Endometriosis Relief of Pain: Experts Explain Laparoscopy, Chronic Pelvic Pain, and Why So Many Women Are Still Suffering

15:55Dr. Emily Jones:You all need to get that joke in episode one. For me, it was the spleen. The spleen. When I was training into endometriosis surgery, I remembered my teacher telling me, you're never going to find endo in the spleen because it's immune tissue and it will defend itself out of the disease. And I've performed two splenectomies. that's the same thing in English because of endometriosis. So yeah, well, me and my team, of course, but yes. So yeah.

16:25Dr. John Smith:If your periods knock you out, if sex is painful, if you're told your scans are normal, but your pain isn't, listen up. That's not something you have to just live with. Endometriosis is often missed, misdiagnosed, or managed without a full evaluation of what's actually happening. Endoglobal specializes in advanced endometriosis review, including imaging assessment, multidisciplinary evaluation, and excision-focused surgical planning. They offer affordable options and a complimentary consultation to review your case and determine whether surgery is even right for you. If you're tired of guessing or gaslighting, start with answers.

17:12Dr. John Smith:Go to drbrighton.com slash endoglobal to schedule your complimentary consultation. 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. How about you, Cindy?

17:33Dr. Jade B. K. Brighten:I had a patient once who would bleed out of her ear every time she had a patient period.

17:39Dr. John Smith:Oh my God, we should be like, you know, playing a game here.

17:42Dr. Emily Jones:I think you just won.

17:44Dr. John Smith:Wow.

17:45Dr. Emily Jones:But there have been reports on the eye, on the nose, on the larynx. There was just the wrist.

17:50Dr. John Smith:But we don't all get to see that. I see it a lot in the belly button. As an endometriosis patient, every time you have a twinge or an ache or a pain somewhere, you're like, could it be endo? It's a real theory you live with, even after excision surgery of like, could it show up somewhere next? I found it on the surface of the kidney that way. So that's one. I also have a patient coming up in a couple of weeks who does cough blood with her period and has a pulmonary lesion. And by the way, for our listeners, if you have that symptom, you definitely need a proper evaluation. And most of the time to actually see a lesion like that on CT or MRI, it's really best if you are on your period when you get those imaging studies done to be able to visualize that in the pulmonary region.

18:37Dr. John Smith:Does it need to be like day one, two of your period? Is there a window? It's during the whole cycle of when you're bleeding menstrually anyway that you are going to be able to highlight it on the pulmonary lesions. How common is thoracic endometriosis? Is it more common than women might be aware of? I think it's probably more common than even practitioners are aware of, but diaphragmatic disease is 10%, 90 % of that is going to be on the right side. But I suspect that it's higher than that. If you think about it, nausea, reflux symptoms, chest pain, rib pain, coughing, coughing blood is an extreme case, but just coughing and irritation and shortness of breath during the period might be symptoms.

19:25Dr. John Smith:And so some of the patients I've diagnosed have had one, two, three prior laparoscopies where no one saw the disease. And I can think of patients where my first glance up into the upper abdomen, you don't see the disease. But when you go and look, you find the disease. It's easy to find if you're comfortable just taking a look. But if you don't really feel comfortable just even just pushing on the liver or lifting, elevating it to look underneath it, you won't find the disease that exists. So I suspect it's higher than 10%.

20:00Dr. Jade B. K. Brighten:A lot of times it's at the very back of the liver and the very most posterior aspect of the diaphragm, and the liver is domed. And so it's challenging to get the liver pushed down enough. Once you're close and once you're more central, close to that central

20:19Dr. John Smith:tendon, you also are in a greater danger zone of injuring the phrenic nerve. So it's definitely not the thing that everyone is going to be attacking as an endosurgeon. We've talked about you saying chest pain often gets chalked up to just being anxiety in women. At what point of ignoring these symptoms or blaming these symptoms on something like anxiety, does it become negligent? One of the dangers would be providers like emergency providers, pulmonary doctors, There's cardiothoracic surgeons who will treat pneumothorax in a typical way that you might treat someone who didn't have endometriosis.

21:05Dr. John Smith:And so women who present with pneumothorax, a collapsed lung cavity, which can happen in the presence of endometriosis on the diaphragm or in the pleura of the lung, and they treat it with a procedure to seal the pulmonary cavity. and then you can never go back in and remove the disease. So they won't have a recurrent pneumothorax necessarily, or they will have, but they'll continue to have pain. And I've read reports in the cardiothoracic literature of how fabulous, this is how we were succeeded. For six months, we did a pleuridesis by talc in the lung, we sealed off the cavity, and we gave her Lupron or Lyssa for six months, And she hasn't had a recurrence.

21:53Dr. John Smith:Okay, so great. So then she's going to go off the Arlissa. So you can't stay on Arlissa for life. So that's wonderful. They've treated her for six months, but she'll still have the symptoms when she comes off the Arlissa. And she'll still have pain, even if she doesn't have a pneumothorax. Pneumothorax, collapsed lung. This is happening in an emergency situation. What could be done better? It could be recognized that a pneumothorax has a very high likelihood in a woman of being related to endometriosis, and an endometriosis could be called in addition to perhaps a cardiothoracic surgeon.

