes. 

Dr. Brighten: Well, that I was gonna ask you because uh, at the top of this you were saying these tissues respond differently mm-hmm.

To hormones. Can you talk about progesterone resistance that can happen with these tissues? 

Jill Ingenito: Yeah. So I mean, over time I think there are patients that I have that respond really well. Mm-hmm. Like they can get an IUD and they have a Mirena or another progesterone IUD, and they respond well and they don't bleed.

And you're just, everyone's clapping. Like, it's great. Yeah. But I You love when it's easy. Yeah. That can be easy. But for a lot of women. That just is not enough. Right? Yeah. So we've gotta up our game. So if someone comes to see me, they have an IUD, they're still bleeding. I'm like, we have to add some progesterone to the mix.

'cause we need to get to a point we're not bleeding. So, um, for some women who wanna go the more birth control route, that's gonna be a morena, IUD and an Nexplanon, or two Nexplanons or a Morena and some progesterone or a bioidentical progesterone and the birth control pill. So you can't just rely on one thing, which is definitely something that's not taught to gynecologists.

Mm-hmm. And there's no research, there's none, you know? Yeah. There's absolutely zero about [01:02:00] combining these different methods to find something that has the least amount of side effects where people aren't bleeding. Mm-hmm. Um, and you're going outside the box. Right. A lot of times when I'm on vacation, for example, then someone will say, oh, you're, you are doing this.

And I'm like, that's what we're doing. Is she okay? Yes, it's working. So yeah, you have to get creative, you have to be a little bold. You have to do things that other gynecologists aren't gonna do because it's often the case where there's just that progesterone resistance and the normal standard things are not gonna work.

Dr. Brighten: I love that you said there's not the research there, so we have to get creative because we'll hear providers say, you can't do that because there's no research to back this up. There's no research. And then you know, you'll also hear from the general public who are like, well, that's not FDA approved. I'm like, but oh girl, I can tell you how much stuff we do.

That's not FDA approved like many medications we're using in women's health, but. I think it's important that we do look at the individual and I always, you know, [01:03:00] I've had people say like, oh, you're rebellious, and say different things like that because I'm with you on that. Like you have to get creative.

But the way I always see it is that this individual has a finite amount of time on this planet, and I am not gonna wait around for two decades for a research study to validate what they're saying is true about their body and what's working for them. 

Jill Ingenito: Yeah. For me it was learning from someone else who was doing this and like reading through their notes and seeing those patients and be like, oh, she did.

Mm-hmm. This progesterone and this progesterone that made the patient stop bleeding and she got better. Yeah, she did two Nexplanons and the patient, you know, so. A lot of what I do is pretty creative with the, what I have available to me commercially. Mm-hmm. And, um, just finding different combinations. But I would tell there's, you know, patients ask me like, well, I don't see any studies on like dual use as an explan.

I'm like, there are none. Yeah. They don't exist, but, you know, and then people come to us and they're like, oh, we should do the research. I'm like, I don't have time right now. I just don't have time. It is so true. 

Dr. Brighten: Um, you know, it's, I I hear that. So there's been so [01:04:00] many practitioners on this podcast who are like, and people ask me to do the research and I'm like, I, you know, people will say that to me too, and I don't think people understand the time and the money it takes to do a study and clinicians.

Are great at participating in the research study. Not so great at designing and, and orchestrating the whole thing because it really takes somebody just dedicated to that. And it is something that I wish, um, I wish we could be doing more studies, but it's not that easy. And even if you do do a study, if it's not double-blind randomized control trial, people are like, that's not good enough.

Mm-hmm. And you're like, we, we have to start somewhere. Somewhere. Right. We have to start somewhere in building evidence and making a case sometimes to get the funding to actually do the research. 

Jill Ingenito: Mm-hmm. I mean, research is just not my forte. So if someone comes me with a research project and like, okay, it's a really great idea, let's take it to this person.

Dr. Brighten: Mm-hmm. And 

Jill Ingenito: see if they can't help us. But yeah, it needs a whole team. I mean, in the groups, the private groups that I've worked with where they've done successful [01:05:00] research studies, like they have a whole squad. 

Dr. Brighten: Yeah. 

Jill Ingenito: It's not like the clinician that's running that there is like a whole squad of researchers and I don't have that available to me.

Dr. Brighten: Yeah. 

Jill Ingenito: Um, 

Dr. Brighten: what I 

Jill Ingenito: haven't heard you say is Lupron. Yeah, I mean, you can use Lupron. I mean, there's, that's another thing in the toolbox that we can use. Um, I don't use a lot of it because I really do find, like if I do, you know, north Syndrome and Prometrium or like the IUD and Provera, like combining things, I don't find myself having to do a lot of Lupron.

Dr. Brighten: Mm-hmm. 

Jill Ingenito: The only time I'll do it and I try not to do it before an excision, 'cause it can make the surgery just a little bit more challenging in terms of the scarring that it causes. Um, well first of all, people hate Lupron, but second of all, we hate Lupron Don it, they don't feel well. So 

Dr. Brighten: I'm like, oh, they don't 

Jill Ingenito: feel, and I, if somebody wants to do it, I'll do it.

I'll do it with hormone replacement therapy at the same time. Yeah. But I usually use it in a situation where we're talking about like, you know, stage four disease that we excise as much as possible. The patient's still having a lot of pain. She doesn't wanna have another surgery, she wants to try Lupron.

Okay. Mm-hmm. Sounds good. [01:06:00] But how long do you use it? I mean, I'll use it up to two years. Mm-hmm. If someone can make it that long. But yeah, I don't know. It's hard. It's a hard medication to take. 

Dr. Brighten: Yeah. So I've explained it to people like, everybody's like, oh, perimenopause is the worst. I'm like, try going, just like within two weeks you drop into the worst phase of perimenopause immediately and it doesn't go away.

Like it just gets worse. But you are doing add-back therapy. Yeah, I'll do that. So with bioidentical hormones. Yeah, 

Jill Ingenito: no one's to, I mean, what, in my experience, no one is tolerating Lupron without the biotech hormones. Yeah. It's just not happening. But there's providers not doing it 

Dr. Brighten: and Oh, for sure. I seriously, when I look at the brain research of the outcomes of like post hysterectomy, a woman losing her hormones, going without those for years at a time, 30% reduction in her cognitive health compared to her cohort who didn't lose her hormones.

I'm like, this is criminal. It has to be done with add-back. And I did Lupron and I did a tiny dose [01:07:00] of like add-back, um, and an estradiol patch. I'm in a place where I can prescribe for myself. And I did that. And um, that was just to take away the hot flashes. 'cause I was like, I cannot live like this. Um, I, in retrospect, I'm like, my brain was struggling so hard, I should done more.

And then I did progesterone as well at night to, to be able to sleep and, um, to also keep my sanity. But that also wasn't enough. I had, I was bringing, like, seriously, that's when I discovered, like Saffron is amazing for mood. It's so necessary, but it's a very, very hard medication. But some 20 somethings they're being told like, this is it.

Like this is the best. Or we'll wait until it's really bad to have surgery. And as somebody who had surgery in their early forties, I'm like. Damn, I wish I had surgery in my twenties. That would've been so much easier to come back from. Mm-hmm. 

Jill Ingenito: That definitely, it's easier to come back when you're younger.

