Welcome to the 4th episode of Hello Uterus! Today we put a spotlight on menstrual blood and why it's important to do so. We deep dive into the topic of endometriosis and menstrual blood with expert Dr. Christine Metz.
Welcome back to the fourth episode of Hello Uterus! In today’s episode, we dive into the remarkable research conducted by Dr. Christine Metz in an expert tour of endometriosis and the importance of menstrual blood research.
In this week's Hear Me! Hear Me! Q & A segment, we address the dismissal (gaslighting) of pain experienced by uterinekind. We believe your pain is real. Dr. Metz gives her advice on what to do when no one will listen or believe you.
Discover the hidden secrets our menstrual blood holds and how further research could change the future for all uterinekind. Interested? Learn how you could be a part of the change by participating in this week's highlight study: ROSE (Research Out Smarts Endometriosis)! Visit https://www.endofound.org/rose-study for more information.
We end on a high note with equality progress. Tired of unequal pay? Follow the path taken by the US Women’s Soccer Team! The battle was hard; they came prepared. And they won!
Tune in this Thursday for our After Show conversation with Dr. Christine Metz where we’ll continue the conversation on endometriosis, uterine research, and how to get more out of your consultations with doctors.
Join us back here every Tuesday for all things uterus, in service to you, uterinekind.
Carol:
This week's expert guest is at the forefront of endometriosis research. She's the head of the Laboratory of Medicinal Biochemistry and a professor in the Institute of Molecular Medicine at the Feinstein Institutes for Medical Research. She is the director for OBG Way and research for the Maternal-Fetal Medicine Fellowship at North Shore University Hospital and Long Island Jewish Medical Center. Dr. Christine Metz and Dr. Peter K. Greggerson received the 2018 Northwell Health Innovation Award for their research on developing a novel noninvasive diagnostic test for endometriosis. She received her bachelor's with honors and distinction and Masters in human nutrition from Cornell University and her PhD in immunology pathology from New York University. She established her own laboratory in 1998 in Manhattan, New York, where she focuses on research on the regulation of inflammation. Much of her work has centered on improving women's health. I learned of Dr. Metz's research in Scientific American, where her opinion piece is titled, to better understand women's health, we need to destigmatize menstrual blood. But it's the subhead that had me writing an email to Dr. Metz. Diseases such as endometriosis would have a cure if we could talk about them and study them without shame.
Thank you for being with us today on Hello Uterus. Dr.Metz, after reading that bio, I'm assuming that your free time is like 6 seconds every two weeks. And so we're really appreciative that you are spending this time with us today. Absolutely delighted to be here and share my thoughts and our research with you and your guests. We're fangirling here at Hello Uterus, because what you're researching, it's like discovering Oz. You just go, seriously, someone is actually doing this. Finally. I have a feeling we're not in Kansas anymore. Menstrual blood. It's not as if it could be without its secrets. So you study menstrual blood, and I learned that it has a fancy name. You know what that name is?
Dr. Metz: Menstrual effluent is what we call it because it's not exactly the same as blood, but it's always been referred to in the lay public as blood. The odd thing is that Effluent is really considered something that's discarded and not needed, which maybe is also a misnomer because we feel that, in fact, Menstrual blood or Menstrual Effluent is a treasure to really understanding Uterine health.
Carol: Actually, before we get into what it is, I really want to know about the AHA moment when you landed on menstrual blood as having stories to tell. Can you take us back to that moment in time?
