Pain During Sex, Causes, Symptoms & When to See a Doctor | Dr. Ana Sierra

28:25You can tell How about the vagus nerve? You have a lot of terminal wrenches. So the vagus nerve transmits the information from the cervix. It bypasses the spinal cord and goes directly into the brainstem. There's like the nucleus of the solitary tract where all of the information for the orgasm integrate, among with other things. But especially in patients with spinal cord injury, they can still fear orgasms thanks to vagus nerve. That it's only on the cervix. So yes, it's really important to know all of this. Hold on. We got to talk about this, okay? Because think about, you know, just from an evolutionary perspective, like why would this be the case?

29:05The vagus nerve runs from the brain. It innervates the gut and the heart and the cervix. What was mom and nature doing? Just speculate with me. What was mom and nature doing with that? I don't know. It's like a straight line and you can see all of the connections of the vagus nerve And it has been think about like to be the treatment for pelvic floor muscles or pelvic, not pelvic floor muscles, but for pelvic chronic pelvic pain. Yeah. Yeah. Specifically, it has been like one of the things that maybe we can modulate in order for our patients to feel less pain. It's still on a very early stage in order for us to see that really the vagus nerve stimulation, it's the way to go and is going to cure so many patients about their pain.

29:49But we do know this, that there's a lot of nerves that we don't know and that they are innervating this. Well, and when you think about vagal tone, so vagal tone is associated with more heart rate variability. And that is associated with better health outcomes, more resiliency to stress. We are always trying to get people to stimulate their vagus nerve. So gargling, humming, singing, massaging. There's even like devices that can vibrate with your vagus nerve. And this is a way that can really help you manage your anxiety. It gives a sense that you're safe. And so it makes me wonder, what is mom and nature doing putting a vagus nerve in your cervix?

30:33It's receiving information about safety, which is something that I have framed a lot to patients is that, you know, when we talk about pain with sex, like relationship issues come into this. because one, it can affect your relationship. But two, if your partner isn't making you feel safe, how can you have that level of vulnerability? You know, people think, oh, vulnerability, like you're being intimate. No, someone is physically inside your body. Like when we're talking about vaginal penetration, like that's incredibly vulnerable. I feel like it's one of the things like driving in cars, we just take it for granted because it's just like, that's what people do.

31:07And yet like driving in a car is also like this really dangerous, vulnerable thing. like we're flying down the highway, I don't know, in kilometers in the U.S. Lake, you know, it's like 65 miles an hour in this metal thing. And we don't stand back and think about like, there's so many things in our life where we just kind of take it for granted. And yet our biological self is still scanning for, am I safe or am I not in these environments? Yes, of course. I think, well, about the orgasms, you know that there are a lot of nerves that go into it, right? We have, of course, the pedundal nerve, But there's also a sympathetic and parasympathetic phase of it.

31:43So we do have the hypogastric nerve and the inferior hypogastric plexus, that is like the uterovaginal plexus, and the vagal nerve. So we do have these four groups of nerves that do contribute in order to get this response. First, the spinal cord and then into the brainstem and then into your cerebral cortex. In order to have all these hormones releasing of oxytocin, dopamine, prolactin, noradrenaline. We have all of this mixed up. So I think there's a lot more in orgasms than just the things that sometimes get described. Yeah. Eczema is unpredictable, but you can flare less with Epglyss, a once-monthly treatment for moderate to severe eczema.

32:25After an initial four-month or longer dosing phase, about four in ten people taking Epglyss achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing. EBCLIS, Librikizumab, LBKZ, a 250 milligram per two milliliter injection is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema, also called atopic dermatitis that is not well controlled with prescription therapies used on the skin or topicals or who cannot use topical therapies.

32:54EBCLIS can be used with or without topical corticosteroids. Don't use if you're allergic to EBCLIS. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with EpGliss. Before starting EpGliss, tell your doctor if you have a parasitic infection. Ask your doctor about EpGliss and visit epgliss.lily.com or call 1-800-LILY-RX or 1-800-545-5979. You know, in my book, Is This Normal? When I was advocating for pain management for IUDs, I had found that, you know, the vagus nerve is one of the nerves that innervates the cervix.

33:27But something I didn't think about then, but I'm only thinking now in this conversation is that we talk about how good orgasms are for our health. And there's all these reasons, but I also wonder, is it helping with that vagal tone? And it's very possible. We need research on this. Now I'm like, I got so many questions. I need some studies. It can be relaxing. So definitely, yes. Yeah. I think this is really interesting. Let's talk about the physiology and the nerves and what is going on with an orgasm. Because I think, you know, the research is actually really boring when you ask people, like, what's an orgasm?

34:06And everybody's like, it's a buildup of pressure and a release. And it doesn't matter what gender. They all, like, say the same thing. And I'm like, that's the human experience of it. It sounds really dull. It's much more dull than what it is. Let's talk about what is actually going on physiologically. Because I don't, this is a conversation we've never had on this podcast. Okay. Well, we have the excitatory phase that is mediated by the parasympathetic system. So you're going to have this release first. and then you're going to have a plateau mediated by the sympathetic system. And then all of this integration of systems are going to get into your brainstem and your cerebral cortex, and they're going to have the release of hormones.

34:44I love that. So you have dopamine, you do have prolactin, you do have oxytocin, and you have noradrenaline. So after this, we have the plateau. Well, we have the descent of everything, and that will be mostly. Yes. Yeah, we have the descent of everything. But what's really cool is that that leads into the refractory period, which women have like this much of a refractory period and men have like this much of a refractory period. That's the only thing about women that it's a good thing. Like multiple orgasms are like the only thing good about being a woman. Oh, no, there's so many good things about being a woman.

35:17those are the only one that men cannot like uh sometimes men can go like oh but i won't be i won't like to be the one who's able to charge a baby or carry the baby and if you go to men and you tell them yeah but i can have multiple orgasm they were like ah yes oh it's funny um everybody was reading these books these sarah j mass books um that have faith have you read them yes oh okay like Akatar, I don't know if you had the same thought, but these men, they have an orgasm and then they're ready to go again and go again. And I'm like, what is happening with the Fae that the refractory period is so short in the whole time?

35:58I'm like, I'm like, you know, people are like, oh, you're really into these spicy books. And I'm like, I usually fall asleep during the spicy scenes. I'm really dull like that. But I'm like, but I'm also like, what is happening with the refractory period and like, how is the, like physiologically, like what is different? I read the books and I've never thought about that. So now you give me something to think about. We read them, you know, I think the six books coming out or something, we read them, everybody through that lens. People can let me know in the comments, like, what do you think is physiologically going on that they have shortened their refractory period?

36:31So in terms of nerves, okay, so the gold standard of achieving an orgasm for women is the clitoris. We know this from the research. It's the predominant way that women will orgasm. But there are women who report vaginal orgasms without clitoral stimulation, although it's hard to know, right? Because the clitoris is like this giant, like, it's like half an octopus in there, right? There's only four vagrants just hanging in there. So it's like, well, maybe it is being stimulated. But you mentioned cervical orgasm. Can you talk Talk to us about the different ways that women are able to achieve an orgasm and how that relates to their nerves.

37:10Yes, of course. For example, patients that do went through a hysterectomy that no longer have cervical orgasms, they still have clitoral orgasms. They still have their G-spot and they still have their vaginal walls. So through all of this, they can still achieve an orgasm. But the thing is that they refer to it as different if they have pleasure before. okay sometimes they hate it then they don't like it so they they are even relieved by don't having any cervix anymore so they are happier but sometimes they do miss it yeah it depends on the women if you ever get your cervix smacked really hard that i'm like i always think like men are like oh you women have no idea what it's like to be like kicked in the balls and i'm like okay have a gynecologist hit your cervix with the speculum or close the speculum on your cervix and that is far, far worse, I would contend.