Um, a Lupron is just a challenge I find. I can't get a lot of takers. Mm-hmm. Unless, like I do sometimes use it. Where we've done that excision, the patient has bowel lesions, diaphragmatic lesions. They're not in a place where they can [01:08:00] have these big surgeries. They don't have access to those specialists.

That's when, I'll try Lupron, but why does Lupron make the surgical outcomes worse? The fibrosis that it, that it develops mm-hmm. In those lesions. So as it starts to kinda like kill it off, so to speak. Yeah. It just ends up creating this like scar, you know? Mm-hmm. Just very similar to like, if you have surgery and you have a scar, it creates this scar that's just.

It's difficult to dissect out. You can't get the normal planes that you would get, which is what you wanna get to. You wanna get to the normal planes and the anatomy to know that the endometriosis is gone. But when that fibrosis is there, you're like, where is the end? Where is the normal anatomy here that makes it challenge challenging?

Dr. Brighten: When someone uses Lupron for two years and then has excision surgery, can there be worse outcomes? Can it be more difficult to recover from? 

Jill Ingenito: In my experience, it's harder to excise. Okay. Um, and it puts you at a little bit, I think that course we know this state, I think it puts a little bit higher risk of complications, um, especially when it's like around your ureter.

Mm-hmm. So that can make it more challenging to [01:09:00] dissect the U ureter out safely because of that scarring and fibrosis that happens from Lupron. 

Dr. Brighten: Yeah. And I wonder for the patients who are listening who are like, I had, what I was told was complete excision surgery, that pain has persisted, could, and they would have a history of Lupron use.

Could there be something related to that? There could be. Um, 

Jill Ingenito: there definitely could be something related to that. Neuro remodeling, if you don't get good relief from an excision, that that's kind of a basket of things that it could be. So, it could be that. It's not endometriosis, it's the whole picture, right?

Mm-hmm. There could be a vascular disorder, there could be a bladder condition, a bowel condition. There could be a lot of other things that need to be looked at. So that is not, I wouldn't say Lupron. I would go to like my first thing like, oh yeah, Lupron. That's definitely what it is. Yeah. I wanna go back and be like, okay, wait, let's see what, tell me more about your pain right now.

So I can kind of see is there something else here in your picture besides just endometriosis? Because a lot of times there is. 

Dr. Brighten: Yeah. Well I think that's important for people to hear is that Lupron is [01:10:00] one consideration, but I really appreciate, 'cause I think that it's really easy for us to like kind of get like our experience, our bias, and just be like, I see this all the time with Lupron, so it's just Lupron and it's like you are saying it could be Lupron and I need to do my due diligence and ask more questions.

Yeah. 

Jill Ingenito: Definitely. 

Dr. Brighten: So what other kinds of things could be going on if somebody, so one person wrote me and they said, I had ex excision surgery and a hysterectomy 10 years ago, and I still get menstrual cramps. 

Jill Ingenito: That could be a couple of things. It would depend on if the ovaries are present or not, but that could be pelvic floor.

I mean, the two biggest things that I see that get missed is underestimating how painful pelvic floor muscle dysfunction is. Mm-hmm. And number two is vascular disorders. I think there's a wide variety wide. Endometriosis is largely unrecognized, but pelvic venous disorders are even large. Even a bigger basket Yeah.

That are unrecognized. So in that situation, I'm usually having [01:11:00] someone see an interventional radiologist who can do a good job evaluating for pelvic congestion and, um, seeing if there's a role there. And then also making sure people are doing pelvic floor PT with a good pt. Mm-hmm. So I have like a couple of places where I'll send you, and then there's a few places where I'm like, you gotta have pelvic floor PTs that are very versed in endometriosis and pelvic floor.

Dr. Brighten: Yeah, I, I agree with the, uh, endometriosis component. And after my excision surgery, I've been doing pelvic PT for like nine months now. Uh, but then I had to have knee surgery, so that's off the table. I was like, I need a three month break from that while I do PT for my knee. But, uh, the. Trigger points that I didn't even know I had.

And I will say that I feel like, because I was seeing her fur before the excision surgery, but after the excision surgery, it's like the layers of the onion started to come off and now the lesions were removed, we were able to get deeper and I'm just like, [01:12:00] I, you know, I was making a joke to her 'cause I had this really painful like, cause in my legs to bounce trigger point and I was like, I'm pretty sure that's like when I fell in the monkey bars, uh, or you know, the stairs when I like, and people on YouTube can see me straddle and fell when I was like nine.

I'm like, it hit my, I'm pretty sure it's like way back then. Like that's how like deep this feels is that it's like, it's been with you for decades right now. So I think it is really important to consider the pelvic floor physical therapy piece. What is pelvic congestion syndrome for patients? People listening who don't know.

Jill Ingenito: Mm-hmm. So pelvic congestion syndrome is gonna be, there's a number of different. Diagnoses that fall under that bucket, but it's basically the veins in your pelvis are not returning blood to your heart like they should. Mm-hmm. And so blood is pooling in different areas and that can cause pain. And so I think there's a lot of pelvic pain that's caused by pelvic I Congest syndrome that we haven't really acknowledged.

And I think as somebody who trained, you know, as a [01:13:00] gynecologist, we're the basic, what we're taught is that pelvic injustice syndrome is very commonly seen on imaging, but it's not clinically significant. And I don't think that might is correct. 

Dr. Brighten: Okay. 

Jill Ingenito: I think that that's what we're taught, but I think the more we see some of these newer therapies coming out from an interventional radiologists like iliac vein stenting and some other venous therapies and people getting relief, I think we need to pay attention because.

I think that that's even a larger area that hasn't been acknowledged. 

Dr. Brighten: What are the symptoms of pelvic congestion syndrome? They can 

Jill Ingenito: be all the same symptoms of endometriosis. Fun. That's the problem. Yeah. So that's where I say like if you don't get, if you get some relief with your excision and you don't get complete, okay, have we really looked at pelvic floor and is there a vascular cause as well?

Dr. Brighten: Mm-hmm. 

Jill Ingenito: And um, I think one of the things, you know, it can be pain outside of your cycles, it can be heaviness or pressure, but a lot of times it is very similar overlap of symptoms. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: So while I think endometriosis is like this thing that's getting up and moving, I think we also have to [01:14:00] acknowledge that there's other things that can cause your pain.

Mm-hmm. So if you get an excision, you're not better. You gotta have somebody who can dig deeper. 

Dr. Brighten: Yeah. 

Jill Ingenito: Um, and the two most common things that I see contributing to pain are gonna be the pelvic floor and the vascular disorders and pelvic congestion. 

Dr. Brighten: What if someone's seeing varicose veins, spider veins in their legs?

Mm-hmm. Could that point that we've got pelvic congestion issues? 

Jill Ingenito: Mm-hmm. Mm-hmm. Same thing with swelling. Mm-hmm. A lot of POTS patients, so people who have, um, pot symptoms or even just orthostatic tachycardia syndrome, which is where your heart rate races when you go to stand up. So I think, um, that can also be a big sign.

Like when I see someone who's had an excision, a good excision, and they have pots and their legs are swollen. Yeah. Varicosities and like, we have to get you to see. A vascular, interventional 

Dr. Brighten: pots, A DHD, autism, EMDD, endometriosis all also go together. So as you bring this up, I'm just like, there's, so I, you guys in the comments, you can, if you are popping off light bulb moments, I wanna, I want you to definitely let us know.