22:30Dr. Jade B. K. Brighten:Especially when it's a recurrent thing and it always happens on their period. There's actually a name for that. It's called catamenial pneumothorax. Indeed, yeah.

22:38Dr. John Smith:So the thing that clinicians should be doing is bringing in the endo expert. If female presents pneumothorax, it is an endo expert who also is accompanying them in the room to make sure that we know what we're dealing with and that we're not sealing off a cavity and making it so that this becomes untreatable.

22:57Dr. Emily Jones:Exactly. Refer the patients to the experts. We have a patient that had fenestrations on the diaphragm and they placed a mesh on top of it. So removing the disease with the mesh on top of it, yeah.

23:13Dr. Jade B. K. Brighten:Can I just make a comment? Simple things being simple. The vast majority of patients with chest pain, 98 % of the time is myofascial pain and comes from a super tight pelvic floor. and the spasm on the inside of the pelvis extends out to the outside of the pelvis and then it goes up. It also can go down. These gals get a lot of really tight IT bands. They get pain in their hips. They get pain in typically it's whichever side that the pelvic floor is more spastic in. So I don't want everybody who is listening to think, oh my God, I have pain in my chest. I must have thoracic endo. The vast majority of women with endo who have upper abdominal and chest pain, it is myofascial and the PTs can help you with it.

24:12Dr. John Smith:That's great. But I think also to Shanti's point, if you're going to have laparoscopy, they should at least be checking the diaphragm during that. And so I think that's a good take home for patients is like, it doesn't mean that this is thoracic endo. However, if you are going to have the surgery, we want to ask that the surgeon is going to check that. And I think that's a good question. We're going to have more questions that people should ask their surgeons. But it's also, you know, I think a really good one is like, do you check the diaphragm during surgery? I'm curious what symptoms should never be brushed off without anatomical investigation.

24:49Dr. John Smith:Like all symptoms. Okay. I mean, so I think we blow off things like as, as widespread practitioners, we, we, we don't pay too much attention to fatigue, to nausea, to reflux, to chest pain. We just assume it's anxiety. However, sometimes that nausea can, I've had patients where you remove their, their diaphragmatic disease and their daily chronic nausea and vomiting goes away. It's like a miracle. And so if we are blowing that off and just saying, oh, well, you must be taking too much non-steroidal NSAIDs and ibuprofen and so that's why you have gastritis, we might be missing something. And maybe 10 % of the time we are.

25:38Dr. John Smith:I want to discuss pain management further, but first I want to hear it from you. What is the most unhinged endometriosis intervention a patient has brought to you that you then discovered actually worked? I feel like a lot of my patients on GLP-1s have told me that their inflammation and pain has improved while they've been on that medication.

25:57Dr. Emily Jones:I really have learned a lot from our physical therapists. And one of them tell me that there's an association between the dysfunction on the pelvic floor and the temporomandibular jaw. Oh, yeah. So there's some form of treatment that can be done on the same, because most of these patients have an alteration in the temporomandibular jawline.

26:20Dr. John Smith:Yeah, there's been, so doing a pterygoid release, which I'm not going to do it because I have lipstick on, but if you're watching, you stick your thumb in your mouth and actually releasing the jaw. Some women will say like, yeah, my, like a pain was sex. It was like easier to have intercourse. Like there's been some really interesting things that patients will report when they get that. And the first time I ever heard it was Botox. Someone got Botox for their TMJ. And then they're like, oh, everything is feeling better downstairs. And I'm like, say more. Say more about this. Cindy, did you have something you want to add?

26:53Dr. Jade B. K. Brighten:I mean, it's not really unhinged. But I mean, we share a lot of patients with naturopaths. And I have a lot of gals that are on NAC and glycine, which are cofactors in the production of glutathione, right? And glutathione is like one of the biggest free radical scavengers in the body. And anti-inflammatory diets, I used to be so skeptical and now I'm like, you know, do an anti-inflammatory diet. I was going to bring up NAC as well.

27:27Dr. John Smith:We have data, we actually have research data that shows an endometrioma can shrink a little bit by taking daily N-acetylcysteine and about as much as it shrinks by taking a birth control pill. Yeah, and what's interesting, the studies are sometimes using 600 milligrams, but it seems to be the sweet dose is like 1 ,200 to 1 ,800 milligrams a day. And often people will say, well, oh, they only have the patients take it for three months. So you take it for three months and then you don't need it. I'm like, as someone who's been on N-acetylcysteine for like probably 20 years, it's like one of the things that when I learned about it, it's got to be like one of my favorites.

28:05Dr. John Smith:You know, I'll share one of the unhinged things that I found I wasn't expecting is the vibration plates that went viral on social media. I got them like, I got it like years in advance because I was like, I want to challenge my balance when I'm working out and I'm doing weights and it's great for lymphatic. And I started doing stretches on it. And when I went back to my pelvic PT, Deanna, who you know, She was like, what did you do different from last week and this week? Because your pelvic floor is completely different. And I'm like, I stood on a vibration plate, leaned forward on a bar and like shaked out my, I shook out my hips and did all of these stretches on it.

