In this episode, we are joined by Dr. Meenal Misal who specializes in minimally invasive gynecologic surgery. She gives us an inside look on the life of a gynecologist and minimally invasive surgeries. Thanks for listening uterinekind!
Tylenol, Prozac, Lexapro, Zoloft, and the list continues. These well-known known medications are taken nearly every day, so why are they under our radar? Today we’re bringing you another round of shocking uterine news, especially for those who are pregnant. The stories told today are a reminder of the importance of funding research and looking towards proper treatment for your uterine conditions.
When searching for proper treatment, our episode’s guest is a prime example of what to look for in a care provider. We’re joined by the extraordinary minimally invasive gynecologic surgeon, Dr. Meenal Misal. Dr. Misal shares with us an inside look at the journey to becoming a gynecologist, the truth behind being a gynecologist, the importance of minimally invasive surgery, and hormonal birth control.
Lastly, we end on a high note! Anyone want herpes? It might just save a life!
Thanks for listening, learning, and being you. And join us back here every Tuesday for all things uterus, in service to you, uterinekind.
Carol: It is unclear how we don't have evidence that there are no data that prove say it with me. Fund research on conditions that affect uterine kind. I'm Carol Johnson, and this is hello. Uterus.
Today we're joined by Dr. Meenal Misal a minimally invasive gynecologic surgeon who represents the future of gynecologic healthcare. But first, uterus in the news.
Acetaminophen is a generic medicine that is sold under brand names, including Tylenol. Buckle in. A study suggests that women who take painkillers like Tylenol while pregnant are more likely to have children with ADHD or sleeping problems. Children were about a fifth more likely to have attention deficit hyperactivity disorder or some form of insomnia by age three if their mothers regularly used Acetaminophen insomnia. We're running around thinking, why is my child not sleeping? Why is my child not sleeping? Oh, maybe because no doctor told me that I shouldn't take Tylenol while I'm pregnant because it leads to insomnia in children. This is something that has emerged as part of what some researchers are calling a growing body of evidence. That's called research to highlight the risks of common overthecounter painkillers on the unborn. Although it's unclear can we just pause so that we could all collectively rip our hair out? It's unclear how the drug causes ADHD or sleep issues. And we know why it's unclear because it's not been studied. Acetaminophen has also been linked to autism, language delay, and decreased IQ. This is insane. How long has Tylenol been out there? How many times are we told to take Tylenol for headaches or other pain by our doctors? Is anybody aware of this? Because this is the first time I became aware of this. Researchers analyzed data from over 2400 mother child pairs from Pennsylvania, where women recorded their drug use and filled out a prenatal stress questionnaire during their third trimester. Yeah, like that trimester is not stressful. So essentially it's from that data that they have come to this conclusion. Now get what the CDC says. They've acknowledged that the growing evidence is there, but says more research is needed to understand whether the risk of birth defects is related to the medicine or to the conditions that they are being used to treat. Oh, really? Now, CDC, there are two uterus in the news stories today, and this quote really impacts the next one that we're going to talk about, but I just want to read it again. More research is needed to understand whether the risk of birth defects is related to the medicine or to the conditions that they are being used to treat. I don't know. I'm kind of thinking that if you're taking Tylenol because you have hemorrhoids the size of baseballs, that it's probably not the hemorrhoids that's causing the issue. Just a thought. And yeah, we agree. More research is needed. And then there is the vicious cycle, right? So in other, more research is needed news. We begin with a definition. SSRIs. They are selective serotonin reuptake inhibitors, and they're the most commonly prescribed antidepressants. As the name suggests, they prevent the reuptake, or the reabsorption of serotonin, allowing serotonin to remain in circulation in the body at a higher level of concentration than would normally be the case. Serotonin is formed in the pituitary gland, in the brain, and in the gut. It's a neurotransmitter, so it runs around delivering messages, and it acts as a hormone in the body. So it's part of that hormonal neurosystem that regulates everything in your body, every single thing. Serotonin specifically affects mood, digestion, sleep, and, as we'll find, it, clearly affects one's sex drive. SSRIs are commonly known by these brand names celexa, Lexapro, Prozac, PAXEL, Pexova, and Zoloft. We're going to have to have have we need to have an episode where we just make fun of drug names. That has to happen. Or we take drug names and we pull them out of a hat and we make band names. That actually, I think, is a better idea. Why are we talking about antidepressants? Because they are often prescribed for people who have treatable Uterine conditions for the air quotes. It's all in your head diagnosis. It's one of my favorites. I love that diagnosis. It's so easy. You can just look at someone and you can just tell that it's all in their heads. Anyway, the problem here is that when you're tossing these prescriptions out for it's all in your head diagnoses, the person who goes and fills that prescription is likely not aware that the SSRIs can ruin their life. Sure, the side effects are called rare, but are they? Because I found studies that show between 25% and up to 80% of those people taking SSRIs experience sexual side effects. None of them good. It does not make you hotter, better in bed, none of that stuff. It's actually the