163 Pelvic Pain Playbook – Endometriosis, Fibroids, Cysts & Torsion

Hello and welcome to episode 163 of the Physician Assistant Exam Review Podcast. This week we’re going to be covering pelvic pain, masses, and discerning surgical emergencies versus this can get watched for a little bit. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. I’ve been behind this microphone for what’s about to be 15 years, which is unbelievable to me. It’s been such a pleasure to be working with students with helping students with producing this content. I appreciate that you guys allow me to do this, that you support me both with your time, with your attention, with your focus and with, and monetarily, quite frankly, so that I can continue to put this content out there and continue to help students.

It’s just been an absolute blast and we continue to grow each and every week. And that’s because of you and because you’re sharing the show, because you’re sharing where you are doing well, the resources that are helping you. So I’m going to just throw in there on top of that. If you could, if you’re getting something from the show, please share it out to your cohort, share it out to your classmates, share it out to your faculty or wherever you share resources and content. There’s people in your class who are struggling, who are absolutely struggling. They’re not mentioning it. They’re not talking about it.

They’re scared to talk about it. But maybe we might be able to change how they do some things and help them get through PA school. I hear so much from students and not to be a downer, but students who are getting… They’re at risk for expulsion, they’re at risk for being decelerated, they’re on their third or fourth PANCE attempt, and I just think we get out in front of this better if we talked more about the skills involved rather than just the content, the content. As you know, content is king, it’s the most important piece, but I see students every day who do not have content gaps and cannot pass the PANCE because they don’t have the skills. Anyway, today’s episode is going to be all about endometriosis, uterine fibroids, ovarian cysts, and ovarian torsion. We’re going to walk through those four conditions.

We’re going to talk about how they compare to each other, how you treat them, how they are similar, how they’re different, because that’s the way that you study when it sticks. Our priming questions for today, let’s go ahead and jump right into those. What’s the definitive diagnostic procedure for endometriosis? The definitive diagnostic procedure? Oh, if you haven’t listened to the show before, the priming questions, you’re not supposed to know the answers to these. If you do, you are a rock star. If you don’t know them, don’t worry about it, but don’t ignore them.

Your job is to think and process the material even if you don’t know it. I promise you won’t remember it wrong. You’ll build out the scaffolding, the neural networks that will hold the information better if you try. So what is the definitive diagnostic procedure for endometriosis? What’s the first line imaging for suspected uterine fibroids? Does normal Doppler flow rule out ovarian torsion? What’s the most common type of ovarian cyst in reproductive age women?

And what type of fibroid causes the heaviest bleeding?

Alright, let’s jump into endometriosis. Endometriosis is something I am quite familiar with. In my practice as a surgical PA, I work with a ton of excellent GYN robotic surgeons. And a handful of them are experts in endometriosis. So I spent a lot of time dealing with this condition surgically. This is the presence of endometrial tissue outside the uterine cavity. You’ll find it on the ovaries, the fallopian tubes and the pelvic peritoneum and the uterosacral ligaments.

We’ll talk a lot about uterosacral ligaments next week. We talk about prolapse, those are ligaments that help hold, that help, that help pull up the uterus and the vagina. And that’s going to affect us next week with prolapses. But for this week, that’s a lot of times where you can find these implantations of that endometrium. And the major problem is, now think about, what is the problem if you have endometrial tissue in the pelvis? Well, it reacts like endometrial tissue, so it bleeds every cycle. This causes inflammation, pain, and from my perspective, tons of adhesions and scarring.

Risk factors are nulliparity, early menarche, shortened cycles. And the idea is Sampson’s theory, which is retrograde menstruation, is the dominant, is the issue here. And that’s the dominant there. There are others, but that’s the dominant one right now, so what causes this? If you have Mullerian anomalies, so outflow obstructions, the disease is accelerated. Family history is also a risk factor. Relatives have seven to 10 times higher risk, sorry, not percent.

