Birth Control for Endometriosis? Hormones, Progesterone Resistance, and What Doctors Aren’t Telling You

27:59I mean, no one wants to do surgeries, but it's like a less invasive option to offer a patient. Even less invasive for, I'm sorry, nutrition. I mean, nutrition and physical therapy. Go. Sorry. I was just going to say another thing. For somebody that has a marina and they are experiencing mood alterations, they could always swap out the marina for a Skyla, which was designed for teenagers that has substantially less progesterone. Now, I don't typically use the Skylas unless I have to, but it would be a less hormonal, it'd be a better option for somebody with adenomyosis than a copper IUD. It would still give them contraception, and maybe it wouldn't suppress the adenomyosis so much, but at least it wouldn't make it so much, It wouldn't make it worse like the copper one would.

28:54Yeah, and the HIFU wouldn't be birth control. That would just be treating the adenomyosis symptoms. Yeah. And do any of you use low-dose and altrexone? Absolutely. Say more. Well, so I think it's a great option for patients who've had excision surgery and then still have some residual pain. And maybe they've been deconditioned from years and years of being in pain. And so they have central sensitization. They have increased inflammation. We know that LDN, which is low-dose naltrexone, is also very effective if someone has Hashimoto's in terms of decreasing total body inflammation and improving in that area.

29:37But it also is helpful for patients with ongoing pain after surgery. Do you know the mechanism by which it is anti-inflammatory? It works on opioid receptors within the brain. And it's so much, so like speaking about central sensitization, our opioid exposed patients tend to have like almost like a sensitization after being exposed to opioids. It is such a better option than. Because their receptors get upregulated when they're on all the drugs and then it takes a while to get back down to. If ever, if ever. But good for them to know if they are on LDN before surgery that they come off of it a couple weeks ahead of time so that they will still be able to respond to opioids in the post-surgical period.

30:26It's also important to know that this is something that has to be started low and slow. And if you have crazy nightmares, that is something that is a known side effect. And so that's why it's typically started at one milligram and then a slow increase over a two-week period of time before getting to the therapeutic dose, which is typically three milligrams. But some people feel good at like one and a half, two milligrams. But that is one of the most common things that I will hear from patients is like, I had these wild dreams that kept me awake. And it's like, okay, you may be sensitive or they've seen someone else who's put them straight on three milligrams as a dose, which is a great therapeutic dose, but it can be way too much for the brain, way too quick.

31:08You mentioned nutrition, Ana. What specifically about nutrition can be helpful? You know, not just from the endometriosis perspective, but from the hormonal perspective as well. I am not a nutritionist and I usually refer my patients to a nutritionist because I work in a multidisciplinary center. But on the basic level, we need to test the patients about their specialty or special things that make them more inflammatory. There are special type of foods that make their inflammatory system go wild. And if you add this inflammation to the inflammation that endometriosis causes, it's like feeding the fire.

31:46So some patients are sensitive to gluten. Some patients are sensitive to dairy. and some patients are sensitive to chocolate. Some patients are sensitive to... Don't say that. Even like tomatoes, they do like crazy diets starting whenever they're like experimenting in which are the foods that make them bloated. I would really recommend them to don't do that and to seek a nutritionist in order for them to get a proper diet and not do anything like it's too restrictive for a long period of time. We always advise our patients that it's like an 80-20 rule, that we do not expect them to travel with a Tupperware to every family meeting or everything.

32:31A very large part of society is eating with the people that you love. So if you don't share this, you're losing a part of your social self. So you should be able to have that strong basic or strong basis of 80%. So you have the other 20 % that you can go outside and have whatever it is that you enjoy with your husband if you want to go one night out or enjoy with your friends or something. But it's really, we can see a before and after when patients do have a proper nutrition help. Endometriosis doesn't always show up the way people expect it to. And too many women are left managing symptoms without a full evaluation of what is actually happening.

33:16Endoglobal specializes in complex endometriosis care, including advanced imaging review, multidisciplinary evaluation, and excision-focused surgical planning. You deserve a team trained to recognize the full scope of this disease. To learn more or schedule a consultation, visit drbrighton.com slash endoglobal. that's d-r-b-r-i-g-h-t-e-n.com slash e-n-d-o-g-l-o-b-a-l I think those are all all these elimination diets are best done with a nutrition expert so you can truly get the data and see what is and isn't working for you when it comes to these diets I think it's important for people to understand they're therapeutic therapeutic has a window of when we're using it and it should not be lifelong.