opposite. And I'm curious, how is this discussed in most consultations? Because being depressed and taking an antidepressant to relieve the depression that then causes sexual dysfunction, which leads one to feeling broken, undesirable, less alive, doesn't seem like an excellent way to treat depression. And the stats of 25 to up to 80% of people taking them experience these side effects. That's not rare. Bro how anybody can say rare side effects include yeah, maybe it should be the rare occurrence that no side effects occur. Maybe that's how it should be worded. Here's a quote from an article on SSRIs and side effects. Rebecca Graham is in her early forties and has had no sensation in her genitals for eight years, since she came off of the SSRI drug Sertraline, which she had been prescribed for. Seriously? Hold on to something structurally sound. Symptoms of premenstrual syndrome. Yep. She got prescribed an antidepressant for PMS, which is partly covered by the diagnosis abnormal Uterine bleeding. It is a common chronic condition that affects one in three people with a Uterus who are menstruating. It is not depression. It is a common chronic uterine condition. So this is why it's really important that we pull back the curtain on how gynecologic care is structured and delivered, so that you can understand why or not understand why. So that you can spot someone who is not trained to treat your condition, but is legally allowed to prescribe pharmaceuticals. Right, because an antidepressant is to treat PMS. And then look what happened to Rebecca. Eight years. She says, my whole genital area is numb. I feel like I've been castrated. I thought things would improve, but they never did. My partner and I live as best friends, and I've given up on the idea of children. I've been told it pains me to read this part of her quote, because we all know from birth control to antidepressants to any other medicine under the sun, likely we all have either heard these words directly or we've listened to friends describe this experience in a consultation. I've been told SSRIs don't cause numbness, that no condition could explain my symptoms, but that a lot of emotions control that area of the body. It's like being gaslit by the medical profession. And, quote, so hard to not throw things when you read that. Really hard. That no condition could explain my symptoms. But that a lot of no condition. Yeah, because it's not a condition. It's a side effect. It's a side effect of a drug, and 25% to 80% of people experience it. So stop with the gaslighting. It is infuriating. The article continues to say, and this is the heart of the issue, while what these patients have experienced is recognized in the medical literature and even has a name post SSRI sexual dysfunction, or PSSD, there is little evidence or research that proves a definitive link to the drugs. Well, I would like to ask who's going to fund the research that proves the link when it would rip profits away from pharmaceutical companies? Finally, from this article, david Baldwin, professor of Psychiatry at the University of Southampton, cautioned that doctors still don't know whether PSSD is caused by SSRIs or as a symptom of recurring depression or anxiety. Okay, I'm going to tell you it's not. And I'm not a doctor, and I'm still going to tell you it's not, David, because people who are depressed can still feel their genitals. Their genitals haven't gone numb. See how it happens? She wasn't even depressed. She had PMS, right? So her PMS did not cause genital numbness. I wonder what it was that caused the genital numbness. And I guess we're never going to know because no research. It feels like in the US, we're totally trained to accept pills as safe. They wouldn't be able to prescribe them if they weren't safe. I mean, sure, side effects are rare. I'd offer, given that they keep saying more research is needed, that we don't know if they are rare. And not only that, we probably don't even know enough to connect the dots. Just like David is now taking that back door exit. Like, hey, we don't know. So it really could be the depression or the anxiety or the PMS. This is why the burden is on you to determine if you have no other options and the side effects are acceptable given the alternative. But please don't get led to a drug as a quick fix without a definitive diagnosis. PMS is a legitimate chronic uterine condition. PMS may cause people to feel depressed. Depression does not cause PMS. So maybe screwing around with the hormones is a bad idea since we know so little about the hormones in our body. We don't even know all the hormones, so great segue too. This is why at Hello Uterus, we make sure to cover minimally invasive gynecologic surgery in depth and educate you on the types of gynecology practices you may encounter so you can be informed and make informed choices. Each episode is like a mini consultation that you didn't have to pay for when we featured guests, and a lot of good information that you can start to acquire and share so that we can stop this type of nonsense that's going on. What Rebecca is experiencing, to me, it's is heartbreaking. Using an antidepressant to treat PMS makes me want to bang my head against the wall. Before we break a plea to pay attention to research and research funding, or the funding of research. Not that you have to go research funding, but the funding of research, because it appears that funding flows faster to drug candidates in order to get them approved. And then further research is scuttled because of lack of science or evidence, which is Aka funding. And our bodies pay the price and we need to put an end to that. So stay tuned because when we return, we will have in studio the future of modern gynecology. And she's awesome. Dr. Mel Masal, a fellowship trained, minimally invasive gynecologic surgeon. Today, that's like spotting a pink elephant in the wild. But this is changing and we are so grateful to have time with this talented surgeon and wise woman. When we come back, we will introduce you to Dr. Masal.