That’s a huge vastly different number. 7 to 10 times a higher risk. Clinical presentation, you get cyclical pelvic pain that starts before menses and worsens throughout the cycle. Dyspareunia, but it’s deep because it’s all on the uterosacral ligaments. And you also get infertility. That scarring will cause that. The pain is cyclical and progressive.

It gets worse over time, not better. Dyspareunia in endometriosis is deep, like I said, it has to do with hitting those uterosacral ligaments and the posterior cul-de-sac. Dyschezia, which is painful defecation during menses, you can get that when you have posterior lesions, right, on the rectovaginal septum. The other thing you want to note and pay attention to in the next one, because I think this is relevant and easy to remember, are endometriomas, which are chocolate cysts. Those are ovarian cysts that literally look like they’re filled with chocolate sauce when you rupture them. They’re not filled with this nice clear fluid, they’re literally filled with chocolate syrup. That’s what it looks like.

In my understanding, is that old blood is what collects inside of there. And a question stem here would likely describe a woman with cyclical pelvic pain that worsens with menses, deep pain with intercourse, and difficulty conceiving. So to diagnose this, we’re going to get a pelvic ultrasound because you’re going to do that out of the gate if you have someone with pelvic pain, right? It just makes sense. It’s not invasive, no radiation, relatively cheap. If you’re in a GYN office or an OB/GYN office, you probably have this in the office. You know, we were talking about this a couple of weeks ago with the 33 Days to Pass the PANCE students in one of the workshops, we were going over questions and one of the students had a question that was, “Well, what’s the next best step for this patient?” And with some sort of, I can’t remember exactly what the question was, but it was a genitourinary problem.

And the question, and one of the answer choices was to do a cystoscopy to look inside the bladder with a scope, and that’s what the student picked because it totally made sense.

Let’s take a look and see what’s going on. The problem was this patient was in an office setting in a family care setting. Family care offices are not set up to do cystoscopy at the drop of the hat. It doesn’t happen that way. So that’s not the next best step for this family practice doc or this family practice PA. So these next step, next best step questions can be tricky. But a pelvic ultrasound in a GYN office or in an OBGYN office, probably they have it.

So this is the first line imaging. This is going to look for a thickened wall or for those ovarian cysts. But it doesn’t diagnose endometriosis. It just gives you some impressions and it rules out some other issues we’re going to get to in a minute. Because again, this patient is coming in with pain. That’s what you’re trying to start with. So don’t start with endometriosis.

Start with a picture in your head of a patient coming into your office who’s complaining of pelvic pain. So as you work them up, you’re not going to start with an x-ray, right? We’re going to start with an ultrasound.

Now, the next step, if they’re still having pain, and the ultrasound shows some findings that point in this direction, you can take a look laparoscopically direct visualization, and then you’re going to biopsy. So we go ahead and we stick a scope in, and we look around and see if we see these implants in the abdomen. And you can see, you know, you will get what looks like normal tissue that you send out for biopsy that can have some endometriosis on it, so I’m not saying you can see it every time. But some lesions are very obvious. They have this black to bluish coloring. The pelvis looks inflamed. There might be scar tissue, but there’s no lab tests or imaging to confirm the diagnosis.

You’re doing biopsies. On physical exam, you may find a fixed, retroverted uterus. So the uterus might not, when it says fixed, I never understood this in PA school. It’s real simple. If you’re doing a pelvic exam, You should be able to actually move the uterus around a little bit. If the uterus is fixed, you can’t move it. There’s a reason you can’t move it.

It’s tacked down by something. So there’s some sort of adhesions and scarring issue in there, which, in a patient with pelvic pain, points to endometriosis. A retroverted uterus, same thing, or nodules along the uterosacral ligaments. So you can feel the uterosacral ligaments. If you feel lumps in them, there’s a good chance you’ve got endometriosis there. So all of this seemed really esoteric when I was a student. I just had to memorize these words.

