Well, I'll let you guys at least start reading, okay? All right, so for our first case, we have a 42-year-old female presenting with new dyspareunia that has been worsening over the last year, urinary concerns, and an inability to tolerate genes at all for the last six months. For the last eight years, though, she could only tolerate softer genes for two to four hours. She's also having other symptoms, including joint pain, brain fog, anxiety, and poor sleep. Her birth control pill was stopped when she turned 40 due to her blood clot risk. Since stopping birth control, her periods have been much heavier and more painful, and now she's having severe anxiety and mood concerns in the week before her periods. And so if we go on to her exam, and I can go back for you guys to see that, but her exam demonstrates pretty notable vulvar and vaginal atrophy, and her pelvic floor seemed to be okay once she stopped guarding during the exam. She did not tolerate SSRI trials, and norepinephrine or Agestin worsened her anxiety and depression. Dr. King, is there anything else that you would do to address her endo and PMDD? This whole like you turn 40 and can't be on hormonal suppression, what is that? Right? Are you with me? Okay, next slide. That's number one. Did she have diagnosed endo? No. So she's never had laparoscopy. Okay. Did she have problems getting pregnant? Is this like pimp the professor? What is happening right now? Am I doing this right? Okay, then let's just say yes, she does have diagnosed endo, but it was previously well controlled. Perfect. Okay. Okay. And then she was on hormonal suppression and then her periods were fine. She felt good. And then they said, you turn 40, so you can't be on this anymore. I have some thoughts. And then let's say she just started vaping. Good for her. I'm just kidding. Don't do that. She has a lot of nicotine. Don't do that. Okay. So progestin only is completely safe. Yeah. So I would start progestin only something. I usually do like north syndrome five or marina IUD that would bridge her to like 48 and you can put a second one in. So I think if you just stop. for periods with progestin only, that would be my recommendation. Now if she doesn't tolerate the norepinephrine. All right. So she doesn't tolerate the norepinephrine. What's her physical exam? Does she have pain, uterine pain? Hard to say. So my differential is going to be pelvic floor spasm with possible adenomyosis. So endo and adeno are really closely associated. Has she had babies? I'm sorry. I'm asking a lot of questions. So if she's had pregnancies, too, that could increase your risk of adeno. And so I would then be looking at the adeno picture. And so if she's not tolerating adrestin, I'd say Mirena IUD. If she says no Mirena IUD, take it out, TLH. Has anyone ever really used a ton of like drosperinone only? Because I've been doing that for a ton of PMDD and people that can't do oral estrogens. And so I've been finding less mood impact with that. So I was kind of leaning towards that. »» I think this is somebody who would do really well with a TCA or mirtazapine, honestly. Like if you go back to that case, so she's not sleeping well. And I honestly, I know she's got weight gain, but I would just do very, very low dose and I'd focus on just trying to get her feeling better overall. If she's sleeping better, maybe she'll be more active. And either the TCA or the mirtazapine will help her sleep better, the TCA will have less weight gain. And then that might help her with her pain as well too on the pelvic floor. »» Not the heavy duty. »» No. That I can't do anything. »» Because the other consideration is that, you know, she's probably perimenopausal too. And so like if Slynn, or sorry, she's using drosperinone and ethanol estradiol, and so she was getting some estrogen replacement at that time. And so if we just did the Slynn and we're concerned about the VTE risk, you guys could always add on transdermal estradiol, which is totally safe and fine. You're just changing the delivery. And so, for her GSM, she was initially treated with vaginal estrogen and referred to PT, which helped her baseline, but she still had bothersome OAB. And so then we added on a beta 3 agonist and her OAB was well controlled, but she's still not tolerating the jeans or tight pants at all and her vulva's constantly burning. When we repeat her exam, her vulva exam still has notable atrophy, but the vagina is not atrophic. Is there anything you would do differently at this point? I'm out guys, this is all you. Normally, I would normally add on either like a combo of compounded E and T, or I would do DHEA. Typically, I have less issues with compounding DHEA because it's not a scheduled drug and you're getting conversion to both estrogen and testosterone, and given that the vulva has more androgen receptors, that's probably going to be a lot more helpful. So then you added on DHEA, she's lubricating better, having better tissue arousal, sensation, pleasure. She's no longer having pain with intercourse, but she still can't tolerate tight pants or jeans and still having vestibular burning day to day. What are some topical treatments we would