Your dizziness when you stand up is real. Your pelvic pain is real. Your fatigue is real. And there's actually a connection between all of it that most doctors were never taught to look for.

If you've ever been told your dizziness, palpitations, or pelvic pain is "just anxiety," this episode is for you. Dr.Dr. Alexis Cutchins is a cardiologist treating POTS and MCAS—she's willing to say 'I don't know, let's figure it out' instead of dismissing patients.

We discuss what POTS actually is, how to diagnose it why 80% of her POTS patients have venous insufficiency, and how treating the veins can sometimes cure the POTS.

We also talk about the connection between POTS, mast cell activation syndrome, hypermobility, and pelvic venous disease conditions that often travel together and are frequently dismissed.

Dr. Alexis Cutchins explains why the venous system is a "lost organ system" that no one really learns about in med school,how left iliac vein compression (May-Thurner syndrome) can cause everything from pelvic pain to back pain and headaches

Plus, we discuss women's cardiovascular health, microvascular disease, coronary vasospasm, and why women's heart attack symptoms can look completely different including neck tightness from allergies that's actually cardiac ischemia.

Highlights:

• You don't need a tilt table test to diagnose POTS simple office based or at home tests can help identify it.
• First-line POTS treatment: volume expansion (drink water, eat salt), compression stockings, treating comorbid MCAS.
• About 80% of POTS patients have venous insufficiency treating it can dramatically improve or even cure symptoms.
• Pelvic venous disease is diagnosed with MRV (not CT) and treated with stenting by interventional radiologists.
• Women's heart attacks can present as abdominal pain, neck tightness, or jaw pain—not just chest pain.
• These conditions run in families mothers and daughters often share the same constellation of symptoms.

If you've been dismissed for POTS, MCAS, pelvic pain, or any constellation of symptoms that don't fit into a neat diagnostic box, this episode validates what you've been experiencing. These conditions are real. They're treatable. And more doctors are finally starting to listen.

Make sure to subscribe to the podcast so you don't miss upcoming episodes on related topics, and share this with anyone who needs to hear that their symptoms matter.

Get in Touch with Dr. Cutchins:

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Get in Touch with Me:

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things. I'm going to do a great intro after we're done. I really do look forward to the whole symposium. I think it's going to be wonderful. It's going to be outstanding. Awesome.

Yeah, yeah, I'm excited. I just love going to meetings that are way outside of my area of expertise. I feel like I get so much more out of them than going to like an ACC meeting and being around a bunch of cardiologists. Yeah, yeah, yeah.

Yes.

Yeah, yeah, yeah, same. mean, right. And you know, talking about sex is so fun. So it's funny because we had Tanya Dempsey on like two years ago or something like that. And it was like, I think she joined Ishwish after that. So hopefully, you know, hopefully. But we're gonna do this. And if there's anything you want edited or removed, Carrie can do that. You can just say, can you cut that or whatever and she will.

Yeah, I mean, awesome.

Sure.

But yeah, we'll go, I'm gonna start, because I have a lot to talk to you about. What's so interesting is there was, and I'm gonna mention this in the talk, there was like a, are you part of the physician community groups on Facebook at all? Okay, there was one that came up today, like it was like the general physician community group, which I'm not gonna say specifically who they are on the interview, but they're like, we're so sick of POTS, like everyone's coming in with POTS. So I think we should talk about how like, you know, all that. Yeah, it's a real.

Some, yeah.

I know.

Yes, it's very real. It's very real.

Okay, awesome. Okay, we're gonna get started and then we'll talk some more after. Okay, hey y'all, it's me, Dr. Smeena Raman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. I'm Dr. Smeena Raman, board certified gynecologist, sex med specialist, and menopause in downtown Chicago. Today I have a wonderful guest who I've been, I can't wait to talk to her about what we're gonna talk about today. But it really is,

Shirt.

a time I feel like where people are more and more, and especially women, are more and more walking into clinics saying, I think I have POTS. And depending on who you ask, it's either a long, overdue and overlooked condition or the most frustrating thing a clinician sees because they don't think that's true or they don't have the time to evaluate. On my end, I feel like in my clinic, I see so many patients that have the triad of things that we're going to talk about, but also, you know,

as someone that treats sexual dysfunction, know, vestibulodynia, vulvodynia, and the matriosis, MCAS, all the things come. And I think it was just a few years ago where I was like, wait, these are all related somehow. And I realized that there's literature out there. So I can't wait to talk to you about this. But I think there's some real frustrations from doctors who don't know that this is a thing or maybe do and think it's more of a zebra than it's probably more common than it is. And then I feel like the community

and the social media and all the things are allowing patients to potentially identify themselves as this. But that's why I'm really excited about my guest today. Who you guys heard in the intro is an amazing cardiologist who recently moved to New York to start her own practice, which we're gonna talk about, but was at Emory. I'm joined today by Dr. Alexis Cutchens, who is a cardiologist who has become one of the most trusted voices in the space of POTS and MCAS and long COVID space.

not only because she claims to have a lot of the answers, but because she actually listens to her patients, she follows the data where it exists, and she follows patients who maybe haven't felt heard. So thank you, Dr. Cutchens, for being here today. I'm so excited to talk to you.

Hahaha

Yeah, thank you so much for having me. I'm thrilled to be here.

Awesome. Well, you know, my sort of signature name is gyno girl because like, you know, I love superheroes. And so I always, my first question I always like to ask people is what their origin story is because we all have like, you know, I want to hear about like how you came into medicine, but also like, how did you fall into the pot's world? Because, you know, some of this kind of fell into it through patients, but I'm curious to hear what you're going to say because no one, I think accidentally decides to take a deep dive into.

Yeah.

Dysautonomia. I switch this cardiologist and so yeah I want to hear all about it.

No, yeah, yeah, it's, it's, yeah. So, I guess the grassroots was, I kind of knew I wanted to be a doctor since I was little. And I don't know why, because I don't have any doctors in my family. This was not something that I'd grown up with. I just felt like it was going to fulfill a lot of my interests. I liked science. I liked talking to people. I liked having relationships with people. And so,

Right. Yeah.

Right. Yeah.

From a very young age, I knew I wanted to do it. So, you know, fast forward to med school. I went to Emory and I had a great experience there. did, you know, what's interesting, I was trying to decide between internal medicine and OB-GYN. And when I started medical school, I thought I was gonna be either a surgeon or an OB. I just really like procedures, really like doing things. I was like, this is gonna be, like, this is gonna be where it is, right?

Yes.

Isn't that so funny?

Yeah.

So I did, I had a special rotation my fourth year with an amazing gynecologist. I shadowed her for a month. It was like kind of a sub-I and GYN so that I could get an idea of if I wanted which residency to do. And I was applying to both residencies at that point, like literally filled out applications for two different disciplines, because I didn't know. And at the end of that month, she was like, I don't think you should be a GYN. And I was like,

Wow. You know.

