Welcome to season two Uterinekind! In this episode, we're joined by Dr. Eugenio Colón from the Center for Endometriosis Care in Atlanta to discuss minimally invasive gynecologic surgery and the best methods on how to navigate treating endometriosis.
Welcome to season two Uterinekind! We are delighted to be back with you in the podcasting space, bringing you the latest news in female health, interviews with doctors and researchers, and people who are breaking trails to improve our experience with gynecologic and full-body female healthcare. Make sure to tune in to our episodes to continue to spread awareness and spread education to lift health and body literacy for all uterinekind and have better health as a result!
The Mahalingaiah Lab at the Harvard T.H. Chan School of Public Health has launched The Beauty Edit Study! With the increased amount of research that emphasizes the higher usage of hair and consumer products among Black women. The evidence is clear: Black women are at a higher risk of exposure to hormonally active chemicals, or EDCs, and related diseases but it doesn’t just stop there! Chemicals in hair products have also been linked to hormonally mediated endocrine diseases that are more prevalent among Black, Hispanic, and Asian women and girls. We cannot keep dismissing this information for women of color. Want to learn more yourself? Consider joining The Beauty Edit Study! The Beauty Edit Study aims to address these concerns by providing a mobile-friendly website with comprehensive educational content to increase awareness and understanding of the effects of endocrine-disrupting chemicals on the reproductive and endocrine systems for 3 weeks.
To learn more information about The Beauty Edit Study, visit https://www.hsph.harvard.edu/mahalingaiah-lab/research/enrolling-studies/the-beauty-edit/
Joining us today is Dr. Eugenio Colón with the Center for Endometriosis Care in Atlanta, a world-class excision surgeon with a passion for shared decision-making and early intervention of endometriosis. He teaches clinicians, he's a minimally invasive gynecologic surgeon, and he's trained to do excision surgery, meaning he has the trifecta you want when choosing a surgeon! In this episode, Dr. Eugenio Colón shares his personal experience that led him to focus on endometriosis treatment, emphasizes the need for specialized surgeons in minimally invasive surgery for endometriosis, and advocates for separate specialties for obstetrics and gynecology. He also gives his best tips on what to do as a patient or doctor when navigating treating endo! It can be hard to access endometriosis specialists, especially one as skilled as Dr. Eugenio Colón, so stay tuned for this interview and share this interview to raise awareness and educate people about this common debilitating condition!
Lastly, we end on a high note that you’re gonna want to write down!
Thanks for listening, learning, and being you. And join us back here every Tuesday for all things uterus, in service to you, uterinekind.
Carol: The time is now. 2024 is the year we rewrite this narrative. Female health ascends, empowered by the surge of innovation. I'm Carol Johnson, and this is Hello, Uterus.
. Welcome to season two. We are delighted to be back with you in the studio, bringing you the latest news in female health, interviews with doctors and researchers and people that are breaking trail to improve our experience with gynecologic and Full body female healthcare.
This is going to be a remarkable year. So please subscribe to Hello Uterus, wherever you get your podcasts, make sure to tune in to our episodes and then spread this information because it is so crucial that we spread awareness and we spread education so that we can lift health and body literacy and have better health as a result.
That's our commitment to you to make it easy for you to stay in the know. So do subscribe and please leave us a review. If you love this podcast, it helps spread the word that the show is here and we'd be so appreciative Joining us today is Dr. Jose with the Center for Endometriosis Care in Atlanta, a world class excision surgeon with a passion for shared decision making and early intervention of endometriosis. It could be hard, to access endometriosis specialists. So stay tuned for this interview and share this interview to raise awareness and educate people about this common debilitating condition.
And essentially look at this as a free consultation, courtesy of the generosity of Dr. Jose. But first uterus in the news, we're back from the JP Morgan Health Conference in San Francisco, and female health was on stage, center stage. Not all the time, but trust me way more than in previous years.
Most promising were the conversations around the economic returns, and they are massive that result from investing in female health. So the thing that I'm most excited about is the fact that this data will not be ignored for much longer. I can just feel it. I can feel it. But we also have to recognize the problems that will not go away with the application of innovation.
Innovation will only thrive when problems like racism and bias in female health are eliminated. And that is why this book is so important. Legacy. A black physician reckons with racism in medicine, Dr. Uche Blackstock, Harvard trained ER doc. The type of doctor Brittany Watts would have benefited from encountering during the tragic loss of her pregnancy.
It was Brittany's third trip to the hospital in Ohio after the spontaneous abortion. Let's please end the word miscarriage. And it was at that third trip where she could have encountered a person like Dr. Blackstock, but instead she encountered someone who reported her to police. Brittany was charged with abuse of a corpse. This is what the repeal of Roe has accomplished. A desire to prosecute even when there's no evidence. Thankfully, the grand jury agreed. Britney Watts was cleared of charges, but not cleared of harm.
Dr. Blackstock talks about weathering, stress and racism impacting black health. This ongoing, consistent experience of running into barriers to care, of running into barriers to exist with equality in this country, and the toll that that takes over time. So while Brittany Watts was cleared of charges, Brittany's experience is a masterclass in weathering.
She's going to be impacted as a result of this experience for a long time. And as a testament to her strength as a person, one of her missions now is to make sure that this never happens to anyone else. We need to. Change the laws in this country and return conversations about our health to patients and their care teams happening within the privacy of a physician or care appointment and out of the hands of the legislators, the police, and the hospitals.
Y'all have a lot more to focus on. Go do that. And while you're doing that, we're all going to read Legacy because being informed is step one in taking effective action to support Your health and your community and to affect the experience of care for everyone. Speak out and defend the rights of women and girls to have access to compassionate and empathic care and read Dr.
Blackstock's moving, inspiring memoir, Legacy. And now a quick word from our friends at the Mahalangaya Laboratory about their new beauty edit study.
Angel: With the increased amount of research that emphasizes the higher usage of hair and consumer products among Black women. The evidence is clear: Black women are at a higher risk of exposure to hormonally active chemicals, or EDCs, and related diseases but it doesn’t just stop there! Chemicals in hair products have also been linked to hormonally mediated endocrine diseases that are more prevalent among Black, Hispanic, and Asian women and girls. We cannot keep dismissing this information for women of color. Want to learn more yourself? Consider joining the beauty edit study! The Beauty Edit Study aims to address these concerns by providing a mobile-friendly website with comprehensive educational content to increase awareness and understanding of the effects of endocrine-disrupting chemicals on the reproductive and endocrine systems for 3 weeks.
To learn more information about The Beauty Edit Study, visit their website which will be linked in the description of this episode!: Now let’s get back to the episode https://www.hsph.harvard.edu/mahalingaiah-lab/research/enrolling-studies/the-beauty-edit/
Joining us today, Dr. Eugenio from the Center of Endometriosis Care. The first few words that I'm going to say about Dr. Eugenio will be music to your ears because if you've listened to this podcast for any length of time, you know that our two favorite words, really three favorite words, high volume surgeon.
If you are going to see a surgeon for any gynecologic surgeon, what do you want? You want high volume and that's what we have for you today. Dr. Eugenio is a high volume board certified surgeon specializing in minimally invasive surgical care for the treatment of pelvic pain and excision surgery for endometriosis referred to as laparoscopic excision of endometriosis or LAPEX.
He previously completed a fellowship with Dr. Cinerevo. at the Center for Endometriosis Care and, then returned to the Center for Endometriosis Care from his role as director of the SLU Center for Endometriosis and assistant professor in the Department of Obstetrics, Gynecology, and Women's Health in the Division of Minimally Invasive Gynecologic Surgery at St.
Louis University Medical Center. All that to say, That he teaches clinicians, and he's a minimally invasive gynecologic surgeon, and he's trained to do excision surgery, so that's like the trifecta of best guest of the year. And to, to go ahead and just, make this even more grandiose, he's received several awards and we're not surprised.
Over the course of his career, including the Dean's Excellence in Teaching and Top Community Based Teacher of the Year awards from the Warren. Alpert Medical School of Brown University, and the Laparoscopic Resident Award from AAGL, which is the Association for Gynecologic Laparoscopic Surgeons, these types of awards, when you're searching out a physician, especially a surgeon, this is what you want to see.
And I recognize that they don't grow on trees. We did not find him just blooming in a garden somewhere. He has been busting his tail to accumulate this information, the education. You don't walk out of med school like this. You don't walk out looking like Dr. Eugenia. It takes time and effort on the part of the doctor to make it happen.
So welcome to Hello Uterus, Dr. Eugenia. We are so delighted to have you.
Thank you for inviting me. Thank you for having me.
Absolutely. I want to start our conversation with something that I was, I was honestly gobsmacked when I heard you say this, because I don't think I've ever heard another surgeon Own up to this. or another doctor, own up to this.
But in an interview, you were discussing your medical school training and how early in your career when seeing a patient, you observed your own conditioning around dismissing or minimizing symptoms. And this patient happened to be from the Dominican Republic, which is your home country. And can you tell us a little bit about that experience?
So, that's kind of the reason how I got roped into doing endometriosis, right? Somebody guilted me into this. basically, short story is, I was an attending at a hospital in Rhode Island which I loved, and, I saw a big part of the Latino community that is in Rhode Island, which is part of my own community.
So I did have a patient that had horrible pain basically her story was, I took her to surgery, she had some cysts, I drained her cysts like I was taught to do, we tried to remove some of the cysts, a lot of it was really bad at that time, and I was not, and I realized that I didn't have the training to do any of that.
So then I referred the patient to the joint oncologist, and they saw the patient, they spoke to the patient, and they basically said well, I mean, like your tubes are destroyed, everything's destroyed, we can offer you, like, basically surgery to remove everything that's affected, which you may lose both ovaries, the uterus, and all these things, on a patient that wanted to be a mother.
So she came back to me and said, hey, what can you do? And I was like, this is out of my league. Like, I'm sorry, let's just give you medication, and let's do the whole song and dance, which they teach us in, in, in Residency. Let's give you Lupron, let's give you, multiple medications, let's suppress you, let's give you an incredible amount of pain meds until, you know, hopefully blunt your pain and you would go away.
And then if you came back, well, I mean, it sounds horrible, but like, if you came back You're like, well, you know, you're a drug seeker or kind of blame the patient and you hear, and I've gone to multiple institutions and I've heard attendings from different walks of life, from different trainings and different hospitals in the U.
S., And then some attendings from different locations in which they would say things that are very similar or complain about patients in a very similar way. Oh, she's just, a pain in the tush. just send her to go somewhere else or tell her, that we can't see her anymore.
We'll cancel, I've heard of doctors cancel patients appointments where they're too difficult. And I was like, oh, abandonment. Oh, that's what that word is, right? So,
Awesome. Trauma. Yay.
trauma, right? Yay! but, I mean, push comes to shove. I saw this patient. I didn't know what else to do to her. So I gave her Lupron.
She didn't get better. she didn't want to go to the oncologist. Just wanted to be a mother. saw her and her mother and her some other family member. And then I talked to them and, you know, we can't do really much to about this, let's give the medication time.
like, a month or two months later she came back, and came back with her mom. And they came back, I remember it was a Saturday morning clinic. And, her mom, she walks in reluctantly, she's giving me the side eye and all that stuff, and I was like, hey, what's happening, how are you doing?
And then the mom says, tells like, hey, tell him, tell him what you tried to do. I was like, what? And she goes, well, she tried to commit suicide. I was like, crap. And then, you know, we got into a conversation and basically, when she blamed me, I broke down. I was like, you're from my home country and you don't want to help me.
And I was like, holy Jesus.
Wow.
So that was very traumatic for me. And, you know, like my AMA cried, I cried, mom, everybody cried. And I was like, I just had to realize that general OBGYNs are not trained at all on how to deal with patients with endometriosis and chronic pelvic pain.
Can you say that again?
Like, general OBGYNs are not, are not, and on top of that, like, a lot of, if you see what happens in most of the country is that these patients are referred to, to gynecologic oncologists, but what's the issue?
They shouldn't be, right? But what's the issue? Also, gynecologic oncologists are spread thin in this country. ? have, it's not that they don't want to help, it's that they have patients that are literally battling life and death situations. So on top of that, to give a gynecologic oncologist to add all the other issues that are there for an endometriosis patient takes them away from saving lives in that way.
Not that Not treating endometriosis patients is not saving a life, but this is something that has a life expectancy of a year to five years, right? So it's a different type of, of saving a life, ? So they should focus 100 percent on that, which means that what's the alternative? We need to train highly specialized surgeons in minimally invasive surgery that are also specialized in endometriosis.
So one of the stories that I think I was mentioning earlier is like before years and years ago. Like, there was no such thing as gynecologic oncologist at the beginning, right? So, any woman that was found to have a cancer was treated by a general of GYN before all the specialties came into play. So, when did we realize that it was better to treat women with cancer by a GYN oncologist, right?
When they were able to prove that they got really better outcomes, but what was the thing that they were measuring? Life or death? Treated by a general GYN, life expectancy, give you X number, was one year. Giving, treating, being treated by a specialized gynecologic oncologist, your life expectancy was five to ten years.
So immediately you can see that there's a significant difference, but the, what we're measuring is quality of life and death.
right,
But how do you do that for minimally invasive surgery and endometriosis? we're only talking about quality of life and pain, not, not death. So it's really hard because it's so subjective,
Yeah, and we're talking about, we're talking about quality of life of females and also predominantly females of color.
which nobody really cares about, right? Nobody, nobody really cares about quality of life for women or pain or, or any of that stuff because, you know, life. Which, which is stupid, but it is what it is, right? So we have to work with what we have and we have to make it better. So, which is why I'm a big proponent of minimally invasive surgery, surgeons and trained.
and being trained by people that do surgery, and having an outcomes based, specialty, Like if you were, treating patients with endometriosis and chronic pelvic pain and you're doing surgery, but on top of that, you're putting them on suppressive medication. It's bananas, Which is the same thing that I told you earlier, right? Like you, we take patients to the operating room to do surgery to look for a disease, But what happens to this patient that we're going in to look for the disease? What is the patient a lot of times on, on hormonal suppression? So you are taking a patient to the operating room to look for a disease that you may or may not know that she has.
And then you're going to give the medication that is going to, say it with me, hide the disease.