consider? »» We never started amyotryptiline on her, but that's definitely something you can consider. You could consider delta ligand in that situation, that helps. There's also a lot of just kind of thinking more herbal and over-the-counter. There are actually capsaicin studies that can be really useful. »» I would just stop wearing tight pants and jeans. »» Take them off. Take them off. »» Just wear some comfy stuff, right? »» Like people. »» Yeah. I actually do that a lot too. You know, like they come in and they're wearing the tightest. I'm like, I cannot feel good. I mean, it just can't feel good. It can't. »» Now, Beth and Ingrid, are there like any specific tools you would use for patients for like entroidal pain besides like dilators? »» I would probably have her switch from a dilator to a vibrator, starting really low vibration, just really small doses so she can do even external. If she's really sensitive, sometimes they can do vibration over their underwear for very short periods, like two minutes every day and then get more tolerant to that. And sometimes that just helps them not only desensitize, but not be so afraid of contact there and wiping, that type of thing. »» I would also like to look at, so way back you mentioned that she had left buttock, low back pain. Look at if there's some origin of issue going on from the hip and the back that needs to be treated and the abdominal area. So I don't know if she has other history of scar tissue, whatever it may be, but there can be a generator from any one of those locations. So whether we do soft tissue work, mobilization, fascia releases, I've had so many patients who have vulvar and pelvic floor symptoms and I go in the abdominal area or in the hip area and those symptoms get a lot better. So I just want to look at drivers from another area to determine, you know, is that feeding into it, especially because she's had it so long, and then a little bit of central sensitization just because, what is it, eight years I think total, right, so a long time. So is there something else we need to do, bring down in other ways that can help her with that as well? »» And then are there any like tissue manipulation techniques you guys recommend to patients like prior to sex or incorporating into foreplay? »» Sometimes I incorporate. So we will do dilator work or vibrator work, but I teach my patients what to do on their own. And a lot of times I teach them about the positions that can cause the least pain or is less threatening to them, depending on the person. And we incorporate doing stretching, lots of lubrication ahead of time so that when they do try to have intercourse, and I say sometimes intercourse is going to be a little bit of work at first so it's comfortable and easy to do, and then it becomes a little more natural and enjoyable. I wish it could be enjoyable right away, but for everybody it's not necessarily so until they get back in the saddle I guess I'll say, and they feel more confident and comfortable. I don't know why I came up with that one, but I just feel like you kind of have to crawl a little bit into the fear, and you know, she's had this pain so long and just the hesitancy to have intercourse can be a big part of the problem. So even if her pelvic floor seems okay, we kind of have to treat the whole brain-body thing again with that as well. So I would highly recommend teaching them how to do that, or if they're comfortable do it with their partner, right. Have their partner involved in it. Some patients are like, oh no way, and other patients are like, cool, I'll bring my spouse in, I'll bring my significant other in with me and we'll do it. And they learn things together. So it's kind of interesting, that's really patient-driven and what they're comfortable with. »» Okay. Any other comments on that? Really fun perimenopause patient? »» Okay. So second case. We have a 61-year-old female with the above bowel concerns in addition to some urinary urgency and frequency. Her exam demonstrated high-tone pelvic floor dysfunction and atrophy. Dr. Talen, what are some things you'd recommend for a basic bowel regimen? »» I would make sure, do we have normal transit constipation or slow transit constipation? Get a SITS marker. This sounds like it's probably overflow. Constipation with intermittent diarrhea. It could be a mixed picture, but most likely it's going to be an overflow picture. So I'd get a SITS, make sure you know exactly what you're dealing with. That's going to really help you to target what you do. Because if you've got somebody with slow transit and they're retaining all 25 of those markers, the colon's so hypomodal that it's unlikely you're going to get any benefit from those lifestyle and dietary modifications, you know, the basics, exercise, diet, water, fiber. A lot of these patients as well, too, get bloating just generally at baseline. So adding something like fiber is not going to be in your best interest. And I'll skip that part. So in this person, let's just say I did the SITS, and they have slow colonic transit. I would go to those secretagogues that we talked about, but only if they had tried and failed an over-the-counter