What?

really? my gosh. Okay. Why? Like what? Give me the, give me the feedback. This is amazing. You know, I'm not used to hearing things like that. And she's like, you just ask way too many questions. You would not be satisfied seeing our population of patients in clinic with pelvic pain and you know, menorrhagia and all of the things you would just want to have more answers. And we don't have time in our clinic to make that happen. So, right.

Yeah.

Yeah. And we don't have answers and we can't tell.

And so she's like, I just think you should go into medicine. And I was like, okay, okay. I appreciate that like very, very sound and good advice, right? So I did internal medicine and then I was very interested in all subspecialties and I knew I wanted to subspecialize because I wanted to kind of hone in on one topic. And I ended up really liking the ICUs. So I was thinking pulmonary critical care or cardiology and

No?

Yeah. Yeah. Yeah.

All the people in the medicine ICU were dying of cancer and had a lot of stuff that couldn't be fixed. And everyone in the cardiac ICU was walking out, you four days later after their heart attack. And so I liked that kind of instant gratification and fixing things. And so, and I also felt like in cardiology, the bread and butter is chest pain, palpitations, atrial fibrillation, you know, these things that are kind of more interesting to me than asthma and, you know, shortness of breath. So I went into cardiology.

Yeah.

Yeah. Yeah. Yeah.

And I did my fellowship. I spent three years doing research because I was really interested in seeing if that was something I wanted to do, if I wanted to go into basic science kind of medical research. this was at University of Virginia. And I realized that that's not what I wanted to do. I was much happier seeing patients, taking care of patients in the ICU, doing things that were very intense, but to me could be kind of shut off in my mind. Whereas with

Yeah. Yeah. I guess it was at Emory as well.

Thank you.

research and grants and publications. It was like never ending. And that was really hard for me to kind of sit with at away from work, you know? So I went to Emory and I took a clinical cardiology position. And like you said in your intro, you know, I had patients coming in with palpitations, young women, you know, they wanted to see a female cardiologist. There's not that many of us. So, you know, I started seeing all these female patients and, that was what I wanted.

Yeah.

right, because I wanted to be a GY, OBGYN to begin with, right? So I was, you know, I was interested in women's heart disease. I was interested in taking care of women. All these women were coming to see me. It was great. One of these women came in and said, I think I have POTS. And I was like, what's that? I don't know what POTS is. I had to literally leave and go ask like one of my colleagues in the other room, what's POTS? What is she talking about? You know, Google it, all of these things.

Right.

Yeah.

He happened to be the one person at Emory who knew what POTS was or really took it seriously. And he actually gave me a very nice definition and helped me understand it and sent me a PowerPoint presentation that he had done. And so I was lucky enough, because if I had asked that question to anyone else, I think my trajectory probably would have been very different. But he was very, yeah.

wish me.

That's nice.

Right. There was that always anxiety or it's in her head. Yeah. Yeah. Yeah. Yeah. That's what I did.

They would be like, it's not anything real. Like, those people are crazy. You know, whatever it would have been, right? And so I ended up getting so educated by someone who actually believed that POTS was real, right? And there weren't that many of them. So I went back and I talked to the patient. was like, look, I don't know what this is, but let's try to figure it out. Like, I'm happy to start you on some medications. Let's, you know,

That's amazing.

Yeah, there's still not too many of them.

increase your fluids, eat some salt, whatever. And so over time, I started seeing more and more patients with POTS and learning more and more about POTS. And I think what's kind of led me down the path that I've been led is my curiosity and my kind of like, want to learn more. I want to know what's going on with these patients. I want to figure out what's driving their symptoms.

I believe that their symptoms are real. I believe that there are things we can do to fix them, to help them. And so, you know, it kind of snowballed, right? And then I started seeing so many patients, I started seeing patterns. And I started learning more about other things like mass solitivation syndrome and venous disease and Ehlers-Danlos hypermobility, right? And so pieces started coming together and coming together. And then, you know, eventually I started doing research and

Yeah.

Thank you.

creating a database of patients and it just kind of escalated from there. But I will say that I think if I had gone into OB-GYN, I would have been taking care of the same population of patients. Or if I had gone into pulm critical care or rheumatology or neurology, I would have been saying taking care of this population. This is clearly where my mind is most interested. It's like, is my lot.

Yeah.

Totally. Yeah.

Absolutely. This is where it falls. Yeah. Yeah. Yeah.

And so I got here through cardiology, which I'm very grateful for because I have like an extra level of comfort prescribing medications that not many people want to prescribe because I've gone through my cardiology training. And so I'm very glad I did it this way. And I'm also glad that I didn't know what POTS was before I started practicing, to be honest, because I taught myself. everything I know is filtered through my first.

I heard.

Yeah.

view. It wasn't like someone told me this is what it is. This is what we do. Yeah. Yeah. So I think that's made me better at treating these patients, you know, and looking for a root cause. Because if I had learned about it any other way, I would have just chalked it up to, it's all, you know, your autonomic nervous system is not working. And in my opinion, that's not the only thing that's going on in these patients, you know? So, so that's the long story.

Right. The biased images of, yeah.

100%.

Yes.

Yeah.

Oh, yeah. That's Yeah, I love that. And most people that have heard me speak, I have a similar, know, similarly, came into sexual medicine that way. And that's kind of how, when I have different people, you know, to talk about EDS or MCAS, some of these other conditions, it's really because I'm trying to get, you know, a grasp of some of the patients that I'm seeing with these, you know, conditions and situations. But there are probably a lot of clinicians that listen to my podcast. I want you to talk like let's

Yeah.

Let's break down what is POTS, how do we diagnose it, and what are we looking at for treatment strategies? Because even this morning, I was telling you offline, there was someone that was posting like another patient coming in. It was a cardiologist who was really upset on one of the Facebook groups because everyone thinks they have POTS now. so he, I'm kidding me, it's not a good machine, but at least, because it was anonymous, but it was more like, oh, and all the answers were like, oh, super tento, super tento, you know. So that's what people think, right? That's a lot of.

Right. Yeah, and it's so frustrating.

Yeah.

Yeah, I know.

And there were a of people that were in there taking it seriously, but unfortunately.

I see these kinds of posts. I mean, we're not in the same, probably same Facebook groups, because we live in different parts of the country and it's usually local and whatever. yeah, I see the same comments and kind of thoughts, you know? And it's hard, right? POTS is something that not a lot of people want to treat. And there are reasons for that, that we could get into, you know? But let me explain what it is.

So, yeah.

heart.

Yeah.

and how we diagnose it and kind of what the strategies are for POTS. So POTS is a syndrome, right? So if your patient has a heart rate increase of greater than 30 beats per minute after going from lying or sitting to standing, they have POTS, okay? So it's not a disease. You can't do lab work for it.