38:03Or maybe have a condition like endometriosis when you have your ovules stuck into the backside of your uterus. That will be like having your testicles stapled to your leg. Yeah. So maybe that'll be it. Yeah. I think people right now are probably, their eyebrows are like in their hairline, like what? So we talked about, so the clitoral orgasm. Yes, everybody accepts that. Cervical orgasm, I think, I actually wrote an article about this like eight years ago for MindBodyGreen and people were like, you're crazy. This is not a thing. I'm like, patients tell me it's a thing. But the G-spot, that one is super controversial.

38:42There are people who are like, absolutely not. There's no such thing as a G-spot. It was just some man trying to name a part after himself. Tell us, because you're the nerve specialist all up in the pelvis, what's the truth there? there's an anatomical spot there and you can even feel it that the there's like a change into the muscular and the vaginal layers it's more uh like hard like rugles how do you say it in yeah it's more like the your nose uh yes yeah not like rinkled i would say like it has different texture the rugay is what you're saying yes thank you yeah yeah so if you did stimulate this they It can achieve orgasms quicker sometimes and with more intensity sometimes.

39:29And it also can help if you can get a little bit of pressure up to the tip of the uterus so you can get everything more together and you're going to feel more feels. So pressure on top of the abdomen pushing the uterus down is going to basically make that G-spot present. Yes. It's going to be more prominent. Yeah. You're going to have more space. Yes. Yeah, well, it's just really interesting because it's mostly gynecologists that I see that say that will refute the G-spot. But what's interesting is that these same gynecologists will also admit that they had absolutely no education in like pleasure and sexual health.

40:09Like it was very, very minimal. It's just being like, pain with sex, yes or no? Can you have a baby, right? Like it's really reductionistic a lot of times in women's health. And it's really hard when I see men talking about female orgasms. I was like, yeah, you cannot feel it. So I'm sorry, but I don't know. I was seeing an interview yesterday of a really old doctor that says that endometriosis can get cured through hysterectomies. And I was like, no. And there another doctor was like, yes, trying to explain the way that women feel pain. Yeah. Like, there's no way that you can understand or that you can explain me this because I cannot even understand it because I'm not feeling it.

40:56So I think sometimes, I don't know, I don't like the way that they do try to explain it or understanding or gaslight our patients. Like, oh. Yeah. You know, to your point about men co-opting women's health, I think that is really the problem is that they center themselves. they center themselves as experts. And what they do in doing that is that they de-center women's voices, women's experiences, and they disempower women by saying like, I'm a man, I'm an expert on your body. I know more than you do about your body. And in reality, we are unique. We all have like, right, we basically get like this same roadmap of a makeup, but there can be variations, but our experiences within our body are what are absolutely so unique.

41:43So I absolutely agree with that. I cringe when I see men online and there's just been this really big phenomenon lately too online where a lot of men are wanting to step in and be experts over women's bodies. I find it so bizarre. That's not to say they can't have expertise, right? There's male gynecologists. They're brilliant. You know, uh, Ron Cabrera, who've had on the podcast, mutual friend of ours, you don't hear him talk about endometriosis from like, this is the way it is. He talks about it from this is what women tell me. This is what women say they experience. And I think that that little bit of a nuance makes all the difference.

42:22And it's very telling. I think, I always joke that I want to run through doctor's offices, like throwing red flags, like when they do and say things. If you have a doctor who is talking down to you, or asserting that they have an expertise that like means that your experience is invalid, that's a red flag. And to me, it's a red flag when I see men talking about women's health conditions and just stating like, this is a fact across the board and I'm telling you this. And so this is why it's true and not actually saying from women's perspectives, this is what they say. I think in women's medicine, we have to center women's voices and women's experiences, especially when we consider how long we've been left out of the literature.

43:06and I had a really good podcast interview that I'll link to with Dr. Sarah Hill, who we had dinner with. And she made a really good point that even though they decided to start including us in the research, they only include us for about nine days of our cycle to get us as closely matched to a man. So there is, the people are like, oh, we know about pharmaceuticals. Women are included now. We actually have a huge gap of the luteal phase that we don't understand what is going on with women in terms of drugs, in terms of like their experience a lot of the times. And I would imagine the same is true when it comes to pain.

43:37Of course, yes. We are not the same person one week after the other. Like we can see this in how our bodies, like everything about our bodies is different every week. So this, I try to explain this to my patients. When they go, then they get really frustrated, for example, having their results if they start working out with their husbands. And they see that they progress so quickly, but we're different. So we don't have to do the same diet or the same physical program because women are not little men. And that's something that really happens a lot of the time when you go to the gym and you try to work out and they don't do any type of exercises like it's the same routine, only you have to lift less weight.

44:26and I was telling I think it'll be hard if you have to tell your coach oh right now I'm in my luthier phase can we go it'll be really great if you can have I don't know a female like a specialist and you can adjust your hormones into your workout so you can get the results that you're looking for I think that's something to think about maybe 10 years but it'll be great if we can try to focus on this. Because sometimes even with diets, like do try to, for example, the fasting, like when you have really large periods of fasting, female bodies respond different to male bodies and they do not get the same results.

45:10And they also get frustrated by this. But it's different because our fat develops different and their muscles develop different because they have testosterone and all of the hormones that are different. So we are not little men. Yeah. There's like this meme of a doctor trying to explain a patient. We have, and he tells that we have studies on mice, chimpanzees, rats, I don't know, like cats. But they have, we never occurred to do this in a female, in a women's body or something like that. I was like, yes, that's totally right. Like, we really need to understand how do women's bodies work in order for us to try to help women.

45:53Yeah. Yeah. I want to come back to the orgasm conversation. I think that was a really good tangent for us to take. But you have a little bit of a clitoris model. It's actually probably, well, that's a beautiful vulva, I must say. It's a vulva. So the vulva would be the outer part? Yeah. Well, it's the people that are listening to the podcast. This is a model she's showing me. You should come to YouTube and see it. I didn't realize they said, oh, this is a beautiful vulva. And people listening might be like, what is happening right now? But it's like, holographic. It's like, it actually goes with the whole background.

46:27I think it was 3D printed. Yeah. Yeah. And you can see the vaginal hole. I mean, the vagina will be the inside part. So the vulva would be the outside part. And then you can see a little head in here. So you can detach and see the octopus that Dr. Vyron was telling you about. But this isn't an eight leg, so I got to come up with a better name. So this will be the full clitoral body. So you can see there's four branches. Two of them are really wider and this will be near to your labia majora. Not exactly there, but those will be the perineal. So you can have orgasms and you're still stimulating your clitoris while trying to go to outsider part.

47:04And also the clitoris, right? Yeah. No, that is, did you 3D print that yourself? No, no, no, no. This was a gift from one of my patients. Oh man. Okay. So my little preteen has been trying to convince me to get a 3D printer and seeing that I'm like, hmm, okay. Maybe you could do really cool stuff. Yes. And you would be like, mom, you're so weird. I was like, you're absolutely right. But it's a good thing. Yeah, it definitely is. So when someone is having difficulty achieving an orgasm, maybe there's pain, maybe there's not. Could this be related to nerve dysfunction? Yes and no. I think we both know that sex, it's so much more and not only about sex.

