Endometriosis Surgery: What Most Doctors Won’t Tell You

27:20It's sometimes hard to tell. I mean, usually when you have endometriomas, you have what we call frozen pelvis or obliterated posterior cul-de-sac, so you can't even see the bowel that's involved. It's hidden under all the adhesions and the endometrioma. So, I mean, I do think if you see something like that, a pico-shriek and shriek is the best thing to do. Often patients with bowel symptoms have gone over and over to their primary care providers and to GI surgeons and had colonoscopies that have been negative. And the reason for that negative colonoscopy in most cases of endometriosis of the bowel is that endometriosis grows from the outside of the bowel in and not from the inside out.

28:01And so we don't see it always on colonoscopy, even if it's a large lesion growing from the outside. And colon cancer is different from that. So colon cancer, you can pick up on colonoscopy. So patients are often told that they don't have any problem in their bowel. There's no endometriosis in your bowel because they had a colonoscopy that was negative. What should a patient know about surgery when nerves are involved? There are two kinds of lesions. You have intrinsic lesions or extrinsic lesions. I think I've seen one intrinsic lesion in my life. Most of the cases that endometriosis affect nerves, it's because they have extrinsic lesions.

28:41As Shanti was saying, endometriosis grows from the outside to the inside. So the thing about when you don't think about the nerves, it's about the outcome. Because one, maybe the pain or the dysfunction, it's not going to get better. It depends on how many years the nerve has been affected in order for us to tell the patient, you can get your bladder function back, or you can have your pelvic floor function back, or maybe the function on your leg in case of sciatic nerve involvement. You're going to be able to have strength again or the movement again. So it depends on how many years it has been affected, but also it depends on the skill of their surgeon and the physical therapy afterwards.

29:27So having this in mind and having this conversation beforehand helps the patient prepare themselves. Because if I told you that after your surgery, you may have to self-catheterize your bladder in order for you to pee, it's going to be a whole different mindset up that this is like a surprise. Oh, I'm not able to pee what is happening. If I told you, well, it's part of the process and maybe you're going to gain back your ability to pee. So it's a whole new conversation and mindset of the patient. Because sometimes they think that a surgery will cure them and it'll make everything better. But if you don't do the tests beforehand, you will not be able to diagnose everything.

30:14So that's why it's important. What test beforehand? We usually do MRIs and we usually do physical exploration. And in some of the patients that need them, we do urodynamic testing. And do you always recommend physical therapy post-op if there's nerve involvement? Even pre-op. It's even better. They get better results if they begin their physical therapy before the surgery. And how far ahead is preferred versus like, you know, this is the best we can do? Sometimes the best they can do. I mean, sometimes they fly from another country and we have one week of them. So they do two sessions before. And sometimes we have even one month to prepare them for surgery.

30:55And that's even better because the nutrition can get taken care of and also the physical therapy can be taken care of. And also depends on the dysfunction of the patient. Yeah. Sometimes we have patients that are not such hard cases, and sometimes we do. I was telling them about a patient that we had that in their last two months prior to our surgery had only eaten mango. So she was really malnourished. So the amount of complication that can come with a malnourished patient, it's higher. So you have to take care of this before doing the surgery. So PT and nutrition before surgery, do you run any panels, like do any blood work to see if there's any nutrient deficiencies?

31:35Yes, of course. But usually we refer them to our nutritionist who's going to check about their amount of muscle, the muscle mass. And also if they have any anemia or any problems with the proteins in their blood. We do this workout or workup before. So if someone's anemic or they have low muscle mass, does that mean you need to delay the surgery? Yes, but it depends on the patient also. Because sometimes we cannot delay, for example, a ureter that has been taken and they have a risk with kidney. Most of the surgeries can be delayed a little bit, but there are some cases, specific cases that cannot be delayed.

32:18Endometriosis 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. I agree with starting physical therapy ahead of time when possible, and also very soon after surgery.

33:10Like within a couple of weeks, they could begin physical therapy. That's the main thing. But then afterwards, I really begin to counsel patients more about their nutrition. Six to 10 servings of fruits and vegetables. I have a list of supplements that I think are valuable. Food sensitivity panel, hormonal treatments, often bioidentical. Are there any things, Vicki, that you think are ideal that people get in place before they go into surgery? I spent a lot of time on the counseling part. I definitely think having support at home, setting up your home so you're not reaching or squatting, making sure all the medications you have that you're going to need for after surgery are at home.