Dr. Metz: Absolutely. I've been studying endometriosis for the last 20 years, and most of my work focused on the inflammation associated with endometriosis, primarily focusing on the lesions, which in most women, they occur in the pelvic cavity or the abdominal cavity outside of the uterus. And those lesions of endometriosis are actually cells that are like cells growing inside of the uterus, which we know is shed as Menstrual effluent. We also know that the uterus is not a closed organ. And in fact, over 90% or almost all females who menstruate actually retrograde menstruate into their abdominal cavity at the same time that they menstruate out of their vagina. In addition, there are only 4% of mammalian species that menstruate, and only those animals, including non human primates, are known to have any form of endometriosis. So 96% of most mammals don't menstruate. They have estrocycles, and they do not get endometriosis. But I think the thing that has the most scientific validity for trying to understand the endometrium, which is shed as menstruation, is that there have been many scientific publications demonstrating that the endometrium, that's the cells lining the inside of the uterus are different in women with endometriosis when compared to healthy controls. And our thought. I collaborate with Peter Gregerson, and our thoughts were to actually start studying menstrual effluent or menstrual blood. And we were very surprised when we looked into the literature that there hadn't been no studies published to date that really ever investigated menstrual blood in the setting of endometriosis. A couple had looked at menstrual blood in the setting of infertility, but the details of the menstrual effluent were not well described. And most of the studies that have ever been published are really based on regenerative medicine, in which there are stem cells in menstrual blood that they were used to study how you could regenerate organs and tissue. And that's kind of not a surprise when you think that every single month, the endometrium, the cells lining the uterus have to be repopulated. So they do have these tremendous stem cells that can generate a new endometrium very quickly. So it was really the scientific reports showing that the endometrium of women with and without endometriosis is different. That pushed us to say, okay, let's delve into this and really go for it.
Carol: What roadblocks did you meet straight away?
Dr. Metz: We had so many roadblocks, I can't think of exactly the first one, but probably the most obvious was that no one had really studied menstrual blood in any significant detail. So there were no protocols. There are just no protocols to follow. We didn't know how to collect it. We didn't know how to process it. We didn't know how to utilize it. We didn't know hardly anything. And we had to develop methods for all of those things and then to do them rigorously so that it could be used and studied as a biological specimen. So the first thing was how are we going to collect it? And so we solved that by luckily meeting up with a company called Diva International from Canada, who produced one of the earliest menstrual cups. And they offered to donate the menstrual cups to our study. And I have to tell you, in 2018, when we were doing this, it was very difficult to find people who are familiar with them. They weren't as popular as they are today. And now, of course, that has changed with the widespread use of menstrual cups. But at the same time, we faced a challenge that women with pelvic pain, such as those with endometriosis, as well as younger females who have symptoms of endometriosis, would not be able to use a menstrual cup. So we actually had to invent a menstrual collection sponge to be used. And that alone was a challenge because we're not bioengineers, we're biologists, and actually Peter is a geneticist. So that was kind of out of our comfort range as well. But we were really pushed by our participants to come up with something so that they could participate. So from the participants perspective, they were all in ready to go? Oh, yes. It was very interesting interacting with all of the early Rose stands for research outsmarts endometriosis all of our Rose study participants because they really were encouraging us to figure out ways to help them. And we've had such wonderful interactions and support by participants.
Carol: So Rose research Al smarts endometriosis, fantastic acronym there. We want to give acronym props in the study. Can you describe, I guess, the intent of this study?
Dr. Metz: So the intent is actually twofold to really deal with the main concerns that women with endometriosis face. The first is the lack of tolerable and effective treatments for endometriosis. Most of the treatments are hormone based. These treatments do not stop the disease. They do not cure people. The only cure that's available is surgery, and many women could undergo surgery 1012 even more times. I think that is due in part to a complete lack of understanding of the disease in order to develop better treatments. The second goal of the study is to develop better, improved diagnostics. The only diagnostic that is available that can definitively diagnose endometriosis is laparoscopic surgery. So women have to undergo adolescents and women alike have to actually undergo laparoscopic surgery in order to be definitively diagnosed with endometriosis. And that leaves them with scars. And I think that's a major inhibitory factor for getting diagnosed. And so we've really thrown ourselves into developing a non invasive diagnostic based on menstrual blood.
Carol: And so in collecting the menstrual blood, you're analyzing menstrual blood from people who have either well, have they been diagnosed with endometriosis or are they displaying symptoms of endometriosis?
