- Good morning. I am Dr. Devin Garza.

I'm a private practitioner here at North Austin medical center, Women's Renaissance group, and I've been in private practice for the last 25 years.

I'm here in Austin, Texas, my favorite town.

And today we're going to be talking about endometriosis, pelvic pain.

And what I like to do when the groups are small, and by the way, we're recording this today.

So this will be lots and lots and lots and lots of people will be able to see this for a long time to come.

What I'm hoping to do is to bring some perspectives of awareness of sensitivity, not only to the medical community, which we had a meeting this morning, but we're also to the public and be able to have kind of a increased perspective on what does this mean perhaps for you, or what does this mean for your family member or someone else that you know.

The lecture I'm about to give you, I just gave I'm using the same slide deck.

I'm gonna use some of the same language and some of the lines I'm gonna change a little bit.

So I make sure everybody understands it.

But I'm also going to talk about it from the perspective of a doctor who works with this every single day.

Part of my practice is kind of evolved around the use of robotics.

And that's gonna be a little bit of the lecture.

Really I'm not gonna try to teach you how to use one.

What I'm gonna try to do is let you know why I think it's very helpful and how that particular tool allowed me to do better care for my patients.

That's a lot of what today's going to be about, but we're also gonna talk a lot about endo.

We're going to do question and answers and I can't give you a full consult today or anything like that, but I can help on some of the most common questions that I would hear.

So we're gonna talk about.

We have some videos to watch what we're going to do.

The question and answer session.

We're going to describe and discuss endo and the role of endometriosis in pelvic pain.

How that is, why that is, what we do about it?

And then, how does the robot help that stuff?

Okay, so I always start with this slide because it's my perspective.

So who's giving you the talk.

I've heard your perspective on where you're coming from.

Not to talk a lot about me, but just to let you know, it wouldn't be the same lecture coming from somebody else necessarily.

This is a sunrise in Hawaii.

My wife and I love sunrises, I mean sunsets, and so sunrises typically she may not want to wake up for.

It's the exact same thing I think is beautiful.

And I think it deserves a lot of attention and she doesn't.

So my perspective on endometriosis and, my patients and my tool kit in my clinical skill set, isn't the same as everyone's.

And this is my perspective on how I'll give this talk today from a robotic surgeon and why I do robotics.

We'll talk about that a little bit.

But also as someone who really likes to take care of trying to be a champion and a hero for their patients.

Most of us like that, we want to do that.

It's just a matter of your ability to manage that type of stuff.

So pelvic pain, right?

Pretty much something you guys are familiar with seeing your family members with, or seeing yourself in the mirror, or at some point in time, realizing that there is a lot going on here.

There's so many different possible things.

But the one thing I'll always tell my patients is, I'm not sure why your doctor said this, but I can almost assure you, It is not all in your head.

Raise your hand if you've had anybody ever say that to you or in some form or fashion, look at you like that.

That's what we see a lot of.

And the problem is maybe that they love you fine, they care fine it just as very likely, they don't have a good understanding of this kind of a tip of an iceberg phenomenon that endometriosis can be.

In a patient's mind, they don't know what it is.

Sometimes they can't really describe it.

Well, I mean, doctors and their families we're patients as well, right?

We're also patients.

And so being able to help your doctor with your symptoms is key.

So as other patients or endo sisters ask about how do I talk to my doctor, just say be as articulate as you can.

When does it hurt?

What makes it better?

What makes it worse?

Is there any bowel symptoms involved, anything a bloating, diarrhea, constipation?

Anything with your bladder that's involved, any blood when you empty your bladder, when you urinate?

Does it hurt during your cycle?

All the information is very, very valuable to your physician.

From the gynecologic causes of pelvic pain.

You may have been to the ER.

I bet if you say raise your hand, everybody's gonna raise it.

But going to the emergency room and you're diagnosed with pelvic inflammatory disease, when really the diagnosis doesn't fit that.

Another thing is the bladder issue that we talked about.