33:55I definitely agree with nutrition. I think anemia and correcting that is huge in the recovery period. I do check that often, like iron panels. And if they're malnourished, definitely send them to a dietician and nutrition. Right now, I have a patient coming up for surgery next week, and she herself is an exercise physiologist, and she works with athletes. And she has just become so debilitated from her own disease, but she's managed to keep herself functional through really expert nutritional techniques. And so she was asking, can she do this carbohydrate drink before surgery and this special protein drinks.

34:35And I'm all about this. I drink a lot of nasty stuff before my surgery. Exactly. And so let's go. That's kind of on the forefront of what I think is really important adjacent to doing surgery. Surgery is traumatic. Surgery in and of itself is an inflammatory state. I understand the toll that it takes on your body and the incredible importance in particular in the setting of endometriosis of having adequate protein. And then particularly my vegan patients, making sure they understand what their sources of protein are going to be. And sometimes patients have, as you said, your patient was only on mango because everything else made her feel bloated.

35:15And so our patients are limiting their diet so much because they feel so terrible. Imagine like you eat something and you instantly feel bloated and it ruins your day. And so this is their life, right? And so really trying to figure out ways to bolster nutrition, protein, and these are extremely important aspects of our care. Well, I think exercise is also important. The ARAS protocols to enhance recovery after surgery show that 30 minutes of walking every day for at least two weeks prior to surgery really helps. Yeah. I want to put a plug for exercise because my audience knows this. Anna knows this.

35:57My friends know this. My husband has caught me crying, bawling, working out. And he's like, what are you doing? And I'm like, I know if I can just get to five minutes, I'll start to feel better. And by the time I hit 20 minutes, this endo pain is going to be cut in half, if not completely diminished. And so for people listening, it can feel impossible because of the pain. You know, I shared in another episode, three weeks of like barely being able to move because the pain was so bad. I still got up and I still walked and I still made it happen because I was like, give me those endorphins. And I will say that has been one of the most effective therapies in managing my endo, but it is the hardest to absolutely, I will just be the first to say, I do not want to get out of bed.

36:42I do not want to, I don't want to do anything about it, but I'm like, I know if I can just get there, then the pain isn't going to be there. I just wanted to add something, which is we have a lot of patients with overlapping conditions, and one of them is Ehlers-Danlos. And those patients have a really difficult recovery or can. If they haven't been diagnosed before or like, I feel like it's really important for patients with Ehlers-Danlos to like prehab, like what Anna was saying with the PT. I feel like it's even more important because those are the patients that use a walker for six months after surgery.

37:14If they are not diagnosed before and they're not getting the treatments, which are mostly supportive and related to PT, they really suffer after surgery. And they're not mentally prepared for that. I want to say one final thing, and it's a really sensitive topic, which is that when patients are severely overweight, and I'm talking about a body mass index over 45, approaching 50, it makes it harder for us to do the surgery and to really adequately remove the disease. and really to be able to see down deep into those corners and in the posterior cul-de-sac and look up underneath the ovaries and everything and also diaphragm disease.

38:02Obesity is a really delicate subject because it's so often patients who are obese are told that's why they have pain. And yet so many of them happen to also have endometriosis. And so finding that balance where a little bit of weight loss, and maybe this is one area where GLP-1 analog drugs can be so useful and getting down just a little bit at least and getting down into that range under 50 body mass index, that's going to help the outcome of the surgery. Well, in the risk of going under general anesthesia. Multiple complications, right. Even tolerating the positioning during the surgery. Tolerating the positioning, yeah.

38:42Being able to be respirated during a surgery. I've had surgeries aborted because the person was a smoker and with a high BMI, and they couldn't adequately respirate her under anesthesia. Yeah. It's important considerations. And, you know, as you were bringing up EDS and the connective tissue disorders that can come up, this is where mobility work is so important. And whenever I talk about this, people are like, no, but stretching is bad for us. mobility work of the joints is not stretching in the sense of like you think of a yoga pose and just holding it. It's about strengthening the joint capsule so that you do have more stability.