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Today we have Dr. Meenal Misal, a clinical assistant professor of obstetrics and gynecology at the Ohio State University Wexner Medical Center. Joining us, she received her medical degree from the University of Arizona College of Medicine. Her residency was at Cedarsinai Medical Center in La. And one of the main reasons why we're talking to her today is because she chose to do a fellowship at the Mayo Clinic Hospital in Phoenix, Arizona, and was honored as a society of gynecologic surgeons. Fellow scholar received an AAGL recognition of excellency and minimally invasive gynecology from Cedarsyani and won the Stanley Harris Gynecologic Research Award from Cedarsyani. She's a slacker. She's not bringing her A game, are you? Definitely bringing the A game. Thank you for spending time with us today. We really appreciate you carving out some Saturday afternoon time to talk uterus with us. Oh, thank you so much for having me. So one of the reasons why I was so excited to discover you was because of the fellowship that you did in minimally invasive gynecologic surgery. And in reading a piece that you wrote published in Contemporary OB GYN about your choice, you call out something that most physicians don't talk about, and we need to be talking about it. So I want to start with this quote. In most residencies, a great deal of time is spent on obstetrics outpatient clinic or night float coverage. We spend barely a year dedicated to gynecologic surgery. Contrast that with general surgery residents who spend five years training in the operating room. So that is quite a statement. Was that a surprise to you when you were in your residency?
Dr. Misal: I kept my first year residency. I kept waiting for something magical to happen in the sense that I would suddenly have the skills. But at the end of my intern year, I'd only done two months of gynecology and realized that there wasn't that much coming up, and it seemed more and more unlikely that I would graduate. Being an amazing surgeon, I had some mentors in residency who were mixed fellowship trained, and I could definitely tell the difference in what they could perform surgically, what they felt comfortable handling, and solely put the connection together that it just wasn't possible to be that skilled without fellowship.
Carol: And so then you made the choice to do that, and you talked about how some people try to talk you out of it. How did you metabolize the information that they were giving you and stay true to your own intuition about what you wanted to do?
Dr. Misal: This is kind of a tricky topic, and it's certainly nuanced, but a lot of the feedback I got when I was considering applying for fellowship was from Generalists who rightly pointed out that I didn't need to do a fellowship to be able to be a gynecologic surgeon. And so some folks pointed out that the opportunity cost of losing two years of attending income wasn't worth it to them. The Migs Fellowship is also not a bog accredited currently. Maybe it will be in the future. And so there was some also legitimate concern that after you put in two more years of training, that you don't get compensated any differently than a generalist. In fact, at the time there was data published that GYN only surgeons make less money than OB GYN. So from a very practical perspective, I think people were looking out for me when they gave me that advice. There are probably also some people who were less positively intentioned. I do think that there are some generalists who feel offended isn't quite the right word, but tension. That there are these other fellowship trained folks who are encroaching upon their area or stealing surgeries or patients from them is actually funny because it doesn't make sense to me. But one of the things that I was told when I was a medical student is that OBN is great because when you're young, you can do OB, and then when you get older, you can relax by doing gin. Only that doesn't make sense to me at all because now that I know you don't want a surgeon who is older, hasn't really done high volume surgery in years because they were Obstetrics heavy, or why should that be considered relaxing anyway?
Carol: Yeah, and also it sort of mirrors how this is my personal opinion, how people are viewed as they age with their uterus. Right. You're a birthing person for this period of time, and then after that is complete, we're just going to kind of hold your hand all the way through menopause and hope things go okay. And then you think about ten years to get a diagnosis for endometriosis, eight years to get a diagnosis for fibroids, and you start to put the pieces of the puzzle together. And the picture is gross because it says a lot with bias. It says a lot about bias and a lot with bias.