28:40Dr. John Smith:And it completely, she's like, you've like released so many trigger points. So that's my unhinged share. What I want to ask you, Vicky, though, is why don't NSAIDs and opioids address endometriosis pain adequately? I mean, because they're not really targeting the source of the pain, to be honest. I feel like NSAIDs can be a little bit helpful because they impact inflammation. But especially if you have deep infiltrating nodules, and Anna was speaking about this, they have their own nerve endings that are, you're not going to improve pain from something infiltrating into your rectum. With any medication, I mean, it's going to take surgery to make you feel better.

29:20Dr. John Smith:Let's talk a little bit about how these lesions are different because we talked about it a bit in episode one, but you just said they make their own nerve endings. What about these lesions make them challenging to treat? Because they infiltrate tricky areas like the rectum, the cecum, the small intestine, they infiltrate nerves, the bladder, the ureters. I mean, these are very delicate areas with surrounding structures that you really have to have a high level of expertise to treat them. And medical management, unless you're completely asymptomatic from them, medical management isn't going to do anything.

29:56Dr. John Smith:If you're having pain or symptoms or even infertility, surgery is really the only answer for these types of lesions.

30:04Dr. Emily Jones:Is there anything you'd add to that, Ana? No. I'm thinking about whenever you have a patient in pain, I will think about the pain as an experience. And if you think about patients in pain, some of them will have a different, the experience will be different if they are with their family and were alone. Then when their work life balance is different, or if they have some kind of support, the pain they feel is different, even though the signal is the same. So pain is not only signals and there's a difference there.

30:41Dr. John Smith:And speaking of difference, I want to ask you, what is the difference between inflammatory pain versus residual nerve pain and why does this difference matter?

30:50Dr. Emily Jones:It's different in the origin, but for the patient is going to be the same experience. So I think that what we should address as clinicians is the difference between visceral nerve or visceral pain and somatic pain. Because as Vicky was saying, visceral pain is a pain that your patient cannot tell you where is it. It's endometriosis pain. Everything hurts. And it's associated with neurovegetative symptoms. Like when I have the pain, I'm pale. My hairs are like standing up. I have nausea. I want to vomit. That's visceral pain. And somatic pain, they're going to show you when one finger here, it hurts here.

31:32Dr. Emily Jones:So we're talking about different types of transmitting the pain and a different type of source. If you start by this, you will start defining the etiology of the pain, and maybe you're onto something into helping that.

31:46Dr. John Smith:We talked a lot at the beginning about what long-term pain can do in changing the nervous system, in shaping the brain, in shaping your future experience. And we promised we'd come back to some solutions around this. What are things that can actually help with pain?

32:03Dr. Emily Jones:Neuroplasticity can go both ways. So it can go on the way that you have shaped or life has shaped your brain into being very good at feeling pain. But they can also be very good at remembering how your pelvic floor functions. So we have found that pelvic floor therapy is really helpful in order for them to feel different experiences, especially with patients with endometriosis that they no longer recognize. Do I want to pee or do I have pain? Do I, because, you know, the muscle activity is like the window. It's a window to the way that our patients deal with the world. So if you find a contractual pelvis, it's because they are hiding or they're protecting themselves against their pain.

32:48Dr. John Smith: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.com slash E-N-D-O-G-L-O-B-A-L.

33:33Dr. Emily Jones:So if we start addressing this and start teaching them our, one of the things that, doing a scan and seeing what is this, this is pain in my bladder. This is wanting me to be, to again, starting to recognize the real signals on your pelvic floor. It's going to help you lots. Physical therapy, body scan.

33:55Dr. John Smith:Is there any other lifestyle therapy? I think Cindy has.

33:59Dr. Jade B. K. Brighten:Well, there was a study about 10 years ago where they had patients with endometriosis of all stages. And they measured markers of central sensitization pre-op. And what they did was they did a pressure test. So they took something and pushed on forearms, and they measured how much pressure did it take before the perception was pain instead of pressure. How much force did it take before the patient perceived it as pain instead of pressure? Then they operated, they did good excision surgery, and then at six months post-op and 12 months post-op, they reassessed these markers of central sensitization.

34:47Dr. Jade B. K. Brighten:And guess what? They got better. And so every primary pain stimulus that you can remove helps to reverse central sensitization.

34:58Dr. John Smith:And that's why it's so important, I don't know, to treat the entire disease, the overlapping conditions, and also the endometriosis. And not deny patient surgery when they need it, because it may be one way to remove a pain.

35:14Dr. Jade B. K. Brighten:But if they also have hip impingement, you know, that needs to be dealt with. If they have herniated discs, if they have, you know, if they have thoracic outlet syndromes, if they have all these other things that you can get, you know, that some of them come from a tight pelvic floor and then everything gets twisted and then your whole axial skeleton doesn't work right.

35:36Dr. John Smith:I want to get into some more specifics about pain, but first I want to play two truths and a lie with Ana. Okay. So I'm going to make three statements and you're going to let the listeners know which is a lie. So the first one, you can walk but still have severe nerve involvement. Two, Botox can be used to treat nerve pain. And three, birth control is the best treatment option to stop the progression of endometriosis, which is the lie.