Dr. Metz: No. We have three cohorts, three groups of menstruators in our study. The first group are healthy controls who do not have any symptoms consistent with a diagnosis of endometriosis. The second group are those who have been definitively diagnosed with endometriosis and know they have endometriosis. Then there's a third group of people who we have enrolled in the study who are symptomatic patients. And we're hoping that these patients will undergo the laparoscopic procedure in some time to tell us whether they have a definitive diagnosis or not. And that's kind of the tricky group that we've been working with because we have found that most of them over the years actually don't go on to getting a diagnosis in a timely manner, and that's very frustrating because they remain then symptomatic. They may have endometriosis, they may not. It's unclear whether they're getting an aggressive treatment for the disease if they're not definitively diagnosed. And endometriosis is continuing to grow right over time, it spreads. The problem with endometriosis is that it does progress in a person's body. It doesn't really decline until menopause. So it's definitely a problem that is there for women for a very long time.
Carol: I hear a lot of conditions described as dissipating. The symptoms dissipated menopause. And it would seem that the obvious leap there is that it's hormonally impacted. But is it possible that it's not? I'm asking maybe not necessarily about endometriosis, but just in general about this idea of like, oh, well, if it goes away at menopause, then it must be hormonally impacted. Could it be something else?
Dr. Metz: Yes. I mean, there's a lot of evidence that hormones do, in fact, shape the disease and could be implicated in pain as well. So this disease, endometriosis, is characterized by excess estrogen and a reduced sensitivity to progesterone. So the problem with excess estrogen is that we are now learning that estrogen actually can really drive pain in women. So if you have excess estrogen, which many of these women do, they probably feel pain very differently than those who do not have such high estrogen levels. So that's clearly a problem for women with pain. And then the progesterone sensitivity is also a difficult problem because the first treatment for endometriosis is typically birth control pills and progestin. And if you are not sensitive to progestin, how will that help you? When they give you progestins, maybe you need a much higher dose. So there's a lot not understood about this disease that leaves treating it very difficult.
Carol: So in looking at effluent, I'm trying to show off. Now what secrets do our plots hold? What are you finding in there?
Dr. Metz: So the first thing that we set out to do was to analyze a particular cell type in menstrual effluent called the endometrial stromal cell. Now, the endometrial stromal cell is very important in the uterus because it undergoes a differentiation process. It's called decidualization. It's absolutely required for a healthy pregnancy. And it had already been reported using endometrial biopsies, which are painful and invasive, that stromal cells from those biopsies showed a defect in decidualization when they were obtained from women with endometriosis. So we used our menstrual effluent to collect these same endometriosromal cells that would be obtained in a biopsy. But in a natural biopsy, as you would say, menstrual effluent is pushing out the tissue of the endometrium. And we found the exact same defect in patients with endometriosis that in fact, they did have a decidualization impairment. It may contribute to the infertility that some of these women face, along with the aberrant hormones contributing to infertility as well as lesions contributing to infertility. But that was our first discovery. And we thought, wow, we have this great way that we could discriminate between patients with and without endometriosis using these cells. But the downside or the limitations are that we had to grow the cells, we had to culture them. We had to do a decidualization assay in vitro. And then we had to measure a downstream outcome of that process, which was time consuming, cost money, and it was labor intensive. And it was kind of a complex assay, which we thought that the FDA would not think was such a great diagnostic approach or screening approach. But that's what we had in the very beginning.
Carol: When that happened, when you made that connection in the laboratory, do you guys high five throw confetti?