39:20So for anyone listening, that's something that a good physical therapist will work with you on. And I, this was, I'm so glad you brought this up because it was a question I was going to ask, because now that we know endometriosis overlaps, autism, ADHD, EDS, MCAS, so histamine issues, mental health disorders, autoimmune disease, cardiovascular disease, right? There's this huge list. All of those things are made better with nutrition and exercise. They are not cured. And so for people listening, if you have these co-occurring conditions with endometriosis and you're like, I can't get surgery yet, know that every step that you make in your nutrition and lifestyle is going to result in better outcomes in your surgery, but it's also going to help these co-occurring conditions that can also flare with a surgery.

40:10Why are doctors removing an organ, the uterus in this instance, for a disease that by definition exists outside of that organ? Well, partially it's what they're taught. Partially it's financial. You know, there are times when a hysterectomy is a good idea. So what are those times? When is this something that should be considered? So hysterectomy is the best treatment for uterine pain, pain from a uterine source, but only when somebody does not desire future childbearing. So you can be 21 and say, I've known from the first day that I had a thought that I never want to have a kid. You can be 35 and have four kids.

40:56It doesn't matter. As long as you know absolutely for sure, without a doubt in your mind. And second of all, uterine pain tends to be central pelvic crampy pain. It can be pressure, heaviness, like there's a bowling ball sitting on top of your vagina wanting to come out. Sometimes that pressure is pelvic congestion, but a lot of times it's associated with a uterus, especially a large uterus, whether from adenomyosis or fibroids. If you have cramping at the end of an orgasm, that is a sign of adenomyosis. My favorite description by a patient is, I've got a hot fireplace log sitting in my pelvis.

41:39That is absolutely a perfect description of uterine pain, whether it's adenomyosis, whether it's fibroids. But if someone also has endometriosis, then you also have to remove the endometriosis because removing the uterus won't cure endometriosis, but removing the endometriosis also won't fix uterine pain if you don't do anything about the uterus. I had a listener question that she said, I'm postmenopause and I have had a hysterectomy, but can my endometriosis still come back? Yes. Dr. Redwine wrote a paper on postmenopausal endometriosis, and it is somewhat similar to endo in younger women who were on the pill.

42:27It is less biologically active, but it's still there and it can still grow. I have a patient who has a rectal nodule, but she's deathly afraid of surgery. And I think she was 50 or 51 when I first saw her, and the nodule was like two and a half centimeters. And she was perimenopausal then and she just wanted to wait. And so every year I see her and I ultrasound her rectal nodule. And she was on progesterone for a while and it actually got down to about one and a half centimeters. Then she was worried about something in her eye. And even though I told her progesterone doesn't influence anything bad in your retina, it's okay to keep taking it.

43:13She stopped it for a year and the nodule grew. Yeah. And it grew back to about two centimeters. So now she's back on her progesterone. She's happy. She's fine. What questions can a patient ask a surgeon that immediately reveals that they're qualified? That's a great question. So starting with their training, really important that they've had advanced skills in minimally invasive surgery. I also think that if they are a provider who also delivers babies, that they are less devoted to advancing their surgical skills. So knowing their surgical volume is important. I would say at least 8 to 10 surgeries a month at minimum for good volume.

44:00And then asking questions about, do they do any ablation? What do they think needs to happen to help them with their pain? These are some of the hot things that come to my mind. I feel like if they work in a multidisciplinary team, that is a good sign that they have. Yes, absolutely. You know, like we have a colorectal surgeon as part of our practice. Like I have a urologist that I do surgeries with. We have a thoracic surgeon that we operate with. If you have collaborators that can take on advanced disease with you and help minimize, because that helps minimize the risks of a major surgery for the patient, that's a sign that that's a surgeon that knows what they're doing and is familiar with complex disease.

44:42Also going through the process of certifications, we have the I Care Better, we have the SRC, and you have to show them your videos and you have to show them your data. Especially in the SRC, you have to show them everything. You have to send them videos of your excisions. You have to send them the casistic of all of your patients and the amount of complications that you have. And you need a minimum of 300 patients in a period of time. So I think going through that and to have these type of surgeons that somebody else have checked them that whatever they're saying, it's real. I think it's important.