'cause I [01:15:00] think you just connected a lot for a lot of people and I think pots gets ignored a lot or it gets relegated to just, this is just a cardiovascular issue. You need to see the cardiologist without considering that like the nervous system's involved. And now you're like your entire pelvis vascular system could be involved as well.

Mm-hmm. 

Jill Ingenito: Um. Yeah, I mean, this is only something I've just started learning about from experts in the area. And I saw one speak at a conference who happened to live like down the street from me. So I spent a couple days like working with her. You're like, coffee, I'll make coffee every day. Teach me about pots.

Um, it's, it's shocking though. Yeah. Like just spending a very short period of time with this group, learning how many pelvic pain patients they see who've had good excisions, who still have pain, and then it really ends up being some type of constriction in their pelvic vessels and they get better with stenting and other types of therapies.

So I think we're gonna learn more about that in the future. They're doing some studies, some other people are doing some studies that are gonna be coming out, but. [01:16:00] It's largely been taught to the gynecologist that pelvic congestion syndrome may be seen on imaging and it doesn't have any symptoms, but I think that it actually probably 

Dr. Brighten: does.

Yeah. Stenting? Yes. You said it twice. People don't know what that is. Stent, break it down. 

Jill Ingenito: So a stent is basically like a long kind of tubular structure that you can put in a vein. Like if you have Nutcracker syndrome or mayur or these are different vascular or venous, um, issues that can open up the vein and keep it open instead of having the vein constricted.

So it opens the vein, it keeps it open. Blood flow can get through the pelvis, back to your heart, back to your brain. So you don't feel like, you know, have pot symptoms or 

Dr. Brighten: Yeah. 

Jill Ingenito: A lot of the pelvic pain can go away. Once we've relieved that constriction in the VA vein and opened it up. 

Dr. Brighten: Why is there constriction in the vein?

Like what is going on there? 

Jill Ingenito: So sometimes it can be from anatomical, just anatomical variations. Mm-hmm. They're more common than you would think. And um, other times it can be from endometriosis, from scarring and from adhesions. Yeah. So those are kind of 

Dr. Brighten: interesting. So what are you doing? So someone's having an endometriosis workup.

What are you [01:17:00] doing to check for pelvic congestion syndrome? Which EE everybody listening won't acknowledge, has a big bucket, right? Is a bucket. Mm-hmm. And there's lots of other things, uh, that can be diagnosed specifically within that bucket. But you see someone with endo and means they tip you off. They say, yeah, I have pots as well.

What, what do you do to work that 

Jill Ingenito: up? Are you doing imaging? So in that situation, it's really important to listen to the patient. Like what, what is the quality of the pain? Is there a heaviness? Especially if anybody describes a heaviness to their pain. I'm like, with the combination of pots, especially if I see some lower extremity swelling, I'm like, do you wanna do your excision first or do you wanna see interventional radiologist first to see if there's a way we can treat that?

Mm-hmm. And it, and it's, everyone's a little bit different. Um, some patients. They have just like the classic pain during their periods, but if anyone's having pain during their periods and outside of their periods, the two biggest things I'm thinking are pelvic floor and a venous congestion. So pain outside the period and a heaviness are two of the biggest things.

Mm-hmm. And then pots, that would be another big one where I'm [01:18:00] like, we really gotta have you see someone. And the problem with these venous disorders is that the protocol and the MR MRI has to be correct. And that a lot of times the radiologist isn't even looking for it and they just completely miss it.

So while you might have an MRI that says it's totally normal, I could be wrong, it really has to be looked at by somebody who does a lot of, a lot of vascular. Mm-hmm. Pelvic pain. 

Dr. Brighten: This, so we talked about. You need a radiologist who actually gets endometriosis, who's been trained in it, can look for that pelvic congestion syndrome.

You need a radiologist that specialize in that. I think that's so important for women to hear because just like women are told your blood work is normal, but you have all these symptoms, you also might be told, oh yeah, well your, your imaging is normal and it's not. You have to have that expert read it.

Yeah. How, how do people find that expert though? Because that's the thing, I mean, people ask me and I'm like, I know a lot of people, like I know, I know a lot of people. I called my friends, I was like, who's the radiologist I need to send this to? But I'm like, how does the average person, because you know, the way it [01:19:00] flows in the United States is that when you order it, it goes to radiologist.

We can actually say, I wanna get it over to this radiologist. But if your doctor doesn't know who to get it to, what, what can a patient do? You're like, I have no answers. I don't have an answer. 

Jill Ingenito: This is like a hot topic for me mentally that I'm trying to kind of uncover. Um, there's a couple people in the United States that I know are doing this work and are doing it right.

And so I just have to send it to them to have them take a look. But can you name drop them? Oh, sure. Yeah. So, uh, Brooke Spencer and her team at the Minimally Invasive Procedure Center in Highlands Ranch, Colorado. And then Dr. Hutchins, which I can't remember where she's located, but she is online. Um, she's also doing a lot of this work as well.

Dr. Brighten: Mm-hmm. And 

Jill Ingenito: so I don't, I just don't think there's a lot of intervention radiologists that are interested in the pelvic pain patient Yeah. And helping them. Right. And from what I understand from these people who are doing these procedures, like the. Iliac vein stenting is even if you [01:20:00] get to the point where they're like, yeah, you need an iliac vein stent that can help with your pelvic pain.

They're not placing the stents always correctly. So this is like a bucket of, I don't even know what to do at this point. Yeah. Um, for my patients, I send them to this, this group I'm say they look at the imaging, they determine what the issue is, and they put in a stent. And that's why if you saw my post recently, like I took an entire day off to go learn from these people because I felt like it was that important.

As important as endometriosis to find out what they're doing, how they're doing, and how it can help people. 

Dr. Brighten: Does pregnancy put you at risk for pelvis? Yes. Okay. 

Jill Ingenito: I didn't even get the question out. Yeah. Pregnancy can put you at risk for pelvic congestion, but I have seen a few patients actually who have not been pregnant, who've had it.

Yeah. Yeah. Um, and sometimes your doctor can see it. I've been looking more and more for it. When I do my scopes, when I do my excisions, I've been looking more and more for it, and you can tell like the vessels are just really dilated and mm-hmm. Tortuous and kind of twist and turn, kind of like a varicose vein in your pelvis.

If I see any of that and the patient has symptoms [01:21:00] after her excision, I'm like, I gotta get you over to these people. 

Dr. Brighten: Yeah. 

Jill Ingenito: For them to take a look. An MRI and then determine if you're a candidate for a stent. 

Dr. Brighten: Yeah. Is there anything that patients can be doing outside of surgical intervention for this? 

Jill Ingenito: No, because it's like a constriction.

I mean, there probably is, I don't know. But yeah, we're talking about a very narrow couple millimeters where a venous is supposed to be, you know, wide open and mm-hmm. And painted like, I don't know how to correct this to this. Yeah. Without a surgery or a stent. Yeah. So it's like, I don't. 

Dr. Brighten: Yeah. I wonder, like, I, I also wonder if like, there's something going on with the nervous system of like, what about, uh, potentially like nutritionally, you know, we know like B flavanoids, vitamin C is like really good for veins.