But an ovarian cyst, can mimic certain things.

And so your ER doctor may say, well, it's just a ruptured cyst, even though they didn't find a cyst, they didn't see a lot of fluid on the ultrasound to support that.

They're just gonna call it something.

Mittlescmirtz is that kind of pain you get with your ovulation or ovulation pain.

It means pain in the middle.

So mid cycle pain, when you ovulate, that can be, if you're not on something, that's gonna keep your ovulation under control or prevent ovulation like the pill or something like that.

Or they'll say it's just adhesions.

And those things may be true, it's just that you can't just say it's black and white, one thing or another and they all may be to some degree kind of combined.

Plus endometriosis can cause symptoms in all of these areas.

So we never say it's all endometriosis, but always understand that the endometriosis can affect all these other systems.

And it's not easy to tease these diagnoses apart.

When we talk about it endometriosis patients frequently have lots of questions.

I mean they're like, what is it?

How do I, why do I, it, how did I get it?

What am I going to do about it?

How do I get rid of it?

What about getting pregnant?

All those things are valid and they're very important and it's not black and white.

It's not a cookie cutter approach.

Although there are protocols and systematic ways of going through this type of stuff from your doctor's perspective.

Common symptoms of endometriosis are the chronic pain components, right?

Chronic, that means you've had it for multiple months, four, six months.

Definitely painful sex, deep, not kind of entry pain and not the kind of pain that's just once in a while, even though that's still possible, it's that deep pain almost every time.

And honestly your doctor on an examination, if they can reproduce that pain, it's so likely to be endometriosis, so likely.

That's frequently the initiating factor that I will decide to take someone back to surgery for, to actually diagnose it.

And we're going to talk about that in a minute.

Pain with your menstrual cycles, not a couple of Motrin and you're good to go, but debilitating you're out for four hours or you can't make that party or you're out for two days.

There's, variations in how this can look for any woman, but highly, highly suspicious in patients that have this type of stuff.

Painful bowel movements all the time, maybe, but for sure if at your cycle things can get worse and it hurts when you have a bowel movement, stabbing pain, you have to tell your doctor that.

It points in my mind, I see images in my mind because I've seen them so many times of what that's probably going to look like.

And I want to get the appropriate physician, a colorectal specialist, or a general surgeon there to help manage the bowel aspect.

So it's important to let your doctor know as many symptoms as you can possibly detail.

Less common, but not unrelated, but can be certainly endometriosis are going to be nausea with your menstrual cycle, bloating.

Does that mean you have endometriosis on your GI tract?

Maybe. Definitely. Maybe, but it can be a secondary symptom as well.

Bleeding when you empty your bladder, when you urinate, you actually see blood that's really, really important.

Could it be a kidney stone? Sure.

Could it be just a terrible urinary tract infection, a hemorrhagic cystitis we call it? Maybe.

But it needs to work up.

It needs to be evaluated and you need to tell your doctor, all these things.

Rare. Okay.

So people always think once I have endo, they think of it in a former fashion like cancer.

And to some degree, I understand that.

And I treat it kind of in that way, from a perspective of trying to remove all that I can.

That's true, but it's not like cancer spreads as commonly.

I want to make sure to give you perspective on this kind of stuff.

It's not common to have endometriosis on your diaphragm.

It doesn't mean it can't happen, it absolutely can.

I have met those people.

Every month you drop a lung or part of your lung drops.

You can't breathe.

It's really, and it's in the literature.

It certainly is.

It requires not only your gynecologist would typically be very, very unequipped to manage that, but a thoracic surgeon with your gynecologist with lots and lots of preoperative discussion so.

Difficulty breathing, pain breathing your lung drops on a monthly basis, other organs as well.

Not likely that you're going to get endometriosis in your brain, okay.

So a headache if you have endometriosis, you wouldn't think I've got endometriosis in my brain.

It's so rare and uncommon.

It would be very, very unfortunate and it can happen.

Can doesn't mean that it probably will.