Yeah.
I mean, I mean, it sounds like a comedy. Like, it's so funny.
totally agree, and there's nothing funny about it, but it is. it is ludicrous, and I wonder if, I'm curious about your opinion on this. Do you think maybe obstetrics and gynecology should be two separate specialties, and then within gynecology, should we perhaps be funding the expansion of minimally invasive gynecologic surgical training, and he's drawing something.
I think I see a percent sign there. So yeah, is that 10, 000 percent? Excellent.
Why? So there's countries in which they are doing studies in which they're separating obese from GYN. 100%. I mean, it's something that eventually, it may have to happen. Because obstetrics is deliveries, kids, babies, pregnancies. That's it. Right? But gynecology, right, it has to be a totally separate field. A totally separate field, right?
Or we do a,
different specialty.
yeah, it's a totally different like you or we should do a track in which we would do two years of general OBGYN. And then you do two to three years of specialized in obstetrics. And after that you have high risk obstetrics, which is maternal field medicine, and then you have the other track, which is two years of general OBGYN plus two to three years of what?
infertility. Urology, urology, GYN oncology, minimally invasive surgery, pelvic floor, like, like, different things, infertility, within the GYN standpoint. And once you're pregnant, you go over there, right? So it has to be that. Like, for example, general surgery in this country is five years. So for a general surgeon is operating for five years.
before they graduate. OB GYN is four years and most people spend more than half of that time doing OB.
Right.
Unfortunately, Because of the way and the variability in, programs, there are programs that are a lot heavier in obstetrics than GYN. So even though there's a minimum benchmark, there are residents that are basically barely meeting that minimum benchmark. From the GYN standpoint, their OB numbers are not a problem.
They can get that in their sleep. But their GYN numbers, people have to struggle. The basic numbers of the minimal amount of hysterectomies you have to do before you get graduated. Or minimum amount of proceeding gyroscopies and stuff to get graduated, right?
oh, and you brought up hysteroscopy. I want to bring that up. But before I, before I go there, I just want to say, like, we're being repetitive on this podcast about this particular topic for a really important reason. It's not like it's a pet cause or we think we're so smart because we figured something out.
It's
Which one?
the topic of how patients don't recognize, not to their fault, they don't recognize that an OBGYN is not the same. from place to place to place. That it depends on what their business is. It depends on how they've structured their practice. It depends on what their particular personal focus is.
and it's all awesome. Anybody operating at a high level, anyone going into OBGYN care right now, I honor you because it is really hard right now. is just literally to make sure that as a patient or as a caregiver, as a parent, especially of an adolescent, that you understand these things, because it might be complete news to you.
You might have never had an issue of your own to deal with, and you might think, I think that an OB GYN is an OB GYN is an OB GYN and it's not the case. And then the other thing that I'd like to say about that is, in your ideal world where obstetrics is one specialty and gynecology is another specialty that has sub specialties such as minimally invasive gynecologic surgery, I don't think physicians should have to pay for that education.
Because that's what's gating a lot of people from pursuing that path. They, they come out of med school and think, well, I can start making a really good salary now and be an obstetrician, or I can continue my schooling and rack up more debt. And, you know, and, and I just feel like that's just terrible.
so it's funny you would say that, for example, because when I, graduated residency, I wasn't attending. in my mind, was one of the best hospitals in the U. S. Like, Women and Infants Hospital in Rhode Island, it is absolutely astonishing what they've done and, and the amount of care that patients get.
Like, the directors of the departments that I met there are inspiring people, But in our practice, when I, when the practice, the community based practice where I worked at, I've had the pleasure of working with such great people, but one of the things that we understood early on is that we sat and had meetings.
Okay, if you see a patient that has XYZ, who wants to take care of this patient? I do. So we all knew that if you have a patient that had One of these issues, medical issues, we're going to feed them to one provider. Why? Because it becomes more efficient. You have one provider that's going to treat incontinence, or this, or that, or PCOS, or I want to see every teen patient.
Or so we would funnel people and then everybody got way better care, Oh, you're going to do robotic surgery? So when we get all the robotics cases to one or two physician instead of giving everybody doing a little bit of robotics, doesn't make sense, right?
It's important to look, and I'm not going to really tell you the numbers, I'm going to have you do a little bit of research on that. Like, how many, like, hysterectomies do you think the average OB GYN does? It's very little, a year.
A year, probably, probably about a hundred.
No.
100?
A year? No, way less than
I'm thinking surgeon. I'm thinking surgeon. I'm not thinking the average OBGYN.
The average OB GYN, I may be wrong, but the last I read, don't do more than 15 hysterectomies a year.
Oh wow, it's going to say two a month. So even less than that.
Like, don't. Right? So, that's the thing. Cases should be funneled to doctors that are doing high volume. Right? In our practice, even in our practice, and I knew that early on from when I was in practice in Rhode Island with the team, which was phenomenal but it was a very collegial practice, but it was very honorable because you decided even though I can do this, it is a better use of my time to see patients and treat them for this.
And then if I find an issue, I can send them to a high volume surgeon. And within my practice that does this and this and has way better outcomes and has way less risk of complications.
Yeah. Two really important things that patients need to be focused on when they're considering surgery. And that, that's, should be the way that every surgical or every practice is operated, but it's unique, isn't it? It's not how it
It's not, it's may not be because everybody in the practice, you may be in a model that says, well, the more you do, the more compensation you have. So then everybody wants to just like claw, claw and do a little bit. and it's understandable, it's financially, everybody wants to do well so that they can pay for all the, the racks and racks of debt that you have from med school.
fortunately for me, because I went to med school outside of the us when I came to the us, I had no debt for, for med school. Thank to my thank you mom and dad. I appreciate that. Right. Uh, but
We, we appreciate it too.
yeah. But, but one of the things is that when I was. Thinking about going back into fellowship and going back to earning 25 percent of what I was earning before, The only way I could, I, I did that, it was hard. Earning, after earning, X amount and then going back to earning 25 percent after doing that for 4 years. Most of my other GYN friends says, Are you crazy? I got lots of people telling me, Why are you doing fellowship? You don't need to do this. Because I was, I was doing lots of surgeries.
Like,
I like being in the OR at that time, I didn't have any kids, so when I was my wife was in fellowship in Michigan, so I was like, you know what? Instead of me being home watching TV, I just want to put some cases and do cases Saturday and Sunday, which is kind of crazy, but it was happy for me, right?
There's no work life balance, because life was work and work was life, and I was happy. But besides that it's just important to know that, like, hyper focusing on people that do lots of surgeries is always a good thing. More volume equals higher expertise, greater outcomes. Not that you're not going to have complications, but you're significantly minimizing your risk of complication.
It's just one of the things that we tell patients.
yeah. And it, it's an important conversation to have because I think overall gynecologic care has been presented as simple. and I put it up there with neurosurgery and oncology surgery. gynecologic care is, is incredibly complex, made further complicated by a lack of research.
So, there's a lot that we put on the shoulders of our OBGYNs. And, and it's a situation where we need to do a lot of cleanup on aisle six and just make this a better experience for everyone. And so it's really important that as a patient that you understand the structure here and what's going on behind the scenes because as with anything else that you do as a consumer, right, any, any meaningful decision you make, or meaningful purchase that you make, you do your research.
And so this kind of information is really beneficial, um, especially given how little we know about these, these conditions.
to interrupt, I mean, that's exacerbated in one thing. There's a quote by past editor of the New England Journal of Medicine. It's very, I read it and I
was like, Jesus. So basically
after working in as an editor for 20 years, he said that something like it's no longer, said something like it's no longer possible to believe much of the clinical, research that is published.
I'm like, wait, what? And he goes like, no, it's, it's no, it's no longer possible. This is the editor, the past editor for 20 years of the New England Journal of Meta and saying that we cannot believe a lot of the research that's published, right? Because the greater the financial interest backing the research, which is what unfortunately you need a lot of finances to do research, to hire people, to collect the data, to study the data, right?
You can always modify things to go towards your point of view. or the point of view that you're trying to do, it's sad, especially because a lot, sometimes a lot of these research, research that's been done, they have to produce research or they don't get promoted. So also their own compensation is sometimes tied to being able to publish something.
So grants and all these other things are also affected and influenced by this, right? Like people, oh yeah, there's X and XYZ grant from this pharmaceutical company, come and apply for a grant. But obviously, they get the last say on your findings.
right.
If your findings are absolutely destructive to their study, guess what's going to happen to that study?
will not see the light of day. Exactly.
important when you're looking at studies, scroll all the way to the bottom and look for the financial relationship between the Study authors you can't even just look at one study. Like you, I never do commercials for uterine kind on this podcast.
I'm so bad at self promotion, but I'm going to do it right now. Like we have a section on our app. Dr. Eugenio doesn't know about this, where we summarize clinical studies for, people so that they can understand them and read them. so if you want to get accurate information and, accurate studies that you can have, you know, summarized for you, check out uterine kind.
I'll have people who use the app be like, how come you never promote the app on the podcast? And I'm like, I don't know. My brain just sometimes only works in one way. And so when I have an opportunity to talk to a physician, I am. all about the physician in that case.
So we were talking about your experience in Rhode Island and, that really sort of like pivotal situation that you found yourself in where, about how endometriosis isn't life and death compared to cancer, but we all know that,
really, it is extremely important for the patient.
It is, and we do lose people to suicide because of, you know, they just cannot imagine continuing on in this particular case, and there are other conditions, like premenstrual dysphoric disorder that may be riskier as far as that's concerned, we can admit that quality of life is really important and, being able to have an equal shot at a good quality of life is something that, that we all want for everyone.
It's all something people deserve.
yeah, absolutely. Yeah, they deserve it just by being born. You know, they don't have to be, a particular contributor to society or an able bodied this or whatever. None of that. It is because you are born that that you deserve to have good quality empathic care. In that situation, you talked about a parent, and I'm assuming an adolescent, right?
Some, some around 19, 20, 21? Was that a fairly young patient that you were dealing with? What would you say to parents may think that their child is just dealing with the same bad periods that they had or, you know, is maybe not accurately identifying their experience. Like, how, you know, you and I sat next to each other on a plane and I told you that my daughter has really bad periods.
What do you first think when you hear that?
Well, putting myself in the position of a parent is unfortunately something that I do a lot. I don't know if I mentioned this to you before, and when we were talking like 10 minutes before this, but obviously dealing with patients with endometriosis is a heavy, heavy thing in life. So first for some time I was like, this is a lot.
I need a mental break because I had so many patients crying in the office that they were in pain and their mother or their family members didn't believe them. for whatever reason, and then we had surgery and gave them pathology, gave them pictures. I do a video with patients. I give my patients the video of their surgery and make a video when I give them sometimes anywhere between 30 to 60 pictures.
I take their cell phone and go, okay, picture number one, video. And I record myself talking over the pictures and marking. And then the patients go back home and talk to their parents It's, it's cathartic for them. It's like, I am not crazy, So that is so powerful. So that also changed me in a way that like now I absolutely prefer to them to come with somebody in their support structure so that when I sit down and I crack my models and I talk about this and that and I educate them, then the, either the husband.
It's like, wait, what? And the, like, understanding of the things that are happening to their partner or their family member is such a big thing. But if nobody sits down and talks to them and explains it to them It's hard for them to understand. so there's a lot of guilt that they have, right? So when I was being, when I was going down that dark path of being super sad and maybe depressed, the only thing that got me through this was the birth of my daughter.
Like when she was born, I was like, Because unfortunately, I'm an empath, so I take in all that negative thing and all those feelings of sadness. It's tiresome to do this all the time. But what drives me to continue is that when I'm doing surgery is like, what if this is my daughter?
What would I want somebody to do for my daughter that I can do for this patient?
Mm hmm.
And that kind of like clicks it for you to like continue to push forward. And don't, even if you're tired, it doesn't matter. Keep going, keep going, keep going. You have to make sure that you do give your best to this patient.
And that same situation is to sit down to and talk to the parents. Okay, dad or okay, mom, let me help you understand what the disease is. And a lot of the times what happens is there can be some cultural issues as well. What, what's another issue? All the women in my family had issues with periods and we're not dead.
We're okay.
We're okay. First, and then I talk to them, like, first of all, pain is individual. Second of all, what, how old were you when you had your first child? Oh, 21, 22. Oh, great. How old is your daughter now? 34, 35. And she can't get pregnant, and she's been trying for some time. Why? We all know that as women age and the matriosis progresses, infertility gets worse, So, there's many different factors that can affect women's fertility over time, but one of the biggest things is that, like, if you are in high school and then in college, And then doing postgraduate studies and more things and more MBAs and baccalaureates and 50 different things to improve your professional life, and you're delaying childcare like you want to do for yourself or your family, then it's like a slap in the face that after you did all the things correctly, then when you want to have a family, you can't. And it's absolutely devastating. And it's something I never tell my patients. You need to get pregnant now.
Right,
Like, it's like, oh, it's like going and buying a car. Let's just get pregnant now and forget about, forget about the life path that you chose for you.
right,
now or you won't be able to get pregnant.
That is one of the most horrible things that you can tell a patient. Because they have a plan for their lives, You can educate them. Obviously, as time passes, fertility may be an issue. If you treat endometriosis early enough, you can prevent infertility. You can prevent it. I mean, I have that belief.
If you treat endometriosis early enough in patients that are teenagers, you're preventing bowel disease and significant endometrioma. If you're treating it properly early enough, you should be able to prevent all these things. And one of the things that you know, one of the things that you can definitely prevent depression, suicidal ideation, self harm, because they are not believing that they're crazy.
One of the things that I, I saw a patient earlier this year before coming to the CEC that I had operated on like over a year ago. And when I saw her initially in the consult, Like, when I was doing her pelvic exam, I saw that she had a lot of cuts in her legs, so she was doing, she was doing a lot of self harm.
And I kind of asked her, like, hey, what's, like, are you okay? Do you want to talk about this? And why are you doing this? Just trying to get to the bottom of this, right? And I will never forget when she said, like, this is the only pain I can control. And I was like, holy crap. So it's like, so like, what? That is like, I could not process
of a cliff. Yeah. It's
Yeah. I couldn't process it. Right. So then when I saw her like a year or so later, she was like, Remember what I told you about that? I have, after surgery, I have not cut myself once. And that was literally, I was on cloud nine until I got home and didn't take out the trash and got into trouble. But that's another story.