They have uterosacral nodules. It has a fixed uterus. And I’m memorizing these lists that mean absolutely nothing. They’re just words I’m spitting back. Almost like a four year old telling you the square root of 144, right? They can spit the words back about the square root of 36. They can spit the words back, but they have no idea what they’re talking about.

That was me in PA school learning this stuff. Now that I’ve been there and I’ve seen it, it’s actually not that hard to wrap your head around. You may also get a CA 125 that’s elevated, but that’s not specific or diagnostic. It just kind of helps point in the direction.

So let’s talk about treatments. Your first step here is going to be NSAIDs. That just kind of makes sense, right? And then you’re going to move to hormonal suppression. This is either going to be OCPs, progestins, GnRH agonists for moderate to severe disease. What you’re looking for here is to create a pseudomenopause state. So Lupron is something you can use.

Or we go in and we remove the tissue. Laparoscopically, we excise and ablate the tissue. So we burn it, we cut it out. Because you can remove good chunks of the peritoneum without causing a real problem. Yes, it’s painful, it’s not exactly pleasant. But this is the definitive for diagnosis and for treatment, is to go in and remove it. A lot of times we do this for infertility as well, because, and the patients have an increased chance of conceiving.

I think it’s within the six months after the procedure, something like that. You’re not going to be asked that close, so it’s not going to matter for your test. It’s just conversational, to make it stick better.

Now, if you have someone who is no longer childbearing and not interested in having children, a hysterectomy with bilateral salpingo-oophorectomy will solve this problem, right? If you think about how it works, that totally makes sense. So, as far as this is concerned, our exam keys. Cyclic pelvic pain plus deep dyspareunia plus infertility is endometriosis. Pretty straightforward. We want to stick a scope in and look around and get some biopsies to diagnose it. You can get an endometrioma, which you’ll see on ultrasound and is called a chocolate cyst because it’s filled with this chocolatey looking substance.

You can do estrogen suppression and NSAIDs. Primary dysmenorrhea improves with age and after pregnancy; endometriosis gets worse.

Next, we have uterine fibroids or leiomyomas. These are benign, smooth muscle tumors of the myometrium, most common benign gynecological tumor and most common indication for hysterectomy in the U.S. And we do tons of these. I see so many of these. We work on the da Vinci robotic system and we take out tons of fibroids and do tons of hysterectomies for fibroids. You can get different symptoms depending on the location. So it’s just this smooth muscle tumor, it’s benign, except that it grows and it can cause pain and it can cause bleeding.

They can also become necrotic if they grow so big that the blood supply can’t keep up and that has its own set of lovely symptoms. But if it’s submucosal, they’re going to bleed a lot more. Right? So you can get a lot of bleeding. Intramural fibroids cause a lot of bulk into the uterus. You can, we get, I mean, we literally have 20 week, 26 week uteruses that will take out well above the umbilicus that are just filled with these fibroids. It’s not uncommon in our practice.

Risk factors. African American women have a two to three times higher incidence and more severe disease. Clinically I see this. We definitely do more of them on African American women, but by no means have I done a study on this, but I could back this up just anecdotally. Increased estrogen exposure is another risk factor: nulliparity, early menarche, obesity, and exogenous estrogen. Family history is another one. Fibroids grow under estrogen stimulation.

So they get bigger under pregnancy and shrink after menopause. So in some cases, you can do some watchful waiting and hope that menopause takes care of it. Clinical presentation. Again, submucosal into the uterine cavity, you get heavy menstrual bleeding. This is the most common: prolonged periods, iron deficiency anemia. I see a lot of patients come in who are anemic. It’s funny because sometimes they will be difficult to get cleared medically for their anemia.

