Endometrioma: The Hidden Sign of Deep Endometriosis That Could Affect Fertility | Amanda Chu

16:56Dr. Amanda Chu:Brighton, D-R-B-R-I-G-H-T-E-N. Share your symptoms and you'll get a fully customized treatment plan and unlimited messaging with your doctor. Plus, you'll get$20 off your first order today. That's M-Y-A-L-L-O-Y.com, code Dr. Brighton.

17:18Dr. Jolene Brighten:Now, on to the things that I had a problem with. I saw who wrote, you know, I looked at, you know, the three authors and I said, who are these people? I would say that the primary specialty that treats this disease now is MIGS, so minimally invasive gynecologic surgeons. And there was not a single MIGS provider on there. And there was family planning. And I think there was a fertility specialist. And so I think it's really challenging when you have people speaking about this disease where it's not 50 percent of your clinical practice, 80 percent, maybe even 20 percent. I'm not I'm not 100 percent sure.

17:48Dr. Jolene Brighten:And I also have to sort of compare them to guidelines that maybe you've alluded to, like the S. Ray guidelines. Those guidelines put out there, put out by the European Society of Fertility. You know, they're 190 pages. Right. So we got maybe 10 pages and I was sort of like, you know, where's where's the rest of this? And we only got to diagnosis. I was like, I think we're going to wait another 15 years for the rest of it. And nothing in those guidelines told me anything that I think if you treat endometriosis patients, you shouldn't know at baseline. Right. So I think that was really disappointing.

18:23Dr. Jolene Brighten:And I have a confession in that I haven't renewed my ACOG guidelines. So it was behind a paywall. And that was really upset. I couldn't even access the guidelines. Right. And so and to be clear, ACOG and ABOG, our accrediting board is completely different. So ACOG, you know, puts out a lot of our sort of our general guidelines, you know, in the U.S. And so I had to go to a colleague, ask for them. And I think I'm going to continue to let those lapse because it wasn't helpful for me. Right. And that was that's just a shame.

18:53Dr. Amanda Chu:Let me ask you, though, why does ACOG believe they have the right to put these guidelines behind a paywall when other societies internationally make these completely available because they know it will change the standard of practice to be better for women's health? I don't know. Make it make sense. ACOG and most gynecologists always bring endometriosis back to, do you want a baby? Yes or no? That's going to determine everything for you. And we're talking about fertility, and it is important. And women should be able to hold a baby in their arms if that's their goal. But also, the complete reduction of endometriosis to only being in our pelvis, only being a reproductive issue, negates very serious complications.

19:42Dr. Amanda Chu:I mean, recent research showing the impact on our neurological health, the impact on our cardiovascular health, the way my jaw dropped at the cardiovascular risks that go up and how women under the age of 40 are at significant risk for cardiovascular events, including stroke. That right there made me pause of like, and we're giving them the birth control pill.

20:04Dr. Jolene Brighten:Even that bulletin, we didn't address postmenopausal patients. You know, we just we just addressed so many different populations. I don't I don't think I think it's hard to know where to begin with that. And and look, yes, they get a pat on the back. They are trying. But I just I think for a population that has been waiting and expecting so much, I think if you had honestly just held off and come up with more inclusive guidelines, that would have been better. and to open up the door in the panel to providers that are treating this disease more regularly.

20:40Dr. Amanda Chu:Well, let me ask you, if someone is listening and they've learned they have an endometrioma, is there anything they can do to start to support their body to protect their future fertility? What's something they could start to implement tomorrow? And then we're going to go further into talking about surgical application as well.

20:59Dr. Jolene Brighten:The challenging thing with endometriomas is that they come back. There's a recurrence rate. So even if you take them out, they can come back. And one of the things that we know that hormones treat, and I'm usually talking progestin-based hormones or progesterone, is that if we don't treat them, they have the ability to come back and continue to damage that ovarian reserve. So for a lot of patients, you know, peritoneal patients, patients with deep endometriosis without endometriomas, I talk about hormonal suppression. But I really try to hammer it home with my endometrioma patients because it's really challenging.

