Endometriosis Symptoms vs Normal Period Pain with Dr. Patrick Yeung

27:56Are they focused on trying to remove the disease and optimize the anatomy? Or are they relying on this post-operative suppression to suppress whatever they don't get, which really makes them say they don't have to get it all. It's always a red flag to me when a patient says, oh, my doctor said they got all they could, but by the way, they really should be on Lupron for six months after surgery. That tells me they know they didn't get it all and they're trying to use Lupron or some kind of post-operative suppression to suppress what they didn't get. Or they need to go to IVF. They're not trying to really optimize the patient's own anatomy.

28:37You want somebody who is really focused on doing that. Okay. Tell us how those cells respond differently to hormones and how they act differently because they are not following the rules of the endometrial lining. They're activated by hormonal stimulation so that estrogen can activate it or make it more symptomatic. And so all of the kind of status quo approach is to try to block estrogen stimulation, either by medications like birth control pills, which are all progestin-based or progestin-dominant, progestins being synthetic progesterone, which is the counter hormone to estrogen, or to shut down the entire axis altogether and put the patient in a state of chemical menopause.

29:24But again, we're understanding more now that endometriosis is more than just a hormonally activated disease, there's a whole modulatory or neuroinflammatory component of it, either in its cause or effect that also has to be addressed in addition to or after the surgery. And we see that there can be prostaglandin production, there can become histamine imbalances. And so there's a lot more going on. You mentioned progestin. Everyone, I will link to show notes. We've done episodes on why progesterone and progestin are not the same, but what is the role of progesterone, bioidentical, like oral micronized progesterone or using it vaginally with endometriosis?

30:07Right. So you can take progesterone to try to block estrogen or reduce estrogen dominance. You can take it throughout the cycle. That's what a birth control pill does basically, but you can also take it time to the cycle. You can take it when your body would naturally produce it in the second half of the cycle. And you can use bioidentical progesterone, which is the same compound that your body makes, and just support the cycle at the time that the body would normally make it. And sometimes that helps symptoms. Absolutely. So we want to keep going on our journey of, you know, someone who may be going for excision.

30:48So we first do the mapping, do the surgical consult. I assume that's so that you can get all the right team members in place and give the true informed consent that patients deserve. Now, when it comes to surgery, what are you recommending women do to prep themselves before going into surgery? That's a great question. The healthier the patient can be going into surgery, the better the outcome after surgery. Mm-hmm. So getting in the best possible shape or wellness you can be, getting your supplements all kind of tuned up and being active and all of that's going to help your recovery from surgery.

31:29It was interesting. So for fertility, treating the endometriosis is kind of the surgical part of it. And then there's a whole non-surgical optimization that can happen for fertility for best chances that can happen after surgery. but there's a doctor who's been sending a lot of patients to me from DC, Dr. Margaret Duane. And she tells me, it's kind of unbelievable, but all the patients she sent to me in the past year, which is maybe 10 or so patients, have gotten pregnant within six months of surgery. This is kind of unheard of. And I think a lot of that might be happening because she's doing a lot of the non-surgical optimization before surgery.

32:10So I think that's helping the outcome after surgery in terms of wellness, but also fertility. So yeah, the more that you can do to prep for surgery, the better. 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.

32:54That's d-r-b-r-i-g-h-t-e-n.com slash e-n-d-o-g-l-o-b-a-l. Are there particular supplements you recommend for women with endometriosis, especially in the consideration of they're going to go the excision route? There's a list. You know, vitamin D is important to have optimized. Omega-3s can be helpful in endometriosis, although you don't want to be on omega-3s at the time of surgery. For the blood thinning effect. For the blood thinning. That has to be stopped by two weeks of surgery. Are there particular screening labs you think are important for patients to have before they're going into excision surgery?

33:35We want to know their blood level before surgery. So a CBC. A CBC or blood level hemoglobin. I often do recommend if we're going to potentially be operating on the ovary and removing an endometrioma or doing a cystectomy, just to get a baseline measure of their ovarian reserve before potentially operating on the ovary. So an AMH. It could be an AMH or a cycle day three FSH. Okay. The anti-mullerian hormone, yes. Do you also do follicle count? You could, you know, but the blood test is probably just as good. The antral follicle count is kind of measuring what the blood test is measuring. There are two ways to get to the same idea.