And we try to explain that we’re doing the surgery to cure their anemia, but that’s a round and a round of process. Subserosal, this is on the external surface: urinary frequency or urgency if the bladder’s compressed, constipation if it’s in the back, right? Feeling of pelvic fullness. If it’s within the myometrium, so if it’s intramural, you get pelvic pressure, dysmenorrhea, enlarged irregular uterus on exam. The ones I like to find are the pedunculated fibroids. These are kind of like on a little stalk off the side or the top of the uterus. And the reason I like these is because you’re not digging into the myometrium.

You’re just kind of going in and removing this fibroid on this stalk. So it’s a very quick and easy surgery. So from my perspective, and the patients, it’s quick, easy, and those are the nicest to remove. But they can torse, they can move around inside the patient. You can actually feel them sometimes when they’re big enough. Up to 50% are asymptomatic and found incidentally. We will often see them during pregnancy.

When we, during pregnancy, what we’re doing, when I’m doing a C-section, you can find them on the uterus then, and they’re big and enlarged. You don’t want to touch them during a C-section. The patient has a significantly higher blood flow to the uterus. So you’re not about to do any surgical removal of something that could possibly bleed really badly, so we don’t address them during a C-section, but you can definitely see them and the patients won’t. Won’t have known that they’re there for any other reason. Here the question stem would likely describe a woman with heavy periods and large irregular uterus on exam and maybe iron deficiency anemia. You got to put the pieces together.

How are we going to diagnose? Again, we’re going to start with the pelvic ultrasound. Patient comes in and they have pain, pelvic pain, we’re going to do an ultrasound. These can be seen fairly well on ultrasound, they’re well circumscribed, hypoechoic masses within the uterus or next to it in those pedunculated ones. You may do an MRI for surgical planning. Ultrasound’s good but it’s not great. So it gives you some indications but it is not a clearly definitive, as you want some better imaging.

CBC to assess iron deficiency if there’s heavy bleeding, and you can do a hysteroscopy, which is you’re going to put a scope into the uterus through the cervix, because if you have a submucosal fibroid, you can see them from there. And there’s instruments you can use to ablate or resect the fibroids through a hysteroscopy. So you don’t have to go into the abdomen, you actually go in through the cervix. Treatment. If it’s asymptomatic, nothing. Observe it. Fibroids shrink after menopause, not a big deal.

They make it a little bit heavier bleeding, but if it’s not really bothering the patient, then there’s nothing to do. You’re not going to go in surgically, fix something that’s not really bothering someone. That’s not leading anywhere. If the patient is having issues with bleeding, you can do tranexamic acid or NSAIDs for acute heavy periods, combined OCPs to regulate the cycles. Again, you can do Lupron to shrink the fibroids, especially preoperatively, we do that a lot to bring down the size of the fibroids so when you go in to operate. It’s much, much smaller. Surgically, we can do what’s called a myomectomy, which is to we preserve the uterus, we just remove the fibroids.

Sometimes it’s easy if they’re just one or two, but I’ve literally taken out 20 or 30 fibroids in one uterus. So it can be painstaking and difficult, or it can be very straightforward in the case of those pedunculated ones. You can do a hysterectomy, So if you have somebody who’s older, decide they’re done having kids. Sometimes you have that patient with again 20 or 30 good size fibroids. It’s a lot to go through that procedure to get those out to preserve the uterus. Sometimes it’s a better decision to say, you know what? I’m not going to have kids.

Let’s just go ahead and do the hysterectomy, which becomes a much more straightforward procedure. You can do uterine artery embolization. So you can, it’s a minimally invasive procedure to cut off the blood supply to shrink those fibroids. But again, you probably not going to want to do that if you don’t want to get pregnant. You can do an endometrial ablation. So for submucosal bleeding, you can actually ablate the tissue from the inside. Heavy periods plus irregular and large uterus plus anemia is a leiomyoma until proven otherwise.