But, but
together, bro. I mean, come on. Like, you can't be, you can't be bringing your A game, you know, during daylight hours and then just, you
and then going home and screwing it up. It's fine. I mean, Thank God she forgives me a lot, but you know, but, but it's what I'm telling you. It's like, it's phenomenal, right? So imagine what, what, how different would have life have been if I, we treat her at 17, 18 versus 30.
Yeah, so let's, let's dig into that. let's talk about this adolescent experience, um, because prior to pressing record, you and I also had a conversation around adenomyosis, adenomyosis, adenomyosis. I have no idea what the proper pronunciation is. I call it adno. And we had a conversation about it.
And for those who haven't heard us talk about this before, adenomyosis is when the for Endometrial cells, the lining of the uterine cavity, grow into the muscle part of the uterus. Endometriosis is not that.
Okay.
It has nothing to do with the endometrial lining or endometrial cells and it was really poorly named.
And in my future life, I want to come back and rename the stuff that's badly named. in, in all languages because the endometriosis would be one of the first things I'd change. So with adenomyosis, we were talking earlier about the, how it was perceived to be a condition that developed after multiple births.
And, you know, it affected, uh, females in their late thirties, but more likely forties. And it was largely cured by hysterectomy because that is a definitive cure for adenomyosis. And because it happened later in life, my assumption, my personal assumption is that when looking at the hierarchy of things to fund research on and to better understand and to come up with better treatments for, adenomyosis got shoved to the side because it coincided with a time period where hysterectomy was not as problematic as it would be for someone who's 18 or 19 years old.
Um, but now we're finding out that adenomyosis is affecting people at a much younger age. And when I discussed the data that I had seen, around adenomyosis between the ages of 18 and 30 and the prevalence the, the percentage of females who were, were diagnosed with adenomyosis who also presented with painful periods or dysmenorrhea, that 34 percent of them had adenomyosis.
And I nearly fell over when you said At
I mean, yeah I personally think it's slow. Maybe it's because, obviously I'm a little biased because since I only see complex UIN pastes that are at the end or the line of the road, obviously, yeah, I would have some type of selection bias because I see the worst of the worst. So I see a lot of cases that are, for example, that may be on transitioning.
Okay. Right, they're in a point in their lives where they're going to transition, and they're young, they're 21, 22, 23, some 18 year olds, and they're like, I'm not interested in this, I, I, after you counsel them appropriately, I want a hysterectomy, great, you do a hysterectomy, adenomyosis at like, 21, I was like, wait, what? Right, so then you see it often, right, so obviously, if you do a lot of the surgeries, you'll see it a lot more.
so definitely high prevalence on a condition that for, for decades was assumed to not even show up in, in adolescence. And so the reason why I'm bringing that up right now is because I want to go back to this, this conversation around adolescence and parents and school nurses and unwinding this, these either, false premises that we hold on to or conditioned responses that aren't helpful.
And adenomyosis is a painful, heavy bleeding, right? Those are the two symptoms that really show up the most, right? And and endometriosis can also present with a lot of pain and heavy bleeding, but tends to also have pain that is happening outside of a person's cycle. Is that, is that a fair statement?
Yeah, you can say some of those things. For example, one of the things that I find very common is that We usually talk to patients when we're doing them. I usually say, okay, I'm gonna ask you 50, 000 questions. And one of those questions that I ask them is, talk to me about your period. When does the pain start?
How many days before the onset of the period does the pain start? Oh, not before the onset. My pain is worse on day two. I was like, wait, so, but before the period, you have no pain? No, no pain. And then some of these patients, I mean, I'd learned throughout time that When they say that that's the issue, that their pain is like worse the second or third day of their period, specifically the second day, I'm biased obviously, but in my mind it's adenomyosis to prove it otherwise, right?
Because then the maturity starts to hurt way before the onset of your period, for most, for most of the patients that I've seen. Right? And again, I realize I'm biased. I see only patients with chronic pelvic pain, and I'm atrocious to the anaemiosis, and some of these things, right? So this is what, this is my own observational bias for my own 250 to 350 cases a year for the last seven years, six years, so that's kind of my opinion.
what is, what
I believe it has to do with the amount of inflammation that happens within the muscle in that, in that first and second day. Right? Because what happens within the uterus itself, which is why the pain goes crazy in those days, but when you have, when you have pain from endo, it starts, used to be a couple of days before, because your, because your, your progesterone levels start to decrease, and that starts, that can actually, like, you know, worsen the inflammation that's happening throughout the pelvis and cause significant pain and inflammation, but starts outside of the uterus, So that is something that I've seen significantly. but what's the issue as well? That endometriosis and adenomyosis are really, really good friends and they can coincide, they can cohabit. all the time,
Yeah. SOL fibroids
As well as fibroids, right? I think that I agree with what Dr. Redwine was saying. I mean, we're all, I mean, rest in peace, right?
So, but I may agree significantly with what he was saying regarding that we believe that the future of this is basically identifying what are the genes that are involved in this, right? Places that have the higher risk of developing it, because we know that. from current research that there's around 25 to 30 genes that some of these diseases are sharing.
Fibrosis, myosis, endometriosis,
Yeah, I'm really glad that there's an abundance of funding so that you guys can conduct studies on this. Did you note my dripping sarcasm? Um, 16 million dollars last year from NIH for endometriosis funding. What can you do with that?
banners and commercials, I don't know. Nothing.
Not a lot. Not a lot from a research perspective. So, let's talk to the patient or parent and caregiver of someone who is at the point where they think what they have is bad periods. So they are endometriosis, adenomyosis, fibroids, those aren't even on the edges of the radar screen for them right now.
They literally think, I have bad periods. They go to the gynecologist or the obstetrician, more likely. They go to the, they go to the doctor that delivered them
say,
Oh, that's right. That's very
that, right?
That's, that's very common. I'm laughing because I had that, I had that same scenario twice last week.
it is something that we do and that we kind of like, there's like this badge of honor to say like, I got my, my gynecologist or my obstetrician delivered me. And it's like, all right, but that may, may not be the person that you want to go to when someone is experiencing really, really bad periods.
And you know, I want, even though you, your expertise is on the surgical side, complex gyne surgery, I want you to factor in, because I know you're aware of it, premenstrual dysphoric disorder, NPCOS. and these other conditions, right? so talk to the parent slash patient who literally thinks that they just have bad periods and the thing that they should do is go get birth control.
To, make that go away, and, not, and then do nothing beyond that, from a diagnostic perspective. What do they need to know?
So, the first thing that I do when I have those parents here is go really, really back to the basics, which basically starts as, this is a uterus, this is the bladder, this is the the rectum, this This is the fallopian tube, and this is how ovulation works, so that they can have an understanding of what's the period.
There's a video that I had on my phone that I used to show parents, basically, of having there's this girl on TikTok, and she was dancing, whatever, and she had her bikini and she was at the beach and she was having fun, and she had a drink in her hand, and she was just having fun, right? And she had a white, two piece bikini.
And then suddenly her friend says, hey, I think you just got your period. she looks down and she goes, Oh, I think I'm getting my period right. I'm standing in my bikini. And then compare this to your daughter. What does this tell you? Like, this is what's supposed to happen.
Like, uh oh! Oops!
Oh, I got my period. I forgot. Like, you're not supposed to plan your life around your period.
The period is something that happens but it's not something that should dictate the way you live your life. The moment you start planning your life around your period, This is an issue,
Beautifully said. That should be your baseline. If you're, if you're child, or if you are planning your life around your period, that's your baseline. that there's an
I mean, absolutely. If you're, if you're the parent just saying, you know what, we're going to go on vacation. Oh, but if we go on vacation, Jennifer's going to have her whole issue. So when is her period? No, we're not going to go on vacation. I mean, that should tell you that there's something wrong,
Yeah, but
we need to address it.
yeah, and we need to, we need to unwind that that's, it's happened over decades, right? This has just been baked into the female experience that your period sucks. And, and for some people it sucks really, really, really bad. and you're just unlucky if you're one of those people, right?
So that's really excellent advice because I can hear a, a parent. Say that to a physician, right? So the parent's not going to walk in and say, Well, doctor, you know, based on her this and that, and I think maybe, you know, we should investigate endometriosis. Like they're intimidated. Everyone's intimidated when they go in to see an OBGYN.
And if a parent is bringing an adolescent in who's going to have a physical exam, that parent is walking on eggshells. , even if their child doesn't care and is just like even excited and maybe wants to be a doctor one day, that parent is only half present in that room.
So to be, I can hear them saying, Doctor, she plans her life around her period and that's not normal. And I think that in and of itself will set that, that particular appointment on a different trajectory. So that is
You would hope,
That
but one of the things I was mentioning to you earlier as well was what, like, what's the average time of a Do I N appointment in the U. S.?
the doctor is in the room, six minutes,
Six to 10 minutes, right? And that time, what do you have to do? You talk to the patient. You say a stupid joke. Somebody gets undressed. Somebody's genitals get touched. You give them a, or you order some tests you leave and you have to document
in six to ten minutes.
and six to 10 minutes or 15 minutes. There's absolutely no time.
To ask adequate questions. my visits sometimes include no exam, I talked to the patient for over an hour, an hour and a half, and I don't touch them.
Now you have that luxury, not everyone is structured like that, but to me, I think that is the perfect way to begin that relationship, because we gotta admit that this is, this is really intimate. You know, like, this is more intimate than you getting brain surgery, Like, you are awake on the table and someone is, is physically inside you and you're, you're 16.
it's horrible. And in fact, I, Usually make it a point to not examine virginal females, to not do any type of pelvic exam on, on teenagers whatsoever. So I'm very radical on that. Like, I don't think,
then how do you deal with that? How do you, how do you, manage diagnosing given
so guess what? Teenagers can give you a really good history about their pain and their profile, Family history also gives you a really good indication. So our rate of finding endo I don't want to say the number because it's really extremely high and people won't believe it, but that's okay.
But especially from how I was trained to identify tetoxic patients to figure out, I mean, it was extremely elevated. But then we got into some fights because of my rate of taking a patient to the operating room and finding endometriosis is really high, means that the bar that the patient has to get to so that I can decide to take him for surgery, is very elevated.
So obviously I'm going to get a really high rate, but there are patients that are maybe not getting to this level that I'm not operating them and may have endometriosis, right? in my defense, when I had those conversations with some other physicians was that the last thing I want is to take somebody to the operating room and have negative surgery because I did surgery for no reason.
No negative endometriosis. Because I put a patient at risk of life, death, injury for no reason. So it's a little hectic, but you can do trans abdominal sonograms, you can do different studies, you can talk to patients, but the majority of the diagnosis of endometriosis you get in what? Conversation.
that initial
In the initial intake visit, conversation, and you ask questions in different ways to make sure that nobody's malingering and they're understanding the thing.
You can do different things to figure out if you believe this patient may have endometriosis. Besides, like When you see, when you talk to sufficient endometriosis patients and you're asking them their story when they're 20, 25, after they've been sexually active Guess what they're telling you. The same stuff that the 15, 16, 17 year olds are telling you about their pain history.
The same thing. There's no variation. There's no, there's no black magic. It's the same thing. I had this when I was this age, and now that I'm this age, I'm having this plus infertility, plus pain with deep penetration. So if you talk to your patients officially, you can have a good idea. You can do transabdominal sonograms, you can do translabial sonograms without having to do something internal.
So, so there's different things,
And one of the things, like, in all the teen patients that I've, I've done surgery on, there has been only one patient that I regretted not doing a transvaginal exam or tra or, that is not sexually active, because the teenager is sexually active, then there's a different story.
Right? But a patient that's not sexually active, then no, no sonograms or nothing, just history, and decide if you take her or not take her to surgery. Now I've had a patient that was not sexually active so we did an exam, we talked to them. For her symptomatology, for symptoms she did qualify 100 percent to have endo.
She had also positive family history, so that also increases her risk significantly. So took her to the operating room, and she was 17. And we got in, she had stage 4 endo. And that's the youngest teenager that I've ever seen that had, that unfortunately I could not excise all the endo because she needed to have a bowel resection and she wasn't ready.
Oh boy.
at 17, a bowel resection. But, for example, this week, I just came back from Tijuana, Mexico, at a center of endometriosis that they have down there, that they're doing really great. Great stuff. for their population, right? So, so really, really great doctors, really great things, right?
So one of my friends down there is Dr. Armando Menocal, who is in Morelia in Mexico. And I was doing a presentation on pediatric endometriosis down there, and I brought lots of my videos of, of teen endo, and I don't know what is in the water down there. But the videos that he showed me from teen endo are way worse than anything I've seen here in the U.
S. So that one patient that had needed a bowel resection at 17, they've done bowel resections at 15.
Wow. So is it, genetic or is it literally
There, I think genetic is a big factor, right? But I had never seen a 15 year old patient with stage 4 bowel endometriosis and with diaphragmatic endometriosis, and I was like, and it wasn't like one patient. He showed me like 20 different videos,
Multiples.
multiple patients, multiple patients, different disease. I could not believe it.
I was like, you're kidding. I'm like, yeah, for sure. This is real. These are my patients.
So this is so, this is such good information because We have to, we have to build a bridge between bad periods, I had them to suck it up, take some pain meds, and no, we really have a numerous conditions that are complicated, that haven't really been, historically prioritized, or you know, we lacked the tools to identify them or to treat them, and so we need to, to build that bridge so people understand it.
First and foremost, that a normal menstrual cycle is like what you just described. It's a, it's a person on the beach who's like, whoops, I just got my period. That's a normal menstrual cycle, right? You, you, you just don't, you know, you might get a little bloated, you might feel a little uncomfortable, but if you are organizing your life around your period, something is out of balance.
And the most important thing to do is to recognize it and get to the right physician as quickly as possible. before we go, I wanted to, have you talked about excision surgery and why it is really important that people don't go to any surgeon, just any surgeon I suppose is the best way to say it for endometriosis surgery?
Why is this condition, why does this condition require a unique method? And why is it important that that method or that that surgery be conducted by a specialist?