Dr. Misal: Yes, definitely. There's actually so many things that I could say here. There's so many different facets to this conversation. I don't want to overwhelm you.
Carol: I'm so glad that you said that, because that is the exact process that my brain goes through when I start to unwind this. Like, you don't know which direction to turn in because there's bias at the very beginning of one's career when they're training to be a doctor. Then you get into this situation where you come out of school and you're on Obstetrics. Your primary focus is building a practice in Obstetrics, and then, as you said, you can gradually retire into gynecology. And then I just think like, okay, how do we even begin to make this a healthy setup because it's kind of like in other areas of medicine. You look at it and you think, wow, you're structured so perfectly for this patient experience. But when it comes to gynecology, it's like, yeah, not structured so great. There's a lot we need to fix.
Dr. Misal: No, our field definitely needs to make some changes, but change is really hard, particularly when it needs to happen at the medical school level, at all levels, really.
Carol: Right. And even outside of medical school. It needs to happen in the research community. It needs to happen it needs to happen in society. Now we're having a different podcast. Now we're starting a different, like hello society. But it is remarkable to me. We talk on this podcast. One of the things that we try to do is help both sides see each other better meeting, help physicians see patient experiences better, and help patients understand the physician experience better. And I think it is really kind of remarkable that after you come out of med school and your residency, whether you choose a fellowship or not, at some point you need to come out as a business person and begin a practice and build that practice while you're likely delivering babies. So you've got on call, you've got a lot of unplanned patient consultations and you also have to see 30 to 40 patients a day on average. Right. So when you think about the fact that during your education, you don't have the luxury of being trained in these minimally invasive surgical techniques unless you choose a fellowship to come out and have all of the responsibilities of building a practice and then on top of that have to, on your own, master technologies. So learning what's out there, what's available, whether it's a robot or it's a myoctomy device, whatever it might be, you have to master that. Then you have to master that procedure and you have to do all of that while you're juggling all of your other responsibilities and stay on top of research. Right. That just does not seem to be humanly possible. And I think that's what we see play out in the space that we have gynecologists who are like, yeah, I'm not going to go down that surgical route, so I'm going to keep doing what I do. And patients don't really necessarily know that about that doctor, so they think that they're being exposed to every option available, but they're really not. How do you recommend that people who are living with chronic urine or uterine adjacent conditions sort of manage those obstacles?
Dr. Misal: There are a couple of things I wanted to highlight in what you said. So in the first few years of independent practice, it is actually impossible to achieve all those goals that you mentioned. One of the things that trainees are often advised is that even after you graduate residency, you will need senior partners. If you go private practice, for example, to continue to develop you. And of course in academic medicine you have a whole department of potential mentors. But because there are a lot of clinical responsibilities, most people will stick to what they know. And so from a surgery perspective, we will only offer patients what they feel comfortable performing. And that's actually not incorrect because if you've never, for example, done robotic surgery, you should not be experimenting on someone by yourself. And there are certainly ways of developing yourself and your skills in a responsible way, taking courses, having a senior partner or surgical mentor in a more structured way, develop your areas of expertise. But it's very difficult to do that when you have, like you mentioned, clinical responsibilities, teaching responsibilities potentially, or a lot on your plate. So it's not wrong for someone to only perform what they are good at. It is wrong, however, for someone not to tell a patient that there are other options for you that I'm not skilled at or I cannot offer. Let me refer you. And I think that's the big problem. You think that's going on quite often. I think that issue depends on the person on the physician and the practice environment. I think there is probably regions where people perhaps want to refer, but they don't know of any specialists to refer to. Then there's also probably folks who don't feel that it's important or necessary to refer. Actually, now that we've sort of gone into this direction, my senior co fellow and fellowship did a survey. Study was a relatively small one, but did survey generalist OB GYN about why they would or wouldn't refer to a subspecialist and for what conditions. And a lot of people responded to this anonymous survey saying that they wouldn't refer because they didn't think that the subspecialist offered anything different than their own skills. So there's a little bit of some bias present in our field and maybe it is stratified by generation of training or geographic location or private practice versus academic. There are probably some nuances that we don't know that we can't get from a survey. But back to your main question is how do patients navigate all of this that's happening in the background? How do you find a person, a physician provider that's the best fit for you? It is really, really difficult. There's obviously some ways that I think people avail of themselves looking at their person's website, but of course someone saying that they're an expert in endometriosis or fibroids or chronic pelvic pain or what have you doesn't necessarily mean that they are, but it is a little bit of an indicator looking at the person's. I don't know actually if many people are looking their physician up on PubMed, but it is a possible resource. They should, if you can see what have they worked on, what have they participated in. I think seeing that your physician is a member of a subspecial society is also a good indicator if you're a member of Society for Gynecologic Surgeons, for example, or AGL, again, just being a member means different things. Maybe it could mean that you just paid your membership dues. But I think it's a little bit of an indicator that they're plugged in, invested in staying current, and have a special interest in potentially the area that you need.