Dr. Metz: We were so thrilled. We really thought we had a potential screening tool or a diagnostic tool for endometriosis. And when we tried to get grant funding for it, for example, we faced a lot of hesitation, people telling us about the limitations of our approach. And without funding, we can't go further. So we actually started listening and thought about ways to use the fresh menstrual effluent as we obtain it, so that we could have an immediate analysis that could be used either for screening to identify those who may have endometriosis, who should be pushed to undergo the laparoscopic surgery, or to develop a real diagnostic for endometriosis. The emerging technologies in molecular biology that are being used for cancer research really illustrated to us that there were approaches that we could apply to menstrual blood to see if there were differences between women with and without endometriosis. And that's what we set out to do last year. We spent the year enrolling patients who were healthy controls, those who were already diagnosed with endometriosis and symptomatic patients. And we used their fresh menstrual blood when it arrived at the laboratory to probe it for something called singlecell RNA sequencing methods. And really, it's just a very fancy term to say that we can analyze the gene expression of every single cell in that mixture and look for differences between the groups. And that's what we did. And we found very significant differences in cellular composition of menstrual effluent. One of them, for example, is a depletion of uterine NK cells, uterine natural killer cells that are also involved in fertility in the setting of endometriosis. And we had showed that in our earlier work using a completely different approach of flow cytometry. So it was really great to see that replicate itself. We also saw an increase in B cells in menstrual effluent, and we think that's related to inflammation. And then among those endometriosromal cells that we were isolating and culturing, we actually saw a deficit in the number of cells that were decidualized or differentiated in patients with endometriosis, which also replicated our prior work showing that women with Endo actually have that decidualization defect. We also saw really significant characteristics of inflammation in the samples coming from patients with Endo. So together, all those things are allowing us to develop a diagnostic based on fresh menstrual blood.
Carol: Amazing. So it went from we have this complicated way of analyzing menstrual blood, and then when you need to look at the process from another angle, taking it to let's just analyze fresh effluent and go with that. And that ended up being super productive for you. Am I understanding this correctly?
Dr. Metz: Yeah, it was very exciting. It's just incredibly exciting. And we really want to extend this work and are starting a clinical study to do so well.
Carol: I want to make sure that we reference that. But before we get there, do you feel that in the future that it'll be part of our let's say I don't know if it would be annual, but part of our screening, kind of like colon cancer screening. Right. You get a kit at home and you sample your incredible production that you do in the bathroom and you send it in and it gets analyzed. Should that be part of preventative care for people?
Dr. Metz: So that was actually one of the points that I tried to make in that opinion piece in Scientific American, that menstrual blood is not only helpful for understanding endometriosis, we believe it's going to be incredibly helpful for better understanding uterine health because it's really a reflection of uterine health that last month. So we believe in our big vision that someday that assessment of menstrual effluent or menstrual blood will be part of every annual gynecologic exam, just like a PAP smear is. And we really do hope that other people get on the bandwagon to study menstrual blood in the setting of various diseases that affect uterine health, such as fibroids. There's also infections of the uterus, early stages of cancer infertility there's a condition called adenomyosis that affects the uterus. There's just so many other things that we don't know about because it just hasn't been studied.
Carol: Right. And can we just say, why hasn't it been studied? Should we open up that can of worms?
Dr. Metz: You know, I think in part because of the Yuck factor of menstrual blood. I think that decades ago, very few scientists were women, and I don't think the interest was there to study menstrual blood. I actually looked up the number of publications that have been published on menstrual blood in the last 50 years. It's gone up, but it's incredibly small. My comparator was semen as a keyword, which has many more publications. And then my other comparator was sperm, and there were many more publications on those two keywords than menstrual blood. There was a blip of an increase in the 1970s when the books about my body were published. So it was very interesting to see that. But in fact, very few studies have been done. It's all because of conditioning and opinionated postures.
Carol: It's just the uterus. It's just an incubator for a baby. And it's like I don't know. I think maybe we should study that first before we judge it like that.
Dr. Metz: It's a bit of a shock because to us, if you actually sit there and think about it, it seems as though it's a window into understanding the uterus.
Carol: Absolutely. That's a very simple leap to make. And also looking at the complexity of symptoms, conditions, the complexity of the organ itself, and just pausing for a second and thinking, hey, maybe there's something more here that we should understand before we, for instance, go remove 600,000 uteruses every year. So it's just wild. And I love the idea that it's just a simple like you said, there's no biopsy required. There's no invasive procedure. This is something that we could do at home. We could just collect menstrual blood and send it away and have somebody tell us about the health of our uterus. That would be amazing to me. I want to go back to something that you said a little bit ago. You said that while most of the Effluent is expressed through the vagina, that there's abdominal expression as well as menstrual blood. Did I hear that right?