Okay, number one is because volume matters. Number two is that, patients should definitely do the research for figuring out who's doing surgery. Unfortunately, there are lists out there that, that talk about. Doctors in different states and different places. But the issue is that also talking to your physician, how are they treating the disease?
Are they only are they relying on excision or during ablation or are they using also? different medications like Lupron and Orlissa or other suppressive methods before or after surgery. Before surgery, you're, I already said that that's bananas. But then after surgery, like you do surgery and the patient is in pain and everything's sparse.
Oh, fine. Be on Lupron, be on Orlissa. I was like, so did you remove it? Did you not remove it? Is it that? Is it endometriosis? Did you evaluate all the other 50, 000 things that the patient has in the pelvis that can be going on? It may not necessarily be endo, it may be something else, but masking or giving a patient medication, which is, for example, I'm 100 percent against giving a patient lupron oralis before surgery.
Why? Because one, the side effects it has. are not benign medications. And two, a lot of times they give this medication and they don't have endometriosis. So you put a patient through the risk of all these side effects, like it's a benign thing, but
Yeah, that's, that, it is such a strange practice, like, I, I've heard of giving Lupron to patients before fibroid removal to shrink the fibroids a little bit under
that in that case, there's data on that. So there is data on if you give patients Lupron, you may shrink, you shrink the vascular, the vascular church of the fibroid. So the fibers may be smaller. So it may be easier to cut them out. So you're, you're less destructive. So that makes sense, right? So that, there is some data on that, but let's give a patient some medication before she actually has a diagnosis of endometriosis.
Yeah. So you need to definitely pay attention to the distinction that he's making here. That it is, you can't think don't think of yourself as just a uterus. Think of yourself as a person who could be developing and living with one or more complex physical conditions, right? Because I think we sort of squish ourselves down into this one person persona and, you know, it's like, no matter what's wrong, take birth control.
No matter what really bad condition you have, take Lupron. And it's like, no, no, no, no, no. We gotta, we gotta be clear about that.
We usually give the patient the option, like, do you, do you even have to be on birth control after surgery if you don't want to? The only time I'm actually, like, more pushing towards using birth control is if the patient has a big endometrioma or endometrioma at all, because they tend to recur really fast.
So the risk of having an endometrioma come back is 10 times fat higher than when you have endometriosis on the peritoneum, which is what we call the wallpaper of the abdomen, right? It covers everything except your ovaries inside. It covers your intestines, the uterus, the everything except your, your ovaries, when you have endo on the peritoneum, if you do proper excision going really wide and really deep, the possibility of disease coming back in that area is low. If you did proper technique, with having a good margin, right? In fact, when we take patients back to the operating room, guess where we see endo?
Not in the spot that we removed, at the margins of the stuff that we removed,
Oh,
right? And, but, we feel good because we usually go really wide. And we inspect our margins, and what does, what saves us? Something very simple. I take a picture before I cut out the disease, and after I cut out the disease. So I give the patient, this is how this looked before, this is how it looked after, and if I have to take her back to the operating room, oh, this is what I removed, and this is where I came back. So, I, talked to a patient, like, a couple last week that their doctors wouldn't give them the video of their surgery or the pictures of their surgery saying, well, that's not, that's HIPAA.
I was like, oh, they can't give you your own information because that's HIPAA?
Yeah, that's not,
Like, there's not, there's not a thing.
No, that's called, that's called you don't want to give them that data. You can make up an acronym for it, but that's what it's called.
Yeah, but I believe patients should have, if you want a video of your surgery, get the video of your surgery.
Absolutely. And you know what? Make sure, I'm so glad that you brought that up because I've heard from numerous patients that, they'll ask questions post surgery and the physician gets really miffed at having to answer them. I'm thinking of one person in particular No names who had their uterus removed and wanted to know how the ovaries were fixed now in the body.
Like they, she, she had what I consider to be a beautiful question. Explain to me what my anatomy looks like now so I can, you know, see it, take better care of it, etc. And the doctor was like, why do you need to know that? And she's like, because I want to know it. And, and he goes, I, I just, they're there. he was.
Mad. And, we have to stop doing that. and the pictures mean you get, if you have knee surgery, your doctor's going to show you that beautiful surgical outcome, right? They're going to be like, ta da, look at how great I am.
But more importantly, how are we doing laparoscopic surgery in 2023? With what? with a camera.
Right.
So how are you doing surgery? Like if you had a, it sounds funny, right? But like if you had a plumber and he goes into your house and you have issues and you have to replace a whole bunch of pipes and stuff. The plumber goes into your house and comes back 30 minutes later. And she goes, and it's done. And you're like, really, what? Show me. What did you do? What did you put in?
What did you take out? Right? So, if you're doing surgery with a camera,
of the plumber's like, no, I sealed
it's sealed, and everything looks good. Everything looks good. I'm like, wait, what? Like, you did surgery with a, like, you're doing surgery with a camera, you can take pictures of before and after. It does not take the only, you know what, just the only effort that you have to do is just want to do it.
To take, to show the pictures of patients of before and after. The desire to, like, be transparent. Something that my dad always told me is what? Sunlight is the best that's infected. So you cannot imagine how many times I see pictures of a surgery that are very shady, and, oh, we removed a whole bunch of endometriosis, and then, oh, really, you know what I do?
I go back to the pathology, and I open the pathology report and go, Oh, this is a lot of endo, and I see a nodule, and I'm guesstimating the size, and they removed 0. 5 centimeter of this thing that clearly looks like it's four centimeter big on top of the bowel.
So total waste.
So then, no, no, not a total waste, but oh, we ablated some stuff, and then we cut it all out.
And they have three specimens, three or four specimens, and they're like half a centimeter, one centimeter, or like 0. 3 centimeters. So they do a bite and burn the rest. We removed everything. And then we go back and then I'm like, wait, this doesn't make any sense. How do you remove everything and all the pictures that you're seeing that are speckled?
And then your specimens are one centimeter when you can clearly see that all the pelvic sidewall is infected within the metriosis. , it's essentially lying to patients. Right. And it's hard. And I don't really want to get into this. I am very honest and I give it to patients like this is what you said they did, and then this is what is written in the report, but this is what's in the pathology.
it doesn't make any sense to me, and the pictures don't really make any sense,
right. And the issue of ablation, can you comment on when you feel that that is the appropriate tool to bring into the mix and when it's not?
so ablation is absolutely perfect to do. When you are part of a randomized, double blind control study and you have the bad luck to be in the ablation side of the study.
That's like the best, that right there. I'm just going to say at our end of the end of year episode where we have like the best of, that is going to win the crown. You just won yourself a crown and a sash.
Got it.
that's fantastic, because I was under the impression that in certain places where you can't actually cut in, or to cut in would increase the likelihood of a perforation or something,
Wait, wait, wait. Perforation of what? Of bowel?
let's say bowel or bladder, let's say bladder,
Okay, great. Guess what? The bladder can get repaired. You cut the endo, repair the bladder. It just, this is what doesn't make any sense to me. You're going to open a patient, do surgery, burn the surface of the disease that's into the bladder, and then, oh, I don't want to cause any damage. That's not the case.
The case is, you have to treat it like it's a white cancer. If you leave it on the bladder, it's going to get worse, and then she's going to come back with urinating blood, or it's going to expand into her bladder, and then she needs to be a wider resection, right? Oh, you have endo on top of the ureter. I'm just going to ablate it.
My, by God, don't do that. Because what happens is what? Like, the disease stays there, then you lose a kidney, and then suddenly, oh, we didn't know.
Yeah.
Like, kidneys are for free. Like, you cannot imagine how many times I've seen patients that had multiple surgeries, they ablated the endo that was on the sidewall, and then suddenly the patient has, like, lost half of the function in one of their kidneys.
And now they have one kidney working at 75 percent and the other one working at 25 percent because of extensive stenosis. Those are the lucky ones. Because sometimes you do, you repeat it, and then you do, and then you come back the study shows that the patient lost all the function in that kidney.
So they, guess what do they have now? They have to have a nephrectomy plus removing the ureter that could have been saved by just cutting that portion of the ureter. working with a combined urologist to like, cut that portion and spackle it together, put the ureter back together, or do a uterine implantation.
right. Like we're, now we're, we're looking at a complicated situation that was made 10 times more complicated. And, and it goes, I guess it goes back to, the lack of standards around endometriosis care and, and the need for urgency, around creating those standards.
Yeah.
Well, that was, that I think is just crucial information for people to understand. you didn't get the, the hilarious answer, if you didn't get the point of that, because you're not familiar with clinical trials, what he was basically saying is like the only time ablation should be performed for endometriosis is when you're trying to validate that it's not the right thing to do.
But I mean, and also a caveat to this is, If a GYN does not feel comfortable treating endometriosis in a specific organ, what is the best thing that they could do?
Call another surgeon.
Number one. What's the second best thing?
Take a picture of it, give it to the patient, and say, go somewhere else that can treat your disease.
for sure. And, and, you know, I think that I want to emphasize the need for, obstetricians and gynecologists and primary care physicians and gastro physicians and everybody. Everybody has to know about endometriosis. You know, there needs to be a red phone situation where someone speaks at one time to all physicians and they all hear it.
, but hope that you will join us again, because I, there's a lot of topics that I want to get into with you.
And one of them has to do with, the way that excision surgery is handled from a business perspective. Perspective. Um, I want to get into that and how, the powers that be are making it a challenge for surgeons to get compensated for this surgery properly and how that is impacting patients.
So will you come back and join us again?
100 percent we can talk about that over T.
Over tea. Excellent.
Thank you for having me. Thank you for having me
absolutely, absolutely. So again, I think many people who know endometriosis know the Center for Endometriosis Care, but if it's more really important that you recognize that endometriosis affects people that you know and love, and they may not know they have it.
when you hear someone talk about bad periods, please step up and stop the cycle of these endometriosis. Symptoms being dismissed. And please write down Center for Endometriosis Care in Atlanta and Dr. Eugenio because I know, I know, uh, at least 20 excision surgeons. And I got to say, I put you right up there at the top because
that.
your, your communication style and the way you explain things, you don't dumb it down.
You get straight to the heart of the matter. Like it's how it should be. experienced. People don't, patients don't need to be carried around on tufted pillows, but they also, they need the info and you know how to deliver it. so thank you for being here and thank you for pursuing this specialty.
We need you.
Thank you, thank you. I think one thing, I appreciate you saying those kind words about me, I appreciate that very much. I just hope that, like, after I'm done with my career, people can say the things about me that they say about Dr. Redwine recently. That is definitely an inspiration. One of the things that I think we should touch base into something that, I mean, us endometriosis surgeons, as we continue to evolve, we continue to learn new tricks and we talk at events.
And when we do international conferences, like, Hey, what are you doing? What's working? What has not worked? What do we have to stop doing? So these conversations between like people that you trust, like I was recently in, in. Like I said, like in Tijuana, in San Diego with Dr. Andrea Vidali and I had conversations with him about stuff that he's doing that's working or stuff that he's doing that he's no longer doing because he realized that he can get better outcomes doing different things.
It's like, tell me, it's like we get together with multiple doctors, like at these events and we ask conversations like, Hey, I'm doing this. I'm not really getting good results. What's happening with you? Right. But that gets, you know what you need to do to be able to do that? Get together with a group of people without ego, right?
right.
And that's one of the things that we need we need to fight as physicians We need to fight against our own ego that hey, we did surgery. It wasn't proper Let's still find out a way to send this patient to get proper care. And think about this You see a patient in the office, you evaluate her for whatever, and it turns out that she had a pathology, you missed it, and was a malignancy, and this patient died. You could be liable, right? Because you delayed care, right? What happens when you see a patient that has chronic pain, all this stuff, and has a lot of pain and a lot of everything, all these symptoms, and then suddenly it's only important when she can't be a breeder, right?
But this patient has seen doctors, this patient has been seeing GYNs for 7 to 10 years, but when she can't breathe, that's when it's important. Like it's bananas, right? It's, it's not okay. And then I got into trouble this weekend because in the conference where I was, I basically says, and I did, you did tell me that, well, we're not going to blame physicians, but what did I say?
We have to. Who's, if we don't blame the doctors, I was like, who's, who's to blame? Tinkerbell? Like,
who else are we gonna blame? I, I, I mean, ACOG? Can I say ACOG? Is,
good night. Have a good rest of your day.
is, is, is it, why, why? Why are you saying that? Because I'm not allowed to? Huh?
I don't, I have nothing to say about that.
Okay. Yeah, I mean, I don't, I don't.
I don't know what to say. It's, it's,
I'm gonna, I'm gonna have to, I'm gonna have to go offline to get the, get the response for that.
we can talk about that over tea sometime later.
Okay, that's gonna be a goblet of tea, right? That's a, that's a larger serving. it is, really an excellent way to wrap, to say that we are, we are more than just bleeders and birthers. And, you know, We don't have all the answers, and we don't expect doctors to have all the answers.
When, when a person is educated about how little research has been conducted and how little research you all have to rely upon, you know, that, that is a problem. Other specialties have way more research to rely upon. Cancer, I'm talking to you. And as a result, you have a much better patient care path. You have, everything is just better over there, right?
Research contributes to that a lot. But,
Well, because there's finances involved in cancer research and stuff like that, right? So there's finances and protocols, but the only time there's research in endometriosis is when there is to approve a specific type of drug or see if this works or not, because there's finances involved, right?
which is why, again, we go back to what a 20 year editor of New England Journal of Medicine says, the more financial gain is, or the more finances are associated to specific research, the less one can believe it's value.
right. Yeah, it's got to come from the NIH, right? Without
yeah, it has to be exactly. Research with ostriches, good, bad, works, doesn't work. There's studies out there and I'm not, and I'm looking at you, certain medication that you take orally that you talk about improving pain. at painless sex at three months, but not at six months, right? There are some studies that, um, you know, I'm going to leave it out
have it. You don't even have to have a bachelor's degree, much less a PhD to just go, Hmm.
There's a lot of different things that you can do in research, especially when there's a lot of money involved.
Unfortunately, we need independent research that is very robust, multi centered, but takes a lot of money to do something like that, right? Especially because, yeah, so that we can get proper data.
Yeah.
proper, proper data. But that takes a lot of time and a lot of money.