45:21I think the other thing too to ask, especially if somebody says they do excisions, is to say, how large are your specimens? If they get mad at you for asking the question, that's not good. So now we're moving into red flags. Throw that red flag. Yeah, but if they say, you know, it depends. Sometimes they're centimeters, sometimes they're three centimeters. It depends on what they're on, you know, what specimen it is, you know, then I think that's good. What is a red flag in an endometriosis consult patient should be aware of? So no pre-op assessment. Let's go to the OR. Insisting in surgery. Just insisting on surgery, but not even evaluating for the extent of disease.

46:08So like not really even making sure they'll be prepared to take it on. You know, I think that's a red flag. No physical examination, no medical history, no nothing. It's like, oh, yeah, you come here. Now we know that you have this diagnosis that somebody else made. Let's get you into the OR room. I think that'll be the reddest flag. Or we can't know until we get in there. How bad it is. Red flag. Because we can now, as we've established. And you should. And you should talk to the patient about what it looks like. So the patient is prepared for their recovery and can prehab and can do all the things they need to do to prepare for their recovery and their future, fertility or not, or whatever it is.

46:46The patient should know how bad it is. Yeah. And insistence that someone be on a GNRH analog after surgery. Okay. And why is that a red flag? It indicates that they don't think they can get all the disease and that they need to suppress you afterwards. We try to get most of our patients who do not have stage 3 and 4 disease to stop their hormones at least a month prior to surgery. Especially important in teenagers in early 20s. Because what we want is we want all the disease to be in full bloom so that we can see every little thing. So when you say stop your hormones, are you talking birth control pill?

47:27Are you talking like Lupron? Combination birth control in progestins a month and then GnRH agonist or Depo-Provera probably three months because we want them to have at least a month of normal estrogen levels so that it can feed these small little tiny lesions of endo so that they're more obvious. Studies have shown that the appearance of the disease is altered by age, which is indicative of over time hormonal exposure and also by the use of oral contraceptives and GnRH antagonists makes the lesions less apparent. They look like scars. Yeah. Which doesn't mean that they're gone because they've been on hormone therapy.

48:15They're still there. If your endometriosis pain is still ruining your life, something was missed. 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.

49:09Well, let me ask you, not everyone needs surgery, but what are some signs that someone should consider it? That's a great question. I really think that if a person is having a degree of debilitation that takes them out of work, out of school, out of play, out of sports for any duration every month, that that's a sign that things aren't working, things aren't right, and that we need to figure out what's going on with their pain. Okay. Ana, what should women realistically expect after excision? No excision patient or no patient are the same. So I think we've had so many variables in this afterwards.

49:55I've seen patients that they woke up after the surgery and they're like, that pain that I was talking about, it's gone. And they won't feel it again. So it's amazing. We have other type of patients that the surgery is just the beginning, and now we have to work together because it's uphill from here, especially when you have nerve disease or nerve involvement. I think the best way is to expect whatever your surgeon told you to, because whatever they find in your surgery, it's going to determine what the evolution afterwards is going to see. But for example, in patients that have a bowel disease, usually they stay with us like in the hospital for 72 hours.

50:39It depends on how well they are pooping or canalizing gases or how well their labs work afterwards go. And to be again into the normal life, it's one month. And to start working out, it's two to three months. It depends on every patient. We've had patients that are iron women that are amazing and start with the muscle mass that permits them to move them early. And we also try to do the fast protocol. But it depends on every patient. And this is in my case. We don't see the same timeline in every patient. So let me ask, Victoria, what should people expect in terms of symptoms post-op versus what are red flags?

51:22Yeah, we give warning signs and then there's some things to expect. I think some things that people don't necessarily realize they may feel is like right shoulder pain from the CO2 insufflation that we use. Literally the worst. Yeah, it can be a little scary. You can sometimes feel it in your neck. I think all of us in here try to get all that CO2 out, but every now and then there's a pocket of trapped CO2 and it irritates the diaphragm and causes a referred pain to the shoulder, usually on the right side. I think bloating after surgery is really a common complaint. People often feel extremely bloated.