Location drives your symptoms, but I don’t think you’re going to have to deal too much with that. I don’t think that’s an issue. I just want to get your head around why this bulk is a problem, right? If it pushes against the bladder, if it pushes against the rectum, that’s really going to be your issue. You can use GnRH agonists like Lupron to shrink the fibroids, but it does give some bone loss issues, so we’re doing this just before surgery to shrink the size of them. We’re not, this is not long-term treatment for fibroids. A myomectomy preserves fertility, and hysterectomy is definitive, but obviously causes problems for future fertility.

The fibroids grow with estrogens, so they shrink after menopause.

Alright, we talked about endometriomas, so let’s talk about ovarian cysts in general. These are fluid filled sacs on or within the ovary, most commonly functional cysts from normal follicular development. So normal follicular cysts are very common, obviously. The key clinical question here is functional versus pathologic. And then if you have a postmenopausal woman, it’s benign versus malignant. And that’s what you’re trying to decide. What’s known as a functional cyst is a follicular or corpus luteum.

You get reproductive age women with regular ovulation. Endometrioma, it gives you that endometriosis risk factor. You can get a dermoid cyst. These are all types of cysts that we have. Dermoid cysts are mature teratomas. This is most common in women ages 20 to 40. These are kind of crazy if you’ve never seen them or heard of them before.

These contain ectodermal tissue. So hair, teeth, sebaceous material, I’ve seen a lens of an eye inside of one of these. They’re absolutely disgusting because you have this cyst that, you know, the chocolate cysts, is filled with this thick chocolate sauce, which is kind of gross. These have this thick sebaceous material. So it’s this fatty liquid inside of them. And they also have hair and teeth a lot of times. Teeth I haven’t seen that much.

Hair is very common. Teeth I’ve seen a couple of times. An eye lens I’ve seen once. Really just creepy. And it makes a huge mess inside the abdomen that you have to spend a long time cleaning up with the suction irrigator. There are a bunch of other types of cysts out there, but we’re not going to go into too deep. Postmenopausal appearances have higher malignancy rates.

We have to worry about that and require close evaluation regardless of what size they are.

All right, clinical presentation. Most ovarian cysts are asymptomatic. You don’t know you have them. They’re found incidentally or on pelvic exam. A lot of times we look in the abdomen doing a laparoscopy for something else.

Let’s call it even like a bowel problem. And you see these cysts. A lot of times they’re not a big deal. Asymptomatic, they don’t really matter. They can have this dull unilateral pelvic aching, bloating, pelvic heaviness or dyspareunia. A ruptured cyst can cause sudden onset pain in the pelvis. You can often see this mid-cycle for follicular cysts or shortly after ovulation for corpus luteum.

These are self-limiting, but can be an issue. Those dermoid cysts we were just talking about can torse because they can get big and the weight can turn them around. The question stem here is likely going to be something like a young woman with incidental ovarian cyst on pelvic ultrasound or sudden unilateral pain, mid-cycle with tender adnexa, what are you going to do next? Diagnostics. So where do we start? What’s the first thing we do? Patient presenting with pelvic pain to an OB/GYN office.

We do a pelvic ultrasound. We’re looking for what size it is, the location, Doppler flow, components, septations, whether it’s unilocular or multilocular, whether it’s solid. Those are all things we’re going to define, and that’ll clue us into what type of cyst we’re dealing with. A simple, thin walled, unilocular cyst, smaller than 10 centimeters in a reproductive age woman is likely functional. You can probably just observe it. If it’s complex, so if the walls are thick, if there’s anything solid, if there’s internal blood flow, you’re going to want to get an MRI, or take a look laparoscopically. For dermoids, you might see heterogeneous echogenicity on ultrasound, calcifications.

If you see calcifications in the ovary, you’re thinking dermoid. Those are those teeth I was talking about. There aren’t a lot of reason you should see calcifications in the ovaries. For an endometrioma, it’s going to be thick-walled, homogeneous, hypoechoic appearance. What did we say earlier? We said ground glass, not in the lungs this time, but in the ovary, endometrioma. CA 125 will be elevated in epithelial ovarian cancer, but also endometriosis, PID, fibroids.