Please.

diagnose it with a biopsy, it's literally this kind of, that's the definition, right? So sometimes people will do a tilt table test and get a little bit more formal evaluation. I happen to do orthostatics in the office or something called a nasolin, which is like a 10 minute stand test. I think both of those are perfectly acceptable for diagnosing POTS. Oftentimes the tilt table test can be normal.

Mm-hmm. Mm-hmm.

And then someone is labeled as not having POTS, but they really do have POTS. And so I, and the tilt table test. Yeah, there's a 10 minute stand. It's also called the NASA lean. And those can be done at home. I have a handout that I email the patients before they come in to see me. I'm like, do this a couple of times before I see you in clinics so that we have an idea of what we're, what the numbers look like in your, you know, in your home setting. So that's it.

And you said there's a 10 minute test, said, you stand for.

Right? So what, you know, I like to rule things out. Like I like to rule out iron deficiency, anemia. Those are big ones. I see patients who get referred to me for POTS and they literally have a hemoglobin of seven and they're just hemorrhaging from their vagina. And it's like, right? And I'm like, did you not even try? Right? So, so, you know, that gets fixed and then they don't have POTS. It's great, you know? And so.

Yeah.

So we look for other stuff. We look for thyroid abnormalities, pheochromocytoma, I rule out in all my patients. There are mimicers out there, but once you've ruled everything else out and the patient still has this rise in heart rate, usually the other part of the definition is that the blood pressure doesn't drop. So the blood pressure stays the same, the heart rate goes up and it goes up by more than 30 beats per minute.

That's different than orthostatic hypotension, right?

Exactly. So orthostatic hypotension is when your blood pressure drops when you stand and that's different, although can be kind of on the same spectrum of illness. It's not, they're not mutually exclusive. You can also have a blood pressure increase with a heart rate increase and still have symptoms of POTS with a 30 beat rise per minute in heart rate. And that is, that meets diagnostic criteria as well, as long as the blood pressure doesn't go down, right? So,

And those symptoms, how would you, for those listening.

So symptoms, right. So the typical symptoms of POTS are dizziness, palpitations, and syncope are passing out. So people will pass out. They'll feel dizzy when they stand up. They get so dizzy that they have tunnel vision, or they feel like they have to sit back down again, lie down in order to kind of avoid an episode of.

syncope, you don't have to have frank syncope to have POTS because a lot of patients have figured out how to prevent syncope from occurring. They can feel these symptoms coming on and they lie down or they sit or they do something that will prevent them from passing out, right? So you don't have to have syncope. A lot of my patients have chest pain, shortness of breath, exercise intolerance. And then there's a whole slew of other symptoms that are cardiac.

Great.

Right? So there's associated symptoms. Patients with POTS often also have hypermobility, chronic pain, migraines, GI disturbances, gastroparesis, IBS, know, yes, exactly. Pelvic pain, you know. So the list, I mean, there's a huge, huge, huge list of associated things. And that's what, you know, when you have a syndrome.

Vestibulonia.

So it's funny, because my patients will come in and be like, well, my POTS symptoms are gastroparesis and IBS, and I get migraines. And I'm like, those are all things that are associated with the patients who have this problem. But are they really because of the orthostatic intolerance that you're experiencing? It's hard to say, right? Maybe, maybe not. There could be other things going on. that's POTS. It's real.

this.

Right, right, right, right.

It's treatable. You know, I start with volume expansion, drink more water, eat more salt, compression. We use lower extremity compression and abdominal compression for patients. That's first line, right? And if your patient comes back after starting those things and says, don't really feel much better, my heart rate's still going to 150 every time I stand up, then I start.

medications and the medication strategies are kind of individualized for each patient because each of them has a little bit of a different flavor of pots. Right. So sometimes we start with beta blockers sometimes we start with calcium channel blockers sometimes I start with things that raise the blood pressure like flujo cortisone middendrin droxydopa. So it just all depends on on that particular patient. But what I tell my patients is most patients with pots also have

symptoms, right?

they're doing.

Other things, one of those is mast cell activation syndrome. And the other is hypermobility spectrum disorder, which can also include things like stiff person syndrome and not necessarily hypermobile patients, but connective tissue abnormalities. And then that segues into other problems like venous insufficiency and pelvic venous disease and.

into the transit.

and other vascular compression disorders, jugular vein compression, know, median or critical, all these other things, right, that go along with the population of patients who have connective tissue problems. So what I do when I start treating patients is not only expand volume and do these sort of POTS strategies, but I also empirically treat a mass selectivation syndrome. And that's because I have patients who don't have any symptoms.

Sure. No, just saying. OK. Yeah, I was going to ask to elaborate because some people maybe have heard the podcast I did with Tanya and Dempsey on MCAST. But if you want to just elaborate on what that is for people that haven't.

Yeah, so MCAS is an abnormality of the mast cell. The mast cell is like your first line of defense for immunity. I like to explain it that if you eat some poison, the mast cell is what figures out that that poison is there, tries to get it out of your body by making you vomit, by making you sweat, by making you have diarrhea, like let's get the poison out, right? So the mast cell is what triggers

Right. Yeah.

allergic response, you know, so it's what causes a histamine release, it causes rashes, congestion, know, allergy symptoms. And so the mast cell has a whole host of activities. And those mast cells normally are triggered by IgE, which is your routine allergy response, right? But when you have mast cells that aren't working properly, they can be triggered by many, many things. They could be triggered by

changes in temperature, changes in the weather, changes in elevation, foods, you you name it, right? There's a lot of stuff. And patients with POTS often have comorbid MCAS, in my opinion, and they don't always have those symptoms. Like they don't always have a rash or they're not always, you know, congested or have seasonal allergies or have food intolerances, but...

you'd be surprised the number of people that actually respond to mast cell targeted therapies. And when they come back to see me, they say, well, I had no idea that this was like related, but XYZ 10 symptoms went away, right? So, what, and I believe it's directly rated related to POTS. So when you have mast cell degranulation, you can get elevated heart rate, can get elevated blood pressure, you can get low blood pressure. But your autonomic nervous system dysregulates when the mast cells are

degranulating. And so by helping the mast cells calm down, you help the pots calm down, in my opinion. So it's part of my first line strategy for treatment. And then of course, I look for markers of mast cell activation syndrome. I try to do a deep dive to see if patients have any kind of blood work abnormalities or are looking for other stuff. But ultimately, if clinically they respond to simple medications like antihistamines, that

are very low risk, then I keep going because I've decided that this is the path that we're gonna take, right?

Absolutely, absolutely. And then, yeah, because we, some of what the most patients who have the connective tissue issues and the hypermobility, obviously they have a lot of musculoskeletal concerns as well. But most of them, you know, kind of have probably this genetic predisposition to it, right? So I don't know if the understanding is that that's kind of the thing that probably precipitates all the other things or is there's working all in like, which came first, the chicken or the egg kind of, right?