47:46So sometimes when women cannot achieve orgasms, yes, it can be due to a lesion in the pudendal nerve. But that's not the only thing. It's the rarest thing. Also, the hormonal part of it, that's the rarest thing. The psychological part of the orgasm, that's the most frequent thing that women have to address when they are feeling that they cannot achieve orgasm. Because as you were saying, somebody's inside your body. So having this vulnerability into you, it goes a lot of layers before it. So yes, sex is so much more about just penetration. And it's about a lot of things about the partner and about your life and about everything else.

48:30And then we have all the other layers. Yes, there's a hormonal layer. There's the pelvic floor layer. And yes, there's the nerve layer. But I think we have to address the physical or the psychological layer first. Your call has been forwarded to voicemail. Hi, this is Zoe Deutsch. And Nick Robinson. Our brand new movie, Voicemails for Isabel, is all about those little moments that feel like the universe is looking out. Feeling homesick, then your sister calls. Hearing that perfect song exactly when you need it.

49:08Sometimes life rigs things in our favor. like learning about your new favorite rom-com voicemails for Isabel. Now playing only on Netflix. Yeah, I think that's something that's really important to highlight is that there can be such a strong psychological component that also your past experiences can influence your psychological. So if you're someone, maybe you had a really bad yeast infection and then you had pain with sex, that could still linger. There could be a fear there in your mind. So, you know, as a clinician, how do you help people kind of separate that out of like, okay, which came first, the pain or the psychological aspect?

49:51And how do we heal both of those? Yeah, in the consult, they do have to, when they come to my consult, they do have to like create the history of the pain. So I ask them to write. There's like a questionnaire that I give my patients and they have to send them 24 hours prior to their consult. I think studying the cases before they come to me, it's easier. So I can now see what we're going through. And also the clinical history. When the patient sits and takes the time to see, okay, what happened first, the pain or the yeast infection, now we can have this clues. And also the symptoms that accompany the pain.

50:31Because as we were saying, it's not the same thing to have pain when you're alone, that when you're together with somebody, that the experience of the pain is different. And also the position. Sometimes having a seat is really hard for some of the patients. And some of the patients do feel better when they have their legs flexed because of the psoas muscle that we were explaining before. What other symptoms come through or come together with this pain? Like we were explaining about the pudendal nerve that some of our patients do have this feeling of abnormal object in their anus when they have a pudendal compression.

51:09So there are a lot of things into the nerves that really particularities that we have to understand in order for us to understand the pain. Mm-hmm. And then I'm also curious, like, are you looking at any aspects of like their nutrition, what their exercise is like when you're evaluating pain? Yes, because when they have contracturated pelvic floor muscles, we think about the life that they go through every day. And if they are, I don't know, physical culturist or they do have, I don't know, doctors do have a lot of problems trying to empty their bladder sometimes because we are ordered not to think about it.

51:50And then we have a neurogenic bladders. So that's very common. And we also train girls to have neurogenic bladders. I don't know if this happened to you, but my mom, and now I'm giving this to my girl and trying to correct this now that I know of. But whenever you're going out for something, like you have to pee right now because we're not going to stop in the highway, right? I do this to myself sometimes too. But I mean, to be fair, sometimes you go to a public place and there's not going to be a bathroom or you know you don't want to use that bathroom, right? But now you're emptying your bladder without the signal of wanting to empty your bladder.

52:29So I tell you because this happened to me in my residency. They used to tell me that you have to go pee every time you're going to begin a surgery because you don't really know how much time you're going to take. So by God, I swear that whenever somebody told me that it's your turn to wash your hands, I feel that I want to go to pee. Even though I go and there's just one drop of pee because my bladder may be empty. But I do have a neurogenic bladder because of this horrible thing that we do to ourselves, right? And we accommodate ourselves in order to progress with this. Can you define neurogenic bladder?

53:06Neurogenic bladder is having the necessity or the signal of your body telling you that your bladder is full and you need to empty it without really the need to. And what you're saying is that going to the bathroom just because one's available or you're going to leave the house. So going before you actually get the signal you need to go is training your body for a neurogenic bladder. Yes. Sometimes we have patients that do have another type of problems that they have to place a clock. And we ask them to go every few hours because there's no longer any signal for them. But that's because of pain or damage to the nurse due to endometriosis.

53:50So it's not always a bad thing. Sometimes it's doctor prescribed. But if you do have these things, go to a urologist, a neuro-urologist specialist, in order for you to get a proper examination. How does someone retrain themselves out of a neurogenic bladder? Is that possible? Yes, but you really need a very good physical therapist. It's going to reconnect you with the real signals of your body. You, we've spoken with Diana and she really tries to understand or for our patients to map themselves and to try to feel every muscle and stuff. So you're trying to reconnect with the true signals of your body.

54:29Yeah. She loves that body mapping and she'll message me sometimes. She'll be like, thinking about you, have you been body mapping? And I'm like, how do you know? I've been just like writing my book and being like, body, what's a body? Like, I'm not eating. I have to sit down with three beverages so that I drink enough fluid so I do get the signal to get up and go to the bathroom and move around. Thank goodness, though, I will say I do wear wearables. And so when I'm hyper-focused, my wearable will be like, get up. And I usually get mad at it because I'm like, no, I don't want to be interrupted.

55:00But I'm like, yeah, but I also don't want to end up with pelvic pain or a stiff back or any of the things that come with them sitting too much. So we talked about vaginismus. We've talked about vulvodynia, deep dyspareunia. That's pain with deep penetration. This is typically happening in heterosexual couples. What is going on there? What should women be looking for? Additions, adenomyosis, or endometriosis. Additions cannot always be because of endometriosis. You can also have previous surgeries or previous infections like chlamydia, trichomonas, those like really hard infections, like a very, like a pelvic infections.

55:44Those can really get into like scarring and getting all of the organs together. What can you do if you have pelvic adhesions that are outside of endometriosis? Physical therapy can help. And sometimes there There are treatments in order for us to remove the bacteria that are around it. We should definitely remove the bacteria. Yes, fan of that. And sometimes surgery is indicated. But you have to remember that when you do surgery, other additions can come. So the thing that you can do to prevent additions in surgery, first, avoid bleeding or as much as you can avoid bleeding. Treat the tissues.

56:24like um one of my teachers used to tell me like what's the difference between us and the butcher because if you go to the butcher he's going to dissect the same fascias he's going to do the same thing that you're doing and we're like well maybe the knife the sterilization and he was like no it's the way that he treats the tissue you're not a butcher so you have to go really through each of the layers so if you treat the layers with respect they will advise or heal with respect So that's one of the things that we really have to go through every one of our surgeries. And also there are like membranes and stuff that you can get in first world countries that do help prevent additions.

57:05There are a lot of like Gore-Tex and placental membranes and things that are, some of them are experimental still, but there are a lot of anti-additions materials that we can use in surgeries. Mm-hmm. So adenomyosis or adenomyosis, let's define what that is, and then I'd love to hear how that's causing pain with deep penetration. Okay. There's like a layer in your uterus. I'm going to use my model because I want to. Yeah, I was going to pull out your model. Okay. So this will be if you're looking through a patient like this. So the bladder will be here, and this will be the rectum. See? There's like a layer of everything gets together.

57:44So that'll be the peritoneum and we can... Oh, hang on. I think that might be right behind the mic. Okay. Can we... I may be... Okay. You can see if there's like an inside layer, that would be the endometrium. And then the muscle layer of the uterus would be the myometrium. So there's like an interface between the endometrium and the myometrium. And that layer starts to compromise. So endometrial-like cells start invading the uterus and start changing it. And when they go even bigger, they can even get endometrial-like cyst inside the muscle of the uterus. So that will be adenomyosis. It's endometrial-like cells or endometriosis in the muscle of the uterus.