34:15So I'm just curious, AMH, FSH, is there a level where you're like, no, we shouldn't do excision? Maybe if you're going to go IVF, you should do a retrieval first or, you know, how that's actually helping you in terms of guiding the patient. So if they've got a high AMH, things look great, or low AMH, what is like the route? So that's a great question to highlight the idea that AMH, the anti-Mullerian hormone, is really the modern day blood test for ovarian reserve, which is really a predictor for IVF success rate. It's really not a very good predictor for natural fertility. What we did before AMH is the cycle day three FSH, which is a much better predictor for natural fertility.

34:59So there are patients who could have a low or poor AMH and thereby not very good outcomes or predicted success with IVF, but have a normal or good cycle day three FSH. They might actually have a better chance at natural fertility than IVF success. So that's interesting. Yeah. What FSH are you looking for? We want it under 10 or single digits would be ideal. Mm-hmm. And so for everyone listening, when you get into double digits like 25 or more, that's when we're like, oh, this is looking like perimenopause or depending on your age, primary, ovarian insufficiency. So if somebody has an optimal FSH, how does that influence the removal of an endometrioma?

35:42Well, so that's been looked at. What is the best way to treat a chocolate cyst or endometrioma? Do you just drain it or do you cut out the entire cyst wall? So in multiple well-designed trials, randomized controlled trials, removing the entire cyst wall is better for the outcomes that matter to the patient, including reducing pain, reducing recurrence of that cyst, and natural fertility. It has been shown that cutting out the cyst wall can reduce AMH, which again is worse for IVF success. So there is a debate, an ongoing modern day debate of it's thought that if you have a small endometrioma and the cutoff is usually three centimeters or less and the plan to get pregnant is to do IVF, then maybe it's better to just avoid surgery altogether, go straight to IVF and that the small endometrioma would not affect the stimulation protocols.

36:34But if the goal is to feel better or for natural fertility, then it's been clearly shown that cutting out the entire cyst wall is better for feeling better and natural fertility. Isn't there evidence that an endometrioma, however, because of the inflammation it's creating can actually affect the quality of the eggs that are being retrieved during a fertility cycle? Absolutely. So patients have been sent to me to have their endometriosis or endometriomas removed for the sake of IVF. Because yes, we know that IVF outcomes are worse in the presence of endometriosis. And again, a large endometrioma often prohibits IVF.

37:17So we talked about the CBC or the hemoglobin, getting your vitamin D levels up, FSH, AMH, Any other labs patients should consider having done before going for excision surgery? Not really. Those are the main labs to be done before surgery. Okay. And then are you checking things like clotting disorders and like the usual run the gamut of making sure someone is a good candidate for surgery? We're not doing that if it doesn't come up in the history screening of somebody who has issues with bleeding. Okay. If somebody's had recurrent miscarriage, then, and the usual definition for recurrent pregnancy loss or recurrent miscarriage is more than three losses.

37:59But you could absolutely, you know, start a workup earlier, two or even one. Or if somebody's, you know, using a method of fertility awareness and their charting is not normal, you can measure all those hormones even before the first miscarriage to try to get ahead of it and support the progesterone timed properly to the cycle even before the first miscarriage. But those hormone levels can all be looked at and addressed as well. Okay, so somebody is going into surgery. What should they know about going into excision surgery? I would say the surgery for endometriosis, the goal I call it is anatomy optimization.

38:42So that actually has two parts. Optimal excision I define as cutting out whatever is suspicious for endo in whatever form and wherever found. But even if you can do that, that is still only half the battle. The other half is preventing adhesions and even fewer do that well. And that was very important in our story. So again, my wife had painful periods her whole life, thought it was normal. We tried to get pregnant from day one. After about a year of trying, she said, maybe I have endometriosis. I said, no way. She had bad endo. She had giant bilateral endometriomas. She had one surgery to remove the endometriosis and then multiple surgeries for adhesions.

39:21She's now pain-free. We've had recurring fertility. We're trying to pay that forward. That is the bottom line. But preventing adhesions was really important for our story and for her. So we are very deliberate about preventing adhesions where things can stick after surgery. And that is often overlooked. I really believe both are important. You should remove all the endometriosis, do whatever it takes, and then prevent adhesions, do whatever it takes, and one should not compromise the other. I would say that is how we're getting such good results. And the hope of one-and-done surgery is by combining the best of both optimal excision and adhesion prevention.