So I want to ease some of the tension on that type of stuff.

Yet if the workup has continually been negative and you have endometriosis, you need to present that as a potential, okay.

That's still true.

When we talk about endometriosis from the, what is it exactly?

What is it?

OSIS refers to a condition.

That's just the word that we use for condition, a situation.

And the glandular lining of the uterus is called endometrium.

So endometrium in a condition where it lives outside the uterus is where we get the term endometriosis.

Common sites.

We just kind of mentioned, for the most part, you all know this, but the most common thing is going to be the pelvis.

And why is that?

Because pelvis is shaped kind of like a bowl, okay.

It's the floor and your fluid that lubricates all of the abdominal organs, peritoneal fluid is what that's called kind of rest at the bottom of the bowl for the most part, even when you're on your back, it rests for the most part in the abdominal, I'm sorry, in the pelvic cavity.

So if your intestines are for the most part, moving they peristals, okay, they move a lot.

It's not likely you're going to get endometriosis on your small intestine.

It's not very likely it can.

It's just not likely.

Especially there's rare setups where you have larger intestines are stuck anyways, so your bowel is not really freely moving.

so that can happen.

It's just not likely.

Way more commonly your symptoms are coming from pelvic issues.

And that's going to be the ovaries on the ovaries, in the ovaries, the lining of the sidewalls.

So if we're in the abdomen at this moment, the dry wall here is called peritoneal lining.

There's a lining so that we don't have like the pipes, the electrical, all that stuff showing, right.

Those are your organs that are behind that.

The carpet, same thing, it's a lining to the abdomen.

And that just is place where you'll get most often the implants to occur.

And they cause pain because the peritoneal lining has nerve endings, okay.

They're not real specific.

Like if I close my eyes and pinch my wrist, I know where that is.

Inside if I were to pinch your ovary, you may feel that down your leg.

You may feel that in a very general sense, even in your back.

The back part of the uterus, back part of the vagina, the innervation of the nerves there will be towards your back, okay.

Not specific exactly to where these things are located.

Your hip might hurt if the endometriosis is anywhere near that on the peritoneal lining.

So that can radiate.

We call that not radiation, but it radiates pain.

That's not even where the pain is.

Or the actual inflammatory process.

The inflammatory process is elsewhere, but it feels like it's over here.

Fallopian tubes, bowel, bladder, appendix, make sure who still has an appendix by the way of the endo sisters here?

Okay so, endometriosis can, with advanced endometriosis, you can have upwards of a 30% likelihood of endometriosis on the appendix.

So these are things to kind of talk to your doctor about.

What about my appendix?

Less common areas we talked about, the diaphragm, lungs and brains is much, much, much more rare.

So how many people have that?

Well, everybody in this room for the most part, but it's important to understand the general population, how do they even come up with that number?

Well, it's incidentally at this surgery for a different reason, they saw endometriosis.

I don't know who was making that diagnosis, but what I do know is a lot of people don't recognize endometriosis.

I tend to think it's a lot higher.

It doesn't matter.

What it matters is in patients who are in fertile, the upwards of 40% may have endometriosis.

In patients who have chronic pain, which is the base this whole talk is mostly about upwards of 80% of women with pelvic pain, especially some of the ones I'm going to tell you about chronic painful sex, painful bowel movements, especially at your cycle and debilitating pain with your cycles, right?

Upwards of 80% have endo it's a lot, okay.

It's a lot.

So what some of this stuff really is more, I would call it a bit esoteric, but it's important to understand, where does it come from?

And give me some perspective on that.

Is there a genetic role?

Well, it's complicated, okay.

I think there certainly is.

And there's lots of literature to support that there's a genetic element.

A first degree, relative, by the way, it's your sister you have upwards of about a 30 to 40% likelihood of potentially having it yourself.

You may not respond in the same way, but that's important.

Twins, identical twins, studies on identical twins, high correlation between those, both of them having endometriosis.

Did it come from embryologic tissue as I was forming?

And that's now just being expressed.