osmotic laxative. And I just think that we probably don't teach patients enough about titration of PEG. They'll use one, and then they don't realize if you just use one capsule, you're not going to get an output. You've got to consistently use it. You're going to see some output about two or three days later. Yes, sure, when you do a colon cleanse, that's a very large amount. That's why you're seeing the output. And then finding, I call it the Goldilocks, like how much is too much, how much is too little, finding what's just right for you. And that depends. Are you somebody who lives in a place that's really warm and you sweat a lot? What are your physical activities? How much water do you drink? I think all of that is really important when we teach bowel regimen. »» Great. Now, since starting her bowel regimen, she's now having fewer episodes of diarrhea but still having a hard time passing stool. Her stools are now formed and soft, and she's still having like abdominal pain and bloating day-to-day. Are there any like specific dietary or lifestyle recommendations you'd offer? And PT can weigh in on this too. »» So at this point from my end, we've got the quality of the stool fix, but we don't maybe, and maybe even the quantity. So now this is just kind of fine tuning. So I would tell you that this sounds to me, and again I bring up the tuba toothpaste, it's either the squeeze isn't coming out, you're pooping with the cap on or both. So it sounds like she's doing some type of dysenergic defecation that we've identified. I probably would have figured that out earlier too, because I would have done a DRE and just this is a poor man's manometer, like you can do the exact London classification, squeeze, cough, bear down, and you can tell who's gonna have discoordinated function. So I may have already sent her for anal rectal manometry, and then, and sometimes I'm just like, just go straight to pelvic PT, like you don't need a manometer, we just did in the office. So pelvic PT, and I would say that because she's still having abdominal pain and bloating, now that we've fixed the constipation, this is the fifth domino, bloating, let's do a breath test, right? And let's see if maybe treating you and getting you back to baseline and kind of decreasing the colonies gives you some efficacy and some decrease in symptoms. Okay, so we referred her to PT, she started on vaginal estrogen, any like specific approaches for this patient? She needs all the therapy. So I think she needs to make sure, we need to make sure she's moving her body. So I think first off, make sure she's moving. She definitely has the high tone and the discoordinated pelvic floor. So I would probably start with biofeedback, I think that's a pretty approachable way to start with these people and a lot of education. This is what your muscles do, this is what they're probably doing, and this is how we can fix them, how to poop, how to position herself on the toilet, start that way. And then depending on where we go with high tone, I would say this person's probably headed towards using the balloons or balloon retraining too, which is similar to the manometry balloons that we saw, but we use them in the clinic as education tools. So looks like a little Foley catheter and I can blow it up with air or water and then we can practice coordinating abdominal activation, pelvic floor relaxation and get to some changes that way. Just going back to the dietary and lifestyle, sometimes I like to know when they're eating things, what they're doing it with, what the stresses are when they're eating. Going down the line, I'll have them fill out a bowel diary because I want to know if their connections of what they're doing that is increasing the gas or increasing the bloating or the discomfort. I also want to know again, what's going on abdominally with this person because they probably do need, whether it's a colonic massage that they can do on their own, whether it's soft tissue work, things that I teach them to do to release the tension within the abdominal area because I've had lots of patients that have the pain, but once we're able to get things loosened up and moving, they suddenly reduce that gas and that bloating. So I do want to look at that. I think all the other things are really important to do, but I also want to look at the component of what's happening in the musculoskeletal system to see is that contributing. Again, I've had a number of patients with when they look, there's so much gas. I don't know how they're walking around with that much gas in their system. Or having bowel movements once a month. I've literally had patients bowel movements once a month and they look like they're pregnant. So it takes a lot of work to get that through. So I think we need to look at all of those components to help them 100%. And then I fully agree on the movement component because we are so much more sedentary. We're not meant to be sedentary creatures, yet we are, and that contributes a lot to this low motility, the bloating and so forth. So really looking at getting them to diaphragmatically breathe. We're a canister, so every breath we take, our diaphragm