40:00I love that you told your wife, no way, and then she was like, bet. And there it was. But I want to get into, you had a study, you showed endo can be one and done. If done right, you can do this surgery and it can be a one and done procedure. How are you achieving that when other people are not? Okay, so I just wanted to kind of go off or reemphasize about your point about women know their bodies. That's exactly what I say. I continue to learn from my wife. Good man, going to stay married a long time. And so this idea of one and done surgery is kind of triggering for people and it's controversial and no one's perfect.

40:40There is no cure. I never guarantee that they cannot ever have to need to have surgery again. But I would say based upon our study that one and done surgery is possible. So this was a 10-year study showing a very low rate of repeat surgery. It was under 5 % and the majority of patients did not take any long-term suppression post-op. They were either trying to get pregnant or didn't like the side effects of the suppression. So the majority of patients took no long-term suppression post-op. We told them if we felt like we achieved our goal of removing at all, there was no known or suspected endo left behind.

41:14They didn't have to take the long-term suppression post-op. And again, most didn't. And still such a low rate of repeat surgery. So we're saying one and done surgery is possible in many, if not most patients and without the need for long-term suppression. to at least one and done surgery should be the goal of what centers of endometriosis are striving for. Even surgeons sometimes who treat endo feel like they don't have to remove it all because again, whatever they don't get, they're going to put the recommend what everybody recommends, which is to put the patient on post-operative suppression to suppress whatever they don't get.

41:51They don't have to get it all. Or again, for fertility, they're going to bypass the pelvis and refer to IVF. They don't have to optimize the patient's own reproductive anatomy. or just come back and do it again in two years, which is the expectation versus trying to optimize the anatomy, remove all the disease to avoid the need for long-term suppression post-op, basically because the disease has all been removed to lead to natural and recurring fertility and for the hope of one and done surgery. That is a very different surgical mindset on behalf of the surgeon, I would say. And I think we've shown a very different surgical result for the patient.

42:28And how are you preventing adhesions? We're doing things to help prevent adhesions, which can involve different substances or fluids to float things apart, products made from amniotic membranes, suspending ovaries. Now we're using PRP or platelet-rich plasma. PRP can be used to help ovaries work better and you can inject them into the ovary. But we're actually now using it where after we've cut out all the endo and you have these kind of deep peritonealized areas or these areas where you had cut out the endo, you can coat all of that area, all the pelvis with PRP. Are a lot of people doing that?

43:07Or is that something that like... That's relatively new. Yeah. And to be fair, so my wife had Gore-Tex twice. Can you explain that for people who don't know what that is? Yeah. So Gore-Tex is what they make jackets out of. Nothing sticks to it. But after you cut out a cyst, you can wrap the ovary. Well, we always reconstruct the ovary. So that's another thing that we do. Many people were taught as residents that you don't have to reconstruct the ovary. You can leave it open and it will just heal. Well, you have a raw open ovary, it's going to be more prone to sticking. So we suture it closed so it's smooth.

43:43We can suspend ovaries temporarily with suture that absorbs. So it's lifted off the sidewall and can't stick to the sidewall. But then you can wrap it in Gore-Tex like a piggy in a blanket. And we published a landmark study showing that Gore-Tex doubled the pregnancy rate in patients with infertility and assist. Nobody would think that putting like the lining of a jacket like something that like probably has PFAS in the pelvis would actually increase fertility. Yeah, actually, it's really interesting because whenever we study an adhesion prevention strategy, we look at second look laparoscopy scores.

44:20which is you do another surgery and then count adhesion scores. But really like AMH, that is a secondary outcome. That's not the primary outcome that matters to the patient. What matters to the patient is pregnancy or maybe feeling better or quality of life or maybe even rate of repeat surgery. So this was the first study that was published looking at any adhesion prevention strategy and pregnancy, which is actually easier to ask about. And it doubled the pregnancy rate. But the downside is it requires another surgery to remove it. So I usually only talk about it or offer it in patients who have both infertility and a cyst.

44:56But it did work for my wife. But now it turns out that in the last surgery, she had no adhesions before. In the surgery before that, they removed Gore-Tex, but then coated everything in PRP. So that got me back onto looking at PRP and interested in it. Mm-hmm. Again, they're calling it liquid gold. Can, do you feel like what you've explained here, they could go through and ask their doctor, like, how do you prevent adhesions and see, like, you know, are they using Gore-Tex? Are they using TRP? Are they using, I believe you said the amniotic membranes as well is another route to go? Patients should be asking their doctor, you know, what is your focus?