58:34If it's anywhere else in the body, it's called endometriosis. If it's in your uterus, it's called adenomyosis. And that's basically like a cousin of endometriosis. How often do you see them together? there? If you have adenomyosis, there's a 98 % chance that you have endometriosis. And what if you have endometriosis? Should they be looking at your uterus? Well, if you have endometriosis, yes, it's common. For example, if you have myomas, there's an 85 % chance that you do have also adenomyosis. And also if you have any Mullerian malformations, maybe your uterus is a little shorter or you have like a division between it or 99 % of patients that do have Müllerian abnormalities do have adenomyosis and do have risk for adenomyosis.

59:23So the risk is high. Yeah. And how does this contribute to pain with sex? A lot. Yeah. Okay. So you have something invading the muscle in your uterus. So normally the endometrial or the endometrium do have this like an anticoagulatory something that makes the blood of your menstruation really loose, red, and it can go very liquid and you can get it outside. In cases with adenomyosis, the bleeding has to come from the muscle part. It doesn't have anything that prevents coagulation, so it comes in clots. And your muscle, your uterine muscle has to contract in order to extract all of this. So patients do tell me that they feel the contractions as if they were giving birth in order to take out the blood clots.

1:00:17So I think that it's not a very pleasant thing. Sometimes when they have deep penetration, they're going to have, because the uterus in adenomeiosis is more enlarged. So they're going to have more pain. And sometimes they even bleed. The sympathetic tone of the uterus is more contractuated. So when they bleed through in patients with adenomeiosis, the blood can oxidate itself. So the change of the color of the blood, it's more like chocolate, more like oxide. Just ruined chocolate for all of us. No, but that's a great description. So I think that's important for women to know that in denomiosis, we are going to see this darker colored blood.

1:01:01And that's due to oxidation. Because I think when you don't see bright red blood and you're seeing this brownish colored blood and you just had sex and you're not around your period, you're like, what is that? And so if you're seeing that, see your doctor, because that can be as simple as a transvaginal ultrasound. I say simple, but if you have pelvic pain, having a transvaginal ultrasound can be uncomfortable. I think with the right clinician, I would say go to an imaging center with a woman or see a female practitioner because they definitely understand things a lot better. They can have you contract and tighten, tighten, tighten, and then release, and that can help relax the muscles.

1:01:41There's different things that they can do. So I say this so that if you are someone who's like, well, I have vaginismus, therefore I can't have this ultrasound. You may still be able to, but you have to find the right person. And also that's not the only cause of having a darker color in your, because if you have low progesterone, you're going to have a darker color in your blood. Yeah. So in your period. So that's not the only cause. I'm just, it's one of the costs. Yeah. And also patients with adenomyosis, because of the sympathetic tone, they bleed in pulses. They bleed a little bit, then it stops.

1:02:14Then they bleed a little bit more, and then it stops. That's also a sign for adenomyosis. That's not the only sign. We're not saying that this, if you have this, you have adenomyosis. We're saying it all contributes to the diagnosis. Yeah. And we know, you know, for women listening, I talked about in my book, and I said this before, like you may have a five-day period, and then you have that day where you're like, is my period gone? And the next day, there's a little bit more. That can be really common and normal. What you're saying is based on the contraction. It's like, I bleed, then I don't.

1:02:46I bleed, then I don't. And it's like a teenager driving a car, like a stick shift. You're like, just make it smooth. Let's go. Let's be done with this. So with adenomyosis, you know, the other thing that comes up as we're talking about this is the position of the uterus. And that changes throughout our menstrual cycle. Can you talk about that? Because that can, you know, I think about there's certain positions when you're having sex where there's deeper penetration and you can have more pain. Like, you know, women will be like, I could do what people call doggy style. I don't know if they call it here.

1:03:18Okay. That's fine. Like, you know, in the, like if I'm around ovulation, but like before my period, I'm in so much pain. So can you talk about what is changing anatomically? You have your round ligaments that your uterus is attached to them. And when you have, for example, a disease from collagenous like Ellen Danlos, our patients can even have even more movement in the uterus. Sometimes they even have, when they have retroverted uterus, they do feel more pain and it can cause even congestive pelvic syndrome. There is a practice that we can shorten the round ligaments so the pain will diminish, but also because of the adenomyosis, the uterus is heavier.

1:04:06So sometimes the uterus is supposed to be looking to the bladder and the anterior part. And sometimes because of the weight of the uterus, yes, right. So the uterus will be here. So if you have the uterus seeing your bladder here. So that'll be the anterior version of your uterus. So that'll be a normal thing. So sometimes because of the weight of the adenomyosis, the uterus go backwards and it's attached or more close to the rectum. So they do feel pain during their course, not only because of the localization of the uterus, but also because the uterus is poking the rectum. So that won't be very pleasurable.

1:04:49Plan B is a backup birth control option that's there for you when things don't go according to plan. It specifically works after unprotected sex and before pregnancy occurs by temporarily delaying ovulation. Plan B is available nationwide at all major retailers and through delivery apps like DoorDash. No ID, prescription or age requirement. It's the number one OBGYN recommended brand of emergency contraception. And it won't impact your future fertility. That's freedom to be. Use as directed. Yeah. So I actually did an Instagram story right before you got here. You'll probably see it where I was talking about wearing this outfit today.

1:05:30And I have a dental meiosis and I lost some ligaments during my surgery. And how do you know, I'm going to probably get my period tomorrow or the next day and how like my belly sticking out here because my uterus is bigger. Anyhow, I did the story to kind of normalize this because I think there's this idea that we're supposed to have 12 year old bodies our entire life and that like your lower belly should always be flat and like and and women don't I mean god photoshop was bad enough and now we have ai cover models like now like you you modified women and now you're not even using real women and you're telling us this is the beauty standard and I'm like forget that like I'm gonna show like the weird things that happen to my body and like talk about it and normalize it because you know I have boys And I also don't want them to live in a world where we have these fantasies that we can never achieve or look up to.

1:06:26But people who have this condition, like I can feel that my uterus is getting heavier. I can feel it when I'm working out. It's not that extreme, but thanks, Deanna, for all the body scans that I'm in tune with it. And I'm like, yeah, as I'm working out, I'm like, oh, yeah, I can feel that there. Okay, my period's going to come. But for some women, And it can be a lot more extreme. So I want to talk about what are the options. So if you have adenomyosis that's causing pain with sex, what are your options? It depends on the type of adenomyosis. There are three types of adenomyosis. You can have adenomyosis mixed with myomas.

1:07:05You can have focal adenomyosis. That's like only one part of your ears having adenomyosis. And you can also have diffuse adenomyosis. that'll be like the worst type that's me because there are not a lot of things that we can offer this yeah when you have adenomyomas we can remove the myoma and it'll come out with the adenomyosis if you have focal adenomyosis we can remove the part of your urus that it's with the disease where in patients that do have diffuse adenomyosis especially the ones that are in early stages, that it's only in this area between the endometrium and the myometrium, you have to remove the whole universe in order to get the full eradication of the disease.

1:07:54Sometimes you can have diffuse adenomyosis in the muscle layer. And now with the experience in the robot surgeries that you have better cameras, you can start defining the difference between the tissue layers and you can find adenomyosis in between the muscle layer and you can try to remove them. But to fully remove it, it's really hard experience, especially in diffuse adenomyosis. Yeah. I grew up in California. We have this cut of meat called tri-tip that everybody barbecues. And so I tell people, because people are like, why don't you just have them excise, like take out the tissue that has the adenomyosis.