Right. Yeah, yeah. It's hard to say. There's definitely a familial trend in these patients. Some of them might have really bad MCAS, and some of them might have really bad POTS, or the kind of flavor. There's a spectrum, and one family member might have these XYZ symptoms, and another family member might have these. But it tends to trend in families. And we don't have a gene.

Yeah.

for it. So it seems, you know, there's some environmental component, there's some predisposition, and then there's some environmental component, like you got a COVID or another viral illness or some other trigger. And so, but yes, there's absolutely this genetic relationship. And I can't tell you the number times I've seen a young woman, you know, 16 to 25 or so come into my office with her mother.

And I'm asking the daughter all of my questions and the mom sitting there like, mm-hmm, mm-hmm. Like I've got all of those things, right? And they may not have had as significant of a case that brings her to a cardiologist office at the age of 20, right? But they have the same stuff. They have the same symptoms, you know?

Yes.

It's so amazing, yeah. And you know, from where I see it, it's like if someone comes up with sexual pain and we're working them up from vestibulodinia.

where they have dysmenorrhea and they're having all this symptoms of endo and then, oh yeah, my mom has endo and this and that. And just explaining sort of the systemic inflammation that happens with these disease process or these syndromes and processes. And then, you know, then I also are doing the whole thing, like doing the hypermobile, you know, assessments and, you know, asking about POTS and asking about, you know, MCAS symptoms too, because, you know, from that, that's where I, that's where I went over.

What the?

Mm-hmm.

There's a huge overlap, right? And how many times have you seen, so I ask all my female patients about their periods because, you I don't know, that's what I do, because they all have, you know, yeah, well, they all bleed too much. They all get worst pot symptoms around their periods. Like everything flares, you know, there's a lot going on with that. So, you know, I ask a lot of questions and I ask them how heavy their periods are. you know, I mean, literally they're like, no, I don't have heavy periods.

Yeah.

No. Right.

They're normal. My periods are normal. And I'm like, well, have you missed school? Like, or work? yeah, every month, every month I miss two days of school because my period is so bad and I can't get out of bed and I can't function. And the mom is like, yeah, me too. I mean, that's normal, right? Like the daughter has learned from their mom that this is what a normal period is and that's fine, right? And so it's amazing what we, you know, what we kind of perceive.

Yeah. Yeah. That's normal.

Yeah.

Right. Right.

as like you shouldn't be in that, like you should be able to function during your period. Like you shouldn't have that much pain. You shouldn't be hemorrhaging like liters of blood, right? So it's, you know, it's interesting.

Yeah.

Yeah, yeah. And that's kind of the theme we hear a lot is that women accept suffering and we shouldn't, right? Like this is something that, you know, those of us that are in these spaces realize that this is not something that we as patients accept. We should look for pleasure. We should not accept the pain and the suffering that handed to us. Yeah, totally, totally.

Yes!

Yeah.

Yes, it's crazy, right? yeah, yeah, so.

And it's so funny because I have a friend and I remember when college, she would all let, she'd have all these passing out. And so like now I've reached out to her and I was like, remember all this time she used to pass out and didn't you have really painful periods and like, remember how you could contort your body? was like, it's all related. You're just like, oh, thanks. wish I would have known that.

Hahaha

my God, that's great. I love that.

No, no!

It's not like we have a cure, but we can treat each individual like syndrome or you know, try to get your quality of

Yeah, we have a lot more answers now than we did then, for sure. Absolutely.

Right, for sure. Well, and coming from a cardiologist perspective as well, you're thinking about blood vessels and vasculature. I wanna talk a little bit about it, because I'm gonna have Dr. Brooke Spencer on us in some point in the next month or so, but I wanna talk about how you came up with this, how you guys are working together and when did this evolution of understanding the flow into our pelvis and the insufficiency of valves and these vessels.

Yeah.

Right.

Like explain to me how that sort of evolved.

Yeah, yeah, so for me personally, you know, I had been telling these patients from the get go. Yep.

you

Okay, I'm sorry. Somebody was like knocking at the door. Alright, so yeah, go ahead.

that's okay. Yeah. So for me, ever since I learned about what POTS was, I was telling patients to wear compression, right? Wear compression. I was also telling this to my patients with venous insufficiency, you know, these old people who come in with ulcers on their legs and, you know, wear your compression so that the blood can get drained from that wound so that it can heal properly. Right. So, I don't know, a couple of years in,

Yeah.

Yeah.

I had a patient that was doing fine. She, I didn't know about mass cell activation syndrome. I figured out the vein thing first, but she was like, look, I can't take any medicines. They all give me psychiatric side effects. I do not want a medicine. was like, okay, fine, no medicines. And she's like, I only eat four foods. That's all. I eat these four foods. I wear my compression socks. I drink lots of water and I'm fine. My POTS is controlled. I'm like, great.

Okay, we'll just check in every once in a while. don't know, you know? And one time she came back and she said that she was passing out and her compression wasn't working. And she was really frustrated because she had had so many good years, you know, doing this. And so I was like, well, let's look at your veins. You know, I see this all the time in other types of patients, not POTS patients, but let's see if you have venous insufficiency, because if you have it, then we could fix it. We could treat it without a drug.

Thank

without, you know, it's a simple procedure and maybe that would help you. Maybe that would, you know, get you to the next level. So we checked for venous insufficiency. She's got really bad venous reflux in both legs. Yeah, so the venous reflux is when the valves in the veins of the legs aren't working properly. So in normal veins and normal legs, your muscles, like your calf muscles and your thigh muscles are all pumping blood up back to your heart.

Yeah. Yeah.

You didn't explain to listeners how you do it.

And when the blood is getting pumped up, it stops at a valve. So there's valves all the way up your leg. And every time you get squeezed, the blood gets a little further up. But in patients with hypermobility, connective tissue abnormalities, extends long history of standing or venous hypertension, the blood, the valves don't work properly. Either they get drawn out or they're floppy, right? And so when you're pushing blood up with your

leg muscles, it falls back and it goes into your legs and you pool blood in your lower extremities. Okay. So what helps with this a little bit is compression, having external compression to try to keep blood going in the right direction. but you know, ultimately it's, it's diagnosable and treatable, right? So here I am as a cardiologist, like this would be amazing, right? If we could have something I could fix quickly and get an instant gratification from and not use a medication, all these things.

Right? Right? Yeah.