51:56And it's just the inflammation from the healing process. It can take like four weeks, sometimes six weeks for that to fully get better. Other things is like, you know, you don't have a normal appetite. It's normal not to have a full appetite. It takes time to rebuild your appetite. Fatigue is a huge part of the recovery. You want to give yourself time to rest. You may walk around your apartment or your home, and then you might take a two-hour nap. And then you might walk again for like 10 minutes, and then you might take another two-hour nap. Fatigue is your body is diverting its energy to your healing.

52:27Red flags, fevers. That's not normal. We want to know about fevers, especially if there's any bowel surgery. Pain that's not getting better with your pain medications. Like if you were feeling a lot better and then suddenly you're feeling really, really bad, that's not good. I mean, sometimes people feel worse after a day where they were a little more active, but the general trajectory should be improvement. Although people with central sensitization sometimes don't have that trajectory. So you have to, as a physician, evaluate the patient individually as well. Cindy, do we know what the rate of recurrence when the surgery is done by an expert versus a general OB-GYN?

53:07Yeah, what you wind up with is a 19 % chance of persistence or recurrence over a seven-year follow-up. Nuer's and all four of those studies had remarkably similar numbers as far as the surgically documented cure rate and then the recurrence or persistence. Studies show a 10 % rate of reoperation for pain for reasons suspected to be endometriosis or even adenomyosis. And so our numbers are somewhere in that probably 10 % or less number. I think there's like a larger conversation with this question. I think there's a lot of residual disease that's documented as recurrent disease in the literature.

53:58So like, I think there's a lot of misinformation out there in the literature with regards to recurrence of endometriosis, because if you ask the paper that the ACOG practice bulletin on endometriosis, like basis its recommendations on had like a super high recurrence rate of reoperation in that, in their cohort, it was a study out of the Cleveland clinic. And I think it was something like a 60 % like reoperation. It makes surgery look terrible. Like it looks so bad. But I feel like that's, again, it's like when you look at the collated data versus like the specific centers, and I know that introduces a certain amount of bias, but at least when you look at the specific centers, you know exactly what they're doing in their surgery and that their goal is removal of all visible disease and that they're treating overlapping conditions.

54:44because that's very important because recurrent pain from vestibulodynia or hypertonic pelvic four dysfunction is not recurrent endometriosis pain. Saying as well is that sometimes the first surgery didn't actually get everything. This isn't recurrence. This is first surgery. It's bad surgery, persistent disease, and an incomplete diagnosis of overlapping conditions, including adenomyosis. So I think adenomyosis is often undiagnosed and unrecognized as the source of the persistent pain after surgery. The problem with the vast majority of studies looking at surgery for endometriosis is they don't control for the skill of the surgeon.

55:25And here's the thing. Not all endometriosis surgeries are created equal and pretending they are is harming women. So Cindy, I want to ask you, why are general OB-GYNs still managing a disease that they are not trained to treat. I think it partly comes down to money and partly comes down to ego. There's an awful lot of doctors who really try to do the right thing. They want to help their patients. They feel bad for them. And so they take them to the OR and they do what they were taught to do, which is do ablation. I would say over the last 10 years or so, there's a lot more gynecologists who say they do excision, but that doesn't necessarily mean that they do excision well.

56:12Because as Anna was saying, when a patient has deeply infiltrating nodules on the uterus sacral ligaments, on the rectum, in the rectovaginal septum, there's a lot of really important structures that they have to dissect out, that we have to dissect out. And this training, to get really good, it takes a long time. Endosurgery is not something you can learn in a year or two. But the problem is, is docs that either they do a MIGS fellowship and they don't have that endo training, or they're generalists and they think that they, because they watched a few videos, they can do excision. And they don't get deep enough.

56:54And I think that incomplete excision is a horrible thing for patients, a lot of patients to go through because they wake up in way more pain than they were before they started. And that doesn't even address endometriomas. I have seen so many patients with endometriomas have surgery by generalists or MIGS docs that don't have endo training. They open up the endometrioma and just let it drain, or they incompletely excise the endometrioma. Well, it just reforms and predisposes women to ectopic pregnancies. So I've seen very unfortunate outcomes when women have lost both of their fallopian tubes because of bad surgery by somebody who should not have been doing endometrioma surgery.