works with our pelvic floor. So we want to sync that up, and she's got the dysenergy to begin with, so the bowel movement positioning and all that I think is so, so important in this patient. And when you talk about FODMAP, because you mentioned FODMAP, just remember FODMAP, at least when we teach it, it's not meant to be a forever diet. It's meant to be teaching you what are your triggers so that you'll know, hey, if I eat a Brussels sprout or if I have an all cauliflower diet, like lunch or something, you know you're gonna get the bloating. And part of that is not because, yes, you can avoid it if you don't eat it, obviously, but you can also make a risk to benefit ratio of do I love this so much that I'm willing to deal with the aftermath and now I'm gonna wear my loosey-goosey pants because today is the day that I'm gonna eat sauerkraut. And whatever, people are into a lot of those prebiotics. Anyways, so just making sure that they understand how to manipulate that diet and not getting into a point where they are just restricting their diet too much, right? Because I see that a lot too on the flip side is that they are eating a piece of rice and licking chicken and they still have the same symptoms. So I just, I worry about ARFID a lot in these situations. I like say that in jest, but it happens. Like people come in and they're like, I still have the same symptoms. So making sure they understand how to use FODMAP correctly and then going over habits. When is your gastrocolic reflex? When's your time of the day that you normally, like say it was the quietest day on the weekend and when does it happen? Is it after a little caffeine or is it just anything in the morning, right? Because it could be stimulated by anything. And if it does and it's working, then let's see if we can draw that back to your lifestyle. Is there some time we can carve out in the morning for yourself? And then from the FODMAP diet, I have so many things to say about FODMAP, but there's a new thing called FODZYME. I don't know if you guys have seen this. So essentially it's, the creators are brilliant. It's basically Bino, like all the cellulase and all the veggie enzymes that you get in Bino, but it's a powder that looks like a little packet of like an energy packet, whatever. You sprinkle it on your food. So you're getting the enzymes as you're eating. So it's already breaking it down. So you're not waiting for that little Bino after you've eaten or whatever. So it's in the moment. Brilliant. So there's a lot of that that's kind of coming out. FODZYME, YME, FODZYME is just one of those companies coming out with that. And then going back to the risk benefit ratio. If you love it and you know that eating it gives you those symptoms, and now you understand where the symptoms are coming from, what that will do is that will help them to decrease and get rid of some of that catastrophe sort of, we get a lot of psychogenic nausea. Like if you know something's gonna cause nausea, you can kind of almost will it to happen. And so it's the same thing with that as well. So finding that area to give yourself a little generosity. I ate it. I'm gonna be a little gassy today, but it's okay. I loved it. I wanted it. And I know what's happening. And that education is key, education. Does anyone have any other complex cases? Because I was like, I don't know what else to add to make these more complicated. Anyone? Sure. Absolutely. So I put everything, even though those drugs, you know, like we have an algorithm, I actually don't put any of that stuff in. There's no golden ticket, basically. So everything's on the even playing field. And I will tell patients, as long as it's not gonna cause dilly or something like that, we can explore a lot of, there's a lot of things I don't know about, right? Like there's a lot of different types of medicine I might not know about, but you may find a route that is beneficial, that has some probiotic in it that's specific to you, that works for you and this combination. But I always look on the back. Let's look on the back. Let's be curious. Oh, there's a ton of fiber in this. This has aloe in it, which is anthraquinone, which is what Senna is. And, you know, I mean, if you wanna buy 15 pounds of aloe every day, every week, whatever, and core it out and make a smoothie, knock yourself out. If you wanna go to the dollar store and buy like a, you know, 300 tablet thing of Senna, you can do that too. I want patients to understand what they're doing. So it's all on the same level playing field. Magnesium goes in there too. What else do I use over the counter? People love aloe. They come to me with all sorts of different versions. You know, there's ballerina tea and there's all sorts of stuff. Heather's tummy tamers and whatever. I put it all in my bag and we'll use it. And if it works for you, great. Now, we get to the patient's refractory. They've tried the over-the-counters. They've tried the pegs. They've tried those secretagogues. They've tried the new kid on the block, tenapanor. I didn't mention there's this thing called Vibrant, which is actually a vibrating computer, a little pill that you can swallow. It has a sexy