34:10Outside of that, I would say the anti-inflammatory diet, which is essentially like a Mediterranean diet, is always winning the research. So high polyphenols, high fruits and vegetables, getting lots of fiber, cold water fish, so you're getting all of your omega-3 fatty acids in, nuts, seeds, you know, these whole foods should be the 80 % of eating. And I am 100 % with you when it's like, and then when you go out, stop stressing about food because it's the stressing around food that can sometimes make the reaction to food so much worse. I do want to continue the conversation about hormones. And you mentioned menopause.

34:48Now, there are a lot of providers who will say, if you have a history of endometriosis, you are not allowed to have hormones when you enter menopause. What are your thoughts on that, Shanti? Well, if you have a history of endometriosis and you have not had it excised or treated, you are likely to have an exacerbation of your symptoms if you start estrogen. And so I really believe that if you have endometriosis and you're entering menopause and you're still having symptoms and pain, you still might want to consider excision surgery. And once you've had really adequate excision surgery, receiving estrogen plus progesterone, even in the absence of a uterus, I believe is wise counsel.

35:35And so this for our listeners is controversial. Most gynecologists across really the world believe that if you have had your uterus removed, that you do not need to have a progestin or progesterone with your estrogen during menopause. And I think that because of while it's a small risk, the 1 % risk of malignant, less than 1 % risk of malignant transformation of endometriosis does exist. And so taking estrogen only is risky for someone who has endometriosis. Say someone has had endometriosis. I actually published a case report on an endometrial cancer developing in a diverticulum of the colon in a patient who was using estradiol pellets post hysterectomy and not using any progesterone or progestin.

36:33And so I think she was more at risk of developing this endometriosis induced. It was right next to a bed of endometriosis. It really demonstrates that if you're feeding these endometriosis lesions with estrogen and not counterbalancing it with opposing progesterone, you probably are increasing your risk. The problem that I, this is what I take, the hill I will die on, I should say, with the recommendation that if you don't have a uterus, then you don't need progesterone, is that it again reduces women to just a uterus. And it forgets the fact that we are also breasts, we are also brain, we are also bone.

37:13You know, as you were saying that, like, oh, you know, this is controversial. I was like, laughs in allopregnenolone, like laughs in getting good quality of sleep and staying asleep and not raging out and not losing your cool all the time. And so it's, again, like a really big problem to always be looking at women as if they're a uterus, right? And then maybe a breast. Anywhere a bikini lies is what medicine basically reduces women to. And, you know, to your point about cancer development, it's also interesting because there was a study, and we definitely need more, that if you have endometriomas and you're given estrogen only, you have a much higher risk of ovarian cancer.

37:53And then when they found, if you're given estrogen and progesterone, there is no risk. There is no risk compared to if we give you just estrogen. And so I think even if a uterus has been removed, you can never know that all the endometriosis is gone. So what is the harm in giving progesterone? There's not. In giving progestins, yes, there appears to be an increased risk of breast cancer. There is that increased risk. But with progesterone itself, that risk doesn't appear to exist. But to your point again, pharma is not invested in studying progesterone. No one really is because there's no profit to be made on it.

38:33There's an old French study that was like 80 ,000 women. And it looked at menopausal treatment using bioidentical estrogen and comparing it with three different progestins and progesterone. And each of the three progestins, which included Provera and I believe Northindrone and one other, slightly increased the relative risk of breast cancer, whereas the relative risk of breast cancer with estradiol and bioidentical progesterone was one, which means it did not either increase or decrease the risk of breast cancer when taking estradiol, which is a bioidentical estrogen, with progesterone, which is a bioidentical progesterone.

39:17I think a lot of these problems stem from the worst study in the history of the world, which is the Women's Health Initiative, looking at, forgive my French, horse piss urine. I mean, that's not French. That's just facts. Premarin, and in case you didn't know this, the name comes from pregnant mare's urine. And then Provera, which is the worst synthetic progestin that has ever been made, in my opinion. And given these hormones to women who were 65, they were 10 to 15 years past menopause. They were completely asymptomatic. They were primarily trying to look at the cardiovascular risk. But what they found was that the PremPro group had eight cases per 10 ,000 women per year, increased risk of breast cancer.

40:11But what they didn't realize is that the control group, they didn't exclude women who had been on estrogen only in the past. And the control group actually had a lower rate of breast cancer. And so part of these issues is how the study was designed. The second phase of the study came out and showed that women without a uterus who were just given estrogen actually had a lower risk of breast cancer. And that estrogen did everything that we always thought that it did, which is protect the brain, protect the heart, protect the bones. And protect the colon. Yeah. And the microbiome. And you're right, Shanti, the risk of breast cancer, even with norethindrone, is much less than with Provera.