Are you on social? Where? Tell us where.
on Instagram. Um, I did open a TikTok, but I'm still not, like, ready to go into TikTok.
maybe we should do a TikTok live together and I can, I can help deliver you to the community so that, you know, they can properly embrace you. But when we post this episode, I'm going to link your socials. We'll have those linked in there and we'll share them. because. You need to be talking on social in all that free time you have, Slacker.
And, um, we gotta make sure that, people can find you, because this is, unfiltered information that you need access to. This is the straight scoop, and we can't thank you enough for it. It's rare.
Carol: Joining us today, Dr. Eugenio from the Center of Endometriosis Care. The first few words that I'm going to say about Dr. Eugenio will be music to your ears because if you've listened to this podcast for any length of time, you know that our two favorite words, really three favorite words, high volume surgeon.
If you are going to see a surgeon for any gynecologic surgeon, what do you want? You want high volume and that's what we have for you today. Dr. Eugenio is a high volume board certified surgeon specializing in minimally invasive surgical care for the treatment of pelvic pain and excision surgery for endometriosis referred to as laparoscopic excision of endometriosis or LAPEX.
He previously completed a fellowship with Dr. Cinerevo. at the Center for Endometriosis Care and, then returned to the Center for Endometriosis Care from his role as director of the SLU Center for Endometriosis and assistant professor in the Department of Obstetrics, Gynecology, and Women's Health in the Division of Minimally Invasive Gynecologic Surgery at St.
Louis University Medical Center. All that to say, That he teaches clinicians, and he's a minimally invasive gynecologic surgeon, and he's trained to do excision surgery, so that's like the trifecta of best guest of the year. And to, to go ahead and just, make this even more grandiose, he's received several awards and we're not surprised.
Over the course of his career, including the Dean's Excellence in Teaching and Top Community Based Teacher of the Year awards from the Warren. Alpert Medical School of Brown University, and the Laparoscopic Resident Award from AAGL, which is the Association for Gynecologic Laparoscopic Surgeons, these types of awards, when you're searching out a physician, especially a surgeon, this is what you want to see.
And I recognize that they don't grow on trees. We did not find him just blooming in a garden somewhere. He has been busting his tail to accumulate this information, the education. You don't walk out of med school like this. You don't walk out looking like Dr. Eugenia. It takes time and effort on the part of the doctor to make it happen.
So welcome to Hello Uterus, Dr. Eugenia. We are so delighted to have you.
Dr.Eugenio: Thank you for inviting me. Thank you for having me.
Carol: Absolutely. I want to start our conversation with something that I was, I was honestly gobsmacked when I heard you say this, because I don't think I've ever heard another surgeon Own up to this. or another doctor, own up to this.
But in an interview, you were discussing your medical school training and how early in your career when seeing a patient, you observed your own conditioning around dismissing or minimizing symptoms. And this patient happened to be from the Dominican Republic, which is your home country. And can you tell us a little bit about that experience?
Dr.Eugenio: So, that's kind of the reason how I got roped into doing endometriosis, right? Somebody guilted me into this. basically, short story is, I was an attending at a hospital in Rhode Island which I loved, and, I saw a big part of the Latino community that is in Rhode Island, which is part of my own community.
So I did have a patient that had horrible pain basically her story was, I took her to surgery, she had some cysts, I drained her cysts like I was taught to do, we tried to remove some of the cysts, a lot of it was really bad at that time, and I was not, and I realized that I didn't have the training to do any of that.
So then I referred the patient to the joint oncologist, and they saw the patient, they spoke to the patient, and they basically said well, I mean, like your tubes are destroyed, everything's destroyed, we can offer you, like, basically surgery to remove everything that's affected, which you may lose both ovaries, the uterus, and all these things, on a patient that wanted to be a mother.
So she came back to me and said, hey, what can you do? And I was like, this is out of my league. Like, I'm sorry, let's just give you medication, and let's do the whole song and dance, which they teach us in, in, in Residency. Let's give you Lupron, let's give you, multiple medications, let's suppress you, let's give you an incredible amount of pain meds until, you know, hopefully blunt your pain and you would go away.
And then if you came back, well, I mean, it sounds horrible, but like, if you came back You're like, well, you know, you're a drug seeker or kind of blame the patient and you hear, and I've gone to multiple institutions and I've heard attendings from different walks of life, from different trainings and different hospitals in the U.
S., And then some attendings from different locations in which they would say things that are very similar or complain about patients in a very similar way. Oh, she's just, a pain in the tush. just send her to go somewhere else or tell her, that we can't see her anymore.
We'll cancel, I've heard of doctors cancel patients appointments where they're too difficult. And I was like, oh, abandonment. Oh, that's what that word is, right? So,
Carol: Awesome. Trauma. Yay.
Dr.Eugenio: trauma, right? Yay! but, I mean, push comes to shove. I saw this patient. I didn't know what else to do to her. So I gave her Lupron.
She didn't get better. she didn't want to go to the oncologist. Just wanted to be a mother. saw her and her mother and her some other family member. And then I talked to them and, you know, we can't do really much to about this, let's give the medication time.
like, a month or two months later she came back, and came back with her mom. And they came back, I remember it was a Saturday morning clinic. And, her mom, she walks in reluctantly, she's giving me the side eye and all that stuff, and I was like, hey, what's happening, how are you doing?
And then the mom says, tells like, hey, tell him, tell him what you tried to do. I was like, what? And she goes, well, she tried to commit suicide. I was like, crap. And then, you know, we got into a conversation and basically, when she blamed me, I broke down. I was like, you're from my home country and you don't want to help me.
And I was like, holy Jesus.
Carol: Wow.
Dr.Eugenio: So that was very traumatic for me. And, you know, like my AMA cried, I cried, mom, everybody cried. And I was like, I just had to realize that general OBGYNs are not trained at all on how to deal with patients with endometriosis and chronic pelvic pain.
Carol: Can you say that again?
Dr.Eugenio: Like, general OBGYNs are not, are not, and on top of that, like, a lot of, if you see what happens in most of the country is that these patients are referred to, to gynecologic oncologists, but what's the issue?
They shouldn't be, right? But what's the issue? Also, gynecologic oncologists are spread thin in this country. ? have, it's not that they don't want to help, it's that they have patients that are literally battling life and death situations. So on top of that, to give a gynecologic oncologist to add all the other issues that are there for an endometriosis patient takes them away from saving lives in that way.
Not that Not treating endometriosis patients is not saving a life, but this is something that has a life expectancy of a year to five years, right? So it's a different type of, of saving a life, ? So they should focus 100 percent on that, which means that what's the alternative? We need to train highly specialized surgeons in minimally invasive surgery that are also specialized in endometriosis.
So one of the stories that I think I was mentioning earlier is like before years and years ago. Like, there was no such thing as gynecologic oncologist at the beginning, right? So, any woman that was found to have a cancer was treated by a general of GYN before all the specialties came into play. So, when did we realize that it was better to treat women with cancer by a GYN oncologist, right?
When they were able to prove that they got really better outcomes, but what was the thing that they were measuring? Life or death? Treated by a general GYN, life expectancy, give you X number, was one year. Giving, treating, being treated by a specialized gynecologic oncologist, your life expectancy was five to ten years.
So immediately you can see that there's a significant difference, but the, what we're measuring is quality of life and death.
Carol: right,
Dr.Eugenio: But how do you do that for minimally invasive surgery and endometriosis? we're only talking about quality of life and pain, not, not death. So it's really hard because it's so subjective,
Carol: Yeah, and we're talking about, we're talking about quality of life of females and also predominantly females of color.
Dr.Eugenio: which nobody really cares about, right? Nobody, nobody really cares about quality of life for women or pain or, or any of that stuff because, you know, life. Which, which is stupid, but it is what it is, right? So we have to work with what we have and we have to make it better. So, which is why I'm a big proponent of minimally invasive surgery, surgeons and trained.
and being trained by people that do surgery, and having an outcomes based, specialty, Like if you were, treating patients with endometriosis and chronic pelvic pain and you're doing surgery, but on top of that, you're putting them on suppressive medication. It's bananas, Which is the same thing that I told you earlier, right? Like you, we take patients to the operating room to do surgery to look for a disease, But what happens to this patient that we're going in to look for the disease? What is the patient a lot of times on, on hormonal suppression? So you are taking a patient to the operating room to look for a disease that you may or may not know that she has.
And then you're going to give the medication that is going to, say it with me, hide the disease.
Carol: Yeah.
Dr.Eugenio: I mean, I mean, it sounds like a comedy. Like, it's so funny.
Carol: totally agree, and there's nothing funny about it, but it is. it is ludicrous, and I wonder if, I'm curious about your opinion on this. Do you think maybe obstetrics and gynecology should be two separate specialties, and then within gynecology, should we perhaps be funding the expansion of minimally invasive gynecologic surgical training, and he's drawing something.
I think I see a percent sign there. So yeah, is that 10, 000 percent? Excellent.
Dr.Eugenio: Why? So there's countries in which they are doing studies in which they're separating obese from GYN. 100%. I mean, it's something that eventually, it may have to happen. Because obstetrics is deliveries, kids, babies, pregnancies. That's it. Right? But gynecology, right, it has to be a totally separate field. A totally separate field, right?
Or we do a,
Carol: different specialty.
Dr.Eugenio: yeah, it's a totally different like you or we should do a track in which we would do two years of general OBGYN. And then you do two to three years of specialized in obstetrics. And after that you have high risk obstetrics, which is maternal field medicine, and then you have the other track, which is two years of general OBGYN plus two to three years of what?
infertility. Urology, urology, GYN oncology, minimally invasive surgery, pelvic floor, like, like, different things, infertility, within the GYN standpoint. And once you're pregnant, you go over there, right? So it has to be that. Like, for example, general surgery in this country is five years. So for a general surgeon is operating for five years.
before they graduate. OB GYN is four years and most people spend more than half of that time doing OB.
Carol: Right.
Dr.Eugenio: Unfortunately, Because of the way and the variability in, programs, there are programs that are a lot heavier in obstetrics than GYN. So even though there's a minimum benchmark, there are residents that are basically barely meeting that minimum benchmark. From the GYN standpoint, their OB numbers are not a problem.
They can get that in their sleep. But their GYN numbers, people have to struggle. The basic numbers of the minimal amount of hysterectomies you have to do before you get graduated. Or minimum amount of proceeding gyroscopies and stuff to get graduated, right?
Carol: oh, and you brought up hysteroscopy. I want to bring that up. But before I, before I go there, I just want to say, like, we're being repetitive on this podcast about this particular topic for a really important reason. It's not like it's a pet cause or we think we're so smart because we figured something out.
It's
Dr.Eugenio: Which one?
Carol: the topic of how patients don't recognize, not to their fault, they don't recognize that an OBGYN is not the same. from place to place to place. That it depends on what their business is. It depends on how they've structured their practice. It depends on what their particular personal focus is.
and it's all awesome. Anybody operating at a high level, anyone going into OBGYN care right now, I honor you because it is really hard right now. is just literally to make sure that as a patient or as a caregiver, as a parent, especially of an adolescent, that you understand these things, because it might be complete news to you.
You might have never had an issue of your own to deal with, and you might think, I think that an OB GYN is an OB GYN is an OB GYN and it's not the case. And then the other thing that I'd like to say about that is, in your ideal world where obstetrics is one specialty and gynecology is another specialty that has sub specialties such as minimally invasive gynecologic surgery, I don't think physicians should have to pay for that education.
Because that's what's gating a lot of people from pursuing that path. They, they come out of med school and think, well, I can start making a really good salary now and be an obstetrician, or I can continue my schooling and rack up more debt. And, you know, and, and I just feel like that's just terrible.
Dr.Eugenio: so it's funny you would say that, for example, because when I, graduated residency, I wasn't attending. in my mind, was one of the best hospitals in the U. S. Like, Women and Infants Hospital in Rhode Island, it is absolutely astonishing what they've done and, and the amount of care that patients get.
Like, the directors of the departments that I met there are inspiring people, But in our practice, when I, when the practice, the community based practice where I worked at, I've had the pleasure of working with such great people, but one of the things that we understood early on is that we sat and had meetings.
Okay, if you see a patient that has XYZ, who wants to take care of this patient? I do. So we all knew that if you have a patient that had One of these issues, medical issues, we're going to feed them to one provider. Why? Because it becomes more efficient. You have one provider that's going to treat incontinence, or this, or that, or PCOS, or I want to see every teen patient.
Or so we would funnel people and then everybody got way better care, Oh, you're going to do robotic surgery? So when we get all the robotics cases to one or two physician instead of giving everybody doing a little bit of robotics, doesn't make sense, right?
It's important to look, and I'm not going to really tell you the numbers, I'm going to have you do a little bit of research on that. Like, how many, like, hysterectomies do you think the average OB GYN does? It's very little, a year.
Carol: A year, probably, probably about a hundred.
Dr.Eugenio: No.
Carol: 100?
Dr.Eugenio: A year? No, way less than
Carol: I'm thinking surgeon. I'm thinking surgeon. I'm not thinking the average OBGYN.
Dr.Eugenio: The average OB GYN, I may be wrong, but the last I read, don't do more than 15 hysterectomies a year.
Carol: Oh wow, it's going to say two a month. So even less than that.
Dr.Eugenio: Like, don't. Right? So, that's the thing. Cases should be funneled to doctors that are doing high volume. Right? In our practice, even in our practice, and I knew that early on from when I was in practice in Rhode Island with the team, which was phenomenal but it was a very collegial practice, but it was very honorable because you decided even though I can do this, it is a better use of my time to see patients and treat them for this.
And then if I find an issue, I can send them to a high volume surgeon. And within my practice that does this and this and has way better outcomes and has way less risk of complications.
Carol: Yeah. Two really important things that patients need to be focused on when they're considering surgery. And that, that's, should be the way that every surgical or every practice is operated, but it's unique, isn't it? It's not how it
Dr.Eugenio: It's not, it's may not be because everybody in the practice, you may be in a model that says, well, the more you do, the more compensation you have. So then everybody wants to just like claw, claw and do a little bit. and it's understandable, it's financially, everybody wants to do well so that they can pay for all the, the racks and racks of debt that you have from med school.
fortunately for me, because I went to med school outside of the us when I came to the us, I had no debt for, for med school. Thank to my thank you mom and dad. I appreciate that. Right. Uh, but
Carol: We, we appreciate it too.