So I sent her to a vascular surgeon. The vascular surgeon was like, I'm not doing a venous ablation on a 24-year-old woman. What are you talking about, right? It took us several months to convince him to do this. And he did. And he convinced the insurance company to pay for it. And my patient got her bilateral larynx from the venous ablations. And she didn't come back and see me. I didn't see her for a few months. So I called her. I was like, how are you doing? What happened? And she's like, I'm cured. I don't need to see you anymore.

pots is gone. And I was like, that's amazing. You weren't going to tell me about it? Like, I literally have not seen her again. She has never come back. And that was, I don't know, 10 years ago, maybe. now I will say this was a unique. So then, of course, I started looking for venous insufficiency in all my patients. About 80 % of my patients have venous reflux. we started fixing it.

Okay. I need to fall.

Wow.

Yeah. Yeah.

Right. And tell everyone how you do that, like what you do for.

It's an ultrasound of the lower extremities. So they do a detailed ultrasound. It's not just looking for DVT or blood clot, but that you have to ask for a venous insufficiency study or looking for venous reflux. You have to put that in the order or else you're just going to get like a quick glance at the veins, make sure there's no blood clot there. So usually we do that ultrasound in kind of a reverse trend, Ellenberg or even standing to elicit that reflux. So if you're getting one of those and they're not doing it that way, then

you know, and you have been diagnosed with normal veins, you may not have normal veins. So, but it's very simple. It's just an ultrasound. So in the right hands, it's easy to do. So we started checking all of my patients with POTS, you know, I started asking questions like, do you have leg pain? you have leg, paresthesias? Do you have, you know, swelling? Like all these questions, discoloration, like that I kind of hinted at before, but I hadn't really honed in because those are the things you need to get this procedure.

again. Yeah.

You have to have some symptoms in your legs, right? So everyone had all those symptoms and most people had the venous insufficiency. I had sent a lot of people for venous ablations and a lot of patients came back saying this was like a miracle for them. It really, really helped. Some said it didn't help. Some said it maybe helped with the leg pain a little bit, but their POTS is still there and it's still bad. So it wasn't like a huge home run.

Yeah.

No, yeah. Yeah.

but it wasn't some patients, right? And so it was definitely worth looking into because if you're one of those patients, great, right? So then, yeah, yeah. And so just like everything else in POTS and Mass Octavation Syndrome, it's like not a one size fits all problem. And there's a lot of trial and error as I know that you also experienced in your line of work, right? So then I started, you know,

I mean, everything is spectrum, right? So, yeah.

right.

I learned about mass cell activation syndrome. I started treating that. Then I started meeting people in that mass cell realm. And somehow, you know, I ended up in this group that started talking about pelvic venous disease. One of the people that first talked to me about it was Peter Rowe at Johns Hopkins. He's an incredible researcher and doctor. He's a pediatrician who takes care of chronic fatigue patients, ME-CFS. And he was, I talked to him about my ideas on the lower extremities. He's like, you gotta start looking at the pelvic veins. This guy.

Yeah.

Dr. Smith, Steve Smith, who also is a pioneer in this field, he and I, I know. Yeah, he's like, and I have been, yeah, he and I have been looking at this in POTS patients and I'm like, my God, that's crazy. I'd never even thought of that. And so I started looking, so then I started asking patients about all their pelvic symptoms.

He's in the suburbs of Illinois, right?

Yeah. Yeah. Yeah.

How's your pain? Do you have pain with intercourse? you, do you have pooling of, like, do you have heaviness in your pelvis after you sit for long time? Do you have low back pain that gets worse over the course of the day? Like, I mean, so many questions, so many answers, right? So then I started looking for pelvic venous disease and started talking to people like Brooke Spencer. And Dr. Spencer and I had a four hour long conversation, I think the first time we spoke, because we were both so excited.

Yeah, I love this. amazing.

You know, she's like, my gosh, half the patients I'm treating for pelvic pain had POTS. And I'm like, my gosh, I've been asking about pelvic pain. Everyone has it. You know, it's like when these two worlds collide, you know, it's with people who are really, really excited about something. It's, you know, a fun conversation. And Brooke and I are such good friends at this point, right? Like we're, doing so much together and, but it was, it was great. So I started looking for it, treating it.

It is.

POTS was getting better. I mean, you know, it was inevitable. So pelvic venous disease, which maybe your audience is more familiar with, I don't know, but.

I mean, I've talked about it before, but I'm waiting to have Brooke on to get in the deep dive, but this is a great interview.

Yeah, so Brooke is the guru. mean, she has all the answers. But basically what we're looking at is when you have your aorta on one side of the body and the IVC on the other side, right? So the IVC is coming down on the right and the aorta is coming down on the left. And when the aorta is splitting into the iliac arteries, it has to go down the right leg and the left leg. And the IVC,

Right.

is built from the iliac veins which come up from each leg to form the IVC to go back to the heart, right? So inevitably these vessels have to cross each other and happens in the pelvis so that they can each get to the side they need to get to, right? So when the right iliac artery crosses over from the left side to the right leg and the left iliac vein is crossing up from the left leg to the right side where the

IVC is, there's this intersection and it happens over the spine. And in normal people with normal connective tissue, in my opinion, these vessels are all away from each other in space. They're not really touching. They're not really interacting with each other. Everything is flowing smoothly. It's not really a big deal. But in people who have poor connective tissue, poor stretchier

stretch your tissues, everything is kind of collapsed on top of each other. So that artery is smushing the vein into the spine and you get obstruction and it could be intermittent obstruction or it could be pretty significant, like complete continuous obstruction. And when that obstruction occurs, there's nowhere for that blood to come from the left leg back to the heart. So collateral veins are formed in the pelvis. So there's the highways blocked. You have to reroute on the smaller

side roads to get back to where you're trying to go. And so those veins plump up and you start getting dilated pelvic veins, which pool blood, cause more blood to sit in your pelvis. They congest the organs that need to be drained properly in the pelvis. So that's like your colon, your uterus, your ovaries, everything is congested, right? It's because there's nothing's getting drained properly and you get a lot of pain.

get a lot of dysfunction, things stop working properly. You can get, you know, in addition to pelvic symptoms, can get IBS symptoms, can get back pain, can get headaches because the spinal column's not draining properly, like all kinds of things, right? So we started looking for that, treating it. And not only as patients pelvic, the iliac vein compression, so the left iliac vein compression, and you can look for that. You can use ultrasound.

you look for. Can you tell them how you look for

No, like what image would you do?

in the right hands, depends if the place you're sending someone knows about pelvic venous disease and is diagnosing it, then that ultrasound is enough to diagnose it. When we do ultrasound in our office in New York, we know what we're looking for and we diagnose it every day. But if you send someone to just a regular vascular center vein clinic and you want them to look for Maytherna or this left iliac vein compression, they usually don't find it, right? And so,

That's the problem.

Right.

Yeah.