41:12But with progesterone, it's even better. And what I think is really important for women to understand is, I brought this up in a previous episode, is that women with endometriosis are at much higher risk for cardiovascular disease and having a cardiovascular event, which we know estrogen is protective against. And so it's very easy when you have a disease that's driven by estrogen to decide that estrogen is the devil and the worst thing ever. And really, it's about balance and it's about nuance. And I think a lot of physicians have been out there echoing that, the problem is we just need to get rid of estrogen without regarding the entire body.

41:50What I'm hearing from you, Shanti, is that going into menopause wanting to have HRT, you would recommend having excision surgery first. So there's not the risk of those tissues being activated once in menopause. Or even, this is the tricky thing too I'll bring up, in perimenopause that we often see that estrogen is going high, skyrockets, dropping, high, dropping. And women's endometriosis is flaring. And doctors are like, it's just perimenopause. Even the people that are out there talking about menopause and trying to put it on the map and get things to change are not taking like lot of or stock of what endometriosis patients are saying about their experience.

42:34And this is where using progesterone definitely comes in of like, you have to have something opposing that. And the, you know, to Cindy's point, the just wait until menopause can actually do a lot of harm because there's so much unopposed estrogen that can happen month over month before those ovaries are finally like, all right, FSH, you keep talking, we're done. We're not going to respond to that. Absolutely. I've seen estradiol levels go up into the thousands, peaking at mid-cycle in perimenopausal women. Yeah. At first, I was worried, and then I realized what was happening. Yeah. In the context of this conversation, though, I want to say to Ana, you had said about endometriosis being this inflammatory systemic chronic condition.

43:23Why does that perspective, that definition of endo matter in the context of talking about hormones? I think it's about getting the whole picture in, maybe about that, and not seeing patients as uterus and ovaries. I think that's the whole point of defining endometriosis as a systemic disease. It's something that affects every part of their body, and that can be found in any organ of their body. So I think that's important. But I think also because, well, as you were saying, estrogen and hormones affect every part of their body too. So removing the hormones can affect a lot of other things. And not every patient gets like this advice that if you are on Lupron, you may lose bone density, You may increase your heart disease or your chances of getting heart disease.

44:16These are the things that we have to talk with our patients beforehand. And the informed consentment is really, really important. I think targeting the hormones alone doesn't actually target the endometriosis and the implications it has on your body. So you have to treat the actual endometriosis. And, you know, of course, you can also manage the hormones as a separate issue. but the endometriosis has to be treated. If you remove a young person's ovaries, they immediately go into surgical menopause, right? So their natural GNRH and FSH skyrockets, right? And what happens is this also is going to drive the adrenals.

44:53And then you get this elevation in cortisol. Cortisol, in terms of the world of hormones, cortisol is king, okay? So if you've got elevated cortisol, you've got a state of chronic stress, you're affecting your immune system, you're affecting all the rest of your hormone system, you're affecting your sleep, you are fully, totally driving inflammation, and you can't get away from it. So this is why a lot of the things we talked about earlier, like Vicky was talking about, doing these things for the vagus nerve, calming your vagus nerve, doing anti-inflammatory diet, all of these things are trying to modulate what's happening with our adrenals, right?

45:37So we're in constant stress, we're elevated cortisol. We take out the ovaries, we're in elevated cortisol. We go through menopause, we're in elevated cortisol, and we are like stress biscuits, right? So we've got to find ways to lower that. And one of the ways is diet, one of the ways is hormone therapy. Yeah, and I think, you know, it's really important to understand that any chronic inflammatory disease requires a response from the adrenal glands. And so for however long your body has been struggling with endo, and this is why we see things get worse, right? When women are stressed, when they enter into a decade of life where they're caretaking between children and parents, and there's all of these factors coming on is that your adrenal glands have already been producing that cortisol to suppress that inflammation, to try to control that, is the cause of endometriosis a gut bacteria?

46:26No, actually, there are rhamnosus cepa is helpful, and it has been discovered that in patients that have this cepa predominant in their bacteria on the gut, they have less risk of having bowel lesions. So sometimes it's called like protective, and sometimes we prescribe them to our patients in order for them to not move forward. And you have to think about the connection between the anus and the vagina. They share the same microbiome. So if you have something or any pathology that is going to make you more constipated or not removing the poop and having bad bacteria there, you're probably going to have more symptoms in your vagina.

47:05Yeah, the gut is the primary storehouse for the lactobacillus. And with that, I mean, it's the thing that you can see the changes in perimenopause, especially as estrogen declines. We see decrease in diversity of flora, and it's a matter of time until we start to see the vaginal symptoms can arise from that as well. Does anyone think at the table that the solution to curing endometriosis is going to be treating the gut in terms of where we're at currently? I mean, I think managing inflammation of the gut can help with symptoms. And the nerves of the gut. I'm sorry, the chocobaldolosabal nerves.