45:36What is your volume? What is your goal of surgery? How do you prevent adhesions? All of those, I think, are very reasonable questions that the patient can have for the surgeon that the surgeon should be able to provide answers for. If they don't have a plan to prevent adhesions, options, strategies, that's important to know. You said that you do not do suppression post-op. That is going to be news to a lot of people. So why are you not doing suppression and what are you doing instead? If we have achieved our goal of optimal excision, cutting out whatever is suspicious for endo in whatever form and wherever found, they don't need to be on suppression for the sake of preventing endo from growing or coming back because basically there's no visible disease left behind.

46:26I'm very specific about saying that they don't need to be on suppression for the sake of suppressing the disease. There's this common belief that, you know, you need to be on suppression up until surgery to keep the endo from growing or after surgery from coming back. Neither have been proven. We do stage four endo every Thursday, at least every, you know, week in, week out. And most of those patients have been on years of suppression, years of no periods. And here we are with advanced disease affecting the bowel, requiring a bowel resection. So it's not been proven to prevent progression. And then post-op, again, you might feel better longer, but it's not been proven to actually prevent the rate of recurrence of the actual disease.

47:10So we would say the best way to prevent it from growing or coming back is to remove it. You know, something that Dr. Ron Cabrera, who I had on the podcast said, is that he feels that when women are put on birth control and not investigated for endo, and that's allowed to go, and they're told, just wait until you want to have a baby or wait until things are bad enough, that increased the risk that they will have progressed deep infiltrating endometriosis. Do you agree with that? 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.

47:58Endoglobal 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. Yes, we would say that the best prevention is early diagnosis and removal. Again, you can't be doing surgery on everybody. No one's saying that. But we went through our list of red flags.

48:49You know, if the story is classic for endo and, you know, especially if suppression has failed, the chance of endometriosis goes up. And the earlier you can remove it, then the better for the patient. And in fact, again, with our 10-year study showing a very low rate of repeat surgery, it's not proven. But if you can remove it early and have a low rate of repeat surgery in 10 years, maybe we've done something early to help preserve later fertility. Do you have an age cutoff? Like as in terms of like you have a 15-year-old who has extreme endometriosis pain, is that someone you would do surgery on or would you wait?

49:34Is there any reasoning behind that? So people would say teenagers cannot have endo. That is ridiculous. What? Who says this? lies. I'm not, it's me. Hi, I'm her. Exactly. So teenagers can absolutely have endometriosis. And again, you know, in the right setting, a surgery would be reasonable to look for and treat endometriosis, even in a teenager. Again, teenagers are at the prime of their life. They, I would think, or would believe that are the first to want to live their best life. If they're saying they can't function, they can't go to school, they can't attend the social activities or sports that they want to do, something is wrong.

50:17That is not normal. That should be looked at sooner than later. So if we've done excision surgery, what else should be coming next? I like to say, you know, we remove endometriosis or treat endometriosis as a disease for pain or for fertility or both. But there can be other sources of pain that have to be addressed in addition to or after surgery for endo. And there can be other things that have to be optimized for fertility after surgery. So absolutely for a kind of a comprehensive approach, there can be things that have to be done on the pain side and the fertility side in addition to or after the surgery.

50:54We're focused on just optimizing the anatomy and the surgery, but we collaborate for the non-surgical pain and the non-surgical fertility. And what does that collaboration look like? Well, pelvic pain centers or there can be other sources of pain. There's the evil twin to endometriosis, which is interstitial cystitis, which the classic story is it feels like a bladder infection, but it's not. Two thirds of patients with endo have IC. The treatments are not antibiotics. It's things to help reduce inflammation. The evil triplet is the muscles or physical therapy. But oftentimes the physical therapy is not optimal until the underlying pain generator, we call it, has been dealt with like endo or IC.

51:36But these terms, evil twins, evil triplets, just convey the idea that there may be other things that have to be addressed in addition to or after the surgery for endo. Same thing on the fertility side, there can be the need for optimizing the hormones, the targeted hormonal evaluation and support, we call it. If you're going to measure and support the hormones, it has to be properly timed to the cycle because the hormone levels change throughout the cycle. So using a method of fertility awareness to know where you are in the cycle to properly measure and then support the hormones properly timed is very important.

