In this episode, we are joined by Dr. Ja Hyun Shin, a minimally invasive gynecologic surgeon, to talk about adenomyosis, a common underdiagnosed, and under-researched painful condition with limited treatment options.
2023 is the year we end endocrine-disrupting chemicals. We are OVER it! As consumers, we can try our hardest to steer clear of these awful chemicals in our lives, but when corporations start lying on the labels, how do we stay in check of our health? Coca-Cola has some explaining to do. Be on the lookout because their orange juice is NOT what it seems. Maybe it’s not a coincidence that chronic conditions are on the rise!
With more and more unregulated products and a lack of research on the market, it doesn’t seem like a surprise that a majority of those with a uterus is likely to develop painful uterine conditions. Problematic uterine conditions are so common these days, so why do they go undiagnosed and unheard of for so long? If you’re not sure what is causing your pain, our incredible guest today will make sure you leave this episode as if it was a mini-consultation for this tricky condition! Dr. Ja Hyun Shin, a minimally invasive gynecologic surgeon, joins us to talk about our main subject adenomyosis, a common under-diagnosed, and under-researched painful condition with limited treatment options. We cover what adenomyosis can look like, what treatment options are available, and how you can get on the right track to a possible diagnosis.
Lastly, we end on an eye-catching high note. Art is doing so much good in this world.
Thanks for listening, learning, and being you. And join us back here every Tuesday for all things uterus, in service to you, uterinekind.
Carol: We're running up a mile long escalator while it's coming down hard on our health because companies are poisoning us with the products we pay for. I'm Carol Johnson, and this is Hello Uterus.
Today we are joined by Dr. Ja Hyun Shin, a minimally invasive gynecologic surgeon to talk about adenomyosis, a common underdiagnosed, and under-researched painful condition with limited treatment options. Which is why we need to fund research, but first uterus in the news.
This isn't gonna end well for companies that hide behind lawyers. While profit obsessed leadership demands its formulators defy nature, and instead poison us with a cocktail of endocrine disrupting chemicals. Coca-Cola, I'm looking right at you. They are in receipt of a class action lawsuit, Gwen Phelps versus the Coca-Cola company.
Why? Because they're simply, orange juice is anything but simple. And it's definitely not orange juice. It should be simply not orange juice. Everything in here is processed and dyed orange to fool you. And then maybe the name of the Simply Orange Juice product would be spot on. You know, words of wisdom from my mom.
Life isn't complicated until you yourself complicated, and this is one wildly complicated way to squeeze oranges. The Simply Orange website states since the launch of Simply Orange in 2001, we have been making orange juice simple the way nature intended. Yeah, no, there's nothing about this that is simple and nature intended us to pick the oranges off the trees and eat them.
Okay, so really what's going on here involves something called a black book, which I just can't, not a little black book, because apparently the instructions here are very complicated. Simply Orange is, is a concoction that is the result of a highly engineered and unnatural process. Coca-Cola, as I said, uses a black book process to make the juice from this lawsuit.
I quote, the following, black book is not a natural growing process, but rather hold onto your hats here. An algorithm. that includes data about consumer preferences and approximately 600 flavors that make up an orange . I mean, yeah, I guess you could make up 600 flavors that make up an orange, but you can't make up this stupidity, this absolute insanity that that is simply orange Phelps alleges.
And again, I quote that Coca-Cola matches flavor data to a profile detailing many of the characteristics of an orange. And these batches consist of a tankful of raw juice that may be, I'm gonna throw up, that may be as much as eight months to a year old. Portions from multiple batches are mixed together, some newer and some older for a fresh taste according to Black book algorithms.
The Simply Orange Class action lawsuit further alleges that after processing removes taste and flavor, Coca-Cola employs flavor and fragrance companies to engineer flavor packs to inject back into the orange juice product to make a taste fresh. The same fragrance companies that formulate perfume. The same fragrances that are not at all regulated.
Not that, not that even if there was a law saying that they had to be regulated, we could rely upon them being regulated because the a p a is being sued right now for not following the law and regulating endocrine disrupting chemicals. Get this, the first lawsuit filed about Simply Orange, not being anything orange at all, was in 2012
So, so Coca-Cola and their army of lawyers have been pushing back on this stuff, and I just, I gotta ask, and I'm gonna ask, I, I'm gonna go to Atlanta if they're still headquartered there, and I'm gonna knock on the freaking door and ask like, could you take some of that cash and just actually just squeeze the orange.
Like, don't be poisoning us. You are literally lying to your customers and placing them in danger. It's disgusting. I have a container of this crap in my fridge right now. I paid a premium for this BS product for years thinking I was making a good choice as a parent. Now maybe you can understand why I am absolutely furious right now.
I didn't consider it processed food. I literally thought that they used a massive press to squeeze oranges, and what we got was the juice because it says, you know, simply Orange, and it's marketed as an all natural product the way nature intended that you were just squeezing the orange. And this is what I mean about running up the down escalator.
We do our best to eat a clean diet, relying upon companies to not lie to us. Meanwhile, virtually everything we put on our bodies and consume as fuel for our bodies contains endocrine disrupting chemicals. Chronic conditions are on the rise. Doctors are forced to rely on trial and error and primitive treatments because there's a lack of research.
Millions of people are suffering and remain in limbo. I mean, I just learned a few weeks ago that when pharmaceutical companies make these pills for these various conditions that we're all getting in a, in alarming rates, that they actually process and manufacture the pill with endocrine disrupting chemicals, meaning that birth control pill that you take, sure it has chemical hormones in there that are designed to treat the condition, but there are other chemicals in.
That are part of the formulations process that we don't even know about. Oh man, this is what I mean about running up the down escalator like we are trying so hard listening to the guidance of our doctors doing the very best we can, buying B P a free cans, which are now just lined with other replacement chemicals that are not necessarily any less harmful.
We wouldn't know because they don't test them. I feel like after the focusing on endocrine disrupting chemicals pretty hardcore for the last six months. That one, I'm mad. I am definitely mad. I'm mad on behalf of all of you because I hear the stories like I'm doing everything the doctor's telling me to do.