Dr.Eugenio: yeah. But, but one of the things is that when I was. Thinking about going back into fellowship and going back to earning 25 percent of what I was earning before, The only way I could, I, I did that, it was hard. Earning, after earning, X amount and then going back to earning 25 percent after doing that for 4 years. Most of my other GYN friends says, Are you crazy? I got lots of people telling me, Why are you doing fellowship? You don't need to do this. Because I was, I was doing lots of surgeries.
Like,
I like being in the OR at that time, I didn't have any kids, so when I was my wife was in fellowship in Michigan, so I was like, you know what? Instead of me being home watching TV, I just want to put some cases and do cases Saturday and Sunday, which is kind of crazy, but it was happy for me, right?
There's no work life balance, because life was work and work was life, and I was happy. But besides that it's just important to know that, like, hyper focusing on people that do lots of surgeries is always a good thing. More volume equals higher expertise, greater outcomes. Not that you're not going to have complications, but you're significantly minimizing your risk of complication.
It's just one of the things that we tell patients.
Carol: yeah. And it, it's an important conversation to have because I think overall gynecologic care has been presented as simple. and I put it up there with neurosurgery and oncology surgery. gynecologic care is, is incredibly complex, made further complicated by a lack of research.
So, there's a lot that we put on the shoulders of our OBGYNs. And, and it's a situation where we need to do a lot of cleanup on aisle six and just make this a better experience for everyone. And so it's really important that as a patient that you understand the structure here and what's going on behind the scenes because as with anything else that you do as a consumer, right, any, any meaningful decision you make, or meaningful purchase that you make, you do your research.
And so this kind of information is really beneficial, um, especially given how little we know about these, these conditions.
Dr.Eugenio: to interrupt, I mean, that's exacerbated in one thing. There's a quote by past editor of the New England Journal of Medicine. It's very, I read it and I
was like, Jesus. So basically
after working in as an editor for 20 years, he said that something like it's no longer, said something like it's no longer possible to believe much of the clinical, research that is published.
I'm like, wait, what? And he goes like, no, it's, it's no, it's no longer possible. This is the editor, the past editor for 20 years of the New England Journal of Meta and saying that we cannot believe a lot of the research that's published, right? Because the greater the financial interest backing the research, which is what unfortunately you need a lot of finances to do research, to hire people, to collect the data, to study the data, right?
You can always modify things to go towards your point of view. or the point of view that you're trying to do, it's sad, especially because a lot, sometimes a lot of these research, research that's been done, they have to produce research or they don't get promoted. So also their own compensation is sometimes tied to being able to publish something.
So grants and all these other things are also affected and influenced by this, right? Like people, oh yeah, there's X and XYZ grant from this pharmaceutical company, come and apply for a grant. But obviously, they get the last say on your findings.
Carol: right.
Dr.Eugenio: If your findings are absolutely destructive to their study, guess what's going to happen to that study?
Carol: will not see the light of day. Exactly.
important when you're looking at studies, scroll all the way to the bottom and look for the financial relationship between the Study authors you can't even just look at one study. Like you, I never do commercials for uterine kind on this podcast.
I'm so bad at self promotion, but I'm going to do it right now. Like we have a section on our app. Dr. Eugenio doesn't know about this, where we summarize clinical studies for, people so that they can understand them and read them. so if you want to get accurate information and, accurate studies that you can have, you know, summarized for you, check out uterine kind.
I'll have people who use the app be like, how come you never promote the app on the podcast? And I'm like, I don't know. My brain just sometimes only works in one way. And so when I have an opportunity to talk to a physician, I am. all about the physician in that case.
So we were talking about your experience in Rhode Island and, that really sort of like pivotal situation that you found yourself in where, about how endometriosis isn't life and death compared to cancer, but we all know that,
Dr.Eugenio: really, it is extremely important for the patient.
Carol: It is, and we do lose people to suicide because of, you know, they just cannot imagine continuing on in this particular case, and there are other conditions, like premenstrual dysphoric disorder that may be riskier as far as that's concerned, we can admit that quality of life is really important and, being able to have an equal shot at a good quality of life is something that, that we all want for everyone.
Dr.Eugenio: It's all something people deserve.
Carol: yeah, absolutely. Yeah, they deserve it just by being born. You know, they don't have to be, a particular contributor to society or an able bodied this or whatever. None of that. It is because you are born that that you deserve to have good quality empathic care. In that situation, you talked about a parent, and I'm assuming an adolescent, right?
Some, some around 19, 20, 21? Was that a fairly young patient that you were dealing with? What would you say to parents may think that their child is just dealing with the same bad periods that they had or, you know, is maybe not accurately identifying their experience. Like, how, you know, you and I sat next to each other on a plane and I told you that my daughter has really bad periods.
What do you first think when you hear that?
Dr.Eugenio: Well, putting myself in the position of a parent is unfortunately something that I do a lot. I don't know if I mentioned this to you before, and when we were talking like 10 minutes before this, but obviously dealing with patients with endometriosis is a heavy, heavy thing in life. So first for some time I was like, this is a lot.
I need a mental break because I had so many patients crying in the office that they were in pain and their mother or their family members didn't believe them. for whatever reason, and then we had surgery and gave them pathology, gave them pictures. I do a video with patients. I give my patients the video of their surgery and make a video when I give them sometimes anywhere between 30 to 60 pictures.
I take their cell phone and go, okay, picture number one, video. And I record myself talking over the pictures and marking. And then the patients go back home and talk to their parents It's, it's cathartic for them. It's like, I am not crazy, So that is so powerful. So that also changed me in a way that like now I absolutely prefer to them to come with somebody in their support structure so that when I sit down and I crack my models and I talk about this and that and I educate them, then the, either the husband.
It's like, wait, what? And the, like, understanding of the things that are happening to their partner or their family member is such a big thing. But if nobody sits down and talks to them and explains it to them It's hard for them to understand. so there's a lot of guilt that they have, right? So when I was being, when I was going down that dark path of being super sad and maybe depressed, the only thing that got me through this was the birth of my daughter.
Like when she was born, I was like, Because unfortunately, I'm an empath, so I take in all that negative thing and all those feelings of sadness. It's tiresome to do this all the time. But what drives me to continue is that when I'm doing surgery is like, what if this is my daughter?
What would I want somebody to do for my daughter that I can do for this patient?
Carol: Mm hmm.
Dr.Eugenio: And that kind of like clicks it for you to like continue to push forward. And don't, even if you're tired, it doesn't matter. Keep going, keep going, keep going. You have to make sure that you do give your best to this patient.
And that same situation is to sit down to and talk to the parents. Okay, dad or okay, mom, let me help you understand what the disease is. And a lot of the times what happens is there can be some cultural issues as well. What, what's another issue? All the women in my family had issues with periods and we're not dead.
Carol: We're okay.
Dr.Eugenio: We're okay. First, and then I talk to them, like, first of all, pain is individual. Second of all, what, how old were you when you had your first child? Oh, 21, 22. Oh, great. How old is your daughter now? 34, 35. And she can't get pregnant, and she's been trying for some time. Why? We all know that as women age and the matriosis progresses, infertility gets worse, So, there's many different factors that can affect women's fertility over time, but one of the biggest things is that, like, if you are in high school and then in college, And then doing postgraduate studies and more things and more MBAs and baccalaureates and 50 different things to improve your professional life, and you're delaying childcare like you want to do for yourself or your family, then it's like a slap in the face that after you did all the things correctly, then when you want to have a family, you can't. And it's absolutely devastating. And it's something I never tell my patients. You need to get pregnant now.
Carol: Right,
Dr.Eugenio: Like, it's like, oh, it's like going and buying a car. Let's just get pregnant now and forget about, forget about the life path that you chose for you.
Carol: right,
Dr.Eugenio: now or you won't be able to get pregnant.
That is one of the most horrible things that you can tell a patient. Because they have a plan for their lives, You can educate them. Obviously, as time passes, fertility may be an issue. If you treat endometriosis early enough, you can prevent infertility. You can prevent it. I mean, I have that belief.
If you treat endometriosis early enough in patients that are teenagers, you're preventing bowel disease and significant endometrioma. If you're treating it properly early enough, you should be able to prevent all these things. And one of the things that you know, one of the things that you can definitely prevent depression, suicidal ideation, self harm, because they are not believing that they're crazy.
One of the things that I, I saw a patient earlier this year before coming to the CEC that I had operated on like over a year ago. And when I saw her initially in the consult, Like, when I was doing her pelvic exam, I saw that she had a lot of cuts in her legs, so she was doing, she was doing a lot of self harm.
And I kind of asked her, like, hey, what's, like, are you okay? Do you want to talk about this? And why are you doing this? Just trying to get to the bottom of this, right? And I will never forget when she said, like, this is the only pain I can control. And I was like, holy crap. So it's like, so like, what? That is like, I could not process
Carol: of a cliff. Yeah. It's
Dr.Eugenio: Yeah. I couldn't process it. Right. So then when I saw her like a year or so later, she was like, Remember what I told you about that? I have, after surgery, I have not cut myself once. And that was literally, I was on cloud nine until I got home and didn't take out the trash and got into trouble. But that's another story.
But, but
Carol: together, bro. I mean, come on. Like, you can't be, you can't be bringing your A game, you know, during daylight hours and then just, you
Dr.Eugenio: and then going home and screwing it up. It's fine. I mean, Thank God she forgives me a lot, but you know, but, but it's what I'm telling you. It's like, it's phenomenal, right? So imagine what, what, how different would have life have been if I, we treat her at 17, 18 versus 30.
Carol: Yeah, so let's, let's dig into that. let's talk about this adolescent experience, um, because prior to pressing record, you and I also had a conversation around adenomyosis, adenomyosis, adenomyosis. I have no idea what the proper pronunciation is. I call it adno. And we had a conversation about it.
And for those who haven't heard us talk about this before, adenomyosis is when the for Endometrial cells, the lining of the uterine cavity, grow into the muscle part of the uterus. Endometriosis is not that.
Dr.Eugenio: Okay.
Carol: It has nothing to do with the endometrial lining or endometrial cells and it was really poorly named.
And in my future life, I want to come back and rename the stuff that's badly named. in, in all languages because the endometriosis would be one of the first things I'd change. So with adenomyosis, we were talking earlier about the, how it was perceived to be a condition that developed after multiple births.
And, you know, it affected, uh, females in their late thirties, but more likely forties. And it was largely cured by hysterectomy because that is a definitive cure for adenomyosis. And because it happened later in life, my assumption, my personal assumption is that when looking at the hierarchy of things to fund research on and to better understand and to come up with better treatments for, adenomyosis got shoved to the side because it coincided with a time period where hysterectomy was not as problematic as it would be for someone who's 18 or 19 years old.
Um, but now we're finding out that adenomyosis is affecting people at a much younger age. And when I discussed the data that I had seen, around adenomyosis between the ages of 18 and 30 and the prevalence the, the percentage of females who were, were diagnosed with adenomyosis who also presented with painful periods or dysmenorrhea, that 34 percent of them had adenomyosis.
And I nearly fell over when you said At
Dr.Eugenio: I mean, yeah I personally think it's slow. Maybe it's because, obviously I'm a little biased because since I only see complex UIN pastes that are at the end or the line of the road, obviously, yeah, I would have some type of selection bias because I see the worst of the worst. So I see a lot of cases that are, for example, that may be on transitioning.
Okay. Right, they're in a point in their lives where they're going to transition, and they're young, they're 21, 22, 23, some 18 year olds, and they're like, I'm not interested in this, I, I, after you counsel them appropriately, I want a hysterectomy, great, you do a hysterectomy, adenomyosis at like, 21, I was like, wait, what? Right, so then you see it often, right, so obviously, if you do a lot of the surgeries, you'll see it a lot more.
Carol: so definitely high prevalence on a condition that for, for decades was assumed to not even show up in, in adolescence. And so the reason why I'm bringing that up right now is because I want to go back to this, this conversation around adolescence and parents and school nurses and unwinding this, these either, false premises that we hold on to or conditioned responses that aren't helpful.
And adenomyosis is a painful, heavy bleeding, right? Those are the two symptoms that really show up the most, right? And and endometriosis can also present with a lot of pain and heavy bleeding, but tends to also have pain that is happening outside of a person's cycle. Is that, is that a fair statement?
Dr.Eugenio: Yeah, you can say some of those things. For example, one of the things that I find very common is that We usually talk to patients when we're doing them. I usually say, okay, I'm gonna ask you 50, 000 questions. And one of those questions that I ask them is, talk to me about your period. When does the pain start?
How many days before the onset of the period does the pain start? Oh, not before the onset. My pain is worse on day two. I was like, wait, so, but before the period, you have no pain? No, no pain. And then some of these patients, I mean, I'd learned throughout time that When they say that that's the issue, that their pain is like worse the second or third day of their period, specifically the second day, I'm biased obviously, but in my mind it's adenomyosis to prove it otherwise, right?
Because then the maturity starts to hurt way before the onset of your period, for most, for most of the patients that I've seen. Right? And again, I realize I'm biased. I see only patients with chronic pelvic pain, and I'm atrocious to the anaemiosis, and some of these things, right? So this is what, this is my own observational bias for my own 250 to 350 cases a year for the last seven years, six years, so that's kind of my opinion.
Carol: what is, what
Dr.Eugenio: I believe it has to do with the amount of inflammation that happens within the muscle in that, in that first and second day. Right? Because what happens within the uterus itself, which is why the pain goes crazy in those days, but when you have, when you have pain from endo, it starts, used to be a couple of days before, because your, because your, your progesterone levels start to decrease, and that starts, that can actually, like, you know, worsen the inflammation that's happening throughout the pelvis and cause significant pain and inflammation, but starts outside of the uterus, So that is something that I've seen significantly. but what's the issue as well? That endometriosis and adenomyosis are really, really good friends and they can coincide, they can cohabit. all the time,
Carol: Yeah. SOL fibroids
Dr.Eugenio: As well as fibroids, right? I think that I agree with what Dr. Redwine was saying. I mean, we're all, I mean, rest in peace, right?