Probably there's some degree of that.

We think there are, cause it would explain the patients who don't even have a uterus.

How do they have endometriosis?

That would explain that.

Especially with the background in your genetics of having some predisposition for this condition to develop.

Hematogenous or lymphatic, like it goes through your bloodstream, all these places or through the lymphatics, which drain the kind of the fluid aspect of the blood.

Yeah, there's some degree of that.

Some studies would agree that there's part of that too.

But to be honest, I have so many patients that come in and they just want to throw this retrograde menstruation theory out the window.

I don't think you should, I think it's extremely important.

And it does help us on how we manage you in the future.

Why they put you on the pill, why they want to stop your menstruation, why would a hysterectomy help you in some way, form or fashion?

And why would it not help you in some way form or fashion?

But what retrograde menstruation means is that your uterus is a large muscle.

And as your uterus, squeezes out the menstrual fluid, the tissue also comes off of that, the lining.

So partly blood, partly tissue, but it also squeezes up your fallopian tubes and into your abdominal cavity, mostly there in the pelvis because that fluid generally rests in the pelvis.

We see this.

This is a very typical finding when we go to laparoscopy, especially at a woman's menstrual time.

The fluid from that, that's a laparoscopic picture.

The patient is on her back in surgery and for us to do surgery, we have to put you in a tilt so that if this is your legs, and this is your head, we tilt you back like this so that your intestines fall out of the way up towards the diaphragm, so we can see otherwise it's like looking in a big bowl of spaghetti and meatballs.

And you're trying to look at the meatballs at the very bottom of the bowl, you can't.

So we have to tilt you, and that's what that's for.

With the patient tilted on not on her head, but about 30 degrees, that's still in the pelvis.

And so I'm trying to express to you why that these things affect your pelvis so much is because typically that's where the stuff rests.

And why it implants genetic, sure.

I mean, I can't overestimate how often I've seen patients.

My mom had it, my sister has it, but not necessarily, right.

And then why it hurts some women and other women it's an unknown.

It is an unknown.

But it has something to do with genetics.

So when I try to describe the endometrial lining to patients with the endometrium, what I tell them is it's like this, the inside of a cantaloupe is very different than the part of the cantaloupe, the fruit part that we would eat, okay.

This is the uterine lining, and we always draw it like, it's a big cavity.

'Cause we call it a cavity.

It's not really a cave.

Exactly. It's closed.

It looks more like this most of the time, not that thick, but estrogen causes this to be thicker.

Like if we, this lining here, but progestin or progesterone make it kind of thinner.

So there's this interaction between the menstrual, I'm sorry, the uterine lining, okay, and the hormones.

I know that didn't show up too well, I'm sorry.

But in the earlier phases of the, you just had your menstrual cycle here.

This is the uterine lining and the uterine lining begins to thicken with the estrogen buildup.

Then once you release an egg, it kind of stabilizes.

So the uterine lining is undergoing these changes based on hormones, okay.

This isn't a woman, not on the pill or anything like that.

This is natural.

And then once the body determines you're not pregnant, what happens is all of those hormones essentially fall to a level so low that that uterine lining is no longer supported in the uterus.

What happens?

It comes out.

It starts to come off of the side of the inside of the uterus and the uterus will contract it so the fluid comes out with the blood.

So imagine this happening.

but the endometrial tissue is living outside of the uterus.

It's still responding.

It doesn't know it's in the wrong spot and it doesn't respond normally.

Things happen and things happen to the tissue where it's implanted.

So we know that what happens over the course of time is inflammation.

So I always tell patients think of your eyelash, your eyelash is normal, your eyelash falling onto your cornea, your eye it's two normal tissues, but they don't belong there.

What happens? It becomes red inflammation happens.

So it's inflamed, it hurts.

Now the inside of your pelvis is not as sensitive as your eyes, right?

But think of that process, it's not like a infection.

It's not like cancer tissue, it's normal tissue that implanted.

And if you don't take that out or off, it's always going to cause that.