21:35We take it out, it comes back. We take it out, it has a chance.

21:39Dr. Jolene Brighten:And so I think that is a big one. And, you know, we can talk about it a little bit later, but endometrioma patients do have a higher risk of ovary cancer. And actually, hormonal management reduces your risk of ovarian cancer the longer you take it. And so, you know, whatever you can tolerate, if you can tolerate, that's sort of the conversation I take with my patients. I said, I want to give you quality of life. You know, if I had, you know, everything I could have, you know, within the same sort of bag, I would give it to you. But if we can, if this is what we can have, you know, which means, you know, recurrence risk reduced, ovarian cancer risk reduced, I will take it.

22:19Dr. Jolene Brighten:But if you cannot tolerate this, then OK, maybe we will be monitoring you closely. Maybe we'll be doing trying to do something else for you. Maybe you can speak on some of the supplements. You know, I have a lot of the funny thing is I've learned about so many things from my own patients. No one is more resilient than an endometriosis patient with the Internet. OK. And so things like DIMM, how do you reduce your natural estrogen? How do you try to sort of follow the tenets of endometriosis that we know, which is that it's progesterone resistant? It loves estrogen. It makes its own estrogens. So I think those are kind of things I focus on.

22:54Dr. Jolene Brighten:It's really hard to make them go away because even with medicine, we can't really make them go away. I'll speak to this. We do have a couple of studies that tell you, you know, size matters with endometrioma. So if you have a very small endometrioma, potentially it's worthwhile monitoring. Potentially it's worthwhile doing medical suppression if a patient can tolerate it. I think it also matters sort of at what age they're at, what their immediate fertility goals are. I think that's where that individualized medicine comes in. But I think, unfortunately, for endometrioma patients, hormonal management is huge.

23:29Dr. Amanda Chu:Yeah. And, you know, to your point with DIMM, so I love DIMM, sulforaphane, and calcium deglucarate for managing the metabolism of estrogen and making sure we're moving it out. I am not compelled by the research we have to say dysbiosis in the gut. Bacteria is causing endometriosis. What I think is actually going on is having that gut dysbiosis. You are higher risk for reconjugation, reactivation of your estrogen. The other thing that's beautiful about DIMM is it also affects aromatase. So when these lesions are, and for everyone listening, aromatase takes your testosterone into estrogen. N-acetylcysteine is another one that we've had good research on showing it's comparable to birth control in terms of its ability to help shrink an endometrioma.

24:16Dr. Amanda Chu:My question for you, when you say progestin, progestin, for everyone listening, comes by way of IUDs, birth control, progesterone. Are you using cyclical progesterone in those situations if a woman's still cycling? Are you doing progestin IUD plus progesterone bioidentical? It will do anything that works for a patient.

24:38Dr. Jolene Brighten:Okay. So, I mean, the ideal, and they have sort of looked at this, is unfortunately like things that are more natural, micronized progesterone, it's just sometimes it's not strong enough for endometriosis. This is supporting someone with normal ovarian function sometimes. And so I use a lot of progesterone maybe in my perimenopausal patients, things like this. But sometimes I almost feel like you need heavy hitters for endometriomas. So progestins, so synthetic progesterones, I use Mirena IUDs. Sometimes I'll pair that. So I'll do something called dual suppression. I'll do Mirena IUDs with like maybe a very small dose of norathindrone.

25:15Dr. Jolene Brighten:Unfortunately, in the U.S., we have norathindrone. We have something called SLIND, which is just drospirinone. I know in Mexico and other places you have Dynagest. Dynagest, I feel like, is actually better, but we can't access it. So I actually rarely have told patients, hey, you know, you have family in Mexico. So why don't you go get Dynagest down there and see if that works better for you? And we do know that actually continuous suppression is better for recurrence rates. But again, what will they tolerate? How will they feel on that? So I always say the best pill or the best medication is the one that you take, right?