But, you know, as I, as I spot all this off, I'm like, I other than something that vasodilates you, right? Like, I mean, I, I I'm not, um, an expert in pelvic congestion syndrome. Uh, so, you know, one question I have is that like, are there [01:22:00] medications for vasodilators that might be helpful? 

Jill Ingenito: I think it just has to be, and this would be a great person actually to have on your podcast.

Yeah. Okay. Okay. Either Dr. Hutchins or, um, Dr. Spencer, and they can talk more about it and talk more eloquently about it than I am. But yeah. I can't, I also was thinking that same question. I was there, I was like, is there any way I can help these people without Yeah. Opening up the vessel and I, I mean, other than temporary, put your 

Dr. Brighten: legs up the wall every night, right.

And 

Jill Ingenito: Yeah. But for some of 'em, it's just an anatomical thing. Yeah. That has to be corrected. 

Dr. Brighten: Yeah, so it's a difficult place to be in. And it's also something that like, you know, I bring on surgeons on the podcasts and we talk about surgery, and then we often try to talk about things outside of surgery as well.

But sometimes surgery is just, you know, the only answer what I just went through with my knee, I'm like, no, can we do anything else? Right? And they're like, no, there's literally tissue lodged in your knee joint. You gotta get it out. I'm like, great. Okay. Sometimes, 

Jill Ingenito: right? It's the same thing like with endometriosis, right?

Yeah. You know, you can try medical things, but if you're not getting better, like. I, I, I can't [01:23:00] remove them. Mm-hmm. 

Dr. Brighten: There's no medicine to remove them. Yeah. 

Jill Ingenito: So, 

Dr. Brighten: so one question that came up as you bring it back to endometriosis. Somebody asked, okay, so can endometriosis stay minimal your whole life or is it always gonna grow?

Is it always going to keep, you know, being problematic? Uh, is it something that like I have to worry about it moving into my organs? 

Jill Ingenito: I just think it's, I've seen such wide variety. I would say yes. Sometimes it can just stay very minimal. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Um, and it kind of depends. That's hard to say. 'cause sometimes then they end up going on birth control.

Right. For contraception, just straight contraception. They need birth control. So like, did it stay minimal because that person was on contraception? But then there's some people who have endometriosis very early on where, you know, even them being on contraception, it doesn't matter. Yeah. It just spreads like wildflower.

So I don't, I don't know. Yeah. For some people you just stay kind of this like a minimal stage one, two anti-inflammatory, but. I don't think that's true. I don't think there's like an [01:24:00] overarching statement. Um, usually once I see the endometriosis I can kind of say, okay, this, once you've excised it, like, I don't think this is gonna grow back.

Mm-hmm. Because of it's more like surface level. Um, but that deep infiltrating stuff, I'm like, 

Dr. Brighten: yeah. Well, I think it's also important, you know, as I frame this question is I never want women, firstly, you never caused your endometriosis, and secondly, nothing you did personally like was like the deal breaker of like making your endometriosis like the worst thing ever.

And there's a lot, I think especially now it's become very political of like this personal responsibility in healthcare. And yet what gets left outta that conversation is the environmental impacts that you do not have control over. So when you've got forever chemicals coming through in your water, like you might clean up all your makeup to have it as, you know, endocrine, disrupting free as possible, but maybe your water supply, maybe you live near, um, farmland.

Like there's all of these variables within the environment that also can influence [01:25:00] your health and the development of chronic disease. And so well, I think. It's important. And I always wanna empower people to take as much control as they can over their life. I think it's also important that we recognize that you can live your absolute best life and try your best.

And sometimes life just hands you variables that you didn't see coming and you could have never controlled. 

Jill Ingenito: Yeah. And that's a hard conversation to have with patients, I think. Yeah. Um, just understanding that some of this is out of your control. Oh, totally. I wanna control everything. Yeah. And they do too.

I mean, right. Like they do too, because it feels like something you can control. But you know, I mean, it's the same thing. Like I, my son has a DH adhd and like, I feel like my husband and I will constantly go back and forth, like, we can control this. Like we can fix this. Like, we'll get 'em in the right sports, we'll put 'em on the right meds, like right therapies.

But like, sometimes we're just like, this is outside of our control. Yeah. Like we, and I feel that same with endometriosis. Like I'm like, this is. Uh, you can do all these things and it can still be an issue, so please [01:26:00] don't, you know, keep searching for like, the perfect supplement or, you know, the perfect exercise routine.

Like some of it's just out of your control. 

Dr. Brighten: Yeah. And there's, you know, I think it's really hard when a patient's like, I haven't touched sugar in like 10 years, and I like, you know, don't stay up late. And they, they, they look back and they're like, I did everything perfectly and I didn't get to live my life and yet this still happened.

And I think that's hard and sometimes we have to recognize that like. There is an experience in this life to have as well. And, uh, within wellness culture, I think that perfectionism is something that becomes this gold standard. And, um, and I am, I'm integrative. I'm always like, I want everything. I want every single tool at our disposal because whatever you need is what we wanna use.

I'm a buffet, like I don't eat at buffets 'cause of, uh, you know, uh, foodborne illness, but when it comes to medicine, I'm like, gimme the buffet and let's pick and choose what we wanna put on your plate and what your plate can actually handle. And I think, you know, sometimes, uh, you know, [01:27:00] we have to just look, look at things and say like, you.

You may be thinking, wow, I ended up in surgery anyways. But what you're not actually seeing is that how much worse would this surgery have been? How much harder would the recovery time been? Yeah. Like you don't realize that like everything that you put in was positive towards the outcome here. And that like, not all of us are gonna avoid a medication or avoid a surgery our entire life, but living that life to the best of your ability is gonna influence those outcomes.

I mean, you're gonna reduce, uh, medication side effects in some 

Jill Ingenito: instances. Right. I think that it's important to go through that, like discovering what works well in your wellness journey and also pairing that with what we have available to us, like surgically and medically. It's not a either or. Yeah. And I think, um.

I've had these conversations where women will say like, I, I'm doing all of this stuff. Like, do you think I can still avoid an excision? I'm like, we can try, like we can try to keep you outta the, or, like whatever you wanna [01:28:00] do. Um, but just sometimes we have to, it involves all the things. So, you know, you can't always out smart your endometriosis if it's there.

Mm. You sometimes have to use the tools available. 

Dr. Brighten: That is such a good soundbite right there. You can't always outsmart your endometriosis. I'm like, yes. I think we all need to hear that. You did talk about, um, recurrence. Mm-hmm. How can somebody reduce their risk mm-hmm. Of recurring after excision? 

Jill Ingenito: Yeah. So after ex, so during the excision, it's important to get, like I was saying, to those normal planes in the anatomy mm-hmm.

Where the clear spaces are. So if we can get those wide margins, we know anatomically and things are back together. Um, what I do in my practice is I say like, there's no bleeding after exci. None how you wanna do this. It's entirely up to you. Here's the 500 things that you could do in combination. But there needs to be no bleeding whatsoever.

And I find that those patients have less recurrences in my practice. I, I don't know [01:29:00] that that's true for everyone, but like some of the combinations that I use, like they're not studied, 

Dr. Brighten: you know? So you're saying No cycling? 

Jill Ingenito: None. Okay. Um, but I still have found that in really deep infiltrating endometriosis that I can't, nothing that I can do medically.