It's always going to cause some degree of inflammation.

Inflammation leads to fibrosis.

Fibrosis leads to all of these things can lead to in certain patients, a lot of pain.

So what we know these pain mediators, and I'm just going to give you a couple lot of studies on this type of stuff, the prostate gland and cytokines.

Inflammatory chemicals that lead to and cause pain, more blood flow to that area happens that shouldn't be there.

And then the fibrosis that occurs and this hyper vascularity and all of this leads to things, getting stuck.

Adhesions begin to form and they can be very, very dense or they can be very, very filmy.

We know that locally, the estrogen is way out of proportion to what it should be in those areas.

Okay. In those areas.

And that could be the genetic aspect involved with this.

We also know, and this is a very important one for everybody in this room, especially your friends or your family or educating women with the condition.

The nerve, what we call growth factors, certain things that happen, maybe because of your genetics.

I don't know.

And this implant you couple, all those things we talked about, we put them all together, but we know that the density of the nerve itself will thicken, okay.

So I tell patients, it's like, you had dial up speed, right, real slow.

You have some issue going on in the pelvis slowly that tells your brain something's going on down here.

And for example, if you fall and scrape your knee or you land down the steps, funny, what do you do?

You grab your knee, you grab your thigh, you grab whatever it was.

And you put pressure on it and you rub a little bit around it, right.

That's a reflex.

And that reflex happens because what it does is it floods your brain with more, what we call afferent signal, which means I'm doing something here that I perceive here.

And I'm flooding the pain, fiber sensation that are going from that injury to my brain.

But you can't do that in the abdominal cavity.

So it just hurts.

It's like leaving that eyelash on your eye and you're doing nothing about it, okay.

Over time, what happens is this the nerve density, because of this whole situation, you start to develop a T1 line that leads to your brain.

Now it may not be that big a deal.

So let's say stage one or stage two, which I see all the time, but you're incapacitated.

Are you therefore a wimp?

Is it therefore all in your head?

No, it's neurochemical okay.

It's neurochemical, and these have been shown in studies.

It's real, okay.

Why in one person and not another, we do not know, but it has to do something with genetics.

Is it all about genetics? No.

Is it all about the overproduction of estrogen? No.

It's all these things together, okay.

Knowing this helps you to know why we do certain protocols of management.

So you go through this kind of cyclic process where you have this tissue begins to proliferate under your own hormonal stimulation.

And then you get more vascularity.

The vascularity brings in more of these and sends more of these inflammatory signals.

It just, it's a fire that catches on, okay.

This is the kind of the pathogenesis summarize to you in a way I think you can understand it, which will help you kind of make some sense out of it.

Yeah, but you know, I just want to be out of pain, right.

That sounds great Dr. Garza, I just want to be out of pain.

I know.

Just make it go away, whatever.

But management always depends on the diagnosis.

And then knowing that pathophysiology behind it will help you to understand why we choose certain management options.

So we talk about, you guys have all been diagnosed, but we talk about kind of this working diagnosis, a presumption.

Well, I think you might have endometriosis.

Can we mask these symptoms or should we mask the symptoms?

That's another way to look at it.

And there's a couple of instances where I don't mind masking symptoms.

As long as the patients know, that's what I'm doing.

I think we're going to try to talk through endometriosis for a minute.

'Cause I think you might have it.

16 year old, who is losing schoolwork every month because of her pain.

Obviously teenagers, I've had four of them, go through their ups and downs and moods, but there's something different going on here.

And so, unfortunately I don't get to see all those young girls who were suffering through endometriosis until their parents finally bring them in.

And then we start to talk through this and give them an idea of this is a real, it's very possible this is what she has.

But it's the middle of your school year?

I don't think we'd interrupt her to do surgery.

Why don't we at least mask the symptoms of her cycle to get her through?

I think that's very valid, very valuable.

I'm not running away from it, I'm happy to operate.

The thing is, does she need that surgery?

Well, I don't know how bad it is.