So, but I may agree significantly with what he was saying regarding that we believe that the future of this is basically identifying what are the genes that are involved in this, right? Places that have the higher risk of developing it, because we know that. from current research that there's around 25 to 30 genes that some of these diseases are sharing.
Fibrosis, myosis, endometriosis,
Carol: Yeah, I'm really glad that there's an abundance of funding so that you guys can conduct studies on this. Did you note my dripping sarcasm? Um, 16 million dollars last year from NIH for endometriosis funding. What can you do with that?
Dr.Eugenio: banners and commercials, I don't know. Nothing.
Carol: Not a lot. Not a lot from a research perspective. So, let's talk to the patient or parent and caregiver of someone who is at the point where they think what they have is bad periods. So they are endometriosis, adenomyosis, fibroids, those aren't even on the edges of the radar screen for them right now.
They literally think, I have bad periods. They go to the gynecologist or the obstetrician, more likely. They go to the, they go to the doctor that delivered them
say,
Dr.Eugenio: Oh, that's right. That's very
Carol: that, right?
Dr.Eugenio: That's, that's very common. I'm laughing because I had that, I had that same scenario twice last week.
Carol: it is something that we do and that we kind of like, there's like this badge of honor to say like, I got my, my gynecologist or my obstetrician delivered me. And it's like, all right, but that may, may not be the person that you want to go to when someone is experiencing really, really bad periods.
And you know, I want, even though you, your expertise is on the surgical side, complex gyne surgery, I want you to factor in, because I know you're aware of it, premenstrual dysphoric disorder, NPCOS. and these other conditions, right? so talk to the parent slash patient who literally thinks that they just have bad periods and the thing that they should do is go get birth control.
To, make that go away, and, not, and then do nothing beyond that, from a diagnostic perspective. What do they need to know?
Dr.Eugenio: So, the first thing that I do when I have those parents here is go really, really back to the basics, which basically starts as, this is a uterus, this is the bladder, this is the the rectum, this This is the fallopian tube, and this is how ovulation works, so that they can have an understanding of what's the period.
There's a video that I had on my phone that I used to show parents, basically, of having there's this girl on TikTok, and she was dancing, whatever, and she had her bikini and she was at the beach and she was having fun, and she had a drink in her hand, and she was just having fun, right? And she had a white, two piece bikini.
And then suddenly her friend says, hey, I think you just got your period. she looks down and she goes, Oh, I think I'm getting my period right. I'm standing in my bikini. And then compare this to your daughter. What does this tell you? Like, this is what's supposed to happen.
Carol: Like, uh oh! Oops!
Dr.Eugenio: Oh, I got my period. I forgot. Like, you're not supposed to plan your life around your period.
The period is something that happens but it's not something that should dictate the way you live your life. The moment you start planning your life around your period, This is an issue,
Carol: Beautifully said. That should be your baseline. If you're, if you're child, or if you are planning your life around your period, that's your baseline. that there's an
Dr.Eugenio: I mean, absolutely. If you're, if you're the parent just saying, you know what, we're going to go on vacation. Oh, but if we go on vacation, Jennifer's going to have her whole issue. So when is her period? No, we're not going to go on vacation. I mean, that should tell you that there's something wrong,
Carol: Yeah, but
Dr.Eugenio: we need to address it.
Carol: yeah, and we need to, we need to unwind that that's, it's happened over decades, right? This has just been baked into the female experience that your period sucks. And, and for some people it sucks really, really, really bad. and you're just unlucky if you're one of those people, right?
So that's really excellent advice because I can hear a, a parent. Say that to a physician, right? So the parent's not going to walk in and say, Well, doctor, you know, based on her this and that, and I think maybe, you know, we should investigate endometriosis. Like they're intimidated. Everyone's intimidated when they go in to see an OBGYN.
And if a parent is bringing an adolescent in who's going to have a physical exam, that parent is walking on eggshells. , even if their child doesn't care and is just like even excited and maybe wants to be a doctor one day, that parent is only half present in that room.
So to be, I can hear them saying, Doctor, she plans her life around her period and that's not normal. And I think that in and of itself will set that, that particular appointment on a different trajectory. So that is
Dr.Eugenio: You would hope,
Carol: That
Dr.Eugenio: but one of the things I was mentioning to you earlier as well was what, like, what's the average time of a Do I N appointment in the U. S.?
Carol: the doctor is in the room, six minutes,
Dr.Eugenio: Six to 10 minutes, right? And that time, what do you have to do? You talk to the patient. You say a stupid joke. Somebody gets undressed. Somebody's genitals get touched. You give them a, or you order some tests you leave and you have to document
Carol: in six to ten minutes.
Dr.Eugenio: and six to 10 minutes or 15 minutes. There's absolutely no time.
To ask adequate questions. my visits sometimes include no exam, I talked to the patient for over an hour, an hour and a half, and I don't touch them.
Carol: Now you have that luxury, not everyone is structured like that, but to me, I think that is the perfect way to begin that relationship, because we gotta admit that this is, this is really intimate. You know, like, this is more intimate than you getting brain surgery, Like, you are awake on the table and someone is, is physically inside you and you're, you're 16.
Dr.Eugenio: it's horrible. And in fact, I, Usually make it a point to not examine virginal females, to not do any type of pelvic exam on, on teenagers whatsoever. So I'm very radical on that. Like, I don't think,
Carol: then how do you deal with that? How do you, how do you, manage diagnosing given
Dr.Eugenio: so guess what? Teenagers can give you a really good history about their pain and their profile, Family history also gives you a really good indication. So our rate of finding endo I don't want to say the number because it's really extremely high and people won't believe it, but that's okay.
But especially from how I was trained to identify tetoxic patients to figure out, I mean, it was extremely elevated. But then we got into some fights because of my rate of taking a patient to the operating room and finding endometriosis is really high, means that the bar that the patient has to get to so that I can decide to take him for surgery, is very elevated.
So obviously I'm going to get a really high rate, but there are patients that are maybe not getting to this level that I'm not operating them and may have endometriosis, right? in my defense, when I had those conversations with some other physicians was that the last thing I want is to take somebody to the operating room and have negative surgery because I did surgery for no reason.
No negative endometriosis. Because I put a patient at risk of life, death, injury for no reason. So it's a little hectic, but you can do trans abdominal sonograms, you can do different studies, you can talk to patients, but the majority of the diagnosis of endometriosis you get in what? Conversation.
Carol: that initial
Dr.Eugenio: In the initial intake visit, conversation, and you ask questions in different ways to make sure that nobody's malingering and they're understanding the thing.
You can do different things to figure out if you believe this patient may have endometriosis. Besides, like When you see, when you talk to sufficient endometriosis patients and you're asking them their story when they're 20, 25, after they've been sexually active Guess what they're telling you. The same stuff that the 15, 16, 17 year olds are telling you about their pain history.
The same thing. There's no variation. There's no, there's no black magic. It's the same thing. I had this when I was this age, and now that I'm this age, I'm having this plus infertility, plus pain with deep penetration. So if you talk to your patients officially, you can have a good idea. You can do transabdominal sonograms, you can do translabial sonograms without having to do something internal.
So, so there's different things,
And one of the things, like, in all the teen patients that I've, I've done surgery on, there has been only one patient that I regretted not doing a transvaginal exam or tra or, that is not sexually active, because the teenager is sexually active, then there's a different story.
Dr.Eugenio: Right? But a patient that's not sexually active, then no, no sonograms or nothing, just history, and decide if you take her or not take her to surgery. Now I've had a patient that was not sexually active so we did an exam, we talked to them. For her symptomatology, for symptoms she did qualify 100 percent to have endo.
She had also positive family history, so that also increases her risk significantly. So took her to the operating room, and she was 17. And we got in, she had stage 4 endo. And that's the youngest teenager that I've ever seen that had, that unfortunately I could not excise all the endo because she needed to have a bowel resection and she wasn't ready.
Carol: Oh boy.
Dr.Eugenio: at 17, a bowel resection. But, for example, this week, I just came back from Tijuana, Mexico, at a center of endometriosis that they have down there, that they're doing really great. Great stuff. for their population, right? So, so really, really great doctors, really great things, right?
So one of my friends down there is Dr. Armando Menocal, who is in Morelia in Mexico. And I was doing a presentation on pediatric endometriosis down there, and I brought lots of my videos of, of teen endo, and I don't know what is in the water down there. But the videos that he showed me from teen endo are way worse than anything I've seen here in the U.
S. So that one patient that had needed a bowel resection at 17, they've done bowel resections at 15.
Carol: Wow. So is it, genetic or is it literally
Dr.Eugenio: There, I think genetic is a big factor, right? But I had never seen a 15 year old patient with stage 4 bowel endometriosis and with diaphragmatic endometriosis, and I was like, and it wasn't like one patient. He showed me like 20 different videos,
Carol: Multiples.
Dr.Eugenio: multiple patients, multiple patients, different disease. I could not believe it.
I was like, you're kidding. I'm like, yeah, for sure. This is real. These are my patients.
Carol: So this is so, this is such good information because We have to, we have to build a bridge between bad periods, I had them to suck it up, take some pain meds, and no, we really have a numerous conditions that are complicated, that haven't really been, historically prioritized, or you know, we lacked the tools to identify them or to treat them, and so we need to, to build that bridge so people understand it.
First and foremost, that a normal menstrual cycle is like what you just described. It's a, it's a person on the beach who's like, whoops, I just got my period. That's a normal menstrual cycle, right? You, you, you just don't, you know, you might get a little bloated, you might feel a little uncomfortable, but if you are organizing your life around your period, something is out of balance.
And the most important thing to do is to recognize it and get to the right physician as quickly as possible. before we go, I wanted to, have you talked about excision surgery and why it is really important that people don't go to any surgeon, just any surgeon I suppose is the best way to say it for endometriosis surgery?
Why is this condition, why does this condition require a unique method? And why is it important that that method or that that surgery be conducted by a specialist?
Dr.Eugenio: Okay, number one is because volume matters. Number two is that, patients should definitely do the research for figuring out who's doing surgery. Unfortunately, there are lists out there that, that talk about. Doctors in different states and different places. But the issue is that also talking to your physician, how are they treating the disease?
Are they only are they relying on excision or during ablation or are they using also? different medications like Lupron and Orlissa or other suppressive methods before or after surgery. Before surgery, you're, I already said that that's bananas. But then after surgery, like you do surgery and the patient is in pain and everything's sparse.
Oh, fine. Be on Lupron, be on Orlissa. I was like, so did you remove it? Did you not remove it? Is it that? Is it endometriosis? Did you evaluate all the other 50, 000 things that the patient has in the pelvis that can be going on? It may not necessarily be endo, it may be something else, but masking or giving a patient medication, which is, for example, I'm 100 percent against giving a patient lupron oralis before surgery.
Why? Because one, the side effects it has. are not benign medications. And two, a lot of times they give this medication and they don't have endometriosis. So you put a patient through the risk of all these side effects, like it's a benign thing, but
Carol: Yeah, that's, that, it is such a strange practice, like, I, I've heard of giving Lupron to patients before fibroid removal to shrink the fibroids a little bit under
Dr.Eugenio: that in that case, there's data on that. So there is data on if you give patients Lupron, you may shrink, you shrink the vascular, the vascular church of the fibroid. So the fibers may be smaller. So it may be easier to cut them out. So you're, you're less destructive. So that makes sense, right? So that, there is some data on that, but let's give a patient some medication before she actually has a diagnosis of endometriosis.
Carol: Yeah. So you need to definitely pay attention to the distinction that he's making here. That it is, you can't think don't think of yourself as just a uterus. Think of yourself as a person who could be developing and living with one or more complex physical conditions, right? Because I think we sort of squish ourselves down into this one person persona and, you know, it's like, no matter what's wrong, take birth control.
No matter what really bad condition you have, take Lupron. And it's like, no, no, no, no, no. We gotta, we gotta be clear about that.
Dr.Eugenio: We usually give the patient the option, like, do you, do you even have to be on birth control after surgery if you don't want to? The only time I'm actually, like, more pushing towards using birth control is if the patient has a big endometrioma or endometrioma at all, because they tend to recur really fast.
So the risk of having an endometrioma come back is 10 times fat higher than when you have endometriosis on the peritoneum, which is what we call the wallpaper of the abdomen, right? It covers everything except your ovaries inside. It covers your intestines, the uterus, the everything except your, your ovaries, when you have endo on the peritoneum, if you do proper excision going really wide and really deep, the possibility of disease coming back in that area is low. If you did proper technique, with having a good margin, right? In fact, when we take patients back to the operating room, guess where we see endo?
Not in the spot that we removed, at the margins of the stuff that we removed,
Carol: Oh,
Dr.Eugenio: right? And, but, we feel good because we usually go really wide. And we inspect our margins, and what does, what saves us? Something very simple. I take a picture before I cut out the disease, and after I cut out the disease. So I give the patient, this is how this looked before, this is how it looked after, and if I have to take her back to the operating room, oh, this is what I removed, and this is where I came back. So, I, talked to a patient, like, a couple last week that their doctors wouldn't give them the video of their surgery or the pictures of their surgery saying, well, that's not, that's HIPAA.
I was like, oh, they can't give you your own information because that's HIPAA?
Carol: Yeah, that's not,
Dr.Eugenio: Like, there's not, there's not a thing.
Carol: No, that's called, that's called you don't want to give them that data. You can make up an acronym for it, but that's what it's called.
Dr.Eugenio: Yeah, but I believe patients should have, if you want a video of your surgery, get the video of your surgery.
Carol: Absolutely. And you know what? Make sure, I'm so glad that you brought that up because I've heard from numerous patients that, they'll ask questions post surgery and the physician gets really miffed at having to answer them. I'm thinking of one person in particular No names who had their uterus removed and wanted to know how the ovaries were fixed now in the body.
Like they, she, she had what I consider to be a beautiful question. Explain to me what my anatomy looks like now so I can, you know, see it, take better care of it, etc. And the doctor was like, why do you need to know that? And she's like, because I want to know it. And, and he goes, I, I just, they're there. he was.
Mad. And, we have to stop doing that. and the pictures mean you get, if you have knee surgery, your doctor's going to show you that beautiful surgical outcome, right? They're going to be like, ta da, look at how great I am.