57:50If general OB-GYNs are not qualified to do these surgeries, why is there no protection for endometriosis patients from them doing harm? Well, it goes back to standard of care. And like I think we talked about in the first episode, standard of care is it's okay for a generalist to do a surgery where they do either nothing for a diagnostic laparoscopy or an ablation or an ablation with partial excision, that is not a violation of the standard of care. The only way that we are going to change these things from happening is to change the standard of care. And how do we change the standard of care?

58:33Because harm is being done. And the Hippocratic Oath is first due to harm. And yet, OB-GYNs sometimes knowingly are subjecting their patients to harm. I want to believe the majority of OB-GYNs are just trying to help, just trying to get patients out of pain. But how do we actually change the standard of care so that there is improvement for endometriosis patients? Well, I think we need better data. We have to prove conclusively with data that our outcomes are significantly better than those of general OB-GYNs who do ablation. A patient who's listening to this right now, if they opt to have surgery with someone who is collecting this data, they will effectively be contributing to the body of evidence that can change the standard of care.

59:20Yes, that's the goal. I mean, we don't have this database yet. And it's really hard to do this sort of research without the backing of a university because they have the statisticians, they have the ability to create the IRB. I'm just going to throw a plug out. Anyone who is interested to being a private donor to do research like this can also be helpful. And you can easily have a relationship or establish a relationship as like adjunct faculty within your university and partner with them. So I feel like private funding at this time, at this point in time in the United States, is actually probably the way to go to get this going.

1:00:06Melinda Gates just donated a lot of money to endometriosis research. Where is that actually going? Because I saw the headlines, I saw the yay, and I'm like, but we know bad research has been done. We know research has been done that prioritizes how men feel about women with endometriosis over how we actually treat women with endometriosis. So do we actually know at this point where that money is going towards? We have no idea. We have no idea. There's no way to track that. Yeah. Melinda, if you want to let us know, I would love to know that. But I'm curious, what has been done to make endometriosis its own specialty?

1:00:42Have there been any efforts made? Yeah. So we all have been part of this group within, it's a subgroup within AGL. And AGL used to be called the American Academy of Gynecologic Laparoscopy. Basically, it's the national organization or international organization that promotes minimally invasive GYN surgery. So you would think that that group would be the one that would want to promote even a designation, but to have a designation of you are a center of excellence, you have shown the ability to do excellent surgery. Therefore, we will give you the designation of a center of excellence for endometriosis excision surgery.

1:01:29And I tried to do that, and I'm sure other people have tried to do that, and it has been shot down time and time and time again. And for what reason? Probably multiple reasons, though. Yeah. We also have made some progress, at least now. Within our board certification, there is a subset for people who have trained in minimally invasive surgery, so at least that's a step beyond your generalist OB-GYN. I think that it's very threatening for oncologists, urogynecologists, general minimally invasive surgeons to think that there are surgeons who are going beyond and pushing the envelope of what's possible with minimally invasive surgery.

1:02:22because what we do is often harder than oncology surgery. And oncology surgery is reimbursed more appropriately than what we do. And so I think we just have to keep plugging along and demonstrating that these surgeries are tougher. When I do my operative reports, I document the time this whole surgery took, how long it took me to excise a rectal nodule, how long it took me to excise from the diaphragm, how long it took me to excise off the ureter, and so forth, to begin this cataloging, this information cycle of this is harder than going in, taking a look, and burning a few spots and doing a biopsy.

1:03:08And so insurance companies are seeing that. And the more that we do, those of us who are involved in this, really make bomb-proof proof dictations, demonstrate the degree that is necessary surgically to affect this disease, then we will begin to see change. They don't realize that they aren't trained. They think they're doing what's right. They think they're helping the patient and they're so psyched. They went in and it took 20 minutes. They biopsied a spot, burned a few spots and send the patient home on Orlissa and they are psyched. They've done their job. It's a turf war, more or less. It's a turf war.