36:01Dr. Emily Jones:The last one is the lie. So why does this lie persist? Let's think about each one of the sentences that you said, because I think all of them are really important. First of all, yes, you can walk and still have nerve involvement because there are a lot of nerves. And sometimes my patients tell me, oh, I have sciatic pain, so I should have endometriosis in the sciatic nerve. No, that's not it. I mean, first of all, the sciatic is not only pain on the backside of your leg. It goes all the way into your feet. If it's only on the backside of your leg, it's probably a posterior femorocutaneous nerve or another cause.

36:38Dr. Emily Jones:And there are a lot of causes of sciatic nerve pinchments. For example, now that running it's so hip and fashionable, I have a lot of patients that have the piriformis muscle pinching the sciatic nerve because that's the way that it exits. So it's not always about pain on the legs. I think the most common nerve entrapments by endometriosis are the autonomic systems, because you're going to find more patients that have pelvic floor dysfunction, that have problems emptying their bladder, dysfunction in having sexual intercourse, or emptying their rectum. All of those are nerve compressions because of the autonomic system are so much more common than somatic.

37:28Dr. Emily Jones:So I will go first with that one. Second, Botox can be used to treat nerve pain. It is because it can block the signal and it can help them as a neuromodulator. And in order for them to help ease the pain and also forget the pain. And it helps to this neuromodulation and this changing the way that the patient feels the nerve. So that will be the second one.

37:52Dr. John Smith:Wait, I'm going to ask you more about Botox. Okay. Is that a standalone treatment or do you use it in conjunction with other therapies?

37:58Dr. Emily Jones:It depends on the cause and it depends on the patient. But would you just tell someone just have Botox for your nerve pain indefinitely? No. And also I wouldn't have a patient have Botox. Sometimes they just tap and add Botox whenever there's pain. If you do that, you're not finding the cause of the pain. You're just numbing the pain and the places where it hurts. so you have to find the nerve and then you block that nerve or if you're seeing a contracturated muscle you're gonna try to fix that nerve that muscle but you need to know the anatomy of the muscles and the pelvic floor if you're just placing buttocks wherever it hurts you or you're

38:39Dr. John Smith:not gonna have very good results who should you see for this treatment then because we don't want that tap and poke.

38:45Dr. Emily Jones:Who do we want? A pelvic pain specialist. I would go with that and ask the doctor what technique do they use before they use it on you. Okay.

38:54Dr. John Smith:Now tell us why is it so many doctors? I mean, I have seen very large podcasts have doctors on who say the best way to stop the progression of endometriosis is to take the pill. Why is this wrong?

39:09Dr. Emily Jones:I think because you are not addressing the inflammatory component and you should because endometriosis is so much about the inflammation and stopping menstrual cycles does not fix the problem. So I'm going to say,

39:24Dr. John Smith:I'm sitting here with four of the top female endometriosis experts. So I just want to clarify, have there ever been any quality evidence studies showing that birth control slows down the progression of endometriosis. Well, yes, but only ovarian disease. So only endometriomas. Only preventing formation of recurrent endometriosis of the ovary, choclysis, endometriomas. Yeah. And so we have a study showing it will help prevent recurrence to be on a birth control after excision of the endometrioma. But in the rest of all the literature, To my knowledge, there's no evidence that a birth control pill decreases a lesion, prevents recurrence, or in any way treats endometriosis.

40:18Dr. John Smith:Well, I just want to clarify exactly what you just said, is that this study showed excision first, then the birth control pill, for only the lesion in the ovary. It wasn't no surgery at all. For an endometrioma. Perfect. Yes. Vicky, what were you going to say? I was just going to say Horace Roman, he did his 10-year follow-up study of patients who had surgery. Most of them had deep infiltrating endometriosis of the bowel. And he found that the patients who were put on some form of hormonal therapy post-surgery were less likely to need surgery after. If you're using it for management of adenomyosis, it may help you from having a hysterectomy.

40:59Dr. John Smith:I'm going to challenge this because I have had endometriosis experts on the podcast. Dr. Patrick Yoon has actually done a study showing it is possible to do one and done surgeries. And I'm paraphrasing him. So if I get this wrong, Patrick, I apologize. But essentially, one of the arguments he made is that the use of hormones afterwards, it's kind of a buffer. So you don't have to do that good of a job of the surgery. So like a surgeon doesn't have to have the aim of let me try to get everything and clear out all these lesions because they know they have the padding, the fallback, the comfort of I can suppress their hormones afterwards.

41:36Dr. John Smith:So I agree with that.

41:38Dr. Jade B. K. Brighten:Horace Ramon is one of the best surgeons in the universe, and that is not his mindset.

41:45Dr. John Smith:Yeah, what I want to say— It may not be his mindset, but what Patrick's argument and others have made is that surgeons will sometimes go into it being like, meh, I don't have to do as good of a job because I can always fall back on birth control. I'm not saying this individual. I don't know Horace. Yes. You should have him on your podcast. I'm not pointing fingers to Horace. You should invite him. Sorry, Horace, I don't know. You should have him on your podcast. But what I want to say is I could see how that what I'm saying could be interpreted that way. But that's not how I'm intending it at all.