Dr.Eugenio: But more importantly, how are we doing laparoscopic surgery in 2023? With what? with a camera.
Carol: Right.
Dr.Eugenio: So how are you doing surgery? Like if you had a, it sounds funny, right? But like if you had a plumber and he goes into your house and you have issues and you have to replace a whole bunch of pipes and stuff. The plumber goes into your house and comes back 30 minutes later. And she goes, and it's done. And you're like, really, what? Show me. What did you do? What did you put in?
What did you take out? Right? So, if you're doing surgery with a camera,
Carol: of the plumber's like, no, I sealed
Dr.Eugenio: it's sealed, and everything looks good. Everything looks good. I'm like, wait, what? Like, you did surgery with a, like, you're doing surgery with a camera, you can take pictures of before and after. It does not take the only, you know what, just the only effort that you have to do is just want to do it.
To take, to show the pictures of patients of before and after. The desire to, like, be transparent. Something that my dad always told me is what? Sunlight is the best that's infected. So you cannot imagine how many times I see pictures of a surgery that are very shady, and, oh, we removed a whole bunch of endometriosis, and then, oh, really, you know what I do?
I go back to the pathology, and I open the pathology report and go, Oh, this is a lot of endo, and I see a nodule, and I'm guesstimating the size, and they removed 0. 5 centimeter of this thing that clearly looks like it's four centimeter big on top of the bowel.
Carol: So total waste.
Dr.Eugenio: So then, no, no, not a total waste, but oh, we ablated some stuff, and then we cut it all out.
And they have three specimens, three or four specimens, and they're like half a centimeter, one centimeter, or like 0. 3 centimeters. So they do a bite and burn the rest. We removed everything. And then we go back and then I'm like, wait, this doesn't make any sense. How do you remove everything and all the pictures that you're seeing that are speckled?
And then your specimens are one centimeter when you can clearly see that all the pelvic sidewall is infected within the metriosis. , it's essentially lying to patients. Right. And it's hard. And I don't really want to get into this. I am very honest and I give it to patients like this is what you said they did, and then this is what is written in the report, but this is what's in the pathology.
it doesn't make any sense to me, and the pictures don't really make any sense,
Carol: right. And the issue of ablation, can you comment on when you feel that that is the appropriate tool to bring into the mix and when it's not?
Dr.Eugenio: so ablation is absolutely perfect to do. When you are part of a randomized, double blind control study and you have the bad luck to be in the ablation side of the study.
Carol: That's like the best, that right there. I'm just going to say at our end of the end of year episode where we have like the best of, that is going to win the crown. You just won yourself a crown and a sash.
Dr.Eugenio: Got it.
Carol: that's fantastic, because I was under the impression that in certain places where you can't actually cut in, or to cut in would increase the likelihood of a perforation or something,
Dr.Eugenio: Wait, wait, wait. Perforation of what? Of bowel?
Carol: let's say bowel or bladder, let's say bladder,
Dr.Eugenio: Okay, great. Guess what? The bladder can get repaired. You cut the endo, repair the bladder. It just, this is what doesn't make any sense to me. You're going to open a patient, do surgery, burn the surface of the disease that's into the bladder, and then, oh, I don't want to cause any damage. That's not the case.
The case is, you have to treat it like it's a white cancer. If you leave it on the bladder, it's going to get worse, and then she's going to come back with urinating blood, or it's going to expand into her bladder, and then she needs to be a wider resection, right? Oh, you have endo on top of the ureter. I'm just going to ablate it.
My, by God, don't do that. Because what happens is what? Like, the disease stays there, then you lose a kidney, and then suddenly, oh, we didn't know.
Carol: Yeah.
Dr.Eugenio: Like, kidneys are for free. Like, you cannot imagine how many times I've seen patients that had multiple surgeries, they ablated the endo that was on the sidewall, and then suddenly the patient has, like, lost half of the function in one of their kidneys.
And now they have one kidney working at 75 percent and the other one working at 25 percent because of extensive stenosis. Those are the lucky ones. Because sometimes you do, you repeat it, and then you do, and then you come back the study shows that the patient lost all the function in that kidney.
So they, guess what do they have now? They have to have a nephrectomy plus removing the ureter that could have been saved by just cutting that portion of the ureter. working with a combined urologist to like, cut that portion and spackle it together, put the ureter back together, or do a uterine implantation.
Carol: right. Like we're, now we're, we're looking at a complicated situation that was made 10 times more complicated. And, and it goes, I guess it goes back to, the lack of standards around endometriosis care and, and the need for urgency, around creating those standards.
Dr.Eugenio: Yeah.
Carol: Well, that was, that I think is just crucial information for people to understand. you didn't get the, the hilarious answer, if you didn't get the point of that, because you're not familiar with clinical trials, what he was basically saying is like the only time ablation should be performed for endometriosis is when you're trying to validate that it's not the right thing to do.
Dr.Eugenio: But I mean, and also a caveat to this is, If a GYN does not feel comfortable treating endometriosis in a specific organ, what is the best thing that they could do?
Carol: Call another surgeon.
Dr.Eugenio: Number one. What's the second best thing?
Take a picture of it, give it to the patient, and say, go somewhere else that can treat your disease.
Carol: for sure. And, and, you know, I think that I want to emphasize the need for, obstetricians and gynecologists and primary care physicians and gastro physicians and everybody. Everybody has to know about endometriosis. You know, there needs to be a red phone situation where someone speaks at one time to all physicians and they all hear it.
, but hope that you will join us again, because I, there's a lot of topics that I want to get into with you.
And one of them has to do with, the way that excision surgery is handled from a business perspective. Perspective. Um, I want to get into that and how, the powers that be are making it a challenge for surgeons to get compensated for this surgery properly and how that is impacting patients.
So will you come back and join us again?
Dr.Eugenio: 100 percent we can talk about that over T.
Carol: Over tea. Excellent.
Dr.Eugenio: Thank you for having me. Thank you for having me
Carol: absolutely, absolutely. So again, I think many people who know endometriosis know the Center for Endometriosis Care, but if it's more really important that you recognize that endometriosis affects people that you know and love, and they may not know they have it.
when you hear someone talk about bad periods, please step up and stop the cycle of these endometriosis. Symptoms being dismissed. And please write down Center for Endometriosis Care in Atlanta and Dr. Eugenio because I know, I know, uh, at least 20 excision surgeons. And I got to say, I put you right up there at the top because
Dr.Eugenio: that.
Carol: your, your communication style and the way you explain things, you don't dumb it down.
You get straight to the heart of the matter. Like it's how it should be. experienced. People don't, patients don't need to be carried around on tufted pillows, but they also, they need the info and you know how to deliver it. so thank you for being here and thank you for pursuing this specialty.
We need you.
Dr.Eugenio: Thank you, thank you. I think one thing, I appreciate you saying those kind words about me, I appreciate that very much. I just hope that, like, after I'm done with my career, people can say the things about me that they say about Dr. Redwine recently. That is definitely an inspiration. One of the things that I think we should touch base into something that, I mean, us endometriosis surgeons, as we continue to evolve, we continue to learn new tricks and we talk at events.
And when we do international conferences, like, Hey, what are you doing? What's working? What has not worked? What do we have to stop doing? So these conversations between like people that you trust, like I was recently in, in. Like I said, like in Tijuana, in San Diego with Dr. Andrea Vidali and I had conversations with him about stuff that he's doing that's working or stuff that he's doing that he's no longer doing because he realized that he can get better outcomes doing different things.
It's like, tell me, it's like we get together with multiple doctors, like at these events and we ask conversations like, Hey, I'm doing this. I'm not really getting good results. What's happening with you? Right. But that gets, you know what you need to do to be able to do that? Get together with a group of people without ego, right?
Carol: right.
Dr.Eugenio: And that's one of the things that we need we need to fight as physicians We need to fight against our own ego that hey, we did surgery. It wasn't proper Let's still find out a way to send this patient to get proper care. And think about this You see a patient in the office, you evaluate her for whatever, and it turns out that she had a pathology, you missed it, and was a malignancy, and this patient died. You could be liable, right? Because you delayed care, right? What happens when you see a patient that has chronic pain, all this stuff, and has a lot of pain and a lot of everything, all these symptoms, and then suddenly it's only important when she can't be a breeder, right?
But this patient has seen doctors, this patient has been seeing GYNs for 7 to 10 years, but when she can't breathe, that's when it's important. Like it's bananas, right? It's, it's not okay. And then I got into trouble this weekend because in the conference where I was, I basically says, and I did, you did tell me that, well, we're not going to blame physicians, but what did I say?
We have to. Who's, if we don't blame the doctors, I was like, who's, who's to blame? Tinkerbell? Like,
Carol: who else are we gonna blame? I, I, I mean, ACOG? Can I say ACOG? Is,
Dr.Eugenio: good night. Have a good rest of your day.
Carol: is, is, is it, why, why? Why are you saying that? Because I'm not allowed to? Huh?
Dr.Eugenio: I don't, I have nothing to say about that.
Carol: Okay. Yeah, I mean, I don't, I don't.
Dr.Eugenio: I don't know what to say. It's, it's,
Carol: I'm gonna, I'm gonna have to, I'm gonna have to go offline to get the, get the response for that.
Dr.Eugenio: we can talk about that over tea sometime later.
Carol: Okay, that's gonna be a goblet of tea, right? That's a, that's a larger serving. it is, really an excellent way to wrap, to say that we are, we are more than just bleeders and birthers. And, you know, We don't have all the answers, and we don't expect doctors to have all the answers.
When, when a person is educated about how little research has been conducted and how little research you all have to rely upon, you know, that, that is a problem. Other specialties have way more research to rely upon. Cancer, I'm talking to you. And as a result, you have a much better patient care path. You have, everything is just better over there, right?
Research contributes to that a lot. But,
Dr.Eugenio: Well, because there's finances involved in cancer research and stuff like that, right? So there's finances and protocols, but the only time there's research in endometriosis is when there is to approve a specific type of drug or see if this works or not, because there's finances involved, right?
which is why, again, we go back to what a 20 year editor of New England Journal of Medicine says, the more financial gain is, or the more finances are associated to specific research, the less one can believe it's value.
Carol: right. Yeah, it's got to come from the NIH, right? Without
Dr.Eugenio: yeah, it has to be exactly. Research with ostriches, good, bad, works, doesn't work. There's studies out there and I'm not, and I'm looking at you, certain medication that you take orally that you talk about improving pain. at painless sex at three months, but not at six months, right? There are some studies that, um, you know, I'm going to leave it out
Carol: have it. You don't even have to have a bachelor's degree, much less a PhD to just go, Hmm.
Dr.Eugenio: There's a lot of different things that you can do in research, especially when there's a lot of money involved.
Unfortunately, we need independent research that is very robust, multi centered, but takes a lot of money to do something like that, right? Especially because, yeah, so that we can get proper data.
Carol: Yeah.
Dr.Eugenio: proper, proper data. But that takes a lot of time and a lot of money.
Carol: Are you on social? Where? Tell us where.
Dr.Eugenio: on Instagram. Um, I did open a TikTok, but I'm still not, like, ready to go into TikTok.
Carol: maybe we should do a TikTok live together and I can, I can help deliver you to the community so that, you know, they can properly embrace you. But when we post this episode, I'm going to link your socials. We'll have those linked in there and we'll share them. because. You need to be talking on social in all that free time you have, Slacker.
And, um, we gotta make sure that, people can find you, because this is, unfiltered information that you need access to. This is the straight scoop, and we can't thank you enough for it. It's rare.
Dr.Eugenio: Thank you.
Carol: You're welcome.
we'll be right back with Ending on a High Note. This is one of my favorite high notes because I refuse to give up. I refuse to give up my pen and paper. it's like my weighted blanket. Like if you have a weighted blanket and you love that, my version of your weighted blanket is a really good pen.
and really good paper. And then the quiet time to be able to write with it. And now I'm even more motivated because a new study has investigated neural networks in the brain during hand and typewriting and showed that connectivity between different brain regions is more elaborate when letters are formed by hand. According to Professor Audrey Vandermeer, a brain researcher at the Norwegian University of Science and Technology and co author of the study published in Frontiers in Psychology, she says that her study shows that when writing by hand, brain connectivity patterns are far more elaborate than when typewriting on a keyboard.
Such widespread brain connectivity is known to be crucial for memory formation and for encoding new information, and therefore is beneficial for learning. So I say to the go grab your favorite pen and paper and go back to the old days when a little cursive was like fun and magical and, you know, write a letter to somebody.
it's getting close to that time when we, we should be writing poems, the key word there is should, right? You know, a holiday like Valentine's Day makes you feel obligated, but maybe this will inspire you to take pen to paper and put your thoughts down in beautiful words and, and hand that over instead of chocolate, which probably has a lot of toxic metals in it.
You don't want to ask me for gift advice because I'll tell you about all the things that you shouldn't buy. Yeah, because They have endocrine disrupting chemicals or toxic metals. Anyway, thank you for being here. Coming up this season, we have interviews with pioneers in research and study highlights and physicians who elevate the care experience.
We have big announcements from UterineKind on new features, partnerships, and awareness initiatives. A renewed focus here on HelloUterus on endocrine disrupting chemicals. Exciting innovation spotlights. and we'll be keeping tabs on news impacting female health. Download UterineKind and keep your own detailed medical record to expedite a diagnosis. It's free to use and will save you time and resources accessing excellent care. Getting educated without the nonsense and misinformation helps you better direct your care experience and manage any conditions you're living with.
So get well at uterine kind. We're in the app stores and available online at uterinekind. com. Next week, we welcome Elizabeth McLaughlin, a certified nurse practitioner who mastered nutrition to help with her hormone journey. And now she has a book that helps you work in lockstep with your hormones. If better nutrition, but not complicated nutrition is your goal, this interview is a must.
Her book is titled Sink Your Mood with Food. Buy it wherever you get books. Thank you Angel and the team at Uterine Kind for bringing passion to all you do in support of female health. 2024 is the year where we accelerate change in female health and improve the experience for everyone. And we at Uterine Kind are honored to lift boulders to better serve you.
Till then, be well, be cool, be kind.