25:48Dr. Jolene Brighten:And that makes you feel okay. It makes you feel like you want to go outside and live your life. And so unfortunately for a lot of patients, that's not the case. So yeah, so we'll use it all. things I have heard other providers use that I'm not a huge fan of. And I think that that goes a little bit to physician preference. Like I'm not a big fan of things like Nexplanon or Depo. I think it leads to a lot of irregular bleeding. The Depo leads to a lot of weight gain that's already really challenging for patients, especially if they have concurrent conditions like PCOS. It's just, it's a challenge.

26:19Dr. Jolene Brighten:Women are complicated, surprise. And so I think sort of realizing what those medications were designed for. They were designed for contraception. That is what all the studies are for. And so we're sort of trying to hijack that system and say, okay, what do we have? What do we have in front of us? And what can we use for our patients?

26:39Dr. Amanda Chu:Outside the U.S., there's also a subcutaneous injectable called Monteris. I'd like to see research on that. So with endometriosis, there's a higher risk that you are neurodivergent and you have endometriosis. We know that a lot of those women, so ADHD and autism specifically is where we have the most research. Many of those women report PMDD. As we're coming to understand from the research, we've got neuroinflammation, but we also have maladaptation of the GABA receptors in the brain. And so these are the women that we had the first study just a couple of years ago on ADHD and oral contraceptives, lo and behold, five times risk of depression.

27:24Dr. Amanda Chu:Not surprising to me. I've seen this so many times clinically. These women don't always do well with progestin. They don't do well with oral progesterone necessarily. I mean, it's very individualized and that's where bypassing the liver so you don't get that allopregnenolone spike can be so helpful. But the subcutaneous, as much as I'm like, people don't like to inject themselves every single day. However, it is something that I'm very curious to see that because it's being used for fertility patients to build up that, you know, basically that cushy

27:56Dr. Jolene Brighten:little home for an embryo to transit to be able to burrow into their self.

28:01Dr. Amanda Chu:It is something I'm very curious about to see these other applications and look at like the fertility world as well of like, how do we, you know, shrink the endometrioma? Yes, but prevent recurrence if you have surgery and also preserve future fertility if that's the goal.

28:17Dr. Jolene Brighten:Yeah, I think those are the things we're always thinking about, right? And that's why it's so hard. And I think the fertility goals is one of the hardest. I always tell patients, I don't know, especially if they're young, I don't know who you're going to be in five years. I don't think you know who you're going to be in five years, what you're going to want. I don't know what your future partner is going to want or not want. And so it's not so much about predicting these things 100%. It's about giving them choice, letting them know there are options for them. And so if you can give them back a little bit of autonomy, I think that's at this point, you know, one of the best things that you can offer them.

28:53Dr. Amanda Chu:If someone has an endometrioma, how worried should they be about their fertility?

28:58Dr. Jolene Brighten:Fertility is impacted by so many things. This is just one thing, right? And so I do, you know, I think we caution the way that, you know, I feel like as providers, we always want to save patients heartache that we know could come to them down the road. And so when I have a patient with endometriosis, say they're 25, and I know they have, I don't know, stage two endometriosis, I say, okay, don't worry. I'm going to monitor you. Let's watch. And let's say I'm, you know, you're 25. I'm going to treat you like you're 27. You know, with some, obviously some, you know, some other things to that, but just very generically to say, okay, so if these are things we want to try, I have more time to work with you.

29:41Dr. Jolene Brighten:You know, we're not, we're not panicked. I may send you to a fertility specialist earlier rather than have you wait the full year of just trying. especially if you're anxious about that. So maybe with endometriomas, with deep endometriosis, to give us a lot more time because I think that's the thing you can't get back. It's unfortunate because we use a lot of numbers in endometriosis and fertility. And if you go to a fertility practice, they're just going to throw a whole bunch of stats at you. And that's great. But if you're the 10 % and the 10 % that's not getting pregnant, that's really, really upsetting.

30:17Dr. Jolene Brighten:Right. So how do we try to sort of humanize those numbers? That would be my hope to say, OK, let's just give ourselves a buffer of time so we can catch ourselves.

30:28Dr. Amanda Chu:Can someone get pregnant naturally if they have endometriomas?