So that's one way. Another way is CT scan, is really, really hard. It underestimates disease. It's not accurate. I don't use it. Brooke doesn't use it. Like we don't do CTs anymore. But historically that was kind of used. Now we use MRI. And MRI is obviously less radiation, which is great for the patient, but also we can see more of the venous structures. So we get an MRV.

it.

and Marvie.

which is an MR venous phase. So we let the contrast, you know, hang out in there for a little while. And then we image the patient while the contrast is in the veins, not the arteries, so that we can see what's going on with the veins. And we can see dilated veins in the pelvis. We can see varicose veins in the pelvis. We can see compression of the left iliac vein. Sometimes we also see compression of the right iliac vein or the distal IVC even. And so, you know, we can look for it on the MRI.

amazing.

However, this is another problem. A lot of radiologists don't read this as abnormal. They're like, this is normal, a normal variant. It doesn't cause symptoms. I'm not going to call it as abnormal. And so you really need someone to read it who's looking for it specifically and knows what they're looking for. So the other component of pelvic venous disease is left renal vein compression.

you

And left renal vein compression or nutcracker is another thing we see in this population where the left renal vein gets compressed between the superior mesenteric artery and the aorta and flow stops there. And so you get collateral veins that go down the gonadal vein and up the lumbar spinal veins. And so you can see this kind of dilation of veins going in both directions. And that can also lead to

symptoms, et cetera. But you can see this also on either ultrasound or MRV.

Okay, then.

once that scene and depending on the symptoms obviously like you know I have patients that have presented with persistent genital arousal and it turns out that they have the sources really that pink pelvic venous insufficiency. Dr. Spencer is taking care of some of them but I think that again you know and the patients that I'm thinking of that have had this you know their moms are like yeah you know what I had pelvic venous disease or you know I had you know these varicosities you know there's something that they might not have had

Yeah.

Yeah.

Right?

like these you know significant connective tissue symptoms that you think about but they've had some things that are like red flag you know

Yeah.

And we see more of it with multiple pregnancies. You can develop more pelvic varices and pelvic veins. We see it with, sorry, hang on one second. Yes?

Sure.

Sorry about that. So we see it, we see, yeah, multiple pregnancies. We can see increase in pelvic varicosities and more of this kind pelvic vein pathology. And absolutely you can see it run in families. There's no question.

Sorry.

Right.

Absolutely.

I mean, I think this is great. just, it seems like the more curious we are and I have to say like, you know, our current medical system doesn't really encourage curiosity because if you're seeing a patient for 10 minutes, you can't be that curious. And so I understand the frustration that, you know, I think you're also working outside of, you know, an insurance based system. I work outside of an insurance based system so that we can stay curious so that we can make, help these advances and take care of the patients that other offices, you know, aren't able to given their

Yeah, yeah.

Yeah.

time constraints and some of the other issues that they might have. But I love the collaboration and I love the curiosity and that's what keeps me going too, honestly.

Yeah.

Yeah, I will say, you know, one thing about the veins is they're sort of like a lost organ system. I think no one really learns about them in med school. We don't really, you know, no one really cares. you have varicose veins. Who cares? Right? Like it's, it's purely cosmetic, you know, like it's as if they don't really matter, but 70 % of your blood volume is in your venous system at any given time in a normal healthy person. Right. So

Here's a

there it goes. mean, I can just roll it Yeah. Yeah. Yeah. him. Yeah. Yeah.

Right.

If it's pooling in your legs and your pelvis and it's just sitting there and it's not getting circulated properly, this is a major problem. There's inflammatory markers that get, you know, all kind of that stay there and they're not getting circled. You're not clearing your blood properly. You're, you're not getting enough volume back to your heart. And when you don't get enough volume back to your heart, then you're not getting enough pumped out of your heart. So you don't get enough blood to your brain and other vital organs. Right? So the venous system is actually very important.

Right.

Yeah.

Right.

The doubt.

Right, but no one, as a, I mean, you can talk to vascular surgeons. They're like, we don't do veins. Like, why would we do veins? You know?

Mm-hmm.

Yeah, it's true. And they don't want to do them either. They don't want, especially these kind of cases. Like that's why Brooke is so...

Yeah, yeah, they don't, they don't because they don't really learn about it. And they don't, they don't know about these manifestations and symptoms, right? And so they're, and they're too busy dealing with the arteries, like carotid dissections and, you know, aneurysms and, you know, all the other stuff, FEMPOP bypasses, whatever, all this sexy stuff that the vascular surgeons do. They don't need to learn about the veins because they're busy with doing

Yeah.

Thank

Right.

They're busy doing all the other stuff, right? And they don't really learn about it anyway. Now, when they do, you retire from their arterial practices, they do like to open these like vein clinics because it's like easy money. That's when they start thinking about the veins. But usually it's not in a capacity of like, wow, this person's fatigue went away when I did her GSV ablation. Like they're not asking those questions, but it's very real. I have plenty of patients, you know, who,

Yeah, that's what I was gonna say.

Yeah. Yeah. Yeah.

Yes.

not POTS patients, just normal people with vein problems who come back and tell me, oh, like I can think again, or I'm not tired all day. And so, yeah, so I think, yeah, it requires curiosity, it requires people to ask these questions, think about other symptoms that might improve, document them, and talk to other people about them, right?

Yeah, the break is true. That fatigue and all the things.

Right, absolutely. With regard, you know, for everyone listening, the patients that do come back with some form of pelvic venous insufficiency, you talked about ablation in the peripheral scenarios. What about, explain to people what, like, some of that Dr. Spencer.

Yeah. Right, so someone like Dr. Spencer is, she's an interventional radiologist. So she goes into the Vena system and she diagnoses obstruction. So she uses a Vena gram where she injects dye into the Vena system to look for blockages. She also uses a small catheter tipped ultrasound called an IVAS, intravascular ultrasound. So she takes that little catheter with an ultrasound on its tip and

brings it up through the system to look for narrowings and blockages that way also. So she diagnoses the obstructions. Then she can go in and treat. And for what my patients have, which is predominantly left iliac vein compression, she puts a stent in that area. So the stent is a tube. It's kind of like a mesh metal tube that opens up with a balloon that keeps that vein open under the pressure of that right iliac artery.

Normally, the right iliac artery is compressing the vein, but with the stent there, it props it open. It keeps it patent so that blood can flow back the right way. that's the main treatment. Now, patients can come back if they have more varicose veins in the pelvis and they need to have maybe sclerotherapy or foam injected into those veins to try to cut them off.

Sometimes we have to treat the gonadal vein varices with coils or sclerotherapy. That's another option she does. And then for renal vein compression, the standard of care is really surgical management with auto transplant of the kidney. So we take the kidney out and we put it lower down into the pelvis and we reroute the vein. Some people are doing stenting at the renal vein area, which is...

previously kind of rent fell out of favor because the stent would move, but now people are coming up with a different way to do it. So the stent doesn't move. So that's maybe gonna be an option in the future for patients, but standard of care at the moment is to either surgically move the kidney or surgically move the renal vein. So that's how we treat this.