Dr. Metz: That's correct. And we've known that for over 100 years. The first description of that was published 100 years ago by a doctor, Samson, and it contributes to one of the theories of endometriosis, the Samson theory. But even if you don't ascribe to that particular theory, it occurs in over 90% of women who menstruate that if they actually underwent surgery, you would see menstrual blood in their pelvic cavity, and under normal conditions, it's cleared from the body. And we think that that is one reason it may contribute to endometriosis is that it may not be able to be cleared by the body in specific individuals who are genetically predisposed. Our other thought is that there are alterations in the uterus that change the cells in some way so that when they are effluxed into the pelvic cavity, they're pathologic, they're already problematic, and that contributes to the disease. And that's our theory about what may contribute to endometriosis. I actually think that it's a much more multifactorial disease than we think it is. We think of it as one word endometriosis, but I believe that there are probably many ways of getting to endometriosis, that there isn't just a single path to getting endometriosis. So we are still at the theory stage on much of this.
Carol: Oh, absolutely. We don't understand the pathogenesis of this disease very well at all. And so going back to the subhead on your article, that wasn't just for clicks, right. You do feel that had we taken this more seriously a long time ago, when we had the opportunity to begin studying it, that we would have a cure by now,
Dr. Metz: I would think we would certainly understand it a lot better. And I think in order to treat a disease, you have to understand it. You can't just treat various aspects without really truly understanding it. I think that's been an obvious problem in cancer research. We used to think, oh, cancer, that's just one thing. But now we clearly understand that cancer of every organ is different from another organ. And even in a single organ there are many different kinds of cancers that arise for various reasons. And clearly there's a genetic interplay. There's also a genetic interplay with endometriosis. And there are genetic components that increase your likelihood of having endometriosis. But I think our lack of knowledge is just due to a lack of research which is in part due to a lack of funding for this particular disease. I mean, one in ten women are believed to have endometriosis. But in reality, we really don't know because many people are not diagnosed.
Carol: What is the earliest age that you're aware of of somebody presenting with symptomatic endometriosis.
Dr. Metz: They could actually have symptoms before their first period. And we have met these young women. So it's believed that during development there could be tissue basically misplaced in the wrong spot. That once hormones begin to develop in the body, they get pressured to produce and respond to the hormones. There's also neonatal bleeding theories that could contribute to that very early endometriosis in those select individuals. The neonatal theory is that young baby girls, many of them have a mini period after being exposed to mom's very high progesterone levels. And then at birth it's withdrawn. So they're endometrium sheds. In that case, it would also squirt into the abdominal cavity as well as exit the vagina. And that could make the early seedings for later lesions that could occur. So in fact, you could have prepubescent girls starting to have symptoms of endometriosis and imagine the difficulty of describing that at that age.
Carol: We have women in their forty s, fifty s on and on and on. We have a hard time sitting in front of a doctor and saying, hey, this is what it's like and advocating for ourselves. Can you imagine being nine and trying to explain what it feels like?
Dr. Metz: So there are reports that over 70% of women who have endometriosis had symptoms in their adolescent years. And interesting, the ones who had the most severe symptoms had the most delayed diagnosis, which is all the opposite in our heads that you think could possibly happen to these young people that they were completely dismissed. We have over 20 subjects in the Rose study and we've done some surveys. We found that over 60% of the participants in our study said that they were dismissed during their adolescent years by their family, by their friends and by physicians.
Carol: Oh, my gosh, I have to breathe.
Dr. Metz: Yes, dismissal pain is really huge among women. It's a serious problem. And I think knowing that they have excess estrogen, which means they actually are feeling pain more acutely and more severely than a person without endometriosis, it really breaks your heart to think not only are they in really severe pain, but people aren't listening.