42:15Dr. John Smith:The thing about the reason I trust Horace Roman's study is because he has a YouTube channel and he literally posts his surgeries on there. Okay. I was like, hold up, because he's an influencer? Is that what we're going to say? No, he is an influencer. I'm just digging up his work. He fights to remove disease. Like, and he fights to remove disease completely. for example instead of doing IVF as an option like you do an amazing job on surgery so that patients don't need to have IVF they can spontaneously conceive and that's a lot of what he's shown with his work yeah but I mean I think adenomyosis is under treated or maybe under discussed with patients and under managed there's promising things like HIFU high intensity frequency ultrasound I had our AAGL this year many people were talking about that and it's not really easy to do here in the U.S., but there's other things coming out of the woodwork for adenomyosis.

43:09Dr. John Smith:So maybe in the future, you wouldn't even need to be on the pill. You have to say more about adenomyosis because you're right. These women, they don't get the treatment. It's really common with endometriosis. In my experience, I feel like it's almost a surprise not to see features of adenomyosis on ultrasound for my patients with endometriosis. Do you want to know what my reproductive endocrinologist who I fired said to me when I brought in the objective MRI study that showed I had anomyosis, he said, that's just the new trendy diagnosis, like ADHD. And I was like, we're so broken up and you don't even know it yet.

43:45Dr. John Smith:And my husband was in the room during that conversation because I challenged and I said, this is subjective finding, or this is not my opinion. This is not me just coming in, like saying, I think I have this, like I'm showing you. Radiologist read this, I have this. And my husband was like, you know, I hear you talk all the time about the gaslighting that happens. He's like, I never really experienced it. And to see, even in the face of imaging that said otherwise, how he just decided that, no, you're just making this up. And he told me it had no effect on being able to get pregnant. And I was like, I don't know how you got a medical degree.

44:18Dr. John Smith:I'm going to leave. And that was it. I was gone. That's just so incredible. It's horrifying. I don't want to get too tangential on adenomyosis unless you would like to. We do need to talk about adenomyosis. I mean, it is part of, like, I was going to bring up because because surgery is very wah-wah, right? Because when it's diffuse, what do you, I mean, I have diffuse adenomyosis and it's something that like, people are always like, why don't you get it operated on? And I'm like, okay, so I'm from California and there's something, a cut of meat called a tri-tip. And I was, I'm like, you ever see a really good cut of meat and it's got all this fat marbled in it?

44:49Dr. John Smith:Yeah. That's what my uterus looks like. So what would happen if you went in and took out all the little pieces of marbled sections? You just have this floppy, no form, Like it's not an organ that functions anymore. You know, I think it's just there, just like there are objective criteria to diagnose endometriosis using ultrasound. There are objective criteria to diagnose adenomyosis on ultrasound and MRI that are just underutilized. So it's underdiagnosed. I think in Europe, probably in Latin America, they do a better job because they use these tools that are available to them. It's not that hard to do.

45:24Dr. John Smith:Katerina Exacusos, another person you can think about having on your podcast. A lot of people are really experts in imaging adenomyosis. And I think just giving the patient that information that they have it is so empowering to the patient. It gives them expectations about the outcomes of their surgery, the outcomes of their pelvic floor PT, what other adjunctive treatments they might need as a result of having adenomyosis. I just think the underdiagnosis is very harmful.

45:53Dr. Jade B. K. Brighten:I do think that putting a Mirena IUD in someone with adenomyosis, say, if we operate on them when they're 20 or 25, they're not ready to have kids yet, but they have adenomyosis. I think and I'm not aware of any studies looking at this but I do really believe that it helps that putting that Mirena in and having that progestin kind of slow down the progression of the adenomyosis helps to keep their uterus kind of in the same physiological shape that it's in when they're 20 you know five six seven years down the road when they when they actually want to get pregnant as long as they can tolerate it.

46:38Dr. Jade B. K. Brighten:I think it's maybe 50-50 of the gals with adenomyosis who will tolerate a Mirena and who will not.

46:46Dr. John Smith:Yeah, but there's some studies that in the fertility literature that show like you'll have a higher implantation rate if you do even because they love, they use, this is one area where I feel like Lupron has some data to support its use, but like progestins also have this data to support it and it's a more long-term option that's more viable for these patients. I know it's controversial to use hormonal therapy. I think it's reasonable for adenomyosis until HIFU becomes more widely available or other alternatives are available for it. And what exactly is HIFU and how is it administered? So I've never done it, but it's high intensity frequency ultrasound energy, which is like cheap and easy, which is probably why we can't easily do it.

47:28Dr. John Smith:I don't know. No one's making money off of it, But you just treat the uterus with this during surgery. And it's like, I don't think it's very difficult to do. Is it a one and done treatment? I believe it is. And probably you could retreat if the first treatment was insufficient. There's probably a way to do it again. I don't know that it's widely available, but it has also been used to treat abdominal wall endometriosis. Yeah. And also I think cancer, some cancers have been treated with it. Vibroids. Yeah. Interesting. If your endometriosis pain is still ruining your life, something was missed.