52:11Optimizing cervical mucus, optimizing ovulation, all the functional medicine piece there, all those things can be important and helpful in best fertility chances. And again, they are related as well. I really believe that wellness and fertility go hand in hand. The better the patient feels, the better her chances of fertility. Wellness and fertility absolutely go hand in hand, whether it be pain with endo or mood and PMS. Well, okay, we know that endometriosis, even as surface implants, is associated with pain and infertility. But how is it doing that when the cells are not deep enough to be in the nerves or without distorting tubes and ovaries is a great question.

52:57We don't fully understand that. We just know that by treating even surface endo, quality of life, sexual functioning improves, and fertility chances go up. A patient with endometriosis will have the quarter of the rate of the chance to get pregnant per month. But by treating endometriosis, it doubles that baseline rate, at least. So we know that treating endometriosis improves even surface endometriosis, helps pain, quality of life, sexual functioning, and fertility. The why is maybe less well understood. You know, modern day theories or theories include reducing, what, it's causing a toxic environment in the pelvis, or there's this inflammatory component in the pelvis that is causing infertility or affecting somehow the sperm and the egg, increased central sensitization to pain from inflammatory factors, things like that.

53:57So there are theories about how, what the link is to, of the implants to pain and fertility, but we do know that surgery does improve both. And it's been interesting. I think, you know, we can learn so much from patients and I've seen women who are like, I did a histamine protocol, H1 and H2 blockers, and I was able to get pregnant. Or women who have endometriosis using GLP-1s, not even women who are overweight. And I know there's an argument of like, well, they probably have visceral adiposity. Maybe we didn't do a DEXA scan on this person, but there's endometriosis patients being like, I'm going to use 0.25 milligrams of Ozempic and my inflammation is dropping.

54:41My CRP goes down. I'm feeling better. I'm functioning better. And I think it's, this is, I bring all this up not to tell people run and take antihistamines or run and take GLP-1s, but I think it lends insights to exactly what you're saying when I hear so many endometriosis specialists saying is that there's more to it. There's more to the immune system going on. This is not just a infertility condition. This is not just a pain condition. This is a very complex, as you said, neuroinflammatory condition, and we have to be going deeper. Where do you think the future of endometriosis is headed in terms of treatment?

55:18We have the really excited flooding the system of PRP and preventing adhesions. That's exciting. Are there other things on the horizon? That's a great question. You know, I really have said for a long time that I think that cancer research and treatment is like 30 years ahead of endometriosis research and treatment, or at least endometriosis is 30 years behind cancer research and treatment. So in the world of cancer, you have networks of excellence of cancer centers focused on treating cancer that collaborate, that do research. And the treatment plan is now tailored to the patient. Do you think endometriosis should be classified as a cancer?

55:58It's been called a benign cancer. No one really likes that, neither in the endo world or the cancer world. Women have been saying that when they can't find an endo excision specialist in their area, they go to a cancer surgeon instead. Why do you think that is? Well, it can be that level of surgery. It can be that complexity of surgery. And again, when it's advanced and it's affecting other vital structures, bowel, bladder, vessels, ureter, it can be that level of surgery and complexity of surgery. So oftentimes it is the cancer doctors who deal with advanced endo that requires a team. But the problem with cancer doctors is they're not very good at preserving fertility or even preventing adhesions.

56:43So it really should be its own specialty. where the surgery is focused on removing the disease, but also preventing adhesions to preserve or optimize or restore fertility. That's a very different surgical focus. You say it should be its own specialty. Do you think that it's serving patients to allow the general OB-GYN to do excision surgeries? I decided early on to be good at this. You kind of have to focus on it. You know, it has been said that you should not follow your heart or follow your passion, that you should do what you're good at. And even the bowel surgeon that I work with, that I've worked with now for 10 years, I think over the years, again, we're doing stage four bowel endo cases week in, week out.

57:30Bowel endo. What is that for people who don't know? That's endometriosis. So endometriosis, again, is these cells that are implants on the wallpaper of the pelvis, but it can sometimes or often even go deeper than just the surface and involve other structures. So it can involve the bladder, it can involve the bowel, you can have a nodule of it where it's got some depth to it and it's kind of invaded into the bowel or the bladder or the ureter or whatever. You can get a ball of it in the ovary, that's an endometrioma, but you can technically have endometriomas or nodules in other places also. Yeah, I think it's really important for people to hear that because so often, you know, I've seen a lot of doctors who don't know endometriosis lately on podcasts and clips coming out and them saying things like, oh, it's just going to be found on the uterus.