It's just like, we don't have this, this, this medicine does not exist on this planet yet. Mm-hmm. So there are some cases where no matter what, even if I don't cycle people and I go back in there and they have a recurrence, I'm like, it is what it is. 

Dr. Brighten: Yeah. 

Jill Ingenito: At this point in 2025, here's where we're at. 

Dr. Brighten: Yeah.

Well I wanna ask you though, because there's women who get excision surgery with the goal of getting pregnant. Yeah. So, so then they, I don't get them on anything. 

Jill Ingenito: Okay. Yeah. So that would be the exception is, right, we're trying to get pregnant. Okay. We wanna get, try to get pregnant in those first six months.

Immediately following your excision, like we need to be ready to go. Mm-hmm. An infertility evaluation needs to be complete. We need to know normal se analysis, everything needs to be in order because right after that section, we have about six months. So for those gals, no. Why is it six months? Um, I think after about six months is when they see those [01:30:00] lesions kind of start to regrow and more inflammation starts to build to the point where it can interfere with pregnancy.

Dr. Brighten: Yeah. 

Jill Ingenito: And there was a study that came out recently, and I can't think exactly what it is, but it basically showed after like six months, you should get them in the hands of an infertility specialist. Mm-hmm. But also, like, I always tell patients like, do you wanna do this for another six months? I mean, it's up to you.

You can keep going, but the chances are less and less 

Dr. Brighten: Yeah. 

Jill Ingenito: As you get between six and 12 months. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: So, 

Dr. Brighten: yeah, I mean, that's hard to hear, but I think it's also important to hear, and I've had other, uh, fertility specialists on the podcast that are like, we try within three to six months for her to get pregnant, like post excision surgery.

And then I know it also differs if like the uterus was involved at all, and like if you had to shave anything off the uterus, or maybe there was, you know, a, a focal, um, Aden myosis and you had to remove that piece. So it starts to get really tricky, which is why I think it's really important to highlight what you said, which is that getting that fertility consult and making sure you have that player on the team.

So we [01:31:00] talked about the team mm-hmm. Already, but if you're wanting to get pregnant, that brings in a new team player. 

Jill Ingenito: Mm-hmm. And I think that there's, there's obviously some people who do all of it, you know, and those people are even smarter than I am. But, um, yes, you wanna have. Everything. And sometimes that means having an egg retriever before you have your endometriosis surgery.

Mm-hmm. And sometimes it means after, so working with them to try to make it, make the goal what it is. 

Dr. Brighten: Yeah. 

Jill Ingenito: But excision alone can increase chances of conception by up to 40%. So if you wanna try that, I think it's worth a six month trial, but mm-hmm. After that you need to, we need to loop in the infertility specialist.

Dr. Brighten: Yeah. No, and, and for people listening, it also depends on your age as well of all of these considerations. And it was something that when I was faced with, you know, uh, my endometriosis surgeon was like, okay, you know, we give you a little algorithm of what your A MH is and if your A MH is less than one, you need to do an egg retrieval before you have excision surgery.

And my MH ended up being like over two [01:32:00] and I was like, lies, no. Like rerun that. And then it was over two again and I was like, okay, like 40 something years old. This is. Okay. Like, I'll take it. Yay. However, I opted to do the, um, retrieval first because I knew it was gonna blow up my lesions. I knew that it was gonna be provocative.

Right. Um, and it did. Mm-hmm. I mean, sure enough, they were like, yes, and we saw lots more. And I'm like, yeah, because all of that estrogen stimulation. So I ended up just going that route just for that reason that I was like, every little bugger that exists, I want you to see it. And of course, like I so people listen, you have to wait a period of time for, 'cause you get very inflamed Yeah.

During an egg retrieval and you have to wait a period of time for the inflammation to go down. But it showed me that, I mean, that was really a definitive for me, where I'm like. Everyone with endometriosis needs to understand IVF makes endometriosis worse because it absolutely does. We do not talk about it.

And I was managing my endometriosis [01:33:00] naturally really well. Living pain free. Third egg retrieval. Thought I was dying like three weeks later I was like, I think I'm dying. Like something is so, so wrong in here. And I didn't know I had endo yet and uh oh yeah. And then I had a fatty endometrioma. I'm like, that makes so much sense now.

Jill Ingenito: Yeah. That's hard. I really find that to be a challenging place for, for women who have to go through egg retrievals. I think it really is like, you really gotta look at your life and be like, what am I gonna be able to tolerate? 

Dr. Brighten: Yeah. 

Jill Ingenito: In this period of time, 

Dr. Brighten: I think we have to be honest with endometriosis patients.

I think there's too many reproductive endocrinologists who aren't looking for endometriosis, and when things get really bad, I mean, I woke up from my re egg retrieval crying and they were like, we need to get you more meds. And I was like, um, you know, there was that nurse at Yale who was like, smuggling all the fentanyl.

Um, and I was like, did someone steal the pain meds? Because I'm feeling everything. They immediately were like, we have to do your transvaginal ultrasound, like something's wrong. And they were like, your entire cavity is just. Inflamed. I'm like, yeah. [01:34:00] And nobody ever thought to say endometriosis to me. So I share this story with everybody because, um, if I had to go through it, then it's a great teachable moment that hopefully I can prevent someone else from going through it.

But I wanna ask about endometriosis as I brought it up. So a big question is, is ovary removal ever necessary or should the goal always be to preserve them? 

Jill Ingenito: I think it depends on you. Depends on what your goals are. If we're looking, um, to do an aggressive excision and surgery, and you're young, yes, let's try to keep those ovaries, let's quantify young.

Dr. Brighten: Okay. Um, what, so what, what are we talking about here if you're, is it like if you're under 45, let's try to keep them, if you're over 45 and what size of endometrioma we might wanna remove them. 

Jill Ingenito: I mean, I always try to go in and say like, let's try to keep the ovary. Okay, I like this. Okay. Yeah. So like, let's try to keep the ovary.

Okay. Like, let's just try and see what happens. You know, sometimes, and [01:35:00] it's not a lot, but sometimes it is more challenging to get to those normal planes when you are, um, doing like an endometriosis surgery on the ovary. So sometimes it is challenging to get to that restoration, that normal planes to like get you as much wide excision as possible.

Yeah. Um, and I, I, I, I just kind of go in with, yeah, we can probably, I mean, there's very few situations where I feel like the ovaries need to go unless you want them to go. Like there's definitely people who are like, it all must go. 

Dr. Brighten: Yeah. 

Jill Ingenito: That's the end. Okay. 

Dr. Brighten: I like that you give women the choice. Yeah.

Because some 

Jill Ingenito: doctors, I'm not your mom. Like you decide, okay, you two, what do you wanna do? If you want me to say that ovary and there's this like two millimeters of it left fine. 

Dr. Brighten: But is there a certain age though where you're like, if, okay, let me ask, is there a certain size of an endometrioma that makes you think, Ugh, I probably can't preserve this ovary.

Let's start there. 

Jill Ingenito: I don't have a cutoff. 

Dr. Brighten: Okay. You just try no matter what, just 

Jill Ingenito: try. 

Dr. Brighten: Okay. I like it. And if it's, you know, I'm a fan. Yeah. 