30:31Dr. Jolene Brighten:Yeah. And you can get pregnant if you have endometriosis. What I would say is that we always speak about this sort of natural or normal fecundity, which is the chance that you would conceive. You know, if you're intimate at the right time, depending on how old you are, that can be 20%, 15%, things like that. They've basically extrapolated that number out for endometriosis patients to anywhere between 2 % to 10%, right? So there is definitely a chance. And if you get pregnant, you'll do what all the gynecologists tell you to do, which is go get pregnant, right? Right. And so there definitely is.

31:04Dr. Jolene Brighten:And often that's, you know, a very quiescent time for endometriosis for some women. And yeah, so you absolutely can. It's just that at a certain time point in your life, it may be very challenging to be waiting two, three years to get pregnant. And that may really push your family planning.

31:19Dr. Amanda Chu:Can we put the numbers in perspective with the understanding that these are just numbers, but in terms of like your chance of getting pregnant without endometriosis, like in your 20s versus if you have endometriosis, as we know for everyone, once we enter those 30s, that number is going down.

31:39Dr. Jolene Brighten:Yeah, I mean, I think that's the general, you know, the general numbers I'll use to give somebody perspective, right? So, you know, if every cycle, I would say, you know, say a young couple comes to me and traditionally their chance should be 20 % a cycle, right? And so really you don't trigger an evaluation, an infertility evaluation, until you have tried for 12 cycles consecutively before they're like, hmm, you know, maybe something is wrong. And, you know, they put those there because, you know, at some point, you know, on cycle 11, you know, a healthy couple will likely conceive. And so that's about 90 % of couples.

32:16Dr. Amanda Chu: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. EndoGlobal 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 dot com slash E-N-D-O-G-L-O-B-A-L

33:00Dr. Jolene Brighten:We know if you have endometriosis, those numbers are going to be lower, right? And so it's hard to 100%, you know, take every patient and do that. But if we're looking at earlier disease, maybe your chance is 8 % to cycle. And absolutely, that can happen for you. We just know the younger you are, the better, right? And that's one thing I can't change. And I had a very well-meaning husband sort of make a joke after surgery once. And he was like, oh, like, you know, his wife was, you know, in her early 40s. And he was like, oh, did you make her, you know, 25 again, her uterus 25 again? And I was like, oh, sir.

33:34Dr. Jolene Brighten:Oh, sir. Let's talk about this.

33:37Dr. Amanda Chu:I get so embarrassed for men, but I have to remember that the education system in the United States on health is so bad that I'm like, but at some point as a male adult, You have to like learn some stuff on your own.

33:50Dr. Jolene Brighten:Yeah. And did you think that was cute to say? I just don't get it. You know, I think he was maybe nervous or something. And I completely get that. You know, he said it kind of in this like sort of goofy way. And I was like, yeah, like it's tough. You don't, you know, you just, you don't know what you don't know. And I have this funny phrase I say to so many of my patients when I explain to them why I get an MRI and why I get it at a specific, you know, MRI center, even if they've already had an MRI or I get them reread. And I was just like, you can't see what the mind doesn't know. Right. So if you have radiologists that have never read deep endometriosis, well, you're never going to find that on a scan.

34:25Dr. Jolene Brighten:OK, surprise. Right. And so I always think this this field, you know, I feel like I fell into this, but it has brought on so many more questions. Like this is why you have specialists in so many different fields. I am not the expert on so many other things and I'm still not the expert. But I'm still learning. And I think that's a really important part. We're learning about this together as a community. I've changed how I do my consults even from, you know, four or five years ago just through patients. Right. And it's really disheartening to say that probably 90 percent of, you know, my education about endometriosis came after formal training, after 10 years of formal training.

35:06Dr. Amanda Chu:Let me ask you, do endometriomas themselves harm egg quality or is it more the risk of the surgery?