47:43Yeah, of course. And I think the diet is, we talked about the anti-inflammatory diet, and there's also the reverse, which is the inflammation from the endometriosis leads to gut inflammation. I think the microbiome probably plays a role that we don't fully understand, and it's probably really important in helping our patients mitigate their endometriosis symptomatology and even potentially the severity of it, but is it like an abnormal gut microbiome the cause of endometriosis? As far as we know now, that is not a common belief among experts. If your endometriosis pain is still ruining your life, something was missed.

48:25This disease is complex and without specialized evaluation, it's easy to manage symptoms without addressing the full scope of endometriosis. Endoglobal focuses specifically on advanced imaging review and excision planning. And they offer affordable options, including a complimentary consultation to evaluate your case and determine whether surgery is appropriate for you. You do not have to guess on your next step. Visit drbrighton.com slash endoglobal to book your complimentary consult today. That's d-r-b-r-i-g-h-t-e-n dot com slash e-n-d-o-g-l-o-b-a-l. There was a really fascinating study that was published a couple of years ago where they took auto transplant endometrium and gave it to rats.

49:23And then like a month later, they sacrificed the rats and they looked at their colon and their small bowel. And what they found was that the glial cells of the colon became reactive. And what the glial cells are, they are the cells that kind of insulate the neurons of the enteric nervous system. And by being reactive, what that meant is that the nucleus was irritated and that they were inflammatory. And that the inflammatory cells surrounding the nerves is part of the reason why women with endo have such significant GI symptoms. Yeah, it makes sense. And I do think, you know, to your all of your point is that we know that managing gut health can help with modulating inflammation, can help with endo belly in itself, can help with the removal of estrogen.

50:18So we're not getting reconjugation, circulating estrogens increasing. There's a lot I think we can do with gut health, but I'm on the same page as all of you. I mean, if it was a cure, I'd be the first on it, but I don't think this is the key. And I often think when you have people who have a chronic condition that affects their dietary habits, when we see alterations in gut microbiota, we have to ask the question, was that their first maybe it came from their mothers you know that's completely possible or was it something that developed due to dietary restrictions you know we often see this in the neurodivergent community where autistic people have very different gut microbiomes but we also know they have very different eating patterns and so it's a very chicken or egg situation i just don't think we're at a point where we can hang our hat on this and say just give an antibiotic and that's going to make endometriosis go away.

51:16Certainly, I would love to be proven wrong because that would be like super easy and super sweet, but I just don't think we're going to be there. I want to go into a little bit more about EDS, POTS, MCAS, because we've talked about this a little bit in each episode, but this was a listener question that they said, knowing the body of evidence with endo and the comorbidity list of Ehlers-Danlos syndrome, POTS, dysautonomia, MCAS, how are you changing surgical protocols to be safer for patients in this population? I think there really needs to be a medical counterpart to the surgical treatment of endometriosis because these are very complex comorbidities that we understand simply because we see our patients that have, we see the pattern that our patients have these, but it's not something that we are trained.

52:12At least I'm not, I wasn't trained in, in my residency or fellowship. It's just something that I've learned through experience with my patients. And so I think, you know, we talked a little bit about the pre prehabilitation before surgery. I definitely think POTS needs to be optimized. You probably need a special, you know, we usually do have a little protocol, like a bolus before surgery, a bolus after, salt tabs after. We have the EDS. We make sure that they don't have C-spine laxity that could lead to problems during intubation. Positioning is a lot more careful. Yes. I mean, there's definitely things we take into consideration, but we are not experts and we need partners to help fully optimize these patients and to help them get the full benefit out of their, out of their surgery.

52:59Because the truth is like surgery is much harder on their bodies and, um, and they will have a longer recovery. And I, we set these expectations, but like, we just don't have enough information to take like the best possible care of these patients. A medical counterpart that could like help us would be, I can, I could just can't even express just how beneficial it would be. If you're that provider, please drop us a comment on YouTube and let us know who you are. Also, a lot of our EDS patients have a much protracted course of pain management after surgery. And so a lot of times they will need a second prescription for opiate medications after surgery, sometimes even a third.

53:46Sometimes I'll add what's called a benzodiazepine, something like Valium that helps to, as a muscle relaxant for some of these patients. They come to the table having faced a lot more difficulty in the past. And yes, comorbidity in terms of their pain. They have pain from other sources as well. Well, it's fairly well documented that EDS patients feel more pain for any given stimulus. It's almost like they're born with an intrinsic central sensitization already. And they have more risk of having pain because of their vascular, like the way that they move and the way that they're in like vascular nervous package.