little pod, comes in a blister. You pop it out, you put it in the pod, you click it down, it turns green. It tells you it's on. You swallow it. About six to eight hours later, it's gonna turn itself on. It's gonna do that. Remember I said segmentation? So it does cycles. It kind of turns itself on, turns itself off, turns itself on. And so if you're thin enough, you can feel it. Now again, two things. Well, a lot of things, but two things. You gotta make sure you have a SITS marker because if you've got somebody with colonic hypomotility, then you're gonna end up like I did last week where I had to fish 14 out. And by the way, our Roth net, our little net, is only big enough to carry two. So I did nine colonoscopies because I dropped one on one patient. I'm like, I was exhausted. Anyway, so they were all in the SECAM. So it's a certain type of patient. They haven't had surgery. They don't have hypomotility, et cetera. The other thing is you have to think about where they live, septic tank. Do you care about the turtles? I don't know. Maybe you don't care about the turtles and you just want a bowel movement. That's fine. I'm not here to judge. If it works and it's approved, go for it. So I do have a handful of people who are on Vibrant and they do really well with it. But yeah, and then there was another thing. How big is that? I have so many questions. It looks like a potassium pill. Okay, so a little bit bigger. And it's smooth and it comes in a little blister and it has that little pod that you. I want to put it in the vagina. I'll slip it in there. Does that help with anything? I don't know, I guess. I mean, you might have to go fish it out too. It would bring like blood flow, no? Yeah, I mean, that's a good thing for Vibrant. But yes, so everything is on the same level playing field. And the day and times of us constantly having to get an appeal prior off, talk to people to help them understand why we're picking what we're picking. Sometimes I don't follow that algorithm because I know I want, oh, I didn't mention Motegrity. Motegrity is a serotonin agonist and Motegrity is lovely percalipride. We didn't really talk about that one. So you have serotonin agonism throughout your gut. And thing is, it's great for constipation, but it's also really useful for things like gastroparesis and chronic intestinal pseudo obstruction because you're trying to activate some of this, you're activating the gut where it's slow and dysmodial. But it's not the first thing that's gonna get approved. So you have to, and documenting and making sure you've tried all those things beforehand will be really helpful. So that ways you can get your patient these cool new drugs. No, I have not, unfortunately, I know. And that's where those clinical trials that are looking at like TEMS, you know those big magnets I was saying that are modulating the sacral lumbar region that can be driving the etiology of the pain, but also the function right through that pudendal nerve or whatever nerve system is happening, that can be really, really useful. So maybe pointing them towards an academic center that's doing something like that could be really helpful for them, you know, and then maybe they might get it implanted, but under the clinical trial, yeah. So I'm very quick to ultrasound. It's very low risk. There's really no reason not to. So I think you need to rule that out right away. So in my mind, anyone with change in bowel habits, pelvic pain of any sort, a transvestite ultrasound will tell you right away if there's something going on with the ovaries. So I say that should be, in my opinion, very first line. In regard to screening though, and someone who doesn't have any risk factors and is asymptomatic, that is a really hard space because CA-125s aren't great, transvestite ultrasound isn't great, and then you start catching things that you don't need to do anything with, and then you go down this whole entire other rabbit hole. So in my mind, I do recommend bimanual exams on everybody every year, and I know that's not necessarily what everyone's doing, but I still have patients come back every year for a bimanual exam, but if they're asymptomatic, no genetic history, exam is negative, I don't just do screening ultrasounds. Yeah? Do you agree? And shame on whoever's the gastroenterologist that's not doing MR. So we use, we've kind of gone away from doing a lot of surveillance exams as long as there's no dysplastic tissue that we've ever seen. So we have other tools. We get calprotectin to tell us whether there's inflammatory activity in the gut, which is a stool test, right? And then you can also use MR or CT enterography. We tend to do MR just because obviously you're decreasing the amount of radiation. A lot of Crohn's disease patients are young, so you want to limit that radiation. But you would be able to see something on that, you know. And yeah, think outside the box. Like the moment that something's not, you suss out that it doesn't feel right, it's low cost, doesn't have any, you know, there's no backlash on that for sure. Any other questions? Yeah, so we don't really use Abastin, but we do use antihistamines for sure. Most