35:15Dr. Jolene Brighten:Yeah, and I think this goes back and forth, right? So it's hard to 100 % measure egg quality unless you really retrieve the eggs, fertilize them, take them all the way down the road. And there's already an attrition rate with that. I think what we talk about a lot is so if we think about an endometrioma, you know, de facto, I always say just think about an ovary. An ovary, you know, normal measurements of an ovary are up to, you know, one by two by three centimeters, give or take. So when you have a five centimeter endometrioma in there, actually that endometrioma has actually expanded and compressed the healthy ovarian tissue to just like the periphery, right?

35:51Dr. Jolene Brighten:So just by the inflammation, almost like localized maybe necrosis or pressure, the ovary itself is getting damaged. And so that to me equals not just egg quantity, as we've noticed in the AMH, but egg quality. So even if you pull those eggs, a lot of them won't be good. It won't have, let's say it won't have grown up in the healthiest environment. And I do think that's why after endometrioma surgery, you do see this increase in spontaneous fertility, right? So you're letting that ovary hopefully recruit a healthy, and you just need one, right? A healthy oocyte.

36:27Dr. Amanda Chu:Well, I want to go into the surgical aspect. Sure. So you just said like a five centimeter endometrioma. So at what point do we need to operate for the health of the ovary? Is there like a number of like once it's this size, we're no longer monitoring. If fertility is your goal, we need to excise this.

36:47Dr. Jolene Brighten:So a lot of societies use four, right? That's a very common number that is thrown around. I think that's maybe, you know, what the cutoff they use for certain, maybe certain studies. And so I think that's how we were taught. If endometriomas get to be four centimeters or bigger, we should take them out. I think in my opinion, you know, we're also looking at symptoms, right? So symptoms are incredibly important. So I think, you know, it's the same as endometriosis in any other area. So we would like to improve quality of life. I think it's challenging to leave any endometriomas there because, you know, by default, they are naturally damaging the ovary anyway.

37:22Dr. Jolene Brighten:So I know that we always have this push and pull because those AMH numbers that are looking at your ovarian quantity are, you know, potentially falling. Okay. But they're falling anyways. Right. So I think it's more important to say, hey, you know, do I have goals this moment? You know, what are my goals now? Are my fertility goals like eight years from now type of thing? So it would be, hey, let's, you know, and I think surgical technique is really important. So we talk, there's different types of technique, but, you know, you just want to talk to your surgeon and say, you know, how do you approach an endometrioma?

37:55Dr. Jolene Brighten:Or is there going to be any coagulation? Are you going to take the full cyst out? Are you just going to drain it? Some of them have higher recurrence rates. So if you have surgeons that are really cognizant about that, you know, we don't actually want to hurt your fertility. That's just maybe surprising to some fertility docs, but we actually want to help your fertility as well. Sometimes I'll then say, you know, either before or after, maybe depending on the size, maybe let's remove it. Let's let the ovaries heal for a moment. And maybe, you know, you're young and let's talk about egg freezing.

38:25Dr. Jolene Brighten:Let's talk about that for now because maybe one cycle is going to save you, you know, four cycles many, many years from now, right? So I think all of those are really important and it just kind of depends on, you know, what a patient is feeling at that point. So I would say general cutoffs, yes, four. But to me, any endometrioma, even if you're two centimeters, means something to me. I would still offer somebody excision and, you know, and suppression and management.

38:53Dr. Amanda Chu:What's the ideal surgical technique to remove an endometrioma if you want to preserve your fertility? And what should you always avoid?

39:00Dr. Jolene Brighten:I think you should really avoid just drainage, right? Drainage is really they just sort of pop the cyst, let that chocolate fluid, you know, flow out. and then the cyst wall sometimes just reheals and they fill back up very quickly. So that recurrence rate is very, very high. So if you're going to have surgery and surgery done correctly, we usually recommend a cystectomy. So just to remove the cyst wall, to repair it with really good surgical technique. So usually we're suturing the ovary. There are, you know, maybe a few surgeons that would just leave that cyst wall open. So I'd say, no, it's really important to repair that ovary.