54:29I don't know if that's a word in English, but it can move even more and it can cause nerve compressions. So I think that's why EDS patients have POTS is because their blood vessels is specifically the veins just dilate and they don't contract the way they should. And so they don't have normal venous return. Very possible. Plus the nervous system dysregulation that comes along with all of that. Healing long-term requires a team. Healing requires a team. And specifically for patients with central sensitization, I think that there's a huge role for psychology, clinical psychologists, pain psychologists, and cognitive behavioral therapy to try to help them reduce the amount of anxiety they have.

55:18Because we know anxiety increases pain. Because when pain is processed, the signals come up to the thalamus, the thalamus kind of reaches out to the other sensory cortexes and says, hey, is everything all right? And if we're not seeing anything dangerous, we're not hearing anything dangerous, then it's like, everything's fine, shut it down. And so then the thalamus tells the spinal cord, get out of here. We don't want to hear it. And if it's not okay, if we realize that we just burned our finger on the hot stove, if we realize that a rattlesnake bit us, then our brains ratchet that signal up and our pain is heightened because we need to pay attention to it because something really bad might happen if we don't pay attention to it.

56:04So people with anxiety, when their thalamus reaches out, hey, is everything all right? No, it's not. I'm worried. Something's wrong. And I think that we don't do a good enough job at trying to help our patients kind of ratchet that down. And they have to in order to get their pain under control. I want to ask each of you, what's a practice, a daily practice you would challenge patients to do, you know, big or small, that can make a big difference in their health long term? Shanti, I'm going to start with you. I really encourage patients to journal and to really understand where they are in their lives relative to struggling with pain and overcoming it.

56:50I'm a big believer in that impact that that can have on your own personal well-being. And so just every single day trying to write three pages, and you might start with a very small notebook so that your three pages are little pages. But I think that it helps you to begin to deeply understand your pain, deeply understand what are the triggers, what happened yesterday that made my pain worse today. I am personally a very anxious person. I do meditation. I don't spend hours of time meditating a day. I'll do a 10-minute meditation. I feel like meditation quiets my mind. It helps me understand what I'm feeling.

57:29It's like journaling for Shanti. And then one other thing that I do is exercise. I think if I couldn't exercise, I don't know where I would be because I think I would fall apart. I think exercise would be Ana's answer too. Again, with the validation of our patients, sometimes they're called lazy because they don't do things. I think I will tell them to listen to their bodies and not try to out-exercise themselves or think about them as lazy. I don't know if you've heard about this, about the spoons. I heard this and it was like it made so much sense to me. Because when a chronic pelvic pain patient or a patient that has chronic diseases wakes up, they have a limited amount of energy and they have to decide in which activities they are going to spend this energy or spoons.

58:19and folding the clothes is going to take five spoons and taking a bath is going to take three spoons. It's like, I don't know, another patient explained it to me, it's like playing Street Fighter and then your life starts to diminish and sometimes if there's no more energy and you still want to do things or society forces to or your brain is telling you that you're not lazy and you can do more, then that can even backfire you and turn you into a flare-up. So I would advise our patients to be patient with their body and to really understand in which point they are. And if all they did was stay at home and take care of themselves, that is a very good day also.

59:03You know, endometriosis care, I think we've established, is pretty broken. And it's because of systemic failures. not because patients aren't advocating or, you know, trying to, you know, find the right provider or just not doing enough. So women didn't cause this problem. We're giving a lot of solutions for what women can do for themselves, but they're still living with the consequences of this systemic issue. So I want to go into some of the big issues about what needs to change in endometriosis care. So let's start there. What specifically needs to change in medical education so future clinicians don't repeat the same mistakes that are being done currently.

59:43Training. And they have to understand the disease, and they have to know how to exercise it in an appropriate way. They need the appropriate mentors to teach them these things as well. And I think in addition to teaching medical students and residents, I think we need to focus on, I mean, we have to focus on better training for gynecologists. I think we also need to focus on better training for GI docs, radiologists, general surgeons, and every other specialty that interacts with endopatients on a regular basis. And then I think we have to prioritize fellowship training and reproducing ourselves.

1:00:28My goal in life at this point in time is to to create a center that will live on after I retire. And so I have my colleague, Tristan Newville. She's 90 % trained. And then Jen Yage is my current fellow. And she's on her way to being excellent. The two of them together are phenomenal. I would encourage every surgeon who is good at endometriosis, good at excision, to want to pass that on to the next generation, either in person or even with virtual mentoring, like I did with Vicky a long time ago. Do you think it's fair to say that any clinician who treats women should know endometriosis enough to make a referral?

1:01:26Oh, absolutely. Well, I would go further and say that all pediatricians ought to know as well. And I want to make a shout out to Shannon Kahn, who directed Below the Belt. And she has gone all over the world showing this video and or this film and gone into medical schools and gone into political venues to show people the devastating effects of endometriosis. And I think that the more we continue this education, your work with social media, my work with social media, each of us in our worlds reaching out along with other providers who do this to educate that this disease exists, it can be excised, it can be treated, and there can be multimodal approach to feeling better.