48:04Dr. John Smith:This 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. Yeah. And speaking of fibroids, how often are we seeing fibroids as a co-occurring condition with endometriosis?

48:58Dr. John Smith:85 % is really common.

49:00Dr. Emily Jones:It's even where if you are programming a myectomy, a myomectomy, to not have found endometriosis that to found them.

49:07Dr. John Smith:So I want to ask, what are non-surgical interventions that you offer patients that can actually get them relief and buy them some time maybe before they have surgery?

49:16Dr. Jade B. K. Brighten:We just got a machine in our office called the SoftWave, and it's a shockwave machine. You can use it on the pelvic floor. You can use it on the vaginal apex, kind of through the bladder. You can use it on the abdominal wall. Mostly the PTs use it for trigger points and things like that. And it can help PT be more effective. It can help to release kind of spastic muscles. And it actually works almost like PRP does. So it creates an acute inflammatory process that then helps to get rid of the chronic inflammatory process.

49:58Dr. John Smith:And what's PRP for people who aren't?

50:00Dr. Jade B. K. Brighten:Platelet-rich plasma.

50:01Dr. John Smith:And do you ever use that as part of your endometriosis protocol?

50:04Dr. Jade B. K. Brighten:Well, I mean, not really as part of the endo protocol, but we do have the ability to do PRP. So we draw blood, we spin it down, and then we take the layer where the platelets are. And the platelets have all these little healing factors. They have these little inflammatory guys that can do what the softwave does, which is to create an acute inflammatory process that then helps to break down necrotic tissue and then helps the body heal itself. It's kind of like the little brother of stem cell therapy.

50:38Dr. John Smith:I had it when I had my excision surgery. I asked them to inject my ovaries with PRP. I'm like, as long as you're in there and I am under and I am sleeping, let's like hook a girl in.

50:48Dr. Jade B. K. Brighten:So the infertility, there's quite a bit of literature on kind of rejuvenating ovaries and raising AMH levels and things like this with PRP for the ovaries. So Nervo sprays it on the bed of the excision area. We use fiber and glue to do that to prevent adhesions and things like that. But we use PRP primarily in patients who have either after hysterectomies, if their vaginal cuff doesn't heal quite right or if they have vaginal endo that we've removed and there's granulation tissue or things like that at the cuff. We'll use PRP and it usually will take care of that.

51:33Dr. John Smith:Ana, are there any non-surgical interventions for pain management you offer patients?

51:39Dr. Emily Jones:Acupuncture does help and has a place. I have the fortune of working with a friend that I met. It's been 100 generations of acupuncturists. Oh, wow. Yeah. He's a doctor, a medical doctor and their family is from Taiwan, but he was born in Argentina and now he lives in Mexico. He's really good at understanding the pain because that's the reason that he went into medical school, to understand what he was doing. And now I think we have had very good results with acupuncture.

52:12Dr. John Smith:Vicky, is there anything that you have? I mean, I think along that same vein, I don't think this is the only thing, but I feel like anything that stimulates your vagus nerve, I think, helps. Okay, so you mentioned vagus nerve in episode one, and I was going to make you come back to it. Yeah. Tell people what the vagus nerve is, how do you stimulate it, why does it matter? It's the biggest nerve in the body, and I should probably say what the vagus nerve is. She's a nerve expert.

52:34Dr. Emily Jones:Well, I think this, I think it's a little bigger, but... Okay. That's right. Go ahead. Say it. Say what it is. No, no.

52:41Dr. John Smith:Yeah. Go. So it modulates the parasympathetic nervous system, which is the relaxation nervous system. And that modulates inflammation. So if you have a fight or flight activation or your sympathetic nervous system is overstimulated, you have more inflammation. Studies have shown there's a randomized control trial from the NIH that showed that patients with rheumatoid arthritis who had vagus nerve simulators implanted had fewer rheumatoid arthritis flares. And I feel like one thing that the Eastern cultures have that like have known for millennia, probably, and they're like medicinal approaches is that the key to health is to stimulate your vagus nerve.

53:22Dr. John Smith:So they do that through acupuncture, yoga, meditation, and so many of the practices that we see from Eastern medicine is based in stimulating your vagus nerve. now come to Western lifestyle, especially in the US, and it's hustle culture that we have. Stimulate your sympathetic nervous system, do CrossFit, release cortisol nonstop. And unfortunately, the pain experience is just so much more heightened and inflammation is so much more heightened from that. Not to put it back on the patient, but anything you can do to stimulate your vagus nerve, that means go for a walk in nature, get enough sleep, eat a healthy diet, you know, like be with the people you love, deep breathing, meditation, like anything.

54:03Dr. Emily Jones:And I think that is one thing that may help a little bit. A teacher explained this to me, like if it was, I would try to flush a toilet when the water is already down. Like you flush the toilet and you try to flush it again. There's no water there. So if you don't wait for the evocated potentials to go back again to the membrane of the cell, you're not going to be able to flush again. So you need that relief in order for them to work properly. So some of our patients have like this amount of discharge and discharge and discharge of their sympathetic nerve and we have to help them regulate.