1:08:34And I explained, if you look at a marbled piece of meat and you see the fat chunks that are in it, imagine if you went and you dissected out every piece of fat chunk, what would you have left? You would have this weird, no longer holding a structure piece of meat. That's exactly what would happen to my uterus. So, you know, for people listening, so nobody likes to hear hysterectomy, although some people do. Some people are like, I'm done with this uterus, right? Because it's so big, it's so boggy, it's so painful. The periods are, they're not these like three to five day periods. These are like 10, 12 days of like, when am I going to stop bleeding because it's just so ineffective in its contractions.

1:09:17But one thing that we can use is biogenical progesterone and using that during the second half of the cycle. I don't typically, you know, if you're somebody who's under 35, I like to think more of like vitamin C, vitamin B6, Vitax. Like what can we do to get your progesterone levels up and then also support estrogen detoxification. So helping you remove the estrogen you don't need. Once you get over 35 and especially in your 40s, that's when I'm like, it's a good idea that if you're still ovulating half the month to take an oral micronized progesterone and a lot of people that will help you sleep.

1:09:52If that's not true for you, I have an episode on progesterone intolerance that I will link to so you can watch it. Or even doing vaginal, which vaginal might even be better. It's just women just hate doing it because it's messy. But it may even be better because we know it affects the uterus because it's being placed very in close proximity. So with that, that's not going to be a cure for adenomyosis. That's going to be management so that we're not getting the overstimulation of estrogen, which is really common in our environment because one, most people don't eat enough fiber. Two, xenoestrogens are everywhere.

1:10:32And three, some people have a good time. They drink alcohol or they go, they're not always like adhering to things. So we can have that progesterone buffer so that it opposes estrogen within the uterus. But if somebody is like my primary complaint is just pain with sex. Is that, would you recommend a hysterectomy for that? Okay. No, we do recommend hysterectomies in patients that do not have a quality of life because of their uterus and they have tried everything else before. Yeah. I think there's like, I don't know, like a dual phase that comes with losing an organ that I've seen in the faces of my patients.

1:11:19Some of them are ready to lose one part of themselves. Some of them are not. And we are not in order to force them into it. It's one solution, but it's not the only solution. Yeah. And removing organs just because it's not the other way to go. So no, pain during intercourse, you have a lot of other things like physical therapy, like hormonal treatments that can help you with the pain during intercourse complaint. But if you do have an enlarged uterus that it's causing to bleed every month, that it's causing you to have clots, that it's causing you anemia, that we are not even able to control all of the bleeding that you do have and that your period is determining your life.

1:12:07Yeah. That you cannot go outside or you cannot go and play with your kids because you feel very fatigued or that you cannot go to the beach because you don't feel comfortable. Some of these things that women do experience with having adenomyosis, that's the way I think the uterus is not supposed to hold you back. So if it's done and you have had your kids, if you had your kids, if you wanted them, some of our patients don't even want kids. So that's their decision. But I think that there's a whole lot of things about the hysterectomy that needs to be addressed before taking this decision. There's been speculation and a call for more research about the potential of the uterus having an interaction with the immune system.

1:12:54Have you seen any research around that? Not something that we can have like a randomized control trial that we can say that now this is something that we can really go back into it. But I think there's something there, yes. Yeah. Because some of the autoimmune diseases, my friends that are specialists in this told me that if they get a hysterectomy before a certain age, especially before the age of 40, patients with autoimmune diseases get worse. Interesting. So I don't know if there's there's this is not a randomized controlled trial. This is just an observation in a very small group of patients in Mexico.

1:13:34But yes, something like that. I mean, and this is the thing that's so hard to do is that we know the randomized control trial is the gold standard. And, you know, Dr. Sarah Hill made such a good point during our podcast episode. I wish that we had talked about this when we were at dinner because she had said to me, the way we have designed science, the entire design model of science is for men. And we've never stood back and said, how can we design it so we have a gold standard for women? Because we can't have the same, we can't always do the same thing. Women get pregnant. Women could get pregnant.

1:14:09And there's just so many other variables. And it had never occurred to me that everything that, like, when you talk about things and people criticize and they're like, well, you know, that's correlation and that's anecdotal. And it's like, but have we ever paused and stood back and thought about, did we actually even design science from its inception to serve women? Or maybe do we need to redesign it differently so that we can have good data, right? Because, I mean, I learned so much on this podcast from talking to experts, and I think that's, I mean, we learn so much from listening to our patients, right?

1:14:44I think that, you know, to your point, that observation makes sense because we know that there's also a risk that when you have a hysterectomy that you may go into menopause. So depending on where, and I'm not a surgeon, but this is what I've read, Depending on where cuts are made, that can impact the blood flow to the ovaries. And if the ovaries quit, now we're in early menopause. And we know the transition of losing your estrogen puts you at high risk for developing an autoimmune disease. So everything is linked. Yeah. So what risk should women know about hysterectomy since we're on that conversation?

1:15:24because I see a lot of doctors that are pretty flippant about like, well, if you've had your kids, just take your uterus. You don't need it. I one time had a patient, she got her chart notes from her other doctor. It was so livid. I know it's not professional, it gets so angry, but he put in there that he recommended, she was like 28, that she have a hysterectomy because she was having pain with sex, with deep penetration. And he had said, I'm recommending a hysterectomy so that she can accommodate her husband in the bedroom. I was astounded by this. And I'm like, why? And she's like, well, because he said I have my kids and I don't really need my uterus at all.

1:16:08I'm like, this is a major surgery to have, to have your uterus out. And did you talk to you about physical therapy? No. I'm like, let's start there. But for women who are considering a hysterectomy, let's talk about who you should look for in a doctor and what you should know about recovering from that and what the potential issues that can arise. So you have to do your research and see the type of surgery that your doctor performs. Here in Mexico, we have doctors that don't perform minimally invasive surgeries. So that'll be the first thing to know. If you do have somebody that gives you the option of having less scarring in your abdominal wall, it will be a quicker comeback into life.

1:16:51But you do have a vaginal scar that we have to suture in your vagina. So these types of injuries do take one month to heal and up to two months in order to have sexual intercourse again. So you're talking about doing a hysterectomy going through the vagina? No, you can, in any hysterectomy, you do the vaginal cough to remove the uterus. So if it's a laboscopic, for example, we remove the uterus through the vagina. We do the vaginal cough, we remove the uterus, and then we suture the vagina. Yeah. I just want to make sure that it's clear what we're talking about. Because I think, you know, because we talked about C-section before, and I think that, you know, it's important that we differentiate where incisions are being made.

1:17:36Yes. Because if this is the first time someone's hearing this, if you've had a hysterectomy, you're like, I know the drill. If this is the first time you're hearing it, you might be like, wait, they're not going through your belly? If you have a minimally invasive hysterectomy, no, your uterus will be removed through your vagina. Yeah. So that's how we can accomplish having lesions of five millimeters, removing an organ that is so much bigger than that. and also about the technique and about the experience of your doctor how many surgeries has he done in this year we can ask them that we as surgeons we have to get certified but some like some associations and they do ask us for our statistics so you have to you have an idea of how many surgeries you perform a month and then you can ask them about the complications the uterus it's in between everything.

1:18:27So you can have complications with your bladder, with your uterus, with their rectum. So those are the things that you have to talk about with your surgeon before the surgery, no afterwards. So after the surgery, after one month, you can go into physical therapy. There's a lot of things that they used to think, or when I was in the residency, they They used to tell us that we have to attach the vaginal cuff into the uteroccal ligaments. There's not such a thing as an uteroccal ligament. There's not a ligament there. The peritoneum, that was like the white thing that we saw in the beginning. Imagine that you can cover everything with plastic, that you can fold everything like a self-adherent plastic and you cover all of the viscera in your pelvis.