1:02:20I feel like one of the ways to improve care for endometriosis is to pay for it. Because I think the thing is that the best surgeons in the U.S. are not in network and therefore are not in academic institutions. And actually, I think a lot of our academic counterparts sort of look down on us at a network surgeons who truthfully are just trying to find balance in our lives and do a good job for our patients. but it's really hard to do that because we're not really like the our institutions aren't reimbursed well for the care we're giving so we're not supported and so we have we're treating the hardest most complex patients with the least possible support we're not like the neurosurgeons or the heart surgeons or the cancer surgeons like we are the bottom of the bottom of the totem pole and it's impossible to do a good job under those conditions for these patients I think reimbursement I think we need some governing body to create a standard of care.

1:03:19Like someone needs to step up and say, you know, okay, we don't have enough research, but here's our opinion. Asher has done that in Europe. Like we need someone to do that in the United States. Why do you think ACOG hasn't done that? Because they have opportunity. They reaffirmed their 2012 practice bulletin. ASRM did something along the same lines for theirs. ASRM is the reproductive. I think there's just conflicts of interest there. And so we need a separate body whose sole focus is endometriosis. Because of course, we need the gynecologic surgeons to be leaders in that society that I'm discussing that doesn't exist but should.

1:03:59But we need everyone because the thing is that we just need support from all the specialties that are going to care for these patients, right? the pediatricians, the adolescent pediatric gynecologists. We need the colorectal surgeons or general surgeons that are helping us with our bowel disease. We need the urologists. We need the pelvic floor physical therapists. I mean, we just need all our partners to be part of this. And I think that's the only way to get comprehensive enough guidelines for how complex this disease is and how it can be identified by people other than the gynecologists. I mean, how much pressure can you possibly put on OBGYNs?

1:04:38Like, I don't want to malign our OBGYN partners. I feel sort of like conflicted. I mean, on the one hand, I'm frustrated by some of the behavior. But on the other hand, I feel like they have the hardest freaking job in the world. I think they're expected to do way too much. Yes. It's too much for one profession. The residencies need to be, the specialties need to be separated. Obstetrics needs to be its own thing. GYN surgery needs to be its own thing. We need to have one unified internship and then branch out from there and create surgeons who are really good at doing surgery and, you know, leave OB and office gynecology and tubal ligation.

1:05:17As you were saying before, like, we're the only specialty that the medical and the surgical part is still the same. Yeah, it's together. We need to de-stigmatize reproductive medicine. We need to... For women, because reproductive medicine for men is not It needs to be destigmatized. Like no medical professional should be embarrassed about talking about periods. Otherwise, you just shouldn't be a medical professional. Eczema is unpredictable, but you can flare less with EpGliss, a once-monthly treatment for moderate to severe eczema. After an initial four-month or longer dosing phase, about four in ten people taking EpGliss achieved itch relief and clear or almost clear skin at 16 weeks.

1:05:54And most of those people maintain skin that's still more clear at one year with monthly dosing. EbGliss, Librikizumab, LBKZ, a 250 milligram per two milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema. Also called atopic dermatitis that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies. EbGliss can be used with or without topical corticosteroids. Don't use if you're allergic to EbGliss. Allergic reactions can occur that can be severe.

1:06:22Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EBCLIS. Before starting EBCLIS, tell your doctor if you have a parasitic infection. Ask your doctor about EBCLIS and visit ebglis.lily.com or call 1-800-LILY-RX or 1-800-545-5979. Like periods should not be something that's difficult for anyone taking care of patients, of which half of them are women. You have to talk about a physiologic process. Like it's, you have to be capable of that. You know, I think there's just so many doctors who don't know the very basics of health that you should learn in high school, not even in medical school, but in high school.

1:07:01And I want to shout out to my partner, Melissa McHale. She's of a younger generation. I think we should be supporting the younger generation. We should be uplifting them, uplifting the young people who can do the research and all the things that are harder as we get older under the conditions that we're working in now. So for the clinicians who are listening to this right now, what can they do to start to implement some of this positive change? Like, these are all great ideas. What is the way forward? Because I know there's clinicians right now who just heard everything you said, and they're like, let's go.

1:07:36What's the direction? Know when to refer a patient. That would be the first thing. I mean, if I don't know how to handle this, let's get you to somebody that is going to be able to handle you. Because I have this problem with a lot of patients that gets them like a 10 year after the doctor has tried like hormonal and hormonals and never did a surgery or a proper surgery. So I think, yeah. But other than referring, we also need standard of care to be revised. We need ACOG, ASRM, to be de-influenced by capitalistic powers that be. We need a body that governs all of this. We need better education.