patients though come in and in this situation, you know what else they would have said other than I look nine months pregnant, do I have SIBO? They're obsessed. Social media, they're just obsessed. They think SIBO's the answer to everything. So I guess it depends on how refractory they are. I had a case the other day. So I had a kid, she's got gastroparesis, but she's on TPN, she's got a PEGJ. She has had two pyloromyotomies and she's convinced that the pylorus just keeps shutting down because somebody did an upper GI and it was kind of still doing its job. And she wants a Roux-en-Y, but she also has fibromyalgia and pelvic pain and all these things. Taking your stomach and reducing it to a four centimeter pouch is not gonna get rid of any of that stuff. So that's a person that I would say we've gotta think outside the box. That's someone that I think, and again, it's that criteria, like Rome criteria. What do we call this? I don't know what we call this. We have some data that's being looked at with AI that is trying to tell us sort of where to class these people are these more GI predominant pain patients or are they more pelvic pain patients or are they more psych pain patients and what's driving that. And so I think that AI is gonna be really useful for that in the sense of like building models to try to tease out what we first do with these patients. Neuro gut modulation is where I would go with this person. I would modulate them because there's something happening that I can't control and it would have to be after I had built a patient provider relation. Now, this kid saw me the day before she was gonna go have a roo on Y. I mean, I was just wasting my, I wasn't gonna do anything. So I was like, well, unfortunately, I've seen a lot of these things don't work so I'm here for you if potentially you have symptoms that return. So yes, I think that's when you get into those refractory cases. And I have, oh, mast cell. Everybody's got mastocytosis. That's the, yeah, yeah, MCAS. Everybody's got MCAS. And so I love my allergy immunologist and thank goodness for them. And I'll do mast cell biopsies pretty much on all these patients. So I biopsy the gut. I'll do small bowel, stomach. I'll throw in esophagus. I kind of, I just like pan biopsy these kids. I do the disaccharides. And that way, I never have to scope you again because you've already had just like the kid I scoped last week and I did not make the decision to put this person for another EGD and colon. That was her sixth EGD and colonoscopy and she was 31. And there was, I mean, I knew from the get-go meeting her on that day, I was like, this is a disorder of brain gut and there's no amount of procedures. So for that person, I thought, well, you know what? Let's just rule out and make sure there's no mast cells. And then, you know, sometimes it's that one case and you find it. Oh, absolutely. So, I'll tell you what's more complex than the GLP-1s, because GLP-1s usually have a start and end date most of the time. Although, yeah, we're getting into that spa treatment, I'm gonna be on a maintenance dose, I love it. And I do have one patient who failed Viberzi on the IBS diarrhea side, and we couldn't, we tried an opiate combo, we couldn't get her diarrhea controlled. And she just happened to go, like she did not need to lose weight, but she went to a spa and she got on one of those, and she has control of her diarrhea, so I was like, all right, I hate what's happening here, but I love it, so please see your PCP. Yeah, I'm gonna turn my, exactly. What we have done is, for that patient population, we have, we stop it a week before for procedures, because there is an increased risk in aspiration. And yeah, I get a lot of gastroparesis symptoms. So then we have the discussion, the honest discussion. What's more important to you, what's necessary? If you're someone who's headed down the path of metabolic syndrome, you're 40, you've had a heart attack, you're a walking dog talking, like, you know, ticking time bomb, then I would say GLP-1s in your best interest. And then we will make, we will deal with the bed that has been made. If you are a 46-year-old who has been incorrectly treated and is on, true story, Fentanyl patch and getting the Dilaudid, it's that drug that starts the D, the, and I'm like, you know it's Dilaudid. Don't bullshit me, you know it's Dilaudid. If you're on Fentanyl patch, Dilaudid, and you're on opiates, and you don't need to be on opiates, that's somebody that we think about, you know, the whole village and clinical trials, and that's somebody that I would not, that I would say, like, you've got to, I wouldn't do, like, that's not a bed I would deal with, right? So I expanded that. Mm-hmm. Yeah, so just stop, stop it. Stop it and tell them, let's do a trial. Stop it for a week, and let's get a gastric emptying study. And let's see if maybe we unmask something that previously we hadn't really been aware of because we didn't put those cardinal symptoms together and say, ooh, you know what, that sounds like gastroparesis, but this unmasked it, because it made your dysmotility even worse. But again, I think it depends on the reason why that