54:40Dr. John Smith:Shanti, any pain management? Yeah. So trigger point injections. So sometimes we talked about central nervous desensitization. We've talked about vagus nerve calming down, but sometimes this chronic pain results in deconditioning and really like overholding of the walls of the abdominal wall and also the pelvic floor. And so sometimes I'll just do abdominal wall trigger point injections and also vaginal wall trigger point injections when it's indicated. Once you start with this deep pain when you're a teenager and you go through menarche, your whole body becomes somewhat more tense. And so if they're waiting for surgery, not sure, you can get some relief through trigger point injections and similar to getting body work.

55:29Dr. John Smith:What are you injecting? I usually inject Marcane long-acting lidocaine solution. Studies show that injecting steroids is not necessarily more effective. And also studies show that dry needling can give you a similar benefit. But I I think patients feel an immediate sense of relief when you actually inject them with a lidocaine type.

55:49Dr. Emily Jones:Don't inject steroids. Please don't. Steroids cause a lipoatrophy into the myelin membrane, so the pain comes back harder. Perseverates, yeah. If you have a patient that has the pain increases whenever they are standing straight and the pain releases when they are flexing, because they're flexing their leg and they're releasing their psoas. The genitofemoralis nerve goes through the psoas. So if you look in the ultrasound for the genitofemoralis and block the genitofemoralis, it will give them a larger amount of relief that's sometimes just going to trigger points. I would advise to go through the ilioinguinal or iliohypogastric nerve or the genitofemoralis nerve in the ball.

56:34Dr. John Smith:Yes.

56:35Dr. Emily Jones:So how bare relief. Yes. Lovely.

56:39Dr. John Smith:Vicky, I want to ask you for patients who are in pain, they're trying to seek help from a provider what's a way they can categorize and quantify that pain to get their provider to listen i like what anna was saying about the five d's i mean that's how i collect the information i'm like which bodily systems is this impacting bowel bladder sexual function um pain with periods pain between periods where is it um what's the quality of it you know which ones are at which part of your cycle. I'm like an investigator and interrogator. I ask so many questions from my patients. I think some people's coping mechanism is ignoring it and they get a little intimidated about having to think about all these details.

57:24Dr. John Smith:And that's not my intention at all. But some patients know every detail and they're so grateful to tell someone about it and have them listen. But yeah, I mean, basically, I just want to know all the details about your pain. So where's the pain? What's the quality? Is it sharp? Is it burning? Is it aching? Where is it at in your cycle? What about activities of daily living? Yeah. I want to know the systemic symptoms too, not just the pain, activities of daily living. What is it impacting? And honestly, those details help me a lot. The ultrasound helps a lot. I contact my friends when I don't know.

57:58Dr. John Smith:I'm like, there's a symptom that's really bothering this patient. I don't fully understand it. I'll call Anna. Anna knows I've contacted her about patients and I've called Shanti, Cindy, I contact Cindy all the time. You know, I think the symptoms that the patient has, the ones that are most impactful for them in their lives, like we need to understand them fully where they're coming from. You know, the only way to do that is just to collect like as much information as possible. And when it's beyond my expertise, I go to my friends who know more. Okay. And so if someone's bringing all this data to their provider and their provider is still being like, it's period pain.

58:35Dr. John Smith:It's normal. Is there a phrase or anything they can say that might get that provider to like snap into it, maybe leave the last patient behind and be present in the room here and get this person the help they need? Maybe I'm too passive, but I'm like, you know, maybe we should ask Cindy. I'm like, when you get, when you get someone on the phone that clearly doesn't want to help you, you're like, let me call back later and get that right person on the phone. That's how I see it. You know, like, let me find someone who wants to hear.

59:02Dr. Jade B. K. Brighten:If you go to a gynecologist and they don't want to listen to you about your pain, they're not going to do you right if they operate on you. And so you don't want to see that person. You want somebody who is interested enough in what's going on with you to think long and hard about what are we going to do if we go to the OR? What are we going to find? What might we find? I mean, I want to know in advance everything to expect when I get to the OR, which is why I spend 15 minutes on an ultrasound for every single patient I see. And I don't want to be surprised, but it's the doctors that don't want to talk to people about their pain.

59:46Dr. Jade B. K. Brighten:They don't want to recognize their pain. And the patients are like, how can I get them to, you know, pay attention to me? Well, even if they did pay attention to you, they wouldn't know what to do once they got in your belly. So you just need a different doctor.

1:00:02Dr. John Smith:So I'm going to push back on this because there have been states now, there's counties in the U.S. that don't even have gynecologists, and there are gatekeepers that are PCPs that these women need to take their pain seriously to make the referral so that when they make that three-hour drive to the specialist, their insurance actually covers it. And so I think, you know, I hear what you're saying. I wouldn't let that person touch me either. But I think that is something we just have to name. We don't necessarily have to solve it in this podcast. We have to name it so that patients know that we are aware that it's very difficult to get to a provider that is worth seeing for your pain.