1:03:48Yeah. You need to be able to know that you don't know. And sometimes that's hard. And you need to be able also to hear your patients. That was one of the things that got me into endometriosis surgery. I think that we all share about our stories, but I think it's like frustrating when you treat a patient the way they show you to in residency or in fellowship, and you do the things that they told you that are going to help them, and you don't get the results that are supposed to. It's like, I did what I'm supposed to do, and I did what the guidelines tell me to do, and still you're not better. What is happening here?

1:04:28I think we're failing them. So that's why we're struggling into having a fellowship here also in Mexico by the Autonomous University in Mexico, UNAM, so that we can train new doctors. And also, one of my friends made an excellent point by trying to go to the medical schools. Like, if you go to any person, like, even in not such high socioeconomical grade, if you tell them about where is diabetes, they'll tell you, oh, that's high glucose in your blood or high sugar in your blood. But you tell them about where is endometriosis, it's like they don't even know. It's not so highly diffused. And it affects one every 10 women.

1:05:10So if you go to medical school and tell them, what do you need to use to treat diabetes? Oh, insulin or better diet or something. And what do you need to treat endometriosis? They're not going to know. If we start them young, maybe can be another way to change this. Vicky's point, it's a turf war. The collateral is the patients in this war. And that's what I think is so troublesome is that there can be so much ego around who has the right to cut this patient in the way that they think is best. And in some aspects, you know, I just want people to understand because I think the first thing people listening are going to be like, because they're a bad doctor, because they had bad training, because they went through a training that indoctrinated that in them, that they had to be the best, that they had to fight for this.

1:06:00And then as we talked about in previous episodes, we've got hospital administrators that are making people fight it out. Then we've got insurance companies. And I'm curious because you talked about reimbursement. Are women's gynecological procedures reimbursed at a lower rate compared to those that are comparable in men? Yes, totally. And not just surgical rates, but obstetric rates. Like you can care for someone for nine months and deliver their baby and you make less than a 20-minute orthopedic procedure on the knee. And why do you think that is? Misogyny. You can say misogyny. She's whispering it.

1:06:39You can say it. But GYN pays less than OB. And so there's no incentive for generalists to learn how to do better surgery because they get paid to deliver babies. They'll make 400 grand delivering babies. And if they cut out the OB and all they do is GYN, they'll cut their salary in half. And it's because the reimbursement for GYN surgery is terrible. for what we do. So I was in network within my own practice for about five years before I went out of network because I wanted to believe that I could figure out how to make it work so that it wasn't just that rich women could get decent surgery. I did a five-hour case once on a woman with bilateral endometriomas and a rectal nodule that I could excise with a discoid excision.

1:07:36I I got paid$750. And that's when I said, I can't do this anymore. I have to go out of network. And just to explain, I just want to explain that further. $750 is not what Cindy took home as her paycheck. It's what covered the overhead to run her practice in her office. She's losing money by doing the surgery. And I want to say, so what I'm hearing is that General Lube Gynes still going at it, thinking they're experts in endometriosis. One, we've got a training issue. Two, we've got a, they don't know better. They actually think that they're doing a good job. Three, we've got coding issues that sound like we've got insurance incentivizing them to do bad care, basically, right?

1:08:18This is bad care. They're incentivized. Monetarily, they're incentivized to half-ass a procedure, maybe even do a hysterectomy over actually preserving her ovaries and taking out that endometrioma correctly. They'll actually get paid somewhere around$2 ,000. Most private insurance will pay two grand for a hysterectomy. When you say it's so impossible to find a good surgeon, to find someone who actually knows endometriosis, you are validated in this because there's an entire system that goes from the insurance company to medical school education. And as you talked about in the first episode, pharmaceutical influence, that is making it so that profit happens at the top and it hinders the physicians from actually being able to provide the care patients need.

1:09:03Or even wanting to. It devalues. It devalues their care. It makes it not sexy to do this job. No, it's not financially viable to do this. Right. Yeah. Well, this has been a fantastic conversation. We are moving into our final episode, which is going to be all about hormones. We're going to come back more to progesterone talk, but thank you all for sharing your expertise and for helping women everywhere. It's our pleasure. And thank you. Yeah, thanks for having us.

1:10:00forwarded to voicemail.