58:27That's where you find endometriosis or there's no reason to have imaging. And for people to understand that it really can affect any organ in the body. It's rare to leave the pelvis, but it's not unheard of to be leaving the pelvis. I think it's really important for people to understand that there are other organs involved, which is why you're bringing in specialists for that when necessary. And I think that is one of the things I tell people all the time, get imaging because the best guess at who you need in the room is better than opening you up and realizing we got the wrong team in place. We don't have the right people in the room.

59:07And now you got to come back. We've got to do this again. Or sometimes they're like, we'll take a little bit out and then you're going to come back in six months and do the surgery again. And I think that is part of what you're doing to get to that one and done as often as possible with patients. Yeah. So when these consensus guidelines came out for the mapping ultrasound, the people that promote that, that advocate that say, you should be able to plan for the proper surgery. You should really never be surprised or it should be rare. With the proper imaging, you can know what to expect and plan for the right surgery.

59:46But to answer your question about, you know, what is the surgical focus or what is the point of surgery? Even just to put it simply as oftentimes the transvaginal ultrasound is looking for a cyst and they might see a persistent cyst that is suspicious for an endometrioma. And then they go in and do surgery, which is really focused on just dealing with the endometrioma. But two things happen with an endometrioma. One, they almost for sure have surface disease. So if you just deal with the endometrioma, you've not done anything to the surface disease that needs to be treated because again stage one and two or surface endo can affect both pain and fertility or they'll release the endometrioma or the ovary from the sidewall and deal with the cyst but not deal with the sidewall disease that's often over the ureter that made it stick in the first place and again is also endometriosis that has to be treated on the other side if you have the form of advanced disease that's now in the ovary as an endometrioma, that puts you at risk for the other form of advanced disease, which is maybe a nodule in the bowel.

1:00:52And that's where the mapping ultrasound comes in to look for that. So you really need to be comprehensive to look for and treat all the different forms of endo for best results. When did imaging become available to patients and for providers to be able to really understand the extent of endometriosis because I will hear from patients who will say things like, well, 20 years ago, nobody told me I could have an ultrasound or have an MRI for this, but this is not something... So I don't want anyone to feel bad or feel like, whoa, I should have known better. So when did imaging actually become at the forefront in endometriosis care?

1:01:32Yeah, that's a great point. It's been years in the making. You know, we have really only been incorporating these guidelines, these standards on mapping ultrasound in the past few years ourselves. MRI and ultrasound can be as good as each other. But again, it is really a specialty in its own focus. And you need somebody who is following consensus guidelines or standards to know how to do the MRI. There are certain protocols or the ultrasound. There's a protocol and then how to read it. So it does take specialized training and experience to do imaging well and properly. And those guidelines and those standards have only been in the last few years really become standardized and become more the norm, especially among centers of endo.

1:02:25But we're at a good time now that this does exist. When you say certain protocols, are you doing a gel MRI? So people who do MRIs do involve often rectal gel. Yes. Now, we've chosen to go the route of the in-house mapping ultrasound, which we can do ourselves. We can see the images ourselves. And that involves a rectal prep. So it's an enema an hour before the ultrasound to empty the very end of the rectum so that we can see that bowel better. Okay. So that's how you're doing the ultrasound in-house. Most surgeons that I would ever recommend people to, they're either in-house doing the ultrasound or they're doing in-house ultrasound with a gel MRI and they have their radiologist that they work with.

1:03:17But it's very much tightly regulated in like, this is how the protocol works. This is how we do things. It's not a, you just pop into your OB-GYN, they do a quick peek and then you're on your way. And I think that's important for patients to hear. You know, I've just had somebody send me a message the other day and they were devastated because they went in for their surgical consult and they were told, well, you have advanced adenomyosis. Adenomyosis, I think in the US, I talk to people all over the world. There's no consensus on this name. So with that, they were like, my surgeon was like, you are probably looking at a hysterectomy.

1:03:57And they're like, but my OB-GYN said my uterus looked perfect. And I'm like, your OB-GYN should have been able to see that. They should have been able to see if it's that advanced. And I would also just get a second opinion from another surgeon. Like, just get a second opinion and make sure that you know what's going on. In the case of adenomyosis, in terms of imaging, what are you doing to diagnose that? Well, just to make that point, I mean, endometriosis is by definition outside the uterus. And if all you do is remove the uterus, you've done nothing to the endo. And people think that, you know, if based upon an outdated bad theory, the retro administration theory of Samson, that if you remove, which is basically the backflow theory, that when a woman is having her period, she's bleeding backwards through the tubes and those cells implant, that if you remove the uterus, you're somehow removing the source of endo.