person's on that drug. If it is for a good use, if you are headed towards NASH or MASH, or you're headed towards cirrhosis, and this is a great way for us to manage that sciatohepatitis and diabetes, I mean, come on, we'll deal with your abdominal pain. Yeah. Yeah, and it's hard, and I think, you know, I make a joke about, I make a joke about the pants and everything, but I really tried to, like, we've got to normalize, like, what we look like, and, you know, it's okay to have a little belly fat. And, you know, what really matters when you're 80 is not if you can pinch a roll of fat, it's do you have balance, right? Because what happens, you fall, you break your hip, and within one year, you're dead. I mean, that's just it. So who gives a shit about the fat, right? But we have to do that, we have to teach people that, and we have to, like, say it's okay. And I've, like, given people, I ask them, you talk about bloating, do you fart? I know that sounds like a silly question, but there's, I mean, this is a room full of women. Sorry, sir. Sorry, sir. But, you know, society tells you that is something that is not okay. Do you pass gas, do you pass gas at home? Like, is it a joke? Like, I'm glad when I hear, oh, yeah, it's a joke, and my kids make fun of me, and my husband, or my wife, and whatever. Like, that's great, I love hearing that, but there's a lot of people who don't. And so I think sometimes it's about thinking outside the box, like, why is this failed? You have to ask those questions. So I have prescribed farting to someone. Nice. Good for you. I mean, that doesn't go in Epic, but. You can't bill for that. There's no code, but. Oh. Yeah. Ask your partner if they care. First question is, ask your partner if they care, or they're like, oh, she's so pleasured, she's just letting it all hang out, you know? Like, okay, good, great. I just, we have to help people, let it all hang out, and just be people, and you know. It's just. In clinic, we encourage them to fart. We're like, that's a good thing, good, go for it, you know. It's a bodily function. And you can tell her, at one time, you have about one Coke can worth of gas in your gut at all times, so that, too. When we're talking about FODMAPs, I ask, do you chew gum, do you, in the day of, like, teeth whitening, do you drink through a straw? Anybody has a straw in here? You're just drinking air. Are you on a CPAP machine? You're just swallowing air all night, right? So there's other potential reasons. So, yeah, so I lost my train of thought about what I was saying about gas, but essentially, there are other reasons. And just when you go back to, like, some of the medications, too, because some of the newest medications, weight loss, all of that, what's happening is these people lose a tremendous amount of muscle mass at a time in their life when it is the worst thing that you could possibly do, so those menopause transition, people are all worried about their weight because they can't control it, they've got a gut. They're losing muscle mass, so unless they are counseled to go do resistance training and weight training, which, by the way, we should be doing, they will lose this muscle mass. It looks like they're losing weight. They're actually sometimes gaining adipose, like visceral adipose, and they're losing muscle mass, so we really, really have to watch that. Yeah, they're becoming sarcopenic, and they look like patients who have chronic liver disease where you're just, like, you've eaten away all your, like, you're tapping into any piece of glucose that you can to stay alive, right? Just break it down for people. You need glucose for your brain to work. Is it more important for your brain to work, or for, you know, whatever. You just have to, like, break it down for people, and sometimes you're gonna win, and sometimes you're not gonna get through to them. Well, that was very informative. Somebody had a question in the back. Sorry, I don't know. Please do. We love guest talk. Queefing. Primary care referred two people to her because of queefing. Yeah, vaginal flatus. First of all, has anyone checked, like, is that an ICD-10 code? It is. Vaginal flatus. I love it. I'm totally gonna tease the fellas next week with something like that. I'm gonna bring it up somehow. I don't know how that I will. Yeah. Ring, ring, and talk to that primary care provider, and say, what the hell, man? Like, go over, like, treat the patient, but, like, figure out, like, why it is that they sent to you, because that's a normal thing that can happen. Again, that's like saying to somebody, you know, don't, like, don't pass gas. Normalize it, normalize it. I did just get an order for that within the last month, and she just needed a lot of education, and she was semi-recently postpartum. I can't really remember, so she got the strengthening, but a lot of the anatomy and the education and the change in your vagina is okay after you have a baby, and everything's okay, and usually, if it was with intercourse, that was bugging her, and we kind of had to have the, just have to still enjoy it, so it's not really, you know. It's your body. Yeah, a lot of TLC about it. I mean, oh, for