Jill Ingenito: I don't have a certain size and I guess if it's like 20 centimeters or something and there's zero, you can find no anatomical ovarian [01:36:00] cortex, then maybe. Okay. Um, but I don't have a cutoff.

Dr. Brighten: And do you have an age where you're like, you know, at this age it's probably okay if we, if we take an ovary, like when you're con consulting someone 

Jill Ingenito: I, and I leave it up to them. Oh, okay. Good. Um, I would say probably over 50. I don't know that, you know. That would kind of be, there's some evidence to kind of say over 50 if you're gonna be doing that surgery.

Do you want, really wanna keep the whole ovary? But if you want to, it's fine. 

Dr. Brighten: Mm-hmm. I 

Jill Ingenito: give you the choice. Yes. I wanna keep it over. Okay. We'll do everything we can to try to save it. 

Dr. Brighten: Yeah. 

Jill Ingenito: Um, it may end up like a tiny remnant, but probably under fifties, kind of where they say ovary removal. It might just be easier to do it that way.

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Um, and for people 

Dr. Brighten: listening, the average age of menopause is 51. So your ovaries have already stopped at that point. And for some people, you know, you might be in perimenopause at 45 and it's like, well you're going on HRT anyways and you know, this ovary might not be the healthiest. Yeah. 

Jill Ingenito: Yeah. It's just an individual [01:37:00] conversation.

Do you want it removed? Do you not want it removed? How do you want, how do you want this to go? 

Dr. Brighten: And does the concern for, um, like having ovarian 

Jill Ingenito: cancer ever come into play? Oh yeah. I mean, I tell them if they have family has ovarian cancer, I would just take it out if it's me. Mm-hmm. Um, but a lot of times I find what patients say is, if.

You think I'm going to be out of pain and it's not worth saving, then go ahead and take it. You know, if it's so intertwined 

Dr. Brighten: Yeah. 

Jill Ingenito: Then I would rather get to the normal tissue planes. Okay. Than kind of keep it so as individual and I haven't found a real, like strict cutoff for people, I just kind of give them the choice.

Dr. Brighten: Okay. And then when it comes to hysterectomy mm-hmm. This is something that there, there are still, um, doctors, I'm gonna pull a book out of this southern playbook of bless them that say hysterectomy can cure endometriosis. Can we please talk about that? 

Jill Ingenito: Yeah. Um, that said a lot. Um. I think that it can help quite a bit if you have adenomyosis, which, you know, tends to run with [01:38:00] endometriosis.

And so I think it can help, but if you don't do it with an excision, I, I just don't see how we're, or anything's making sense there. Yeah. Um, I think that comes from a place of, again, people not knowing what to do. Like, I don't know how to help this patient, but I can do a hysterectomy. Mm-hmm. And maybe that'll help a little bit.

It might, it might help with the adenomyosis, but I think, again, that comes from that line of thinking. I've never heard taught in training ever. 

Dr. Brighten: Wait, so you, you were never taught that a hysterectomy cures endo, but yet we've got like a little like. Cage of parrots on the internet who are just spouting that over and over and over.

I think it's, people 

Jill Ingenito: dunno what to do. 

Dr. Brighten: Okay. Okay. Which, you know, to their credit, what you are saying, and I think this is important to dissect out here, is that you're saying they are just trying to help. They're trying to help and they think this might help, but why is it that a hysterectomy without excision is not going to help?[01:39:00] 

Jill Ingenito: So the endometriosis still lives, the actual disease is still living in the peritoneum or that space all around the pelvis. So you've not removed any of it at all. Mm-hmm. So, you know, it's kind of like leaving a big mass behind, you've left the big mass behind, but you've taken out the uterus, it's not gonna help.

Yeah. Um, but this is all, this is not stuff that I'm telling you is taught in training like this idea. And again, I think where I've seen patients come to me where they've had a hysterectomy that had overs removed 'cause you have an end endometriosis exci. I honestly, the gynecologist is not trying to be a jerk.

I think that they legit did not know how to help. Mm-hmm. This person, and there are some people that get better Yeah. Who have chronic pelvic pain, who have a hysterectomy. But I have seen a lot of people with all of it removed and they're like, I'm still in pain. 

Dr. Brighten: Yeah. Oh. And there's also been celebrities who have touted like having endometriosis.

And so I just decided to get my uterus removed and it's like this hysterectomy is like this women's rights thing that like [01:40:00] starts to come up and then I think it's like when Angelina Jolie had her like double mastectomy and then suddenly I had patients who were like, should I get a double mastectomy?

I'm like, why you listen to Angelina Jolie about like medical advice? And I think we saw that in. I think it was like the last seven years, several celebrities just talking about like, I had endometriosis, so I just got a hysterectomy. And I'm like, slow that down. Like that was part of like a bigger conversation.

I'm hoping there was excision surgery in there, but like that only perpetuates the smith that like, just remove the baby container and like, you are gonna be fine. And what we've heard so far in this conversation is that like, it doesn't only have to be endo, like it can be so much more and the hysterectomy isn't just the one one-stop shop for women.

Jill Ingenito: Yeah. The thing about it is, is in the past, I think maybe a generation, the older generation where it, that's what's happened. Like my mom had a hysterectomy. Yeah. My aunt had a hysterectomy, my grandma had, everybody had a hysterectomy. Okay. [01:41:00] It was just like what was done? Mm-hmm. Like they're just like, gut it all.

Take it all out. Um, and I still actually find people coming to me being like, just take it all out. I just want everything gone. I'm like, okay. I'm not gonna just take everything out. We can take everything out and here's what else I'm removing. Okay. But are you taking out the uterus? I'll take it out. Like, so I think that we're like kind of seeing some generational stuff come down there because there that, so it was done like if you had any, anything going on down here was like, just take it out.

Dr. Brighten: Yeah. What's interesting is you say that what comes up for me is that like generationally, that was, are you done with children? Okay. Just hysterectomy. Take it all out. Our generation, 'cause I'm assuming we're around the same age, was like, did you start menstruating? Just take the pill. Like just, just take the pill.

And so much of women's medicine is like. Your lady parts right are the problem and not a well. Hmm. What might be going on? Yeah. I look back at this and I'm like, when I had horrific periods that made me vomit. I missed [01:42:00] school. Like I bled with a heating pad on the ground for like seven days out of every single month.

Like that was so clearly endometrial endometriosis, it's like so clearly. But like doctor after doctor, all I was told is just take the pill. The pill solves everything. The pill is like your best thing. And it didn't help. Um, and I just went through like a decade of depression and pain of taking the pill.

So I think like it really kind of comes on that bigger conversation of like, why do we just have one intervention? And we call it good enough women, you should just be thankful and apply it to everybody. I 

Jill Ingenito: don't know. 

Dr. Brighten: Come on. You don't have an answer. 

Jill Ingenito: Come on. I know this keeps you up at night. I don't know.

I mean, I think it was like the people who just taking everything out with their hysterectomies. Like that's 'cause there was, the pill wasn't available and then like the pill came on the on the scene and then it was like, Ooh, you can like maybe not get pregnant if you don't wanna get pregnant. Yes. We like that part of the pill.

Right? Like, ooh. You know what I mean? So then as many people weren't having to have just take everything out. So it just [01:43:00] kind of has shifted and now we're seeing like more and more people who have been on the pill in this situation and they don't wanna be on it anymore. And they find out, oh my gosh, this is my reality without it.