Why are my fibroids growing outta control? Why do I have cervical cancer? Yeah. Why? Well, we don't have the data because nobody's able to do the research because it's not funded, but. I'm thinking endocrine disrupting chemicals might have something to do with it. We have limited amounts of data. We certainly know that endocrine disrupting chemicals cause cervical cancer.
And given that, can we just get rid of them? Now, you'd be giving your body five star treatment just by only buying actual pieces of food, like potatoes and broccoli and carrots and just simplifying meals. It's better than getting poisoned. Nothing processed, just whole pieces of food and, and I'm not discounting the battle.
I have kids. It's a battle. But I am excellent at consumer revenge. I will not give them a single dollar. Coca-Cola, L'Oreal. Craft Hines, not a dollar. So listen up. Berkshire Hathaway, listen up, which they own significant stock in these toxic product makers, as they say in Silicon Valley. Pivot, baby, because we're not gonna take it anymore.
We're done. I'm not the only one. There are lots of entities out there who have been at this game far longer and are serving lawsuits right now. I'm just here hopefully drawing attention to it and announcing that we are going to be doing a significant letter writing campaign. The letters will be available in the U by Uterine kind app.
Go to@uterinekind.com. Follow us on Instagram at Uterine Kind. We will make these letters available to every. So that you can send these letters to CEOs of corporations, to their board, to their press people, to people in Congress, and we're not gonna take it anymore. 2023 is the year that the endocrine disrupting chemical meets its end, and it can't happen soon enough.
Okay, after this quick break to cool off, we'll be right back with our expert guest, Dr. Jahyun There's no easier way to make sure that your beauty and personal care products are what they should be safe and good for you than finding a source you trust that does all the homework for you. That source is beauty Heroes, a healthy beauty retailer that carries over 120 brands from around the world featuring truly all good for you.
Skin, body, sun, and haircare. Take a look at their selection and save 15% on your first purchase from their beauty store or on your first subscription with the code Uterine kind checkout. Visit beauty-heroes.com. That's beauty a dash H e r o e s.com. Thank you. Now let's get back to the. Dr. Jahyun Shin is the director of minimally invasive gynecologic surgery at New York Presbyterian we Cornell Medicine.
She completed her residency in obstetrics and Gynecology at Columbia University Medical Center, followed by a fellowship in minimally invasive gynecologic surgery at the University of Rochester Medical Center. She completed additional training in robotic surgery at Albert Einstein College of Medicine, Montefiore Medical.
After which she joined the division of Minimally Invasive Gynecologic Surgery. During her time at Montefiore, Dr. Shin served as the Director of Pelvic Pain and Multidisciplinary Resident Robotic Training, and was the associate director of the Minimally Invasive Gynecologic Fellowship program. Within these roles, Dr.
Shin focused on the education and training of residents, fellows, and faculty in performing safe minimally invasive surgeries. She's training future surgeons. Everybody. These are not common credentials for gynecologists. Like for those of you who are longtime listeners, there were buzzwords in there that probably has you cheering like buzzwords, like multidisciplinary resident robotic training, giant.
Yay for that, and a giant yay for focusing on pelvic pain and for the fellowship in migs. It is such a thrill to have you here, Dr. Shin. You are the kind of practitioner that we need to be seeking out when dealing with chronic conditions like Endo Fibroids and our topic today, adenomyosis, thank you for making the time.
I don't know how you have time with all of those responsibilities, but thank you for making the time to be here with us.
Jahyun: Well, thanks so much, Carol. I am overjoyed to be here today, so thank you for inviting me to speak today on this really important topic.
Carol: Before we get into adenomyosis, I would love for you to talk about how your fellowship prepared you, maybe inspired you even to focus your practice on an area that is in in desperate need of talented surgeons.
Can you talk to us a little bit about.
Jahyun: Sure. So the traditional OB, G y N residency focuses on dividing your training period on obstetrics and gynecology. So obstetrics deals with delivering babies and the health of the mother, um, during pregnancy and gynecology has to do with conditions that, um, typically impact fertility.
Bleeding issues, pain issues. Uh, you learn about common conditions like fibroids and adenomyosis and endometriosis, and this is when you get introduced to surgical management as well of some of these conditions. But there's only so much you can do in a four year period. And so when you want to specialize, um, you then go on to do a fellowship.
And the fellowship I did was, uh, in, as you say, minimally invasive gynecological surgery, which is a time period. In my training, I dedicated to learning minimally invasive techniques. So traditionally surgeries done with a scalpel, patients open wide recovery can take six to eight weeks. It can be a painful recovery, but over the past decade especially, I mean certainly even before that, um, but now more recently, minimally invasive surgery really has become the standard of care.
And there are multiple, multiple studies that demonstrate that if and when possible, that minimally invasive surgery will lead to faster recovery times. Um, decreased pain after surgery, allowing our patients. Able to go back to their routines and whatever it is that they want to focus on other than recovering, um, from surgery during fellowship, we primarily focus on three disease states, especially, which is chronic pelvic pain.
Pain. That's pain that lasts six months or more, limited to the pelvic area. And causes of pain include endometriosis and adenomyosis, which we'll talk about more today. And management of large fibroid, uterine, and still being able to remove these masses, benign masses through tiny, tiny little incisions.
And also adenomyosis, um, is in a way its own entity because it's almost like a cross between fibroids in the sense that it can make the u. Grow quite large and also lead to very painful pelvic pain issues and bleeding problems. Those are the primary areas of focus. And now you focus on these areas for a concentrated period of two years, and this is when you get the expertise that you need through doing a high volume of surgeries to become a specialist in these areas.
Not just surgically, but also understanding the medical management behind these conditions as
Carol: well. So you're choosing then to delay starting your own practice and, and continuing on with training, right. In order to receive the fellowship. So
Jahyun: that's what I did. Yes. After residency did an additional two years.
Now the fellowships, uh, are two to three years just focusing on these conditions and surgical techniques, um, and then developing a practice around these conditions. Yeah.
Carol: So I'm curious, and I don't, I don't know if you have a idea of this as these techniques come into play, like laparoscopic surgery and robotic assisted surgery, I'm curious what percentage of those going to med school to practice?
Gynecology will continue on in a fellowship because we, we are just in desperate need of trained surgical specialists for these conditions.