39:35Dr. Jolene Brighten:and yeah I would just say meticulous technique elsewhere so excision in other areas to remove anything especially around the tubes ovaries anexa ovarian fossa is an area just under the ovary that's very common for endometriosis to hide as well so when you're doing that surgery you know I've had actually some patients come to me because just the endometrioma was removed and then they didn't have any other excision and I'm like well what about the rest of it and so I think you know, maybe generalists are doing just the cyst removal, but they're sort of missing the bigger scope of what's happening there.

40:06Dr. Jolene Brighten:I think those are really important things too.

40:08Dr. Amanda Chu:Do you think a general OB-GYN is the best person to see for an endometrioma excision, or should you be seeing an endometriosis specialist?

40:17Dr. Jolene Brighten:I think at the very least someone who has maybe fellowship training or is more focused in gynecologic surgery. So in the U.S. we have a couple of different societies, but AAGL is one of our largest ones. So it's the same. You don't want me to deliver a baby. I haven't done it in several years. And so I just think, and that is complicated in and of itself, right? So you just want someone that understands this disease to the best of their ability and can counsel you about that. Even if they can take out the endometrioma, can they explain to you all of the issues that you might encounter along the way?

40:53Dr. Jolene Brighten:Are they thinking about you now? Are they thinking about you? Are they thinking about that potentially increased risk of ovary cancer for you in the context of your family history? So I think as endometriosis providers, we are thinking about that. And we maybe have the space to think about that. I think there's probably just too much to cover for a generalist, quite honestly. And that's not their fault. That's just how this was developed. We're primary care of women's health. And that's a lot of things.

41:22Dr. Amanda Chu:I hear all the time from women who say, I wish my general OB-GYN understood endometriosis. I wish they understood perimenopause. I wish they understood menopause. I wish they understood postpartum, which I'm like, they should. There is a laundry list of women's health issues that women feel like their general OB-GYN just does not understand. And I think they're right. And I think the problem is, is that we have taken all of women's medicine and stuck it to the OB-GYN and said, You should be a master of all of this. It is seriously just such a blind spot in medicine to completely view women as just the same no matter what.

42:02Yeah.

42:03Dr. Jolene Brighten:And, you know, I think there are differing opinions here. You know, there have been some that have suggested it's just too much to cover. So what we should do is we should split, you know, obstetrics and we should split gynecology because they're almost so different. Right. You have urogynecology, you have GYN oncology, you have, you know, endocrinology, you know, you have advanced family planning, things like this. And so the challenge here is that, you know, if you have endometriosis, you have endometriosis throughout your whole life and you get pregnant during that period of time. And actually, you know, you may have something like adenomyosis and you may get pregnant during that time.

42:36Dr. Jolene Brighten:And so to have some of that fundamental understanding of what your patient is experiencing, it is challenging. Maybe there's some sort of combined track. It's just there's so much to learn and to do. I think that is one of the biggest challenges we still struggle with, you know. And that's why a lot of providers then go on to fellowship because they feel like, okay, well, training wasn't fully adequate. And that's tough to hear. You already spent all this time training. Then you do extra training. And then for me to come out of training and feel like, what did I just learn there that's helpful for me now?

43:08Yeah.

43:09Dr. Jolene Brighten:I have to say this and, you know, I'll, you know, sort of put myself on blast is to say that I was taught to ablate. Right. And so I know myself and I know and I really respect the people that I train with. You know, they do excellent myomectomies and they're really, you know, great robotics and they're good people. I don't think they ever meant to hurt anyone. I think that's sort of just what you were taught. You're in this place and you think the system is great and this is evidence based medicine and you're getting taught certain things. and then to come out and have that sort of paradigm shifted and have people that you looked at as you know mentors and be like you know to have to question that I think was really challenging as a young surgeon and to be like you know we had someone I had one of my attendings sort of say oh like oh like people don't need HRT I was like oh like and you know we would do oophorectomies meaning we would take ovaries and that was just like oh you know they'll be fine that is something I heard in advanced training and some myself and some of my old co-fellows still talk about that.