Yeah. So, you know, I think that'll shift. I. I don't know. I don't know the answer to that one. 

Dr. Brighten: Well, I think we're also seeing doctors like you, like you just like stepped on the scene on social media and you like, ended up in my feet and I was like, this person's fantastic. You're like, um, you, I, I am gonna say this.

I don't want this to be rude, but you are hilarious. Uh, you far more hilarious than your videos, than, um, in an interview. And I know this is more high pressure situation, so I want everybody to go watch your videos and I think they're gonna be like, wait a minute, is this the same person? Um, yeah. You're always like dancing or rocking out or you got your daughter with you.

Yes. And I'm just like, you, you're such an awesome duo. But I think we're seeing more doctors. It's, it's something that like, I wanna pose this to you 'cause I. Has said to my husband, the problem is not, when we think of medical men, uh, misinformation, the problem is not the rise of influencers. It's [01:44:00] not the reach of influencers, it's not influencers at all.

It is doctors who have neglected women who have created this gap and who have forced patients to go outside of the medical community to look for advice. And the biggest thing that doctors can do is not, I think calling out misinformation of like, this person's so stupid, da, da, da, is a really bad negative content.

And it only reinforces in the people's minds who think doctors are the enemy that they are. Mm-hmm. Combative and the enemy. But I think doctors coming online, educating more, being human. Is going to be the most powerful thing to rebuild trust, but also make it to where patients are like, I wanna go back into the medical community.

I wanna go back to them for advice. Yeah. What do you think? 

Jill Ingenito: Yeah, I mean, that was one of the reasons I decided to do it because I debated it for a while and my patients would just come to me with a TikTok like this, TikTok, and I'm like, and I felt like I could do it better and more funny. And yes, I'm probably not as funny in person, but um, I'm also not, 

Dr. Brighten: [01:45:00] people will always be like, you're so funny.

Can you like say a joke when I'm speaking on stage? I'm like, no, I cannot. No, I can. I absolutely cannot because there's an expectation. 

Jill Ingenito: Yes. So yeah, I'm probably more funny and more funny online, but I think that was one of the things that there was just so much negativity about doctors in the endometriosis space.

I was like, yeah. Then I was like, I'm not doing this. I'm like, I'm gonna get eaten alive. Mm-hmm. On Instagram and TikTok. I am going to just get eaten alive if I say things in a certain way. And part of that came from like, you have to be really careful with your language too. Especially in this community.

I found that, you know, sometimes when I, the way I wanna say something like in life, right? Like if I just say it like this, it's gonna not gonna land well. So there's a little bit of finesse learning there, but that was one of the reasons I was trying to do it is like, listen, we're all not the enemy.

Mm-hmm. Like I actually do wanna help people. Like sure I could have just stayed a gynecologist and like done all the like boring, you know, stuff. I didn't have to do any of this. It takes away from my time, my family, like all the things. But [01:46:00] there are some of us who like actually do wanna help. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Um, and I try to bring a little bit of humor to the space because I just feel like it can be sometimes very dark.

Yeah. Um, and. I hope that that message gets out there, that we're all not like that, that there, there are people who care, there's people who are interested in this. Um, so 

Dr. Brighten: yeah. Well, I think it's important. I think the work that you're doing is really important. I made a joke the other day on social media because I explained like, Hey, there's one theory of endometriosis where these stem cells that would have become a reproductive track migrated during, uh, you know, embryonic development.

And like I go through all of that and there, and I made this joke. I'm like, there's a playbook. Of, I don't know if it's like set up, maybe somebody is like really smart with AI and just has it reflexively to comment, but you say something and it edges towards like endometriosis could be derived from the endometrial tissue.

Right. And people are like, endometriosis is not the [01:47:00] endometrial tissue. And I'm like, yeah, bro. That's what I said. Like, and I was talking and they're like, you said that it could have been, I'm like, okay, I know that embryonic development is kind of complicated. We don't wanna get taught it. And even in just like saying that of like trying to acknowledge it, like I get that, they're like, what are you calling me dumb?

I do understand this. And I'm like, I'm not saying that. Like, I'm just saying that like, maybe I could have done a better job and this is complex and confusing and like, and they're like, oh, so you think it's too complex for me to understand? And I'm like, oh, you woke up and chose to hate someone today. And I'm not someone I gotta just, I love that I gotta just walk out of this conversation.

And I think that's like what makes working with the endometriosis community trying to support them so hard is, uh, you know, there's one person. Who comes in and decides that like this pent up rage and anger, like they're gonna offload it on you and it can be really easy to like let that bog you down.

And I always have to just go back and look at the comments and like, I just had someone, um, last night that she was asking me a question about like a hysterectomy. I was like, here's this [01:48:00] podcast episode. And she's like, you've helped me through every stage of my life. She's like, you helped me when I was having period problems.

You helped me when I wanted to get pregnant. You helped me postpartum. And she just went through. She's like, and I've never even met you. I've just seen you online. And I'm like, I'm gonna hold onto that. You should forever. And I'm gonna put this up of like a total stranger on the internet has had every phase of her life affected by me.

And so I say that to everybody listening and to you of like, keep showing up because odds are the person that you help the most is the person you never even hear from or knew they existed. 

Jill Ingenito: Yeah. I mean, there's a lot of people online scrolling all the time, and they can live in small towns in the middle of nowhere.

Mm-hmm. And you can help them. That is, I take those messages and I hold onto them super tightly too. Um, I think another reason I wanted to come into this space is 'cause I come to the table with, I'm just trying to educate, even though if you think my content does not speak to that, I'm just, it does, it's f fantastic.

Okay. But a lot of people will be like, I [01:49:00] think most, a lot of the influencers on. In this space that our doctors are like trying to make money off of certain things, which is why I've gotten a lot of criticism like, what are you doing here? You're not trying to make any money. Like, why? What are you doing?

I'm like, I'm just educating, right? Mm-hmm. I'm not selling you surgery. If you come to me, I make no money if I do your surgery. Or we sit there and we talk like it's the same amount of cash. So I think a lot of people are looking at me like, well, you're just trying to sell surgery with yourself. I'm like, I only take a certain type of insurance.

You can't see me anyway. Yeah. So again, they might have just woke up and decided to hate someone. Um, but it is, it can be challenging. I definitely have days where I look at my phone, I'm like, okay, not today. Yeah. Not today. Why am I doing this? I'm making no money. Yeah, just educating. But I mean, it just, it gives you opportunities.

And I do get those occasional messages. Like I live in the middle of nowhere. Yeah. No one in this town even knows what endometriosis is. 

Dr. Brighten: I think we all, uh, we all get that. I think there's just this idea that like, you, you shouldn't be able to make money, um, in something that's so personal to somebody. I own a [01:50:00] supplement company and it's interesting to me that I actually don't get that much hate for it.

But there will often, there will sometimes be like, oh, you just tried to sell me in your supplements. I'm like, really? 'cause I just told you all the foods to eat for magnesium. So I don't know, like I always tell you to eat nutrition first, but then I'll have people who are like, um, I didn't even know you had supplements and I wish I would've known this because I just discovered it and it helped.