Carol: This leads us right into today's hear me, hear me. Q and A. I want to jump right into it because it speaks to this person's question here. It's from bad at it. I can completely identify with what they're going for there in their stage name. And she writes, when does pain get taken seriously by doctors? My friends don't deal with what I deal with. So is it that I'm bad at tolerating pain or is my doctor bad at figuring out why my period is 100 times more painful than anyone I know from bad at it? What would you say to her?
Dr. Metz: You got to find someone else to listen to. You don't accept a physician who doesn't listen to you. It's really important. And that if you feel that your pain is not normal, it probably isn't. If you have to stay home from school, work or social events because of menstrual pain or pelvic pain not related to having your period at that moment, it's not normal. And unfortunately, some people get told that it's normal because this is a genetic disease and their mothers or their sisters have Endo and they tell their next child in line that this is normal. Suck it up, take your Tylenol and go to bed. It is not normal. And I always tell people to change your physician or healthcare provider to someone who actually will listen to you.
Carol: The best advice, which requires somebody to believe in themselves, which is where gaslighting, medical, gas lighting can really derail somebody's entire life, especially if they're 9, 10, 13, 15, 16. Someone in a position of power is telling you that you're wrong, that what you're feeling is normal. And then from that period on, you sort of begin to question whether or not you understand your own experiences. Are we just overly sensitive? No. Right. Dramatic. Yeah. Doctor Metz, I cannot. Thank you enough. This has been so illuminating and also infuriating because I'm thinking in my head about all the repercussions of the things like, we've only just scratched the surface here. I have a million more questions, but I'm almost afraid to find out the answers to them. It speaks to how much further we still have to go. And I just want to thank you for stepping in front of every one of those obstacles that you faced and for kicking them down and pressing on because you are absolutely right. This menstrual blood holds answers, and there should be no issue with funding because it's going to change the way half the population experiences their life and improve their productivity and their overall health and. Wellbeing. So can we just say a yes every time Dr. Metz contacts, you say yes? That's my professional guidance. Before we go, I'd like to ask you, are you enrolling for studies right now?
Dr. Metz: Yes, we are. The Rose Research Outsmarts Endometriosis study continues to enroll controls. Healthy controls, people who don't have symptoms of dysmenorrhea or endometriosis, people who are symptomatic and are very serious about thinking that they will undergo laparoscopic surgery to be diagnosed. And of course, those with a diagnosis of endometriosis because they are kind of our gold standard with which we can test our developing screening tool or diagnostic tool as we develop it, particularly those symptomatic patients who are thinking that they either are being seen by a laparoscopic surgeon or are going to be referred to a laparoscopic surgeon for that diagnostic surgery. In fact, we have a pilot clinical study ongoing right now enrolling those exact people. It's a substudy of the Rose, and we really need participants.
Carol: Where can people find information on this?
Dr. Metz: If you Google Rose and Endometriosis, the site will be one of the first things that comes up. It's the rosestudy at Northwell Hill. Excellent. So definitely go check that out. If you can help out this research, you can be part of literally changing the entire field of uterine health care from diagnostics to treatments. So please don't hold back.
Carol: But before we go, one more question. Who opens all these and how many gifts do you give them on like, a daily basis?
Dr. Metz: Some days we get five or six samples, if you could believe that's fantastic. Yeah. It's really amazing. We pay participants for the time that they take. It's $50 for a menstrual cup collection, and it's $25 for a sponge collection. We are also enrolling adolescents. I really feel strongly that we have to include them in our understanding of this disease because I think they have the most to benefit from an earlier screening tool or an earlier diagnostic. So we really are hoping to enroll more adolescents ages 15 16 and above.
Carol: Great. Well, we're going to do everything that we can to promote Rose and your research and help you on this quest to bring an end to endometriosis that is something that so many people will benefit from. Thank you, Dr. Matt. And please come back on Thursday for the after show where we continue our conversation. This is the show where imagine I corner Dr. Metz at the local coffee shop and I find out what she does, and then she gets to leave about 4 hours later. Thanks so much. I look forward to it. Excellent. Thank you for being on Hello, Uterus. We really appreciate it.