Jahyun: You know, you first get introduced to these topics and really it's pretty much that. It's just an introduction. Uh, read a little bit about, uh, these conditions in the textbook.
Get to see patients with these conditions on your rounds, but really not until residency. And if you do ob gyn residency that you get to learn a bit more about these conditions. But even then, you're not a specialist in this area. So it's really important for patients who have these conditions who, or think they may have condition these conditions, that they seek out specialists who have done this extra training where this is really all they do day in, day out.
They're not delivering babies, they're not really doing general OB gyn. A very specialized field. And you're right, we are in desperate need of more specialists in this area. You're in California, I know, with incredible hospitals and providers, and I'm calling in here from New York City, and I would say even in a place like Manhattan, they're really only a handful of fellowship trained surgeons for this condition.
So you can imagine what it must be like in the rest of this country.
Carol: It's terrifying. I mean, I, I guess I'm not able to connect the dots on this, but we know that, you know, half of the counties in the country lack just a gynecologist, and we know. That the incidents or the prevalence of these conditions is quite high.
With endo being one in 10, adeno I think is about the same. Um, a u B as one in three women, which includes fibroids, adeno, P C O S, that's a lot of people to treat. And so many of them go undiagnosed. And I think this is where when, I mean I can't connect the dots, I don't have the data that says, well, they go undiagnosed cuz they're not seeing a specialist.
And 41% of people who have abnormal uterine bleeding don't think that there are any treatment options because maybe they're not seeing a specialist. Right. I don't, I can't connect those dots, but certainly the data points are like blaring red lights out. Yeah, absolutely. Which is why this conversation to me is, is such a gift because it's, it's like a little mini consultation with you for the people that cannot get themselves to New York City.
So how would you describe the impact of symptomatic adenomyosis on the, the. Well,
Jahyun: it really ranges. The symptoms are on a spectrum. You can have women who never knew they had adenomyosis until they ended up getting a hysterectomy for another condition. Say for example, fibroids. Or you may have women who have suffered.
For a long time, years before they get the proper diagnosis. One of the things that makes adenomyosis especially challenging is that there's several symptoms and sometimes without the full knowledge of how to treat this condition and being aware of the best way to diagnose this condition, you can go on for a long time with a little bit of this symptom, a little bit of that symptom.
Well, now this symptom got better, but that symptom became worse. So it's very dynamic. So sometimes it's really difficult to pinpoint exactly what your symptoms are, how it all. Makes sense together and then to come to the right diagnosis. But it is so important that, um, you feel confident in your OBGYN who might not necessarily be able to perform the surgery, for example, by a minimally invasive route, but they can at least be able to properly diagnose or even start just having the suspicion, you know, that this patient may or may not have adenomyosis and then running, um, the correct evaluation for a better diagnosis.
Uh, some patients may experience just pain and other patients with adenomyosis may have abnormal uterine bleeding. Um, that's bleeding, that's more than eight days. Prolonged bleeding, subjectively heavier bleeding, bleeding in between periods, spotting, scan, bleeding, anything that's out of the range of normal, which is the eight days.
And, uh, requiring change in your pads or tampons or cups, whatnot. Every one to two hours constitutes abnormal uterine bleeding. Um, but these women may not have pain. And then you have about 20% of women who can have both. Also. Now what is this? Is this. Endometriosis plus a polyp, something totally unrelated, causing the abnormal uterine bleeding, or is this adenomyosis that can kind of explain the whole picture?
So it's really important that at least with any kind of pain and bleeding symptom, that adenomyosis is in the differential and important for patients to bring this up to their providers and ask, you know, could it possibly be this? And if they're not satisfied with the answers they receive, or the treatments they receive, and because they're not responsive to the medications that they're given, then it's important for them to, you know, advocate and consider a second opinion and hopefully getting to the right person even.
Carol: Yeah. So the, the symptoms can be indicative of other conditions. Is there anything that tips you off that has you kind of prioritizing adeno above others when you listen to a patient's expression of their symptoms? Well, let me start
Jahyun: with what is adenomyosis? Okay, so that is when the endometrial tissue, the tissue lining, what's called the endometrial cavity.
The cavity is where a baby would go during pregnancy. It's also where you build up your endometrial lining, and if you're not pregnant, you shut that and that is your period. While sometimes this tissue can imaginate into the muscle of your uterus, and so you still have that whole cycle of bleeding and breakdown of the tissue cyclically during your cycles, which can cause significant pain or abnormal uterine bleeding.
So one of the challenges. Is that one of the first things an ob GYN might do in this case is to send a patient to get an ultrasound. Oftentimes it's, especially in the presence of something else, such as fibroids, which is very common, occurs in 78 to 80% of women. Um, it might obscure a really good view of potential adenomyosis.
Okay. Unless there is a suspicion from the provider that this can be adenomyosis, they may. An mri, which is more accurate when it comes to diagnosing adenomyosis. But the challenge with adenomyosis is that the only way to actually diagnosis is after the fact, which is a hysterectomy, which means the uterus has been removed for other purposes, and the prevalence of adenomyosis found in the specimens from a hysterectomy really range pretty widely, but can be over 50% in women with hysterectomies for these conditions.
So it's really hard to pinpoint and diagnose prior to the actual surgery, which is what makes diagnosis hard, because you actually need a specimen to call it that. But the MRI is something I rely on on the mri. They should be measuring, uh, what's called the junctional zone. And if the this zone, which is the space between the muscle of the uterus and the endometrial cavity exceeds 12 millimeters, that's highly suggestive.
With the patient's symptoms of adenomyosis.
Carol: That's a great tip. So yeah, note that down. Can you, when you do an actual physical exam, are you able to feel, if, if, if the u if there's adeno is the swelling or, or the size of the uterus indicative that there might be adeno? .
Jahyun: Sure. You can tell a lot from the physical exam as well.
And it's important as providers, we're good investigators in this way, kind of putting everything together, the blood work, you know, if there's been significant bleeding, seeing how anemic a patient may be, the M r i as we discussed. But the physical exam also can be telling, so as I mentioned, uh, adenomyosis occurs when the endometrial tissue digs into the endometrial tissue.
And so this can expand and inflame during the cycles. And what you can have is, A boggy feeling enlarged uterus. So when you see on ultrasound, the report might come back as unremarkable, normal uterus, tubes, and ovaries. But if you look a little bit closer, and this is not necessarily for the patient because their job is to, um, you know, rely on your expertise.