I don't know the propensity for that causing infertility or not.

I don't know if she's going to lead to chronic pain or not.

I don't know any of those things, but we talk through it.

We talk through it and now she's got an advocate, a doctor.

And then when is it time for surgery, right?

When is it time for surgery?

We talk through that.

If in her case, the pills not working, it's time to do something.

If she develops chronic pain or somebody comes in with chronic pain.

If there's GI or intestinal or bladder symptoms, we're going to want to work through that stuff.

We've gotta want to kind of make sure I get the right people involved ahead of time.

In case when I get there to surgery, we need an additional type of surgeon to go work.

I'm not telling you the 16 year old is sexually active or anything.

But if someone comes to me with painful sex deep, there's no waiting, there's no necessary wait whatsoever.

If I can reproduce the pain that she's been having, not one time.

I mean, we want to rule out and assist and we're going to go through workup and an ultrasound and imaging, et cetera.

But if the patient is coming and tell me, I just, we can't have sex. It's been getting worse.

I do an exam, I feel that even if my ultrasound is negative, which most of the time it will be because you don't see and know on an ultrasound, unless it's in the ovary and once a blue moon, if it's awful, if it's awful deep, infiltrating endo.

So that person's going to go back 'cause I'm 99.99999.

In fact, I've never seen it where it isn't endometriosis.

And then if imaging, you see someone with pain with an endometrioma, a cyst that looks like there's endometriosis in it.

You're at risk for that ovary twisting on its blood supply and losing that ovary forever.

And it also is an immediate indication that the patient has a higher level of endometriosis.

So those people all will go back for surgery.

What are we going to do?

Well, we're not just going to take a look and buzz, buzz, buzz, buzz, buzz, okay.

We are going in with the ability to see a sensitivity of what it can look like and then wanting to get that eyelash out of your eyeball, right?

We are going to take that inflammatory causing issue out.

That is excision is what that means.

Looking at a laparoscopic evaluation.

So you're under anesthesia.

Everybody here has actually had surgery, I know that.

When you look, not everyone can recognize what endometriosis can look like.

So that is, a skill set that takes some time or surgeons who train under places, where they can help you to see these things adequately.

But, I'm just telling you, from going into residency 29 years ago and moving through residency, most people, most docs don't have the ability to be able to tell the difference sometimes.

And there's ways of doing that.

And the robotic platform going to tell you, I think is a big boost in that.

I always also say you have to believe in the patient's symptoms and believe in everything I just told you about already, which is all of the literature obviously to know that you have to hunt.

You have to look carefully.

You have to look very, very closely at the tissue, but also have a willingness to know that you have to know your anatomy and be able to remove this tissue from wherever it's at.

Okay, so the American Society of Reproductive Medicine has a staging classification, one through four, mild, moderate, severe, there's all these very, very important kind of esoteric for the patient I think.

Value points that give you whether it's mild, moderate, severe stage one, stage two, stage three, stage four.

But for you just to know, stage four doesn't mean more pain.

In fact, for someone to develop stage four means they were probably pain-free for a long time.

If someone has horrible pain and they're 17, I'm pretty sure I'm going to see stage two or three active stage two, stage three is for some people incapacitating, absolutely debilitating.

So for you just to understand, yeah, we do have classifications, but it doesn't mean your symptoms correlate with the severity of your disease.

And we don't know why that is, we don't.

Genetic? It's not because of you.

it's something that's going on at that level.

These are, if you haven't seen it and maybe you've already done lots and lots of research on it by this point, but this is what it kind of looks like to us.

This is a very close inspection with a laparoscope.

And this is not as pretty as it would look even on regular laparoscopy or for sure robotically on 3D high definition visualization.

But these are implants.

They're red, the tissue around here, it looks fairly normal.

It doesn't show up real well, but you could see there's some fibrosis or it's a little bit whiter, thicker around those areas.

Same thing here, a little easier to see.

These are what we typically call powder-burn lesions.

Some of us think that those probably don't even hurt.