1:19:17So with this, that's the peritoneum. And sometimes this plastic can get into a little wrinkles. So you have two wrinkles in your peritoneum in the backside of your uterus. Those will be the uterus sacral ligament. Those are foldings into the endophasia. So that's the backside. And it doesn't have any muscle like the round ligaments. So it's just a lot of connective tissue and it's part of an even bigger fascia. So they used to tell us that you have to adhere the vaginal cough into this in order for them to not have any prolapses. But the thing that we didn't used to know is that the inferior hypoastric plexus, the one that controls how you empty your bladder, how you relax your muscles in order to have sexual intercourse, or how you poop, those nerves are one, like a centimeter and a half or half a centimeter away from those ligaments.

1:20:13Oh, okay. So if you do have this procedure, some of our patients after a little bit are not able to empty their bladder because we are damaging the nerves. So that's a practice that should be avoided. Also, another practice that should be avoided is cutting or burning nerves in order to forget about the pain. This is a procedure that is still being made in Mexico. It's called LUNA because it's the ablation of the utero sacral ligaments. So if you burn a nerve, if you cut a nerve, you do not diminish the pain. You only make it untreatable. And you also will have the other side effects. The emptying of the bladder being really messed up, not being able to have sexual intercourse, and not being able to poop.

1:21:02So that's a lot of problems for a lot of nerves being burnt. Yeah. Do you ever do like anesthetic injections into nerves? Yes, yes, we do nerve blockages. I don't like the one, I see sometimes in the United States, they do this and they tap and whenever the patient feels pain, they block that sign. I don't like this because I don't think that there's a diagnosis behind it. You have to find the nerve, block the nerve. And if the patient feels a lot of relief, even, it depends on where you find the study. They used to say that if it's a 50 % better of the pain, that's the nerve. Now we do know that the pain has to go away in order for you to make the proper diagnosis.

1:21:49So if you do find the nerve that is causing the pain and you block it, that's a diagnostic and also therapeutic way. So if it's just a sensory nerve, you can add Botox to the nerve and you're going to feel the relief of the pain for a longer period of time. Okay. A lot of people are afraid of Botox because they're like, it's a toxin. Shouldn't I not be putting it in my body? Explain how Botox can be used therapeutically when you're having pelvic pain or pain with sex. Pandora jewelry brings the sparkle to your summer. Now with even better prices. Enjoy up to 50 % off select styles from personalized pieces to must have favorites made for the summer.

1:22:31Timeless designs that shine with you through every moment, wherever the summer takes you. Shop in-store or online now through July 6th. Terms and conditions apply. Visit pandora.net for details. Because Botox can inhibit the signal, but when you have Botox on your pelvic floor, you have to be really careful because Botox prevents muscular contraction. Yes. So if you have a contracture or something, it may help. But for example, if you have a prolapse or problems with your pelvic floor stability and you add Botox, your bladder is going to go outside of your body because nothing is going to hold it.

1:23:12So that's why it can even worsen patients with prolapse. So you really have to go with somebody that knows what Botox does to your body and your pelvic floor muscles and it's not indicated in all of our patients. And when you say prolapse, can you define that for people? Because I don't think everyone knows what that is. When your organs are going outside of your body, it's like you're birthing your bladder, your uterus or your rectum. And so for women listening, you'll feel a bulge in your vaginal wall. So if it's the belly button side of your body, that's bladder side. If it's the tailbone side of your body, that's the rectum.

1:23:54But even the uterus can start trying to make an escape depending on the pelvic floor and your history as well. So how effective is you doing a nerve block or Botox for helping pelvic pain? Like is one better than the other? No, the block can only help you with a little bit of time. So sometimes we accompany it with Botox and sometimes they give radiofrequency therapy to the nerve. It depends on every nerve. It depends on every patient. So it's not indicated for all of them. For women who have had a hysterectomy, they didn't have pain with sex, but now they are. What could be going on? A lot of things.

1:24:38You're like, but once again, buckle up. It's like everything changes right now. And you're feeling for the first time things that didn't used to belong there. We used to think about, we think about the pelvis like a peepoth. So you have the bladder, you have the uterus. What's that word? Like a peepoth. A peepod, okay. And you have like a little, three little piece inside of your pod. So you have your bladder, you have your uterus and you have your rectum. So whenever these little pieces like stretching one of their elbows or something, the other two are going to start moving. So if you remove one of these, the other two are going to have so much space, so they're going to move even more.

1:25:18So sometimes if you have pain during intercourse after a hysterectomy, you have to see where is the pain again, because if it's in the outer side of your pelvic floor, I mean in your vulva or in your like in the promontory, well, in the inside or where the penetration is beginning, that'll be one causes it's more frequent to have like lacerations or infections. If it's in the middle part, it's more frequent to have pelvic muscles contracture either. But if it's in the vaginal cough, it's really rare because there are no nerves anymore in the terminal range. So they do don't, they used to feel, or when I've talked with my patients with vaginal cuffs, they tell me that they don't feel anything when they're hitting the bottom.

1:26:05Okay. And so if women are experiencing, who's like the first provider that they should see? Hopefully a GYN that knows about pain because sometimes sutures can get into the way and they feel pain. Sometimes there are residue material. Sometimes they didn't remove the cervix. There There are a lot of things that need to be like checked out before you can address the pain whilst having intercourse in like a deep penetration after a hysterectomy. But it can be addressed. It's not just hopeless. No, it can be addressed. Yes. Every pain can be addressed. Yeah. I want to ask that question because I feel like sometimes when women go to their provider and it's so much effort and energy just to go to a doctor and then they get hit with like, this is just the way it is.

1:26:50Like, this is your new reality that can feel discouraging. And I think it's really hope-inspiring for women to hear from such an experienced clinician as yourself say, there is always a hope. There's always something that we can do with that. For women who are experiencing pelvic pain in general or having pain with sex, should they talk to their gynecologist first? Should they see a physical therapist first? Like, what's kind of the algorithm there of who they should try to see? because the other thing I get concerned about is that there's a lot of gynecologists who don't even know physical therapists are a thing.

1:27:27So they don't refer to that. So maybe for somebody listening, like what are the steps to go through to help get one, find the cause of why you're having pain with sex, but also find resolution? You have to first find it. So first find the place where it's hurt if you have the pain. Then allow us to map it. And then we try to fix it. But about the doctor, you have to go to somebody that do have physical or pelvic pain in some kind of background. Because if you don't, you may get the same answers that you're going to get every time. So yes, do your research and find somebody that do has pelvic pain background in any other, like any studies and or do care about pelvic pain in women.

1:28:15Mm-hmm. We have touched on throughout this episode on endometriosis. I want to talk specifically pain with sex when it comes to endometriosis. What do you most commonly see? Because of the additions. Because endometriosis, we know that can get everything stuck together, like a frozen pelvis. Yeah. So the most common ones are because of the, we have like mapped, like the macro pattern of the distribution of endometriosis. And this is one of the reasons that we do the gel MRI that do have gel in your vagina and in your rectum. The number one place that endometriosis appear is the rectovaginal tabic.

1:28:57Like this. That was me right there. So that's the number one. Number two will be the uterus sacral ligaments. So if you have everything in a gray scale and you have a layer in between the rectum and the vagina and you have two whites into a black, you're going to make the black even more noticeable. So that's one of the reasons that we do the gel MRI. So yes, this is one of the spaces that it's more commonly affected by endometriosis. And we have to remember that endometriosis, it's not the amount of pain doesn't correlate with the amount of endo. We have had patients that do not have any pain and have nodules and their bladder in their rectum in everywhere.