1:08:20Who do we lobby? We need research. We need to fund research regarding reproductive health for women and just women's health, because I think not just reproductive health, but we know all sorts of things present differently in women and that women are underrepresented in research. So we need to fund studies that are focused on women's health. I know at the moment that's more difficult in the climate of the United States, but I do think this is truly an issue that has impaired the quality of the care that women get. And not just the quality of care. I mean, it is impacting everyone who's in a woman's life with endometriosis.

1:08:57And I think that's important for people to understand as well, is that we've talked a lot about the endometriosis patient's experience, but there are also the children of endometriosis women, the mothers, fathers, brothers, sisters, like co-workers, like there is this entire community that's also being impacted by this disease, even in ways that they can't see. And as, you know, Shanti did her appeal to capitalism, like if these women can't show up to work, they're not contributing to the workforce overall. And I think that that's an important thing we have to expand out from because honestly, I don't think ACOG cares.

1:09:39I don't think any of these bodies care. I don't think NIH cares. I don't think anyone cares like you guys care, like I care, like endometriosis patients care and the people in their lives about their health and their well-being. But certainly people are going to start caring when they recognize that one in 10 women have endometriosis. 50 % of infertility that is unexplained is actually endometriosis. So there goes the population when we start to understand that a significant portion of days are missed at school and missed at work. Like this is starting to have ramifications on our society. And I hate to be like, we have to appeal to all these other things because no one cares about us.

1:10:22But like as an endometriosis patient, I dare a cog to prove me wrong. I dare them. Prove me wrong that you actually care about endometriosis patients because that would be absolutely wonderful. So let me ask the question, how can patients participate in change without being expected to sacrifice their health, their energy, their sanity? So patients want to help. They get burnt out just the same way. I mean, I watch endometriosis advocates pop up on social media and they go hard. They're gone for a while and it's because they start to burn out in doing this work. So I'm just curious, what are some simple ways that doesn't overwhelm them, that they can create change?

1:11:02What is making the change, for example, here in Mexico, is the patient asking for the things. It's like the patient advocates for themselves. And sometimes they know more about their own disease than the doctors, that they are going to their offices. So if the patient knows more about something than you, that does something into your brain. It's like, this cannot be done. I have to change. So I think it's a wake-up call for some doctors when a patient comes and presents you a clinical case that you do not understand. It's like, what is this? And I think a very informed patient can help change doctors.

1:11:41Yeah, I think that's true. I think patients are driving a lot of the change in the United States, to be honest. But I also think they're so vulnerable. And it's, they're often, I think it's hard not to have ego when someone is telling you that isn't a typical expert, that they have more knowledge than you do in your supposed area of expertise. So I think we as medical doctors need to do more, and not just the doctors, but everyone else, like the PTs. We need to do more, and patients. I mean, patients can advocate for themselves, but I'm not really sure that's completely fair. I want to also say as a patient, if you're listening to this, when you see doctors that are sitting here who go against the grain, who are fighting against the medical establishment to get you better care, like leave them a positive comment on social media.

1:12:38If you've seen them as a patient, leave them a positive comment on like Google Maps, right? Like go and support them and lift them up because I think it's so easy to channel your anger and hate at people who are doing a bad job, right? And who are totally failing you, or maybe even perpetuating myths. And look, I'm not going to tell you like, don't go check people and put them in their place or, you know, make sure that like information is correct on the internet, but we need to spend more energy building up people who are supporting the community. So when you see someone else with endometriosis share their story, leave a positive comment.

1:13:16it was a lot of courage for them to do that. When you see clinicians who are trying to change things, they're getting so much hate and heat from colleagues and insurance companies and everyone else. Your positive comment can help them keep going so that they don't hit burnout. And it sounds like such a simple thing, but it is so powerful. And I will say at the same time, it's one of the best things you can do for your health. And I think it's really important that we recognize that this allyship, it only gets sustained, right? We are a bunch of little entities, little boats floating out here, and we only stay afloat by tethering together and supporting one another.

1:13:58So I would definitely encourage patients to do that. I would like to close this. It's been such a, I'm so blessed to spend so much time with all of you. But I want to talk about the hope. Like what is your hope? What is the future of endometriosis that we can look forward to? What do you see endometriosis care looking like in the next five to 10 years? I just think there's a lot of hope. I want to get real positive right now. I feel like the younger generation of surgeons, like I said, my partner and actually even my other partner, Dr. Vinsobius, who's the colorectal surgeon, who's so passionate about endometriosis and like talks about it at conferences.