Right. But as a gynecologist, if there's some manner listening, you can look into a little bit further. If we should look into a little bit further, if the uterus. Slightly enlarged even with the consolation of symptoms that the patient may be experiencing and also that the uterus doesn't look entirely smooth and homogenous yet.
Uh, there's heterogeneity to the myometrium and this is something that the radiologist will often describe. And so I see so many women refer to me with, according to them, oh, I had an ultrasound, it was completely normal, and then my OB GN told me was normal. And when you look at it, and if you skip all the descriptions and go down to the bottom, impression says normal uterus, tubes and ovaries, no clear pathology, and not read between the lines or actually read the lines, which says uterus is nine 10 centimeters and there's heterogeneity in the myometrium, those are still abnormal findings that warrant further investigation.
So it's something for both the provider and the patient to
Carol: think about. Absolutely. I, I actually, one of my questions was specific about how do you know if the person who's reading your imaging knows what to look for? Because as you indicated, it's difficult to spot on an ultrasound, and as a patient it can be a little intimidating to wanna say to a doctor.
Um, could you tell me about the credentials of the of the imaging expert that you have? Reading my films, you know, that that might not go over so well, but it kind of feels like that's what we have to do now in a lot of situations because of what you just described, that it just seems like it's a quick pass.
And as long as there isn't some giant fibroid in there that they're gonna say everything's.
Jahyun: Yeah. Yeah. I don't know if, if it's necessarily checking into the credentials, you know, there has to be some faith also in the providers, you know, with the intent of trying to take good care of you. But you know, it's pretty standard for radiologists to describe what they see in the muscle of the uterus.
So there will be a comment about whether there's homogeneity or heterogeneity of the myometrium wall. It's then up to the gynecologist to use that information to put it together with the patient's symptoms, right? Or they may describe cystic appearing spaces in cystic spaces surrounding the cavity or an enlargement.
The radiologist is just describing what they see. , every specialty has its responsibility. They're describing what they see. Then it's up to the gynecologist to be able to look at the images themselves and read the report. But they're the ones sitting with the patient, right? And so with the knowledge of the abnormal bleeding, pelvic pain, um, a slightly enlarged uterus, some disorganization, and the, uh, muscle of the uterus, then they need to take that next step.
Carol: And what, what is the next step? So let's say it's a, it's an m r i or an ultrasound, and there's concern that there is adenomyosis. What would be the next step? ,
Jahyun: like with most health conditions, there's medications or there's surgical management, there's more holistic approaches, and a good provider will lay it all out.
Okay, these are your options. Risk, benefits, pros and cons of each treatment option. And certainly with bleeding and pain conditions, unless there's something structurally abnormal that they can really visualize, they may say, let's try a trial of hormonal, uh, therapies. Many of these conditions are hormonally driven, so endometriosis is adenomyosis.
Estrogen can lead to this pathway that, uh, leads to pain. And so one of the. While the main ways that all these different treatments work is to decrease that estrogen response. Um, so, and it can come in many forms. It can come in the form you provide the patient with, um, all the different treatment options such as a marina i u d, which is a progesterone only device that sits within the cavity and really works primarily.
Space to reach the disease portions of the uterus can significantly improve bleeding and pain. Um, some patients don't like that though the idea of something sitting in their uterus and a foreign object, even though the risks are really minimal, they prefer to have a little bit more control over what they take into their body and when, and so they may opt for taking a pill of some form, either a combined pill with estrogen and progesterone to help control the bleeding and pain or a progesterone only pill.
And then there are other different types of medication. But I guess something I like to emphasize is that if a medication is being tried and the patient has. Been compliant with the medication, taking it daily or however often it is prescribed, and it's not working after two to three months. I say months because it's two to three cycles.
Usually the first cycle is probably not going to have full effect the second cycle. By the second month, you really should start seeing something by the third month. I say if it's not kicking in by then, if your symptoms are not, um, improved after three to four. It's time to think about something else.
And this kind of active management is what's so important to prevent this, you know, potentially decade of misdiagnosis or un diagnosis. So, uh, I would say this is a way for patients to advocate for themselves. How long should you be on a treatment really for no more than three to four months? So from the time they start you on a medical therapy, make sure you have a follow up in three to four months.
Okay? If you can't tolerate it before then that's one thing, but after three to four months, it's time to think of something else, either a different medication or now consider a surgical
Carol: option. Now I just read this comment from someone said on social about, going back to their provider because the option that they had picked, and I, I don't recall if it was ad note, might have been some other uterine reproductive oriented condition.
And when they expressed to their doctor that they didn't like the medication, the doctor's response was, you're not giving anything a try. And, and they were just like, ugh. Like that moment in pre-K or kindergarten maybe when you're a little bit older and the teacher's like, you're not trying and it just like hits you in the gut like an arrow.
So how does, how should someone respond to that? I mean, I, I know get a new doctor is one, is one obvious response, but sometimes there just isn't another option. As a matter of fact, in this particular case there wa I remember her saying, there is no other doctor for me to go to. How do you handle that? How would you recommend handling?
Oh, you
Jahyun: really have to tailor everything. There's no kind of cookie cutter algorithm for it that fits every patient. You have to see why they're struggling with the medication. Is it better for them, for example, to have a marina i u g, because they say, I really want to take this pill every day, but you know what, I have like three children running around me.
I have to get to work by this time. I'm just so frazzled and I forget a pill. They're trying, they're trying. , and it just means that there might be a better mode of delivery that makes it more convenient for them. So you may wanna discuss something that's longer term so you can remember to take it and take it consistently.
Or they may do all of that, but just have adverse reactions that really prevent them from wanting to continue even for another day. You know, a lot of these medications can be mood altering, right? So e so especially the medications that are, uh, primarily progesterone. are pretty effective in controlling some of these symptoms.
Well, it's really not an option if their depression or anxiety is getting worse. They're trying, but they shouldn't be because it could be unsafe for them to continue. So then you might wanna think about, well, with this patient, if they're, if they're having a poor response, um, to this one progesterone therapy, then it's going to be the same with this one and this one.