Yeah. And it seems like from some of the data that I recently got preppy to, there looks like really good results for patients symptomatically. we oftentimes, I know I've sent a lot of younger patients to her, and so the concerns are always around reproductive capacity and what these stents mean and are they going to stay patent and all the things. And so in terms of long-term data, what do we have?

Yeah.

Yeah, so we don't have a ton of long-term data for the current stents that we're using, which have been around for about five to 10 years. But historically, I'll just give you some anecdotal examples. I have patients who come to see me for heart disease, and they had iliac vein stents placed for a blood clot or some other reason 20, 30 years ago. And they've forgotten they're there. Literally, it's like.

They're, yeah, yeah, I had that procedure. I don't know why, you know? And so the patency rate is very high. They really do, they stay in place and they stay open and they seem to just be pretty inert in terms of reactivity to them or any other side effect from the stent itself. I would say, you know, in the patients that I see, the patients that I've sent for stenting, I really haven't had, you know, maybe,

Yeah.

Yes.

I can count on one hand, patients that have had some sort of complication from this that always resolved, right? So sometimes you can get a little bit of a clot in the stent, we give you blood thinners, it goes away. Sometimes you have prolonged pain from the placement of the stent, be given the position next to the spine, there are nerves there, you can get some prolonged back pain, but usually we can get rid of that with injections and we get the IR guys to go in there and do nerve blocks and stuff. And with time it resolves.

there's usually not any kind of prolonged side effect from the stint. But in terms of long-term data, we don't have anything 20 years out, 30 years out. What we do know is, and Brooke Spencer did publish this paper on younger women who got pregnant. Actually, it wasn't her, sorry, was someone else, but there is a study out there that was published on young women that got pregnant after stinting.

issues.

And they were all anticoagulated with lovinox, but they all did fine. There wasn't any complication with the stent. The pregnancies were normal. So that was a non-issue in that case series. It was about 27 patients. So, and I've had patients get pregnant after stenting. I've had patients get pregnant after diagnosis of iliac vein compression without stents.

That has come up a lot in my clinic because we diagnose it and then before we go to treat it, they get pregnant and we're like, okay, I guess you're going to have a baby. And so I usually put them on lovinox because, know, there's no data for that. We don't know, but some women in pregnancy get blood clots, right? Some women get DVT and yes, they could have some coagulopathy, but oftentimes there's no blood work that defines. It's just, it's just a complication of pregnancy, right?

Right.

Yeah.

can see right, yep.

But what if it's because that population of people who get blood clots during pregnancy also have left iliac vein compression going in? Who knows, right? It's the same as like people get blood clots on planes. Not everyone gets blood clots on planes. Only some people. Like it's actually rare, right? But who are those people who are predisposed to getting a blood clot on a plane? Maybe it's the people that I've diagnosed with left iliac vein compression, right?

Yeah, Who knows?

Yeah, right. Right. Right.

Yeah, absolutely. Yeah.

And so, you know, we're cautious about it. Once we have that, once a patient has that diagnosis, we have a lot of conversations about long flights and pregnancy and do we need to do more, you know? So, but to get back to your question, the stent seems to hold its own for quite some time. I just don't have very long-term data. only have, you know, years for the latest, the newest stents that we're using.

Yeah.

And it's because the curiosity has just been in the last, that we've been able to kind of wall this information. And I want to be cognizant of time, but I do want to talk about other cardiologic issues that you are passionate about in women's health. mean, we know women's, in terms of chest pain and MIs and all the things like,

Yeah.

Yeah.

Yeah.

Yeah, the number one killer, all the things, yeah.

And we often, know, women die from their first heart attack more, you know, and it's because their symptoms are oftentimes not the same, right? Like, yes. So I don't have to speak to that a little bit as well.

Yeah.

different. Yes.

Yeah, yeah, so I feel, you know, I'm passionate about women and heart disease and women and cardiovascular disease risk. it's all, everything you said is true, right? I do think there are, you know, populations of patients who are at higher risk for developing heart disease. Those are people who have a strong family history. It's very important. Those are people who have diabetes. Yeah.

Salvation.

Exactly. are patients who, anyone with a rheumatologic condition, lupus, rheumatoid arthritis, you're at higher risk of developing a heart attack or heart disease at a younger age. So we have to be careful and mindful of these higher risk groups. But not everyone is high risk. Usually in women, the risk develops after menopause. So when you lose your estrogen, your LDL skyrockets, your HDL plummets, you start

losing the protective effects of estrogen on the blood vessels and things start going awry. So five to 10 years out from menopause, that's when we start seeing heart attacks in women. In women who have heart attacks in the post-menopausal years, usually the symptoms are pretty similar to, I mean, let me rephrase. If you take all comers, women who have a heart attack, the most common symptom is chest pain or pressure.

Right.

Sure.

out of everyone. That's what you're gonna, you it feels like an elephant sitting on my chest. I can't breathe. It's, you know, something's wrong, right? But it's more likely for women post-menopausal to have those symptoms. If you're pre-menopausal, it's possible you could have other symptoms like fatigue, jaw pain, nausea, know, dizziness.

Yeah.

back to you.

There's, you know, it can be very odd. I have a patient who had some angina in my office. She's 25 and she was having coronary vasospasm, which is not your traditional heart attack, but it's just spasming of the artery. I think it's comes, it's very closely linked to mast cell activation and allergic symptoms. And she was complaining of neck tightness.

Yeah.

And she said that her allergies were really bad and her neck was tight and she couldn't move her neck and she was like holding it. She was super uncomfortable. I did an EKG and she was having EKG changes of ischemia. We gave her nitroglycerin in the office. Those EKG changes went away. Her neck tightness resolved. And so she had no idea that what she was experiencing was actually coming from her heart. She just thought this was part of her allergy syndrome, right?

Yeah.

That's it.

Yeah. Yeah. Yeah.

The symptoms can be vague and misleading. you know, I, you know, I can give another example of a patient in her forties who came into the ER when I was an intern with abdominal pain and she was just having this waxing and waning abdominal pain and she was getting admitted to the GI service and everything was normal. And I looked at her EKG and I was like, this doesn't look right to me. And she hadn't had a troponin checked. Like everyone in the ER gets a troponin check.

Right.

I don't know why this one person had not because she's white and 40 and had abdominal pain. anyway, we checked the troponin, it was through the roof and she went to the cath lab, right? So I think more and more people are aware now that anything can present as a heart attack in a woman, but it is certainly worth stating over and over over again that if something doesn't feel right, if you feel like there's something new that wasn't happening before,

Go check it, go get it checked out and ask about your heart. Don't just go and say you have horrible abdominal pain, say I'm worried. My dad had a heart attack at 50. I'm worried that I might be having something also, right? So.

Yes, I might be having some.

Yeah. And I think there's something about micro-bascular disease in women now, too.