It’s not really specific. Postmenopausal simple cysts, smaller than one centimeter, usually benign, you can observe it, but again, any complex features whatsoever in a postmenopausal woman you need to be worrying a little bit and maybe get a surgical evaluation. Treatments, functional cysts, observed for two to three menstrual cycles, most resolve spontaneously. Or you can do some birth control pills that might also help with this. A ruptured cyst usually just pain management and observation, dermoids or more persistent complex, you’re sending them to surgery for to take a look at that cyst and see if it needs to come out.

Exam keys, most ovarian cysts in reproductive age women are functional and resolve in two to three weeks. If you see calcifications, you’re thinking dermoid. Complex features need to be worked up.

All right, let’s move it along. Last one for today is ovarian torsion. Just like testicular torsion, the twisting of the testicle, this is twisting of the ovary. This is a twisting of the ovary which causes necrosis and ischemia, or ischemia and necrosis, I guess is a better way to say it, you’re compromising blood flow. This is a surgical emergency. This bumps everything else going on in the OR that day and you get the next available room. Risk factors are ovarian cysts or masses, like we said, that dermoid, that large cyst can help to cause this and create this.

Pregnancy enlarges the ovaries and relaxes ligaments, so this can also be a risk factor. I actually didn’t realize that until pulling up notes for this. The right side is more common than the left side because the sigmoid colon limits left side mobility. Clinical presentation, sudden onset severe unilateral pelvic pain. This is most common on the right side, but I don’t think you’re going to see that distinction on your test, but you will see the sudden onset of severe unilateral pelvic pain. That’s very standard. You can get nausea, vomiting.

Absolutely, with these patients. You can get a low-grade fever. The pain may be intermittent if torsion is partial and the ovary kind of twists and untwists, so you might have trouble discerning it, but definitely keep an eye out for that. The question stem is likely, you’re going to have a reproductive age woman with some, maybe some sort of history of fertility treatments or some sort of history of cysts or things like that that will kind of clue you in that there’s an issue here. And then she suddenly has severe unilateral pelvic pain and nausea. That’s a really good way to pick that one out.

Okay, folks, how are we going to start our diagnostic program here? What’s the first thing we’re going to do? I hope you’re raising your hand and shouting out pelvic ultrasound with Doppler. That’s the first line treatment, I’m sorry, not treatment, diagnostic test. Reduced or absent Doppler flow suggests torsion, but normal flow does not rule it out. Normal flow does not rule it out. The ovary, again, a partial torsion with some preserved flow, right?

You can get that where it kind of rolls around and sometimes it’s torsed and sometimes it’s not, but that doesn’t mean it never is. So be a little careful there. It may show an enlarged edematous ovary, free pelvic fluid, or an underlying cyst or mass that caused your torsion. Ultimately, you’re going to take them to surgery and take a look at it, and you’re going to see that torsed ovary. It’s very, very obvious. We do these occasionally. I don’t do a ton of them, but I have absolutely been involved in them.

If the clinical suspicion is high, take them to the operating room. This is a clinical emergency, that ovary is going to die. Treatment is surgical detorsion via laparoscopy performed urgently. Time to OR matters. It absolutely bumps everything else. Or almost everything else. Even a black necrotic appearing ovary can recover after detorsion.

So you may go in and just take the cyst out, you may have to take the ovary out or you could just untwist it and hope for the best. Do not empirically remove the ovary unless clearly non-viable.

Exam keys. Sudden pelvic pain, nausea and vomiting, and a known cyst history. This is absolutely torsion. Normal Doppler doesn’t rule it out. They can have a little bit of a fever, so don’t let that distract you and they have to go to the OR. Woohoo!