44:16Dr. Jolene Brighten:We're like, I can't believe we we did that. We didn't know like we not that we didn't know. We just sort of we would you know, we would ask about it. And that was the response that we sort of got. And that, you know, so so just a caveat to say that, you know, most providers don't go into this because they want to hurt you because they want to dismiss you. It's that the training system is really inadequate. Women are complicated. The system, you know, forces you to have 15-minute visits. How can you possibly encompass all of the things you need to encompass? So I know a lot of my colleagues have been like, okay, this is the one problem we can talk about today.

44:52Dr. Jolene Brighten:So we, you know, what is that? And unfortunately, if you need to, we need to be booking another visit for this because we can't be talking about, you know, X, Y, and Z today.

45:00Dr. Amanda Chu:Which is super frustrating as a patient who's already waited six months to get in. Yes, and is an hour late. Yeah, I mean, it's such a hard system. And I admire that you saw the contradictions and rather than doubling down on the dogma, you were like, okay, I have to do something different. I want to ask you, because you brought up the cancer risk. What is the cancer risk of an endometrioma?

45:26Dr. Jolene Brighten:Okay, good question. So actually in 2024, there was this really big paper in JAMA that made sort of headlines in endometriosis care. And they looked, and the reason it did that was because it was one of the first studies that really subdivided types of endometriosis. And so we're thinking peritoneal superficial endometriosis versus deep endometriosis and endometrioma patients. And it looked at their ovarian cancer risk. So we've long known that endometriosis, particularly endometrioma patients, have a higher risk of certain types of ovary cancer. And so this one really characterized and said, yes, there's a risk across all of these demographics, but the highest risk is in endometrioma patients and deep infiltrative endometriosis patients.

46:13Dr. Jolene Brighten:And so there's, you know, stats are a funny thing, which is that it really said, you know, really sort of scary things like nine times the risk, you know, 12 times the risk, 14 times the risk of the overall general population. And so the average risk of ovary cancer is about 1 in 70. When we're looking at absolute risk, which is slightly different, that kind of doubles that. So that means maybe 2 and a half, you know, in 70. So it's not numbers that we're incredibly comfortable with, which we like. But to give you perspective, you know, breast cancer is 1 in 8, right? So ovary cancer is just particularly tricky because it doesn't have a lot of easy precursors, right?

46:56Dr. Jolene Brighten:So for cervical cancer, we do pap smears. For endometriosis, for uterine cancer, we do endometrial biopsies for ovary cancer. You know, how do we screen? There's really not great screening. And so knowing these things, you know, hopefully better guidelines will come out. But sometimes what I talk to patients about is, you know, potentially hormonal suppression because that can reduce your risk. But if they're coming for some other surgery, you know, they're later in their life, they're done with childbearing, I'll offer things like prophylactic salpingectomies, which is to remove the tubes. We know that that can reduce your risk by about 60 % of related endometriosis-related ovary cancer.

47:34Dr. Jolene Brighten:So just thinking about different options for patients to say, hey, you know, if you're not quite ready, we're not 55, you know, you want to keep your ovaries, okay, we can do something interval. Like in the meantime, you know, if you need a re-excision or you need something else, that can be very helpful. I think that really helps solidify the risk and sort of that risk profile. And to kind of say they bear different risks to patients, right? I think one big thing that I always say to patients is that we treat endometriosis, like every endometriosis patient, like they're the same, okay? And in some ways, that's great.

48:07Dr. Jolene Brighten:You know, we want equality. But people are so different, and we insert in the way that you subclassify and subtype cancer, at some point, we're going to be hopefully subtyping endometriosis. You have endometriosis type A1 or, you know, whatnot. Hopefully we'll get better terminology than that. But and you will be, you know, you know, more responsive to this type of progesterone. And this is hopefully, you know, a little bit more about your clinical course. You know, we have a cohort, which I'm sure is its own podcast that, you know, we're seeing pop up with, you know, mast cell activation and EDS and POTS.

48:42Dr. Jolene Brighten:And they kind of come in this cohort. So, you know, I'm sure that's going to be a subtype, you know, and you'll have more clinical information because we will be able to group those patients together rather than throwing them all into these studies. and just kind of having this, you know, mishmash of information come out. Yeah.