1:29:40And they're like, I don't have any pain. I've never had any pain in my menstrual cycle. I've never had any pain in my life. I'm like, how do you live? And we have had patients that only have peritoneal disease that I think it's the worst because it's the one that affects our patients more. And even it's like a four millimeter lesion, they do feel the worst pain. and it changes their life, like every dynamic that they do have. Some of my patients tell me that they have to organize all of their work in three weeks because they know that one week they're not going to be able to work. So they do still have all of the things that they have to manage throughout the month, but they have just only three weeks in order to do it.

1:30:25So I think that's, I don't know. And they have to alter the way that they have vacations. they have to alter the social gatherings. Everything goes around your disease. That's the thing that I think is very horrible about this. For people who are not familiar with peritoneal endometriosis, can you describe that for us? It's like the outside layer of every viscera. The peritoneum, it's like an outside layer that covers everything. So this is like the saran wrap you were talking about, the plastic wrap. The plastic wrapping. And with that, you're talking about people having very small lesions, but within that, that causing some of the most pronounced pain compared to others.

1:31:09It's interesting because, so you talked about gel MRI. You talked about getting imaging. I know in your clinic, you do imaging before you ever do surgery. I will bring up talking about stages. And anytime I'm talking with surgeons, they're like, we hate stages. They're stupid. Why are you guys still talking about it. And I'm like, stages are for patients. Stages are for patients, not for clinicians, because we'll talk about, and it's just something that like, you know, I tried to talk to people about my Enzian score. People were like, what? Okay, Enzian score is way more descriptive, way more helpful.

1:31:42We have a whole episode on that that I'll link to. But when it comes to stages, I feel like patients, they like to use that language because it's usually the, it took me 15 years and then it was stage four like and to just demonstrate like how big of a deal like this this disease was but as you're saying and I think this is really important just to underline for people is that it could be something that is you just have a couple of lesions but it's causing the worst pain in your life you could be completely infiltrated have adhesions everywhere and you're living your life just fine. And I think we have to validate that just because you're not stage four doesn't mean it wasn't hell that you were living through.

1:32:26Yes, of course. And it doesn't mean that you don't need the surgery. It means that we may try to fix the symptoms with other things. Like we try to go through physical therapy, get a proper nutrition in order to diminish the inflammation. This can do help peritoneal lesions. But it's really important that some of our patients do still live in pain. And we're not going to tell you now, I won't do a surgery on you if there's just a four millimeter lesions. We have to really trust our patients because some of the peritoneal lesions get into pockets and this can adhere to very deep parts of their pelvis, even into the nerves.

1:33:07And they cause really, really in a validating pain. So it's really hard. Is that why peritoneal lesions you think cause so much pain or is there something else? It's the inflammation. It's like having, I explain my patients that it's like having a candle that it radiates like heat. So if you have a nerve, it's like a wire that do have like a plastic rotation. And if you get the candle very near to it because of the inflammation that is burning everything, you're going to have the outside layer of your nerve getting like diminished because the heat is affecting it. Yeah. So that sounds awful. And I think it's a great description for endometriosis because I'm like, yeah, you have to address the inflammation.

1:33:49When it comes to surgery for endometriosis, though, oftentimes you see people online are very divided and you'll see in the endometriosis community, women are like, everyone has to have excision surgery. And then other people are like, no, you can do it all just like nutrition and lifestyle. What are your thoughts about surgery? Is this something that everyone should consider, at least be evaluated for? What do you think? Everybody needs a diagnosis. That's the first part. When they tell me like, what do I need? You need a proper diagnosis. They write me sometimes and like, oh, this is the thing that they told me.

1:34:27No, we need to do a proper diagnosis. Once we have the diagnosis, we can make decisions. All of our patients need nutrition. Most of our patients need physical therapy. That's like the basis of our treatment. It's a multidisciplinary treatment because it's a systemic inflammation, chronic disease. The whole body is participating into getting rid of those cells that doesn't recognize. So it's like having a flu that doesn't end. the inflammation doesn't go away because the cells are still there. So if you don't address this, it doesn't matter what the best, you can do the best surgery that you can, but you're going to still have inflammation.

1:35:09So you need to address the basics. And then there's like statistics that say that from 10 to 20 % of the patients really need a surgery. Most of them can get by without symptoms, having just some changes in their life, in their everyday life, like diet and exercise and stuff. But the thing that we really need to understand is that if you do not address the inflammation, the symptoms won't go away. And even if the symptoms go away, the disease will still be there. So when you don't take care of yourself, the symptoms will come back. Yeah. So people that are not familiar with my story, I had incredibly painful periods, like first three years of menstruating was absolute hell, throwing up all the time, more than seven days of bleeding, missing school.

1:36:02I got put on the pill, did that for 10 years. When I came off, hell returned. Actually, I had all these ruptured ovarian cysts and I had all kinds of problems when I was on the pill that I was like, that was endometriosis this whole time. So things didn't get better for me. But when I came off, it really got bad. And I went in with nutrition and lifestyle, was able to have no symptoms. And I was shocked when I got my MRI, how much endometriosis I had. And I was like, how am I not in pain? How am I not? And it was because I was managing it so well. And for people listening, I also have Hashimoto's and psoriasis.

1:36:42So like, I have to be really like very dialed into my diet and my lifestyle so that I can function. You know, but with all of that, I think, you know, people are always like, why did you get the surgery? Well, I was on a fertility journey. We thought this was going to be the thing that was going to help. That ended tragically. I'm not going to get into all of that. But what I want people to understand because people were like, oh, well, then you have the surgery. You can just like live your life now, right? And I'm like, no, because when you live with endometriosis for 29, you know, it's been there probably since, you know, I was formed as a little organism, but 29 years of menstruating, going through that long of your life, like there are alterations that are going to happen.

1:37:29There's your immune system is already heightened to go into inflammation. But, you know, I also think about the research and I really dislike how many people took the research on the gut microbiome and they're like, we know the cause of endometriosis, it's alterations in the gut microbiome. And I'm like, what does that have to do with lesions being in someone's eye? Like, tell me how these gut bugs made a lesion get into someone's skin or end up in their peritoneum. Makes zero sense. I actually think that having the endometriosis and the dysfunction that's happening with the inflammation, the hormones, like that starts to lead to alterations in gut microbiome, but also the way you start eating, right?

1:38:09Because some women can't even eat. So we see diet changes. Anyhow, I like getting research that's like, oh, there's differences in the gut, but to be like, that's the cause of endometriosis, I think is pretty silly. I took a little more of a side tangent there than I had planned. But for women who are listening right now, who are struggling with pain with sex, we have gone over the different areas that you know what could be so the different areas that can present what can be contributing to it what is something that we have missed in this conversation that I have not brought up and pointed out I think only about the treatments okay okay sometimes there's like vaginal treatments that we can perform I think getting back in touch with your body, I think will be the best thing.

1:38:59And to do the proper or to have the proper doctors to perform the proper physical exams, I think that'll be a thing to really have in consideration if you're thinking about getting a consult. And then for the therapy, it's not about numbing the pain, it's about treating the pain. So when you hear your doctor saying, oh, you have pain, get these painkillers. That's not the thing. If you have pain, let me look for the way that the pain is traveling through your nerves. Let me see the experience of the pain that you're having and then get a solution together. That'll be the thing. Are there any new treatments that are coming up in the research, in clinical practice that you're most excited about?