Yes, so the microvascular, this is a passion of mine as well, microvascular disease, coronary vasospasm, these are all seen predominantly in women and I think overlap substantially in my population of patients with POTS. So I really see a lot of that vasospasm overlap. use a lot of calcium channel blockers for those patients instead of beta blockers and it helps with their chest pain.

Really?

there's certainly overlap there and it's something that should be recognized and treated in a woman. If you have a normal stress test, it doesn't mean that you're not having a cardiac condition. You can still have coronary vasospasm. It can be treated with a calcium channel blocker with nitrates, with other tools and your chest pain will go away, right? So.

Yeah, yeah, and the microvascular disease is a little harder to diagnose though, isn't it?

Yeah, oftentimes if you have severe microvascular disease, you're gonna have an abnormal stress test and you can find it. And we use similar strategies for that. it's treatable. We can get chest pain to go away. And what's frustrating is when it gets dismissed as not something treatable because there's no abnormal test result, right?

Yes.

Right, right, right, right.

So I see a lot of that, I treat a lot of that. I'm very proactive with treatment, obviously, you ask me. Because I believe that people have real symptoms, you know, so.

No, I love it. love it. mean, because yes, and that's I think that's foundationally why like, you know, people like us, we listen to our patients because we have the time to but also because we believe them to we want to make sure that, you know, they've been historically dismissed and our system is failing them. at the end of the day, we're trying to, you know, help navigate this with them. So

Yeah.

I mean, it's why we went into medicine, right? That's why I went into medicine. Like I wanted to help people. I wanted to help people feel better. I wanted to change people's lives, you know? Like it's really impactful and it's very rewarding. And I love what I do. I mean, every day is like a new challenge and a new puzzle and a new adventure, right?

Yes, yes, absolutely. Yes. Right. Yes.

100%.

Yeah, I love it. Yes, absolutely. Well, want everyone to know, I know you were at Emory for a while, but you've just moved to New York recently, right? Is your practice open now?

Yeah, yeah. We're open. are finally the renovations on this space are done. My God, that took forever. But.

Wait, so, Tumi, what took you from... Are you from the South originally? you're from New York,

No, I'm from New York. So I'm from New York. I went to Emory for medical school. My husband was there in graduate school at the same time. And then I went back to New York for residency, and I went to Virginia for fellowship. And when I was finishing fellowship, we were kind of deciding, where should we go? And Emory seemed like the best spot. had the best.

Yep. Yeah.

Yeah.

options for me. It was the best opportunity. so we moved to Atlanta. We brought all three kids down there and we lived there for 13 years. And then I, you I always thought I was going to come back to New York. I didn't think we were going to be in Atlanta forever. And at this point, we're in Manhattan and my kids are all out of the house. I have two in college and one in boarding school. And so we seemed like this was a good time to kind of take on something new.

Yeah. And you're in the city, right? You're in New York City.

Absolutely.

So it took me a long time to decide if I wanted to go into practice with someone else, if I wanted to go back into academics somewhere else, or if I wanted to do my own thing. And ultimately, academics is a hard place for people who do what I do. And so I wanted the space and the time to take care of these patients. I wanted to be able to do things my own way. I felt like it was kind of

a good time for a transition. I made a name for myself in the world of pot so people know who I am. So I felt like this was the opportunity, like, let's try. And so I opened up a private practice in Manhattan. It's on 60th between Madison and Park. It's a really beautiful block right near the park. And we have a wonderful space. I'm very lucky. I don't know. I kind of just fell in my lap.

I love it,

Yeah.

really nice space. It just got renovated. So we've got, I've got ultrasound there. I've got a great sonographer. She's doing an amazing job. She's doing echo and vascular ultrasounds. I have a nurse practitioner who's working with me part-time and a medical assistant and a director of operations. So we're like legit, you know, it's real. And we're taking patients and I'm seeing patients.

Yeah.

We'll put all your information in the notes so that people have.

Yeah, I'm seeing patients in the office. Anyone who wants to travel or who lives close by is welcome to come. And then I also see patients over telehealth. So I still have my Georgia license. I'm seeing patients in Georgia. But I'm also licensed in Tennessee, Colorado, Ohio, Pennsylvania, Wisconsin, Hawaii. I'm trying to think if I missed one. I think that's it. So I'm working on getting my Virginia license reactivated, but

awesome.

Virginia is different. I'm having a hard time with them. So I'm working on that one too. And then obviously New York. So yeah, I'm happy to see anyone over telehealth in any of those states and anyone in person.

Yeah. Yeah. Yeah. Awesome. Yeah.

Yeah.

Awesome. Well, I love it. I love everything you're doing. I'm so happy that you're, I'm really, I think it's great when, know, that's being an entrepreneur in medicine is not anything we ever learned. I also came from an academic background and it was very challenging to start. And I just went from an insurance-based model to concierge so I could spend more time with my patients. And it's been a life changer to be honest, you know, it's like really, you know, but, know, at the end of the day, I think it's,

Yeah.

Yeah.

Yeah, I bet.

It's not something you learn, right? You don't learn in med school how to start a business or practice.

No, no, would, barely learn how to like bill for your time for like, mean, you don't even like, yeah, it's, yeah, we don't.

Yeah, exactly. Right. And so kudos to you for doing it. And absolutely you should because you're somebody that's really sought after for this. And I look forward to disseminating your information so that more people can find you because it is hard to find someone that takes some of these very serious situations for patients seriously. And so it's nice to have a network of

Yeah.

like-minded clinicians that are going to work toward.

Absolutely. Absolutely. And I appreciate you having me today just to spread the word because ultimately we need more people to accept that these conditions are real, they're treatable, we can manage them. These women aren't crazy. So the more I can talk about it, the better in my opinion. So I appreciate the invitation.

Yes.

Right.

Yes, absolutely. Yeah, of course. And I look forward to meeting you in real life in two weeks at Ishwish. So it's going to be great. You're going to love it. It's going be awesome. Well, thank you so much, Dr. Alexis Kutchan for being here, telling us all the great things that you've done and the collaborations ahead. look forward to. We didn't even get into long COVID, but that'll have to be another.

Yeah, yeah, it's gonna be awesome.

my God, have, there's so much more or MCAS and endometriosis or yeah, I mean the list goes on. I could talk about, we could.

We need to do a part two because I, you know, I think there's definitely maybe after Ishwish we'll do another one, you know around long COVID, you know, MCAS along. I want to get a little bit deeper into microvascular disease too. I have a lot people I want to talk to you about. Awesome. All right. Thank you so much. Thanks everyone for listening today. Remember this is a Gyno Girl. Thanks for listening to Gyno Girl presents sex, drugs and hormones.

Yeah, I'd be happy to come back.

Yeah. Yeah. Great. Sounds good. Okay.

Remember, I'm here to educate so you could advocate for yourself. Please join me on another episode next week. Yay.