There's no point in going around and trying everything when the outcome is gonna be the same and potentially dangerous. So then you have to think, well, what are the. Non-medical options, and there are, there's for example, urine artery embolization, which can really be helpful for, um, heavy bleeding. It's a option that's not definitive by any means, but can improve bleeding associated with adenomyosis.
Certainly not a hundred percent. Um, but it also depends on the interventional radiologist who's performing this procedure, and this is a way to avoid medication, yet they want to preserve their uterus. Ready or want to have more invasive surgery or have their uterus removed. So that is one option. For example, that's not medical.
There's radiofrequency ablation that's kind of being used successfully, a bit off label, but with some success and certainly more data needs to be collected on it, which is a minor procedure, not a major surgery by any means where, uh, the gynecologist goes through the vagina, through the oin, into the uterus and ablates areas that have the fibroids and sometimes adenomyosis.
And the thing about adenomyosis is that the average age women start to experience symptoms and. Start seeking help for these symptoms happens to be towards the end of their reproductive phase, so in the mid to late forties, even early fifties. And so speaking then about a definitive procedure, which would be a hysterectomy, is something that should also be laid out from the beginning.
Every patient has different goals for themselves and choices that they need to make. You know, we can only present them with all the options, but that's key. Knowing what the options are, understanding all the risks and benefits as the provider, and putting it all out on the table and letting the patient decide how they want to be treated.
Carol: how would you recommend a patient handle a situation where the physician has made an assumptive diagnosis and wants to move right toward medication with the good intention of experience? In hindsight, having shown that these medications are beneficial, but the patient hasn't been able to have that experience of getting a definitive diagnosis and, and now they're moving toward treatment without really knowing what's going on.
Is there a way for them to advocate for a diagnosis and ensure that these. Steps are taken, like for instance, imaging. That's
Jahyun: a great question. Very insightful question. So I can only describe what I do in my practice, which is that every patient who comes in to see me is looking at the images with me and I describe everything I see and you'll be amazed.
It seems like a lot, like I don't have a medical degree, like how should I understand what I'm looking at? But you do know, you know, you can see the curvature of the spine, you point out where the uterus is. Um, you show them the bladder that's filled with urine, you show them the pubic bone. We know where the pubic bone is.
We know we have a bladder, we know how our spine curves, and it's a great visualization aid. And I think when they can. See what's going on. Um, I could see something click, definitely, and I'll point out to them, this is your intentional zone. Do you see this thick and dark line? Well, it should be this thin, but it's this thick.
That tells me that this is highly suggestive about Anom myosis. And when they see that, then they're like, Oh wow. I have a lot of it. Oh my gosh. And it's just really incredible how much of a better understanding and willingness to try different therapies and when they actually can visualize what is happening inside the body.
So in my practice, um, there's always a follow up. There's no imaging with a phone call. Um, you get the imaging done and we have a video visit because I want to show you what I am seeing, not just telling you what I saw. Um, and I think that just makes a huge difference and just, you know, gives them the confidence to decide a little bit better how they wanna approach.
Carol: Yeah, definitely. When you described that, I was thinking about something that you said earlier when you were describing what adeno is and saying that, you know, the endometrium makes its way into the, the muscular middle layer of the uterus. And I think that people kind of take that in and they don't necessarily, you know, especially in a consultation, you're moving on to the next thing the doctor's talking about, right?
So you just sort of take that in, like, okay, that's the definition of this condition. But I don't know how many people paused to think what it would feel like if you had something in your bicep or your calf muscle that every month was like growing and swelling, and then. Shedding blood that had nowhere to go.
I mean mm-hmm. , you know, some of us have experienced cramps from like running or something and it can be the, the, the most insanely painful experience and that's just your muscle seizing . Like that's not something invading your muscle. Then growing in it and you know, expanding and what have you. And so as you were describing, showing the person their anatomy, the feeling that I got was one of respect.
Like you respect them. To take the time to advise them, which includes some instruction on, on what to look at, but it's pretty straightforward. And then the light bulb goes on because then, then they can see like, oh wow, you know, even with fibroids like. Wow, that's the uterine cavity isn't like a giant bowl that you can, you know, serve a, a stew in
It has like the tiniest little space inside. And so when someone says that you have a fibroid the size of a tennis ball, then it starts to connect, you know, why you're in such catastrophic pain. So that's really amazing that you're able to do that. And I, I hope that as we deal with the challenges that we have in accessing gynecologic care and the equality of access to gynecologic care, that we introduce new offerings that enable people have these same kinds of experience, right?
We just get better at it so that gynecologists aren't having to do one-on-one bespoke education appointment after appointment. But like together we can work to get us all more up to date on our anatomy and informed about our anatomy and able to achieve that holy grail of shared decision making. , which is, is super empowering, right?
What you described was shared decision making, and what I described was a very common experience, which is, ah, you know, they don't, they're not a doctor, they're not, they don't really care about it. They just wanna know how to feel better. It's like, no, we, we need the education. Yeah,
Jahyun: I mean, it's really hard to, and you shouldn't assume how much each patient knows about their own anatomy.
So I start from the basics. I not only show them the images, but I actually take a pen and paper and draw it out. So this is the vagina, this is the cervix. When you put the speculum in, it's being put in here. And I don't give them an opportunity to say, what do you know? Or what you don't know. I assume that you don't know, or that even if you do, don't know, there's no judgment here.
I'm gonna go through the whole thing. Even if you, um, are a physician yourself, I do that even for physicians. Guess, guess what? I have patients who are hematologists, who are GI doctors, who are incredible providers in their own right, in their own field. Um, but ha hasn't done gynecology since medical.
Right. So, but then like, yeah, they may feel silly asking me the questions, so I go about that by just doing it for every patient. And I think that that makes them feel better. And I, I, I can't remember the last time, I don't think it's ever happened where someone's like, well, no, I know that. I know that. No, of course I know that.
No. and there's always something you can teach and, uh, there's a lot going on in there. There are a lot of parts, you
Carol: know. Absolutely. I think maybe part of the reason why we have this sort of mental block around having a detailed understanding of our, of, of female systems is that we as females have been kind of simplified and minimized and like people thinking that the U.