1:39:43Not exactly new, but I think some of the vaginal therapy that doesn't go into the bloodstream can help. Some of our patients have gone through like clinical menopause because they have gone through a lot of injections that suppress their estrogens. We have American girls that are like in their 20s with osteoporosis because of all of the injections that they did have. And they do have pain having in their gores and they deny the estrogen, the vaginal estrogen. So endometriosis patients are not like, if they do prescribe estrogen for their vagina, they do have less systemic function if you have a vaginal estrogen.

1:40:29And it can help so much to those patients that went under all of those years without estrogen or with estrogen suppression or with chemical menopauses that I really hate. But sometimes those type of patients can't. I hate them too. So, and then when they tell them that, no, you cannot have estrogen in your vagina because your endo will come back. Okay. You do have to understand the way that it's absorbed and the dosages that you need to use, but sometimes it can help so much more. I, so, you know, I did Lupron for two months. I got vaginal estrogen. I was not, I was like, this is not even a thing.

1:41:07Like, and you know, my doctor, he had that concern. And, you know, I just said like, respectfully, this is my area of expertise. And I'm doing vaginal estrogen because I don't need a UTI. I don't need a yeast infection going through this. And I also don't need pain with sex. I appreciate you bringing this up in the context of women outside of menopause because we're talking, it's a very interesting thing because we call menopause hormone therapy, MHT. But a colleague of mine brought up that it's not very inclusive because we're actually using what is considered menopause hormone therapy in younger women as well, those who have primary ovarian insufficiency, those who are put on drugs like Lupron.

1:41:50Even the progestogens, the progestin drugs that are used for endometriosis, women can start to have issues with their vulva changing, having vaginal dryness. And so I appreciate you bringing that up because there's going to be a 20-something somewhere who's going to be like, oh my God, I just got given Lupron and it's like sandpaper down there. It's so dry. And so I really appreciate that. Other things that I will say that you can also do over the counter, it's not as good as vaginal estrogen, but vitamin E. There's places that do vitamin E suppositories. You can get them compounded. You can be just really cheap like I would be and just go get 400 IU capsule, poke a hole in the top of it and insert it into your vagina.

1:42:35That's seriously the cheapest way to go with it. But the vitamin E can help plump the tissue and that can help a bit with dryness. It will break down a condom though. Just for everyone to know, anything oil-based will destroy a condom and that can be problematic. And if people are like, but I can't get pregnant. We talked about pelvic inflammatory disease. You can still get gonorrhea and chlamydia, friends. So with vaginal estrogen, is this something that you are using in your clinic with patients who have pelvic pain? Talk to us about it. Because some of these paryonia causes, it's a hormonal cause.

1:43:10Especially we see it more commonly, yes, in postmenopausal women, but also in premenopausal women that are still bleeding. But there are in many perimenopausal women, sometimes they do need vaginal estrogen and it's not a bad thing. So you only need to think about the way that this can be absorbed and the way that you have to counteract in case the patient do have a uterus. But it's not counter indicated and the absorption is less than if you are taking biol orally. So it can be something that you can do and it can change the life of the patient if they have, again, a vagina that it has a mucous layer that can get into it.

1:43:58and do have, again, probiotics and good bugs in there. Yeah, yeah. You know, I always like to talk about estrogen being our little farmer that helps us cultivate the lactobacilli crop. And it's something, so for women who don't know, estrogen stimulates the cells that produce glycogen, which is a sugar that the lactobacilli beat on, lactobacillus acidophilus, these lactobacilli species, they create acid, makes the pH of the vagina low, and that keeps the yeast that does live there in check. So really, really important for the vaginal microbiome. Interestingly enough, I've presented on this in a couple of conferences, and I'm presenting again next month on this, on how losing estrogen changes not just our vaginal microbiome, but our gut microbiome in a very serious way.

1:44:54And so I think it's something that a lot of times people think about estrogen and they think about like, oh, it's just about feeling good. I mean, it's about having great bones, but when we talk about vaginal estrogen, that's also about protecting your vaginal microbiome, which is super, super essential. You talked about oral estrogen. Something I find interesting in Mexico is that doctors aren't using transdermal patches. Yes, we do. You do. Where do you get them? Because they're not at San Pablo. I can get you the brands. And it's easier by gel, but I don't like the gel because they do sometimes pump twice or pump.

1:45:31I don't know that the amount of grammage that they do have. Yes. And you can have, there's like patches of estrogen and progesterone also. Oh, interesting. Yeah. Because what I have seen, you know, I've had a lot of people talk to me about it. And there's the gels, there's creams, and then there's the sprays. And I'm like, I just don't like these delivery forms as much because I can't know if you're getting the exact right dose. Like it's a lot to like recommend or to rely on somebody to eyeball things. And sometimes the creams, the dosage is like, that's higher than someone needs. And to cut it in half is like so tiny.

1:46:11So that's good to know. In endometriosis patients, they're often told you just need to get to menopause. and then not have hormones, and then you're going to be fine. What's the truth there? The endometriosis lesions produce its own estrogen. I have one case that I'm trying to publish because it was so many years ago, so I don't have everything in order to publish it, but there was a referral of a postmenopausal woman. She was in her 50s and have stopped the bleeding for like more than five years. So she had tachycardia and she went to the cardiologist and the cardiologist referred to me because it was a postmenopausal syndrome.

1:46:51So I was like, okay. And I performed an ultrasound and there was like a tumor in her ovary that was an endometrium. So when we performed the excision surgery after, well, she had her FSH normal and her estrogens level not normal. So we were like, what is happening to her pituitary? So something is wrong there, right? So we found out that the levels of estrogen that the endometrioma was producing didn't need or she didn't need to produce the FSH because it was regulating. So I think there's not so much information there because the estrogen that the endometriosis produces doesn't get into the bloodstream labs usually.

1:47:40And in this case, she had estrogens like if she was a 15-year-old, but postmenopausal. So it was really weird. And after we performed the excision surgery, her estrogen levels went down. So I was like, huh, this was self-regulating her. So that's why she didn't have any perimenopausal or postmenopausal syndromes. Her endometriosis was helping her. But what I'm going to go with all of this is that if you have a rectal nodule because of endometriosis and you go through menopause, you're going to still have your rectal nodule. The thing that does go or diminishes is the amount of estrogen. So sometimes, for example, in patients with adenomyosis, as they are not longer bleeding, they do feel a relief of the symptoms, but the disease is still there.

1:48:31With that patient, how was her endometrial lining? I'm just curious because if she had all that estrogen, but no progesterone. Yeah, it wasn't enlarged. It was really weird. It was a really, really weird case. That's why I wanted to publish. But it was before we have like where I used to work. There are not like very records like it was all on paper and the files. And it's a long story. Well, yeah, hopefully we'll be able to publish. I know. I'm like, when you do share that with us, we'll share it with everybody. My last question about treatments, topical lidocaine often gets prescribed when a woman is having pain at the endroitus, the opening of the vagina.

1:49:14What are your thoughts about that? I mean, I can kind of guess where you're going to go, but. Okay. So you can have like, in order when patients have vaginismus or they have memories of pain, because sometimes pain is the memorization of the pain. So when they have had experiences with sexual intercourse that are painful, they remember this experience and they start feeling pain even before the experience begins. So sometimes the gel, the vaginal gel that has like a water-based gel and does have lidocaine can help them to improve the experience. But it won't do anything about the real cause of the pain unless they address it.

1:49:56Okay. So it numbs the symptom, but it doesn't give you any real relief. Well, thank you so much for taking the time. Thank you so much for having me. Yeah, thanks for bringing all your models. Thank you. Good energy in. Good energy out.

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