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49:50Dr. Amanda Chu:and to your point with the endometriomas and the risk of ovarian cancer the other thing that's really important to know is that from the data we currently have is that if you're given estrogen hormone therapy alone that's going to increase your risk of ovarian cancer and this is so important because the generation right now who's in perimenopause and menopause is the generation who has received hysterectomies because ACOG said that it was a treatment for endometriosis. When you don't have a uterus and your doctor says, oh, you don't need progesterone, but you've retained your ovaries and you have a history of endometriomas, they are increasing your risk for cancer.

50:31Dr. Amanda Chu:And that's everyone's fear with HRT is cancer risk. When we put that estrogen with progesterone, they found no risk. We talked about hormonal suppression, which birth control is known to lower the risk of ovarian cancer. what are the things can women do in their like nutrition lifestyle to help lower the risk of ovarian cancer?

50:50Dr. Jolene Brighten:I think the biggest one too is smoking. So smoking has a documented risk of ovary cancer and I would hazard to say it doesn't offer a lot of benefits. The things that really impact ovary cancer tend to be how many times you cycle. So some of the things that you can control and you can't control, right? So sort of the earlier you start to have periods, the later you stop having periods, whether you're pregnant or not pregnant. Pregnancy actually helps reduce the risk. I guess that pregnancy is modifiable, but I wouldn't really consider it modifiable. It wouldn't be something you would do just to avoid ovary cancer.

51:25Dr. Jolene Brighten:You know, I think in this one, I'm not the expert here. I think we're talking a lot more about the environment and, you know, factors that are influencing our endocrine system and are they carcinogenic and things like this. So I would speak to that whole sort of segment and just to say like, yeah, I mean, we don't know, right? We're growing up in an environment that was incredibly different than 50 years ago and we are seeing a lot of cancer. Here are the things that we can do. These are things we know that have documented risk. But so much of medicine has been done based, you know, if you just stay within the textbook in endometriosis, I don't think it's going to take you very far.

52:04Dr. Jolene Brighten:Yeah. And so I think putting that together, just like you were saying earlier with dysbiosis, it's not the actual bacteria. It's why are those bacteria, you know, being allowed to proliferate? Because there's immune dysfunction, right? You know, you do have documented changes in your immune system, right? And so that we know, right? Why, you know, when we used to think that it was 100 % retrograde theory, well, then why doesn't everyone have endometriosis? We pretty much all have retrograde menstruation, right? So some of it didn't quite really add up.

52:34Dr. Amanda Chu:And I would add to what you're saying, I think everything you said was great, is that exercise, regular physical activity lowers cancer risk across the board. And then the other thing is six to nine servings of plants a day. So we're looking at vegetables and fruits, getting a variety and getting those polyphenols. And that's, I mean, if you want to affect your gut health and shift what's happening in your microbiome, six to nine plants a day is going to help with that. And the great thing about cancer is that it's not one thing. It's multifactorial. And we don't even have to address all the things.

53:07Dr. Amanda Chu:We have to address the big things with it. So I don't want anyone freaking out.

53:12Dr. Jolene Brighten:Yeah, it's all the things, right? And I think that leads, just what you're saying, it leads to mental well-being. It leads to, you know, decrease estrogen. You know, you create estrogen in your adipose tissue, right? So in general, you know, exercise is never going to be a bad thing. Like it is really, really important. Muscle mass is really, really important. I find a lot of patients tell me, you know, this low sort of intensity, moderate intensity activity is where they find the best and most positive relief. That might not be for everyone. If you like your HIIT exercises and things like that.

53:49Dr. Jolene Brighten:But yeah, just from what they say, right? Right. You're learning, oh, this is what my body can tolerate. And, you know, it's hard. I feel like it's a full time job being an endometriosis patient.

54:03Dr. Amanda Chu:No, I love that you say that because it is the like such a time consuming disease and it is so expensive. And these two things are absolutely so real. Well, thank you so much for taking the time to sit down with us today. I've really appreciated this conversation.

54:18Dr. Jolene Brighten:Yeah, absolutely. Thank you so much. Thank you so much for having me.

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