They're not active anymore most likely, but remember all those changes going on inside the uterus.

Now the peritoneal lining has covered these lesions and this happening within these little, almost kind of a capsular type of effect.

But this is also abnormal.

Do you see this tension distraction?

So if the endometrial lining has nerve endings and this implant is on my jacket right here, but it's doing this to the rest of the peritoneum, if I was only to vaporize even with a laser or, or whatnot, or cut out just that little bitty segment, I'm not doing anything to the rest of this tension.

And so patients can still be in pain by virtue of that.

These are things that aren't really clear in the literature, but I have seen it so many times over and talked to lots of other docs, et cetera.

That we do a wider area resection, when we see areas that are abnormally puckered, thickened, changes that are due to chronic inflammation, all of those things.

We want to interrupt those afferent pain fibers going to your brain.

Here's a little bit worse, right?

You start to see these kind of pockets form.

You start to see, remember this is normal, right about here.

That's normal stuff, maybe normal right around in here.

This stuff is all abnormal, all of it.

And you have to kind of look back a bit to see where is anything even normal?

Much less, if we look in there and we think that's the only abnormal finding is that big, giant one in your face.

And that this stuff is from some other condition.

Well, what other condition can it be from, right?

Does it hurt?

This would cause somebody to have very painful sex and very painful bowel movements.

That needs to be resected.

But it sounds easy.

It sounds easy.

But when you start looking at stuff like this, here's the uterus and I'm not bringing you the worst things I could possibly find.

I'm just giving you a gradation of what I see all the time.

This can hurt worse than this, okay.

To get that view is a 10 times zoom on a little area, right about right there, okay.

It's not that easy.

Someone with this on the ovary, if you were to ovulate, it would not go very far out of the ovary because of all these adhesions.

This kind of a net around your ovary.

You can't know that until you look.

You can't even begin to treat that until you look.

But when you start finding things like this and this here's your uterus, here's an ovary with big endometrioma in it.

Here's another ovarian cyst.

Or it might even be the fallopian tube.

Here's the bowel, okay.

One wrong move in here, and you can end up with a colostomy the rest of your life, okay.

That's why docs tend to be very careful with you, right.

So I don't wanna throw everybody under the bus.

I just wanna make sure you understand.

It's not as easy as waking up saying, did you get it all?

Most of the time I can say, yes, I got as much as I could find was abnormal.

But when you start having organs connected to each other, the bowel to the ovary, I can separate that.

And then we can take the surface of the abnormal stuff off the side of the peritoneum.

'Cause you don't need that, it'll reform back.

But if we start taking this stuff off of your bowel, you run the risk of serious problems with your bowel.

So just so you know, it's not like we can't do a lot, but there's limits, there's limits to what we can do.

Okay, we direct our management, therefore for the most part.

We're not talking about infertility right now.

We're talking about pelvic pain, pain, pain, pain.

With your symptoms, do you want to get pregnant or do you not want to get pregnant?

I use this little segment to make sure everybody knows that nobody has a cookie cutter.

If I would ask everybody what you've had done, we heard a little bit, but it may not exactly fit for everybody.

And if someone who likes to have a hysterectomy done, because they're done having kids, we're going to talk about that.

What else do you do?

Do you just take the uterus out?

What does that cure?

We'll talk about that.

If they want fertility and you see awful endometriosis, if they don't have pain, it may well be that you don't have to put them at risk of the surgery to take things off of their bowel, to take things off their side wall.

And they will probably get some degree of an infertility assisted reproductive technique, IVF, IUI, that type of stuff.

But for the patient in pain, that's a different thing.

Patient in pain needs to be managed for her pain.

Age of the patient's very critical.

Failed treatment very, very critical.

Severity of your symptoms.

So another time where I kind of say, listen, we have endometriosis, I saw your op note, it's diagnosed.

How bad does this bother you?

Are you losing quality of life?

How much?

And if they're saying a lot, I mean, significant.

It's enough for me to say, let's go back and let's do what we can.