That it's like your appendix, you know that, that it's like a disposable organ. Um, there are reasons to have a hysterectomy, but there are also reasons to attempt to preserve your uterus and not like I was uneducated, terrible periods. And after my second child at 42, I remember right before delivering, I asked my doctor, can we do a hysterectomy at the same time that I deliver?
And thank goodness that it wasn't because there was any like education on how, you know, to try to delay and not disrupt my pelvic anatomy and stuff. It, I think it was like an insurance thing that they couldn't do it, you know? And so it didn't happen to me, but I know so many people who getting that okay for the hysterectomy is the greatest thing ever.
And I get why? Cuz the experiences that they're having with their symptoms are. Terrible. Mm-hmm. , absolutely. But you know, as you point out, like if there's more proactive management of these conditions and that they're diagnosed as early on as possible, then perhaps there can be a delay in a hysterectomy or a complete avoidance.
Right. And even a delay, the research shows that if you delay a hysterectomy, you have less of the potential for some of the more intense complications like cardiovascular conditions and early onset of dementia esque symptoms. And in people who are under 35 that I think it's 35 as the age, it could be even a little bit younger than that.
And I know people who are in their, uh, late twenties and early thirties who are like, I'm never having kids. I mean, even early twenties, I'm never having kids. I just, I don't need this. And it's like, Well, no, you might need it like, I don't know, the body doesn't really manufacture a lot of needless things, you know, like it seems everything kind of has a purpose.
So that is um, a little hysterectomy sidetracked. But before we talk about when that's the right move, because in situations it absolutely is the right move. Are there any, besides the uterine artery embolization, are there any other options? Like have you seen success with any committed diet or nutritional program?
Anything in your own practice where, you know, we may not have data on it, but you've been able to witness somebody have a successful outcome by implement? .
Jahyun: Yeah. There are so many different approaches and then there are approaches that kind of work best when all, um, utilized together. And there isn't the best data for diet or exercise, but in general, good diet and exercise is beneficial to your health.
And when you feel well and when you're eating right, we all. The differences we can feel. So whether it's actually helping to decrease the adenomyosis or really treating the pain and the bleeding, that's really secondary because if these things can make you feel healthy or give you more energy, less fatigue, ways to increase your iron stores, acupuncture, for example, to help with pain associated with your periods, these can all be quite beneficial.
Supplements to traditional medications and surgery as well, physical therapy, pelvic floor therapy. Um, some women may experience pelvic pain, mostly in the pelvic floor area. And so working with, uh, really good pelvic floor therapists may alleviate some of the symptoms to the point that with the Motrin and Tylenol, plus the pelvic floor therapy and some heating pads, getting the acupuncture, eating right, doing certain exercise activities, all of them might decrease your pain by like 10, 20%.
And for them, that might be enough to lead a better quality of life. So, you know, surgery is always the highest risk, right? Risk of infection, bleeding, anesthesia. You may plan for a minimally invasive procedure, but you might need to convert to a big open surgery, um, which can then lead to potential blood transfusions among hospital states.
So it's not something to just jump straight into without. knowing, um, what all the different options are. With that said, though, I listen to my patients, I get an sense of what they understand, and if it's very clear like, I got this doc. I understand I could try this, this, and this, but I really want my hysterectomy, , you know, uh, if that is conveyed, then I know it's their decision, their decision, and I'm going to do my very best to make sure it's done.
And that it's performed safely and that they are going to get the best outcome that we can all hope for. So there's a big role for just patient autonomy and respecting what they want and how far they're willing to go, and within those parameters, working with them.
Carol: Yeah, to make that happen. And then a hysterectomy is a common procedure, which makes me want to caution people from assuming that anyone can do a, a hysterectomy.
Everyone who is a practicing gynecologist has been trained to perform a hysterectomy, but I think that's where it's so important to go back to that image of you walking people through their anatomy. I imagine people picturing like a neat uterus and then a neat little bladder and a lot of space around perfect for you to go in and, you know, easily operate with no issues.
And it's like, no, it's not like that at all. There's nerves and tendons and all sorts of stuff. It's kind of like, think of gynecologic surgery like you would think of orthopedic surgery or brain surgery or, or something like that. It is very, very complicated. And it's also, it's your pelvis , which, which is like the foundation, right, for the body.
I mean, it, it holds so much. important stuff in my deeply technical language, that I'm saying, and, you know, so you gotta, you gotta make sure that you're with a surgeon that really is an expert at working in that area. No,
Jahyun: I think I, I understand where you're going. Um, so not all OBGYNs practice the same things.
So you can have an ob gyn who is an expert in menopause. I can tell you I'm not necessarily an expert in menopause because I've dedicated the past decade to really becoming an expert in surgical management of these conditions and also complex medical management of these conditions. So it's not that they're bad or wrong or bad doctors, it's just that this is not necessarily the expertise.
So there is this, um, misconception that if you're an ob gyn and I need a hysterectomy, while I could just go to my ob gyn, and this is where I would say patients need to advocate for themselves because, Within the field of OB g n, but also in all surgical specialties. What we have seen over and over again is that high volume surgeons have better outcomes, even for easy surgeries, that traditionally any generalist should be able to do the fellowship trained.
High volume surgeons will still have less complications than someone who doesn't do, uh, these surgeries often. So for example, hysterectomies and surgeries for bleeding and pelvic pain conditions. I do, um, several a week. You know, I'm operating two to three ti uh, times a day all day. Oh, right. I'm doing maybe 12, 15 of these a month.
the ob gyn you may have, may have done 15 in their entire career. So it's really important to advocate for yourself and be able to ask sometimes those uncomfortable questions, how many have you done, you know, in this past month? How often do you perform this procedure? And if they offer an open surgery, it is absolutely in your right, uh, to say, , is it okay if I can get or not?
You don't even need to ask permission, just do it, right? But you can say, do you, can you refer me to someone? If that's one approach you want to take, because you might really like them. As an obgyn, I wanna stay with them for general management. But when it comes to surgery, you might want to go to someone else and, and ask for a referral.
For someone who may be able to do this by a minimally invasive approach, you'd just like to, you know, have a conversation about it so that you're, you know, that you can feel comfortable with the decision you're making if it does have to be an open procedure. So I would say if it gets to the point that you're really considering surgery, that you seek out a provider who does this day in, day out, because high volume surgeons lead to less complications and better.