1:04:51So you can't have endo without a uterus. That is absolutely 100 % not true, especially if you've left the ovaries, again, which can produce hormones to activate the endo. People have said the number one thing that we can do to help women with endo is get rid of this bad theory. But you can absolutely have endo without a uterus. In fact, we had a case the other day where she had no uterus and no ovaries, but a giant nodule that went into the back of the vagina and the bowel. So she had advanced endometriosis in nodules in both the back of the vagina and the bowel after surgical menopause. And she not only felt better after surgery, but was so validated in being diagnosed with this disease, these nodules, and having it removed.

1:05:40And again, the importance of the exam. I've had several patients where they've had exams by GYNs, multiple GYNs, and over years, we do an exam and there's not only a giant nodule between the uterus and the bowel that you can feel but it's actually sometimes coming into the back of the vagina and you can see it on speculum examination and it's like how was this missed i remember one patient in particular where you know you could see it on speculum examination you could feel it i told her you have advanced endometriosis based upon the exam alone. And she began to cry. And I said, I'm so sorry. And she was crying because she was so validated.

1:06:23She was happy that she had been given a diagnosis of advanced endometriosis. When she's been told for years, this was just all in her head. Gynecologists are supposed to be the vagina experts. How are they missing this? How is endometriosis being missed so often? It's unbelievable. Again, it's so important for the surgical planning to do imaging of some kind and an exam to look for advanced disease to be able to plan for the surgery. So yes, so imaging can be used as well to look at kind of a form of advanced disease in the uterus, which is adenomyosis, which is where the cells which line the uterus have made their way into the muscle of the uterus.

1:07:03It's kind of like endometriosis of the uterus. But MRI and ultrasound can suspect adenomyosis. Now, if it's normal, it doesn't rule out adenomyosis. Clinically, I suspect it when somebody has had, a patient has had optimal excision, had the endo removed, but they still have significant midline symptoms, whether it be pain with periods or heavy bleeding issues or deep pain with intercourse, then maybe we say it's coming from the uterus itself or it's from adenomyosis. That's how I suspect it clinically. It really is a tissue diagnosis like endo really is. You diagnose it not by looking at it, but on tissue after the specimen has been removed, but we can suspect it or look for it on imaging.

1:07:55In cases of infertility, what can be done about adenomyosis? Well, sometimes adenomyosis, it can consolidate as a ball of it or a mass of it in the uterus. And we can remove that mass to debulk the uterus and increase chances for fertility. But if it's just diffuse and it's not consolidated, then there's no great way to treat it for fertility. People have tried to suppress suspected adenomyosis with suppression for fertility. I'm not convinced that it's very helpful to do that. But if a patient does have suspected adenomyosis, I will say it does not rule out feeling better or chances of pregnancy or getting pregnant.

1:08:46So my wife and I, my wife who had stage four endometriosis was told that she would not get pregnant but through IVF because of having advanced disease and likely adenomyosis. And that's not true. We have a baby board in the office of babies that were born after surgery for endometriosis, and many of them had stage four and were told the same thing. They probably do have adenomyosis and yet got pregnant after surgery. So having adenomyosis does not rule out the chance for feeling better or pregnancy. If a woman listening today finds the right team, takes this root cause approach you've been talking about, treats the disease instead of suppressing it, what could her life look like in the next five years?

1:09:26When patients have their disease, their endometriosis diagnosed and treated, they're so validated in getting answers, but they also can get their life back. Their sexual functioning can improve. They have improved chances for fertility that can result in a baby. And their life, their journey can be totally different. I use my wife's phrase often that, you know, I just work here. You know, God is the ultimate divine healer. But to be a part of helping a patient get their life back or get pregnant has eternal value. And I mean, patients, the number one sentiment or emotion that women have after getting their disease removed and feeling better are often saying, you know, I wish I had done that sooner.

1:10:20but to get their life back to do what they need to do to live their best life or to have the gift of pregnancy you know there's there's nothing better to be a part of that and for the patients it's a whole new lease on life i always say my job is i just feel like i work here and my job is to optimize the anatomy or set the table and then offer it up well thank you so much for taking the time to sit down with us today and share your expertise and for everything you're doing for women everywhere. And thank you so much. You're doing great work for women. Your call has been forwarded to voicemail.

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