If the other side of the coin as well.

I mean, it hurts a little bit when I do this, it hurts a little bit when I do that, I'm okay to say, well, why don't we just watch and see how you do, you may never need another surgery.

Happy to go in if things get worse and you think it's time, I think it's time, you've got the condition.

That's a difficult conversation for another person to have, who's not that same patient.

So it's unique, your treatment is unique.

Surgical of course is the cornerstone around which you build all the rest of your post-op.

So perhaps we'll talk a little bit about it.

Lupron, we'll talk a little bit about progestin, some form of suppression, pain management, all of these things have a place.

Massage therapy, acupuncture.

We are all holistic people.

We're mind, we're body, we're spirit.

All those things matter.

When you've got one thing affecting you, it can affect everything.

Conversely, if you affect everything, you can help affect that.

But in my mind, it can't take the place of surgical visualization and excision.

That's where you build everything from, okay.

I know this is confusing as it could possibly get.

But when you have that conversation individually, based on what your history has been, then it can make more sense.

So is there a place for all those things?

Yes, of course there is, of course there is.

Is it black and white, all of one and not the other?

No, it's not.

Okay, so if fertility is not desired, you're done, you've had your kids, God willing, or you're 36, you never planned on having kids for whatever reason.

That's all up to you.

What is the hysterectomy cure?

So early on in your diagnosis, you had an emergency hysterectomy, sort of, I'd like to hear a little bit more about that.

Is just it'll take care of your cycle.

I mean, I promise it'll do that, but what it doesn't do is take care of your chronic pain.

Will it prevent new endometriosis?

Well, from what I told you earlier, you won't have retrograde menstruation anymore, but you can never be 100% certain you have every little weed pulled in the garden.

That's what I say.

I always say, look, we'll get the big stuff.

I'll even then go down and get the little stuff.

And I've done this so much that I know how to get the little bitty, bitty, bitty, bitty, bitty stuff, but I can't see below the dirt, okay.

And conceptually, there may always be a little bit of endometriotic tiny little areas that because your system has now been hyper regulated towards feeling and sensing pain, it doesn't take much to cause that pain to be severe.

And that's true.

So ovaries, we talk about, yes, the stimulation from the estrogen will still potentially cause that growth of any residual endometriosis, but you probably won't need surgery again.

That's probably true.

You might, and you might get endometriosis in your ovary.

All those things are true.

But for the most part, most of us don't want to take a 32 year olds ovaries out without a really long discussion that 32 year old will undoubtedly or 28 year old or whatnot will undoubtedly have a lot of hot flashes and night sweats.

And so at some point, trying to help her from, for that whole holistic person, that's still there for Lord knows how long we'll likely be replacing hormones, the same hormones, basically.

So it can cause your endometriosis to recur from a pain perspective.

But these are steps you take a little at a time.

My main thing is to tell you, it's not the absolute Trump card I hate using that word, but it's not the absolute thing to pull out your hat.

Okay, it's time for a hysterectomy I'm done.

So Laura, would you mind sharing a little bit of your history and what we've been through?

- [Laura] Sure well first off thank you for doing this.

And having us all here today because this is really important.

I wish that there had been something like this, or I had known about something like this years and years and years ago.

I would like to say that while we all live different lives, where there is that sisterhood is that our stories are, I think pretty similar for what we go through with this.

And that's where we bond in it.

My journey has started about 20 years ago and it was very frustrating in the beginning because I didn't have anyone listen to me.

I did have doctors kind of try to tell me it was in my head or maybe it was this or that.

And something just didn't feel right to me.

And so I kind of just kept pushing and pushing for answers and finally, I had a laparoscopy and was diagnosed with a stage three.

I believe it was when I was 23 at the time.

And I just knew that the pain that I've been experiencing was not norma, it just wasn't normal.

And you know that in your gut.

So it's been a very long road and I actually did.

It was interesting when you just said that there was a period where you could go without pain, if you have severe endometriosis.