sure, for sure. So if you've got somebody who has Crohn's disease, Crohn's disease, not ulcerative colitis. Ulcerative colitis is just gonna stay in the mucosa. You have to have intramucosal disease that goes through, so if you've got Crohn's disease, and you've got somebody who has fistulizing Crohn's disease, yeah, be suspicious. So in that situation, in that situation, if you have a Crohn's disease with somebody who's fistulizing, and they're not on a biologic, or they're on a biologic, and they're failing, and they're refractory to any kind of medicines, then that's somebody that you need an MRI, and that's someone who needs to, you have to involve colorectal, and that's somebody that you need to do a colon to make sure that their disease is stable. Now, if you do the Calprotectin, for example, and it's negative, and then you just make sure with your MR, or you throw in a colon, and it's all negative, that's not a fistula. Oh. I'll tell you how I do it, because I'm tertiary, quaternary, and Katie was in here earlier. We get a lot of stuff from the community. I think you just make yourself available to these people, and you just call, and you say, hey, I'm just calling to talk about our patient, and I just saw them in clinic, and kind of here's what I'm thinking from the GI standpoint, and here's my cell phone, and feel free to call me or text me, and I think that's a good way to do it. Call me or text me, and I think that's what you do with the community, not the patient. Not the patient. Don't give them your cell phone. But I think with providers in your community, and we talked about it's not a silo, right? It's a village. I think you make yourself available, and that way, maybe you can answer a question before it becomes a referral, and nobody's wasting their time. Well, then you have to send them to GI. But that's not a good referral. That's a go straight to GI, pass, right? Like that was, yeah. And it's not just Crohn's. You can think about other reasons that you get the shill eyes, so diverticular disease, people who have really, you know, very poor fiber intake and have diverticular disease, and you can think about other reasons that you get the shill eyes, so diverticular disease, people who have really, you know, very poor fiber intake and have diverticular disease or genetically have that predisposition. I don't do a lot of this, I'm endo, but I would imagine, like, queefing alone isn't, like a fistula that's causing queefing, there's gonna be a lot more symptoms, right? Like you're not gonna show up and be like, oh, I have Crohn's? Oh, shoot, I didn't know I was just queefing at yoga. This is some, yeah. Right? Like I'm pretty sure you're gonna have some other things going on. This is someone who has blood, mucus, diarrhea, losing weight. There's other systemic symptoms, plus the queefing. Yeah, so I think it just, again, is that clinical picture of, like, what makes you alarmed, and I think if you're getting it from, like, the same person over and over, like, we have a hospital, an academic hospital, and we have some groups that just, they just keep consulting us for what the fellows say are silly things, so I think if you're gonna go into private practice, let's just, cha-ching, cha-ching, cha-ching, easy, right? From a consult, but it's also maybe important to take some time and just do a little education, but this time, provider to provider. You had a question. Yeah. Yeah. I do too. I do think you have to, you know, obviously, you have to be aware of your language. And I know you were just saying it, you know, this is where chat, your secretary is really helpful. You're like, please help me say this in a really professional manner. This is a stupid ass consult. I do that when I have to tell the fellows that they're getting on my nerves, I'm like, oh, so my artificial secretary. But I think that establishing those, that establishing those connections are really helpful for our patients, you know. And then just setting a standard, like in my group, if somebody sends me anal rectal manometry and they haven't done a DRE, you're going to hear about it from me. Because you can't tell me that you think this person needs anal rectal manometry and then you never did a rectal exam. And then I go in there and I find something else. I found one lady had massive fibroids. And they were just, all it was, it was causing this like prolapse into her rectum. And I'm like, well, first of all, I can't even put the manometer in there, because this thing is going to say it's positive all the time, right. So it's like a wasted slot. I have people booked out until December. We're the only academic center on the West Coast of Florida. So in that situation, I'm pissed, because the system doesn't allow me to help people. And you just created a situation where I could have already taken that patient and done something else and then provided someone else care there. So then I, in that situation, I go straight up to my colleague and I'm like, dude, you ever heard of a rectal? Because it's usually the guys. I'm sorry. It's usually the guys in my group, you know, so.

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