Dr. Metz Thank you for having me
Angel: Help bring an end to endometriosis by participating in the Rose study. The study of menstrual blood may hold the key to the why of Endo. From there, treatments are born. Participate in the Rose steady today. Visit Hellouterus.com and click on the Rose Study blog for more information. Or simply Google Rose study for Endometriosis. It's the first link. Please participate. If you can, you could hold the key to the future for all Uterine kind. Thank you. Now let's get back to the show.
Carol: Well, it's time to end on a high note. This was a podcast full of actionable information. I can't wait to just I feel like I have 50 things that I want to go investigate now. But before we leave and part ways and say our goodbyes and our farewells, we are going to give massive props to the United States women's soccer team for fighting the fight that ultimately got them equal pay for superior play because, let's face it, their play is superior, and finally, they can actually get paid for it. If you remember, after the US men's soccer team failed to qualify for the World Cup in 2018, we all found out that the women's team, who had just gone on to win its second consecutive tournament in 2019, that the women's team was not being paid equally. The crowd was chanting equal pay, but also the players were coming out and talking about it, even though, trust me, I'm sure that was a difficult thing to do because they probably get yelled at for speaking about that's. Just, you don't talk about that, right? That's how they keep us quiet on stuff that needs to change. So at any rate, they didn't stay quiet. Thank you. And the US Soccer Association dictatorship, I don't know. Whatever it is, has agreed to pay a lump sum of $22 million in backpay to the players. That's fantastic. And it will be distributed in a manner proposed by the players, which is great approved by the court. So we'll see how that goes. The soccer Federation will put $2 million into a fund for players post career goals and charitable efforts, with each player able to apply for up to $50,000. So that's fantastic, too. They're going to be making it so that there's an equal rate of pay between the men's and women's national senior teams in their friendly matches and tournaments, including the World Cup. So essentially it's equal across the board. I'm sure that there are going to be issues with this, and it's not going to be perfect, but we got to recognize what a tremendous achievement this is, US soccer President Cindy Parlo Kohn said in a statement. This is a truly historic moment. These agreements have changed the game forever here in the United States and have the potential to change the game around the world. And I'm going to say, yes, the game of life, because we still have to demand fight for plead for equal pay in so many fields of work, right down to the fact that women who stay home to raise children aren't paid, which I think is crazy. I think that they need to be paid for that. There's so much to fix here. We're not going to fix it all in one day. And this is supposed to be ending on a high note. So I'm going to get out of my way and congratulate you as soccer and say thank you to the team at Uterine Kind, including Angel, our producer, who is amazing for making this podcast a reality for giving us the opportunity to bring content to uterine kind so that they can understand their bodies and advocate for definitive diagnosis for the conditions that they're experiencing or for the symptoms that they're experiencing and it's just such a joy to be able to do this. We're going to talk about menstrual blood on and on and on forever. Loudly everywhere. As a matter of fact, I'm so inspired. I want to go out on the street today and I want to talk to people about menstrual blood and see what they say. We're going to do that and we are absolutely going out to long island to visit Dr. Christine Metz laboratory and I want to thank her for making so much time available to us and for us to ask all the questions that we need to ask and I have a million more. She was amazing so thank you for listening. Please do tune in on Thursday for the after show because I'm telling you, it is full of information about endometriosis period blood. It is chock full that's probably really bad. That's a bad analogy, right? It's pleasantly full of information for you and come back next week for another episode of hello uterus visit hello uterus.com to send us your questions and to subscribe to stay updated on our progress with uterine kind a platform that is going to change the way people experience uterine care in this country. You can also email us at hello at hello uterus.com with your questions or you know, just whatever just want to say Hi. We'd love to hear from you. Have a great week. Everybody will see you next week for another episode of hello uterus.