1:14:39I feel like people are just getting into this disease in a way that I never saw before in my life. I just think that people are becoming really excited. Scientists, I have so many scientists reach out with potential projects. And I feel like the interest in this disease is greater than ever. And we have to ride that wave now. And we have to like harness the energy of the advocates that are putting in the effort. And like, they're lifting us up and empowering us. So I think I'm going to just lay this out. This is something I've talked to Cindy about. And my partner, Melissa McHale and I, we want to start and Dr.

1:15:23Obias, our colorectal colleague want to start the North American Endometriosis Consortium for endometriosis surgeons to join together to develop research projects, grants for patients to have surgery, advocacy, and all sorts of things to help, you know, improve the care of endometriosis in North America. So Anna can join. Yeah, I was going to say, like, how much north is North America because I'm in America. Yeah. So I mean, and she can like lead the work on neuropelviology. I mean, we have all these incredible, young, excited people who want a platform to help our patients. And I really think this is, this is something we have, we have to create that governing body that just isn't there.

1:16:12I think that's what we have to do. Podcasts like this and having you here, it's like something that makes me like hopeful for the future because never in my entire life would I dream of having female endometriosis surgeons here in Mexico. It's like I was telling you about this before because when I was training to be a surgeon, we have two kinds of, well, they used to call me, my name is Ana Gabriela. So my male version of my name will be Gabriel. So I was called Gabriel because no females could enter the surgical, you could be a surgeon. So I was Gabriel like for one year in my training. And there were two types of bathrooms.

1:16:51You have bathrooms for doctors and bathroom for nurses. And now I see the hope because you go to a hospital here and you have bathrooms for doctors and for doctoras. So I tell my fellows, like, you don't know what this means, but this means so much for me. So I think the change is underway, but it's going to take podcasts like this and female surgeons getting together and a lot of information to our patients and a lot of advocacy, but I think we'll get there. I want to share a story about Ana because this is part of what gives me hope is that I see surgeons younger than myself who are so passionate, so excited, so talented, so skilled about surgery.

1:17:39And so this is to illustrate how passionate Ana Sierra is, that when she had a newborn twice, for the first six months of that newborn's baby's life, she went to the OR with the baby on her back during surgery and would nurse the baby at breaks between surgeries. This is how dedicated she is to her surgical skill, helping patients with neuropelbiologic pain and endometriosis. And I've known Vicki now for more than a dozen years and watching her devotion and having, you know, this incredible expert in my neighborhood in the Pacific Northwest and realizing when I see even my own patients and how they recover and flourish and send me pictures of their babies, I realize, okay, we are doing something that is helping.

1:18:39and we just need to keep doing it and keep spreading the word and keep teaching. And one of the platforms I teach on is I go and proctor other doctors who are trying to learn excision techniques on the robot. And we just need to keep giving in all the ways that we can and also keep our own health intact so that we can keep having the energy to do this. So, yeah. Well, I agree with what all of you guys have said about the future surgeons that are coming up now training to be endo experts. I mean, they're awesome. They're just wonderful human beings. But I want to change gears a little bit and say that I think that there is some basic science research being done that is hopeful and that hopefully maybe in 10 years, we will have some treatments available for endometriosis similar to some of the newer immune therapies for malignancies, that they are very targeted and that they are based on receptors and certain chemicals on the cell wall of endometriosis so that we can target the endo itself rather than having to use hormones, which are kind of like, you know, carpet bombing.

1:19:54And instead, we can take a little sniper and just take out the lesions themselves. and um i think they're doing a lot of really good work up at mit and other places around the world and hopefully one of them will will work because i mean we know surgery is good but it's not perfect and there's i mean in my practice there's probably you know three percent ish maybe five who continue to have significant pain that feels just like their endo pain, even though they don't have endo. And we can take them back to the OR and say, you know, we look, there is no endo. We've done biopsies 10 different places.

1:20:42They are not positive for endo. You do not. Your endo is not causing your pain, but it's your nervous system. It's your pelvic floor. It's your bladder. It's other things. And so if we did have a different way to manage it, it would be wonderful. This has been an exceptional series. Thank you all so much for taking the time, not just here, but in your day-to-day life to change endometriosis care for the better. For everyone listening, one of the biggest things you can do for us is share this everywhere possible so that we can get accurate information out to the clinicians who need it and to the women who need it most.

1:21:28So thank you all for being here with me today. Thank you for this opportunity. I think this is going to help a lot of patients. This episode is brought to you by Google Chrome. You think you know a browser, but Gemini and Chrome, that's new. It can help you with practically anything on the web, like restoring a vintage motorcycle from a 50-page restoration block, or finally break down that long article you've had open for weeks. Gemini and Chrome is here for it. Ready to make anything online make sense? There's no place like Chrome. Check responses set up required compatibility and availability varies 18 plus.

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