Carol: Yeah. That's so important to know and that that is data backed. You know, it's funny, we even like changing hairstylists, right? We're we labor over that and it's like, oh God, I just feel so bad. I don't wanna, how do I do this? And I don't wanna run into somebody on the street. Yeah. And and it's the same thing with gynecologists.
We're, I mean, I've talked to so many people who are like, oh, but you know, He delivered me and I'm like, my hair is on fire. That's not the, the criteria.
Jahyun: Yeah. And I really think that most gynecologists would have absolutely no problem with that and would be
Carol: understanding. Yeah, it's very true. I mean, as long if you ask the question, you know, some will, some will certainly say, Hey, I'm not the best person for this.
I really think that you should go and meet with this minimally invasive surgeon, but just know that it's your right. And it's also like what you would do in, in every other aspect of your life, , you would find the person who's best suited for the job. Right. So when it comes to your own body, definitely feel confident that that's an okay thing to do.
Two more things that I wanna touch on before, before we go today. And I hope that this is like the first of a few conversations that we can have cuz I have a hundred other questions for you on other things, but sustaining a pregnancy with adeno, so people have talked about being able to get pregnant, but that there's, um, Issues with spontaneous abortions in pregnancies with people, and sometimes they have been diagnosed with adeno, sometimes they haven't, but they're wondering if it might be the cause.
Can you talk a little bit about how adenomyosis complicates the ability to sustain a pregnancy and, and how you address that in your practice?
Jahyun: So, you know, I'm not a fertility specialist. Within the realm of reproductive endocrinology and infertility. But with the data, we certainly need more about it in terms of the impact of adenomyosis on fertility.
Some studies show decreased life, birth rates, pregnancies, potential, um, risks to the mother, certainly an older age of related to hypertension. But, um, it's not completely clear how adenomyosis can impact fertility. However, uh, what we do know is that adenomyosis and endometriosis share a lot of the similar symptoms.
So up to, it's pretty. Varied, but up to 20 to 50% of women with adenomyosis can also have endometriosis, which we definitely know can impact fertility and complicate pregnancies, including implantation, sustaining the pregnancy, the ability to get pregnant tubal factor. So again, it it, you have to really look at the whole picture.
What are the patient's symptoms? Did they have severe pelvic pain or painful periods since their teen years or earlier on? Or is this something that they're just recently experiencing? So it's important to really get a thorough history to try to target what aspect of their fertility might be improved, if there could be further evaluation of adenomyosis and or endometriosis.
Carol: Yeah. And one thing that we haven't stated, we didn't state at the top, but there is no known definitive cause for adenomyosis, which we need more research, but from the fun reading that you get to do in your downtime, do you have any thoughts on promising areas of research and, and do you see hope on the horizon for a better diagnostic pathway and also treatments that would allow someone to maintain their.
Yeah,
Jahyun: well, that's a very good question. We don't really know the cause of adenomyosis, but there are some theories, and one of the leading theories is that it can be an acquired condition, iatrogenic. That is, that it's caused by surgeries to the uterus that allows, that's a gateway for the endometrial tissue to then get into the, uh, muscle of the uterus.
So, for example, previous C-sections or having, um, D n C procedures or, uh, any procedure within the uterus can potentially increase your risk of getting adenomyosis. Can you prevent it? Not sure. I'm sure that having had these procedures was necessary at that time, but what's important then is knowing that you may have had these procedures and then developing these symptoms later on.
Now, you know, you heard me say it, maybe you already knew about it, but that if you've had instrumentation or surgeries previously on your uterus and then decades later you're now having this weird bleeding and pain, they're telling you the images are normal and you can start maybe putting two in together.
Well, the main idea behind how adenomyosis can occur is by way of some kind of previous procedure done on my uterus. This just helps with the investigative part of all of this. But in terms of research, yeah, definitely more is needed to elucidate a cause. Uh, whether it, this is something that's developmental, uh, whether this can be transplantation of stem cells from the bone marrow that develops within the uterus, how it actually spreads.
If so, these are all very important things to look into further.
Carol: Yeah. One of the things that I've wondered is, um, which, and it's not like a original thought on my part, but it, along with having procedures, I would just think that if you had a lot of births that your uterus growing so much and then coming back together and then growing again, and then coming back together, that there might be some small separation in that lining that enable.
The endometrium to, you know, make its way into the, to the muscles. I think that the takeaway is to just really picture that in your mind, like picture your uterus, which is supposed to be pretty small, three inches tall, two inches wide, about an inch thick, and imagine having something foreign to the uterus growing inside the wall of the uterus, and then connect that to your pain so that you can kind of wash away this idea that painful periods are normal and you just must be sensitive.
Forget about that and just recognize that there are conditions that are super common and benefit from getting diagnosed. Maybe this is just me, but not everything is cancer, right? So we sometimes people think like, oh my God, I think I, you know, I hope it's not cancer. And then you don't wanna go to the doctor cuz you're just terrified and eventually that thought goes away and you go to the doctor, you find everything's normal.
I raise that because stress really impacts our bodies and that doesn't make it easier to feel good. You know, I hope that what you take away from this conversation with Dr. Shin today is that adenomyosis is common. The symptoms make it difficult to diagnose. It really negatively impacts people's lives and there are ways to manage it.
Even if you're not ready for a surgery, like Dr. Shin mentioned, uterine artery embolization, which you can research. Knowing these options and being proactive in managing the condition with a physician that cares, it's just gonna feel better. Even if you're in, still in a watch and weight mode, it's going to feel better because you'll be on top of it.
Any final pep talk thoughts for people who are, who either suspect they have it and are having trouble getting a diagnosis or who are living with it and are not, um, really benefiting from their treatments?
Jahyun: Yeah, well the first thing I would say is periods should not be painful. Despite what the male attending in the ER might tell you.
Periods should not be painful. That is not normal. That's not a variation of how you should perceive period discomfort. It can be crampy. , you know that's because of prostaglandins. You can have discomfort. Now, why we see all those commercials about Mitol and whatever else, but that's it. But if it's getting to the point that you're requiring or seeking medical help, okay, that's not normal.