And it's something where you're like, I'm, you have to be comfortable in who you are and what your mission is and what you're really trying to do at the end of the day. And I think that's something that when I. Entered into my forties and I've had like a really rough ride into my forties of things happening that I was like, I know who I am, I know what my intentions are, I know what I show up to do, and I know the history of my character speaks for itself.

So someone may wanna come online and paint me in a negative way. And people online tend to believe the first thing they hear, right? And never actually like look into somebody. Someone says like, oh, this doctor, like she's just a surgery mill. And so she just wants to make tons of money off [01:51:00] that. There's gonna be people that are like, oh, unfollow, you must be, and I'm like, it's sad to me that we are not teaching critical thinking in school.

And it's something that I'm trying to do better with my kids, but also it's not my responsibility to prove my character to every single person that exists out there. Like, my actions have spoken. I have been very public for a decade. And I think at some point you just have to be comfortable with that of like, people are gonna judge me either way.

I've, I've shown them who I am. Yeah. They can make their own decision. Yeah. I mean, I've even had. 

Jill Ingenito: There's a couple like content creators that do menopause that are really big into the menopause and like the hormone replacement therapy, and I follow them. 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: And I've even gone into like large meetings with big groups of OBGYNs, like just for a regular meeting and said, Hey, I learned this from so and so.

Oh yeah. Online. And they're like, what? You're quoting this doctor from online and that person has a supplement company. Mm-hmm. Like obviously, you 

Dr. Brighten: know, and I'm just, yeah. It's just like, I think what [01:52:00] doctors don't get taught, so my background is in nutrition science and I learned a lot about the supplement industry and ob GYN has no problem prescribing a prenatal, but what they don't realize is that there's a lot of contaminants in that prenatal and it doesn't actually even have what it says in it.

And that was the big reason why I ever did my supplement company, because I was like, I'm pregnant. I want it third party tested. I want it heavy metal screened and I wanna know what's in it. And I am going to contract with a pharmaceutical manufacturing facility. So it is at the pharmaceutical grade in doing that.

And I think when people are like, oh, it's just a sub, like they're just trying to sell supplements. Like yeah, there are supplements that I see on Amazon that I'm like, I know how much those ingredients cost that that's not in the bottle. I mean, I have met people at business conferences who are like, oh, we put rice powder in our supplement and sell it to people.

And I'm like, what? And they're marketers from some other country who think this is totally okay. And I'm like, this is wild. And that's [01:53:00] there. So when you meet doctors who have supplement companies, it's often because they're like, I need to take this. I need to control this. Mm-hmm. Because it's so wild out there.

But it's this idea. Mm-hmm. That like. You know, 'cause there are some doctors who are like, all supplements are bad. There's no reason for a supplement ever. And then I'm like, well what if someone has iron deficiency anemia? Oh, iron sulfate. Oh, the lowest quality iron. So that they're constipated and they feel like hell.

Or you could give glycinate like highly absorbable lower dose, gonna raise their ferritin like faster. And you start getting in these conversations and you realize there's been no critical thinking. Mm-hmm. There's only been I heard this thing from someone I respected, so therefore I just thought like, okay, this is, this is just the way it is.

But I know what you're talking about in the menopause space because, um. I know some of these people, 'cause I remember them when, when they were like just stepping onto the space and when they got popular is when other healthcare providers decided they were no longer a human. And that's a weird phenomenon that happens on social media is that once you have a certain number count, you are no longer, you no [01:54:00] longer have to be treated as a human for some reason.

You can be dehumanized and hated on. Yeah. And it's somehow, okay, I don't get down with that psychology. I'm always like, the thing is, is that you have kids, I think about this all the time. My kids will grow up and they will see the history of my legacy of what I did online. And I never want them to see that I taught them to be kind, not to be a bully and to treat people with respect while I went online and did the complete opposite.

I'm like, no, no, no. Yeah. That's what I'm like, that's what on my deathbed would like. I don't know, keep me one foot out of the grave, 

Jill Ingenito: but like, I don't know about this. Yeah. I mean I had like no coaching in this space. I just was like, I'm just gonna start somewhere. None still. Right. I don't think a lot of people do like, and that's now people are like, well you have $25,000.

You need like someone to help you and I do need help. But like, I don't know, I'm just kind of learning as I go and just trying to kind of go back to that same mission of like, I'm just trying to make, provide education in this space. Make patients like see that we're not all Yeah. Like this. Like yeah.

There doesn't need to be so much like hate against endometriosis like doctors and OBGYNs. Well, 

Dr. Brighten: [01:55:00] gynecologists man. People hate, they hate gynecologists. Like gynecologists. It's crazy. Some like definitely have like welcomed in that hate by being really awful humans to other humans who are in pain. Yeah, and I get that, but I think it's so important, exactly what you said of like demonstrating that like it's not a whole field, it just happens to be that you've run into like some really unsavory ones, right.

Jill Ingenito: I mean, most of the gynecologists I know and I work with are really good people who wanna help people. Yeah. Like I've, I don't, I don't come across like these people who show up every day and say like, I don't wanna help these people. Yeah. I honestly think it's that we don't know what to do. Mm-hmm. And so then their ego steps in and they're like, well just get an ultrasound and take the pill.

Yeah. Your ultrasound's normal. Have a great day. So I think that a lot of the hate that's come for gynecologists is just speaks to the large gap in education, in the chronic pain and in the endometriosis space, people do not know what to do. 

Dr. Brighten: I always say no one went to medical school because they didn't wanna help.

They absolutely wanted to help. And the other layer in that is that [01:56:00] insurance ruins everything. Right. It literally ruins our insurance and the pharmaceutical company. They so wisely played the patience to say the doctor is the emin enemy. Well, they raked in all the profits, but told the patient that the doctor is just the money, hungry, greedy, all of that.

I'm like, that's literally pull back the statistics of where money flows and it's not the reality of it, but these big corporations sure did play us all against each other. Sure. I wanna ask you, so for someone who's newly diagnosed or still searching for answers mm-hmm. What's the most important thing you want them to know about living with endometriosis?

Jill Ingenito: I think that, well, I would say endometriosis will not or should not, it's not an automatic death sentence or life sentence. Like there are ways to help. Is it perfect? No. But there are ways to help. And I think a lot of people feel like a ton of relief once they know they have it. But then also they go into this next stage, which is like, how am I gonna live with this?

[01:57:00] What am I gonna do? 

Dr. Brighten: Mm-hmm. 

Jill Ingenito: Um, my whole life I, you know, it's gonna change my career path and whether I have kids and all of this stuff. I think it comes with the diagnosis comes with a lot of questions about your life path. Um, but I think the one thing would be, you know, there are things that can help.

There are people out there that wanna help you. Um, it's just finding those people just feels like a little bit impossible, um, of a health journey. So you just have to be persistent and you have to be, have someone in your corner that can advocate for you. And so, and surrounding yourself with those people.

That's what I would say. 

Dr. Brighten: Wow. This has been such an insightful conversation and I'm gonna link to your social media. Okay. So people can find you 'cause you are funny. Okay. Promise and funny. You make learning fun. I try. 

Jill Ingenito: I try. 

Dr. Brighten: Well, thank you so much. Thanks for having me. Thank you so much for joining the conversation.

 

If you could like, subscribe or leave a review, it helps me so much in getting this information out to everyone who needs it. If you enjoyed this conversation, then I definitely want you to check out [01:58:00] this.