1:00:40Dr. Jade B. K. Brighten:I think the physical therapists and the naturopaths know who to send people to. My office gets more referrals from those two classes of providers than they do from any MD. All of them put together.

1:00:57Dr. John Smith:We talked about the thoracic endometriosis. And Shanti, I'm wondering if there's a breath or posture change that people can make that can help support them if there's a diaphragm endometriosis involved in their case. That's a beautiful question. I don't know of one. But I love that idea. I'll think about that. We're going to have to chime in on it. If you are a physical therapist, I bet you have the answer. And if you could leave it in the comments, you know, on YouTube is probably the best place. And then that way patients can go and see your answers and also know who's an amazing physical therapist to go see.

1:01:33Dr. John Smith:So Cindy, I want to ask you, true or false, endometriosis can always be managed by stopping ovulation with the pill, using medications like Lupron or taking progestins.

1:01:45Dr. Jade B. K. Brighten:No, of course not. I think we have to individualize our patient care for every patient, but especially women with endo and, you know, figure out together what works, what they want, what, you know, what can we try? If this works, great. We can keep going down this path, but if this doesn't work, then we go this way and then we, you know, we keep trying.

1:02:13Dr. John Smith:That's what I was really hoping you would underscore is that individualized care is the best care from the endometriosis patient, not necessarily just one treatment. So Ana, how do we explain nervous system regulation to patients in a way that isn't telling them that their pain is just in their head?

1:02:31Dr. Emily Jones:First of all, you have to validate. You tell them that, one, you believe in their pain. Two, their pain is real because the experience of the pain is going to be real for them, even though the origin is in their head. You have to explain them that, precisely that, that if they have a centralized pain, they're going to feel the same way. There's a book, it's called Diary of the Pain, and it's about a fibromyalgia patient. She explains pain as if it were a presence of someone that she has to share their body with. And she explains that having something is like a constant presence and that makes her never alone.

1:03:10Dr. Emily Jones:And when you think about that and the ways that it changes their reality, their marital status, everything, you have to be compassionate about them and explain them. This is another symptom of your endo and there's nothing in your head. I mean, there's something in your head, but there's nothing wrong with you. And we can manage the symptoms. And we believe in you. You have to validate that. What do you wish partners of endometriosis patients knew about this pain? I often explain them, for example, when the ovaries are attached to the uterus or attached to the pelvic wall. I tell them, okay, how about if I staple your scrotum to one of your legs?

1:03:52Dr. Emily Jones:Do you think you'll feel any pain at all? so that's one of the so they were like oh yeah so she has that i usually make them like a drawing of how they are the how where they are the ovaries and how they're placed and where's the nodule in their bowel and stuff and when when you're talking to them they have like some of our patients have an excellent partner and do help them and do understand them. But in other states or other patients that I have tried or treated, most of them, as they are not longer good for reproductive features or reproductive functions, they leave them because that's the point of getting married.

1:04:36Dr. Emily Jones:So it's hard for women.

1:04:40Dr. John Smith:Vicky, I wanted to ask you, because our next episode coming up is going to be about surgery, but for women listening right now, who should be on the endometriosis team other than the surgeon? So I think we touched on some of them, like, you know, pelvic floor physical therapists are our friends. I have several acupuncturists that I work, you know, I send patients to and who actually send patients to me. There's some naturopathic doctors that, you know, we collaborate with. Anyone else that you guys would add to that?

1:05:12Dr. Jade B. K. Brighten:Interventional pain management.

1:05:15Dr. Emily Jones:Psychologists, psychiatrists. Multidisciplinary team means nobody has the full picture. Then you have to work as a team in order for the patients to feel better.

1:05:26Dr. John Smith:And I want to add, if you're lucky enough to have a good radiologist or someone... Yes, that would be great. And radiologists can also sometimes clear fallopian tubes, interventional radiology, but of course, we've talked about diagnostic, but also functional medicine provider who can really delve into nutrition and work with very specific supplements, work with specific diet, work with food sensitivities. The mast cell activation. So many of our patients have mast cell activation syndrome. So many of our patients have prostate cancer. As well as... Hyperlaxitus. Yeah. I would add on the team is a dietician, a nutritionist, someone who doesn't just understand endometriosis, but understands that perfection is never the goal when it comes to eating.

1:06:13Dr. John Smith:And so I really want everyone who's listening to take away from this that it does take a multidisciplinary team. For years, I'd have patients come to me and I'd be like, okay, we need to get you to the endosurgeon. And they're like, but why? That's why I'm seeing you.

1:06:30Dr. John Smith:I'm like, the same way as a psychiatrist, as other providers. And when we need them most, we don't want to be in an emergency situation scrambling to find who's the best person for you when we could have done that when you were feeling pretty okay. So I appreciate this conversation so much. Next, we are talking in depth about surgery. Why choosing the wrong surgeon can be the most devastating mistake of your life? So thank you all so much for being here with us. Thank you all for sharing your expertise and we will see you all in the next episode. Your call has been forwarded to voicemail. Hi, this is Zoe Deutsch.

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