That is definitely atypical. That's your body saying that there's something wrong. So you are your best physician, and when that happens, this is when you should start seeking care. And hopefully through this talk and others, you have a little more knowledge about the signs and symptoms to look for. But also, if you are distressed, it's really important to speak with your friends.
Chances are you're gonna have some friends who have the si similar symptoms. I'll tell you, so many of my patients are referred from their own friends or family members who experience the same things. Have those conversations with your friends, your family, maybe on Facebook, look to see what's out there, um, and do your research.
You know, I don't agree with everything Dr. Google says for sure. But , the internet can be a good resource. And then at least you can bring something to your physician and say, you know, I, I, I'd like to look into this further. Can you reassure me why I shouldn't be worried about this? And if you don't feel like you're given that reassurance, You're absolutely free to look for another opinion, just like as you point out a hairstylist.
yeah.
Carol: And not feel guilty.
Jahyun: Yeah. Yeah. So I would say listen to your body, trust that you know how it's worked over the course of the years of your life. And when something is different, something is probably.
Carol: Yeah, don't be afraid of what might be up. Just seek to get to the bottom of it. You'll feel good knowing that you're in control of it.
I am so grateful for this insight. Can you share with us, are you on social? Is there a way for people to follow you?
Jahyun: Oh, I should be better at that, but I, I don't do any Instagram or Twitter. I should, everyone tells me I should. Yeah. With all that free time. Yeah. But, um, no, I have a LinkedIn site and, uh, that's pretty much it.
How old of me .
Carol: Yeah. Right. I know. Well, it's, again, I mean, it's, we talk on this show, we haven't talked about it on this episode, but we talk on the show all the time about the responsibilities that you have as doctors, which has only become more complicated every day that goes by, and the number of patients that you need to see and conversations on the weekends, late at night.
Talking to people that you can't fit in during the week because you were so stacked. I mean, it's, it goes on and on. So we understand that. So I think for people to be able to, um, just follow you, I would definitely recommend just checking out our instagram@uterinekind.com and we will put links to your practice so that they can get your name and be able to go on YouTube and listen to some talks that you've given.
And then just stay aware of these doctors that are training the new surgeons that are creating what I hope is a new way for gynecology to sort of flourish. So thank you, Dr. Shin for being here. Really appreciative.
Jahyun: Welcome being here. Great questions and hopefully many would find it helpful. But yeah, glad to be here.
Carol: We'll be right back with ending on a high note
Art Saving Lives. Street art is bringing more than just a feel good boost to drab city center junctions. It is saving lives too. This is amazing just by painting a mural on an intersection, just by having that mural there, the average speeds at the junction were slashed by almost half, and the percentage of pedestrians who've reported feeling very safe at this one intersection in Kansas City, which is considered to be a daunting and dangerous intersection, those feeling safe, jumped from 23% to 63%.
Look at that. A little art, some beautiful painting slows down the aggressive drivers and enables human beings to cross the street without getting mowed down. Little bits of art, they really make a difference. In Europe, a person stumbled into their future. This is so amazing. Thanks to a pothole, mosaics.
Now Adorn potholes in France, Norway, Ireland, Scotland, Germany, Italy, and Spain. And the artist is kind of taking a page out of the Banksy style book and is turning this urban decay into something beautiful, making the streets safer for pedestrians and remaining anonymous. While they go about doing it.
They live in France and, and they, they go around under the cover of darkness, find a pothole, and then build this gorgeous mosaic in it. Described as a bitumen, mender , A bitumen mender. I don't even know what that is. A sidewalk poet. That's very cool. And a macadam surgeon, m mem, at least I think that's how it's said.
It's spelled E M E M E M says his artwork illuminates the wounds of the urban fabric. Oh, it's so good. So his creations are increasingly visible, not here in the States, but all throughout Europe. I'm waiting for an arrival here, and they're absolutely gorgeous. They're these little works of art that solve a problem, which is a pothole, which is a broken ankle waiting to happen.
or a flat tire waiting to happen. So quote from the artist, I made a kind of mosaic, self tailored plaster for it without premeditation. That's, that's what he did when he looked outside and saw a pothole in front of his workshop. It's brilliant. He calls them flax. , which I think is, is a word for um, oh, it's the French word for puddle.
So the flax often resemble, uncovered archeological relics and are already gaining official recognition with six pieces being commissioned. So, gee, do you see that? You see a tiny little problem out there in front of you, and then you're like, oh, it'd be really cool if we just made a mosaic out of it. Now all of a sudden he's being compared to Banksy.
like, fantastic. And then, you know, people look at intersections and see like people speeding through them and pedestrians not feeling safe and pedestrians being hit and they decide, yeah, let's go. Let's go paint that. And then people will wanna slow down to sort of experience the art. And then that's gonna make first safer.
A safer intersection. And not that I wanna go back to the top of our podcast and and focus again on Coca-Cola and the Simply Orange fiasco. But this is really a great juxtaposition. Coca-Cola says, Hmm, how can we make orange juice really, really cheap to produce, but essentially just created a chemical compound that's liquid that people can drink and trick themselves into thinking that they're drinking orange juice.
So that's one way of doing it. And then there's the other way, which is represented by people like the artists that we've just talked about, where they say, you know what? There's a problem here and we think there's a really cool way to solve it that actually is really good for everyone and it doesn't harm anybody.
I'm going with those guys. This Banksy dude, creating the mosaics. Deserve a sash and a tiara. The artists who are painting intersections across America to help save lives. Again, honoring you, just absolutely honoring you, and you honoring you for being here and listening. Please spread the word about Hello Uterus so people can be informed and head to uterine kind.com to check out you by Uterine Kind.
Our app that enables you to really easily collect and monitor your symptoms in a super detailed fashion. We don't do any nonsense AI manipulation, and we don't sell your data. We just created a tool that allows you to get more in tune with your body. And collect and monitor data and then easily share it with your physicians, all while accessing tremendous amount of content created by people who are living with these chronic conditions and also experts that we bring to you so that you can hear from researchers and physicians that you might not have access to otherwise.
And so we hope that you will check it out. Thank you, Angel and Maryelle for producing Hello Uterus and thank you to our guest, Dr. Shin, and again to you for showing up each week to stay informed. Till next week, be well, be cool, be kind.