Alright, so that gets us through this entire section. Our study tip for today is just pay attention to the way that I set this stuff up. I set it up for you the way that I would be studying it in order to get the most questions right. Not necessarily to remember the most, although it has the handy effect of doing that too, but the way the questions are going to come, right? So you’re going to get a patient who presents with pelvic pain. You’re going to figure out what the problem is. You’re probably going to start with the pelvic ultrasound and go from there.

You’re probably going to do a pelvic exam. You’re going to need to know what findings you’re looking for depending on what they’re complaining about. Patient comes in with pelvic pain. You’re unlikely to order an EKG. You’re not going to get troponins. You’re going to order a pelvic ultrasound. Makes sense.

So a lot of the stuff, it’s not about memorizing these lists. Again, that’s what killed me. Don’t memorize lists. Understand the relationships and what you’re doing. Picture yourself standing in that office with the patient walking through the door. Who says, “I have pelvic pain. I don’t know, it’s just this deep pain I get.

It comes and goes. I’m not really sure. I think it might match up with my menstrual cycle. Yes, it definitely hurts when I have sex. And no, we haven’t been trying to get pregnant. I haven’t been able to.” All of a sudden, I’m thinking endometriosis. I’m going to get an ultrasound, but I’m going to do a pelvic exam.

If I find that the patient has pain with the pelvic exam, if I feel nodules along those ligaments, if I can’t move the uterus, now I’m really thinking of endometriosis. So my next step is to go do the ultrasound and that might confirm it or push it in that direction, then I’m going to send him for surgery. We’re going to look around and confirm it and get some biopsies and strip out that tissue. Because that makes sense, that’s the follow-through. That’s the way that we move through a patient. So it’s the same when you’re test questions as it is in real life. I don’t know how to say that any differently.

It’s the same. It’s the same. It’s the same. But if you’re just memorizing lists of disease, treatment, diagnostics, you’re not going to remember it and you’re not going to be a good clinician, quite frankly. You need to be able to pair this stuff together to run through your differential diagnosis, to pull it apart.

All right. Let’s move on to our priming questions. What is the definitive diagnostic procedure for endometriosis? Do you remember, I literally just said it. Laparoscopy with direct visualization and biopsy. What’s the first line imaging for suspected uterine fibroids? This one, if you don’t get this one, man.

Woo, pelvic ultrasound. Does normal Doppler flow rule out ovarian torsion? Nope. What’s the most common type of ovarian cyst in a reproductive age woman? Functional cysts, follicular or corpus luteum. What type of fibroid causes the heaviest bleeding? This is the only one that seems a little tough.

This would be submucosal. Beautiful.

Alright, well done today. This was great. We covered a lot of ground. We tied things together. I hope this is much more clear than it was for me in PA school. I just didn’t get it. I couldn’t see it.

I was memorizing these words. These words, I didn’t make any sense to me. I’m hoping I was able to paint a picture for you today that makes a little bit more sense. That you can see what’s coming. If you found this episode helpful, please share it with a friend, please share it with your cohort, please share it with your faculty so that they can pass it along to struggling students. My goal here is to have the biggest impact I can have on PA students, so they can get the most out of school, get the most out of the rotations, not be stressed and up all night, but actually turn the time they spend, the work they’re doing, into meaningful points on their exams, so that they can sleep at night and stop being so worried and stop being so stressed. That we can get through this, ’cause it’s all about learning, becoming better every day, and helping your patients, and getting through PA school, graduating, and passing your PANCE.

So please share the show, so that I can help as many people as possible, and you can be the hero there, as well, passing things along.

Fantastic. Yeah, that’s it for today. So take care, love to hear your results, how you guys are making out. Absolutely check every single email, if you want to reach out. Love to hear from you guys. You can also find me on Instagram pretty easily, and I’ve been doing a better job of answering DMs in there. It takes me a little more time, ’cause I don’t always think to check it, but either way.

Take care, have a great day, and I’ll talk to you again next week.