Carol: Yeah. And something that you alluded to earlier about skill set and keeping that skill set fresh. You don't want to be in a situation where your physician is performing whatever procedure you need once a month. Right. Okay. It's not something like, if I haven't made chili in two months, I can still go make chili pretty easily. Right. But when you're talking about doing, let's keep it fairly basic, a myoaktomy, the removal of fibroid. When you're removing a fibroid, that's not something you want to do. Just once a month or so, we say, just removing a fibroid. Keep it simple. Nothing is simple when it comes to this kind of surgery.
Dr.Misal: Myomectomy is actually not that simple.
Dr.Carol: I get you none of it is. Just everything from the risks of fluid overload to the fact that oftentimes you get in there and you don't really know what you're dealing with until you get in there and figure it out. And then when someone is speaking to a doctor and vetting them as a potential physician to perform a surgical procedure, what are sort of the minimal baseline things that they should be looking for based on whatever their condition is?
Dr. Misal: I'm so glad you brought that up. In the clinical research world, there's a lot of different definitions for high volume versus low volume surgeons. But things settle out to if you do less than ten hysterectomies, for example, which is a major surgery, less than ten hysterectomies a year, you're a low volume surgeon. We can all agree on that. The definition of a high volume surgeon, people have different opinions. But the definition that I used in one of my papers was over 50 a year. That's a high volume surgeon. And we know that outcomes for patients depend on whether your surgeon is a low volume or high volume surgeon. So that is something you can ask your potential surgeon, how many similar cases have you done in the past year? And hopefully you'll get an accurate answer. I'm really glad you brought that up, because one of the conversations that sort of been out there is whether surgeons should be required to publish their case logs. And I don't think it's a bad idea. I actually just had a patient last week, asked me how many hysterectomies I had done, and I didn't have the number right off the top of my head, but offered to give them my case log. And I said, Well, I operate two and a half days a week, and I've been doing that for a year, so I probably have logged more than 50, but I can tell you the number if you'd like to know. And I think looking for someone who's really transparent about when was their last surgery and how many they've done is really important.
Carol: Yeah. And it's something that I feel like patients in this particular specialty haven't really been exposed to. Like, we've been hearing about joint replacement and hip replacement and cancer surgery and all of these very detailed, progressive or technologically advanced surgeries in other areas. But it seems like when we walk into a gynecologist office, we're just there to sort of be told what to do, or we don't necessarily know the questions to ask. We haven't lived in a society where surgery for gynecologic conditions has been elevated, I don't know, elevated or illuminated or received the profile that it should. Right. We still here in 2022. They just told me to take birth control pills. Just told me to take birth control pills. Right.
Dr. Misal: Definitely agree. I think a lot of the past has been discouraging women from having procedures done, whether or it's something like a tubeless sterilization or a hysterectomy, with a lot of patriarchal medicine with that you don't know if you want that yet. Wait a little bit longer. I think that's definitely true. But to your point about being told, just take birth control, I mean, that's a common reason for folks not receiving an endometriosis diagnosis, because they don't have a diagnostic surgery at a minimum for a long time. And I think part of that is back to the training issue, is, are physicians comfortable with the idea of doing the surgery for endometriosis? And I don't think that many are.
Carol: Yeah, so let's segue into that. And I want to come back to the birth control. But when we talk about endometriosis surgery, the gold standard is excision surgery. And is it accurate? And we can talk a little bit about that. You can share with our listeners a little bit about what that is. Is it accurate to suggest that it's as technical as cancer surgery?
Dr. Misal: 100% excision surgery, everyone's. Excision surgery is a little bit different because it does depend on where the disease is. But endometriosis causes inflammation, scarring, and distorts anatomy. So these surgeries can be extremely complex, and they do require technical skills on par with gin oncologist surgery at times. As far as excision surgery, I agree that excision surgery should be considered the gold standard surgical technique, though our field is wrestling with that a little bit because it's hard to do a direct comparison of surgical techniques. So the few studies that are out there have found mixed results. But the Cochrane review, sort of systematic review of studies, found no difference in ablation versus excision in terms of pain relief long term. But that is, again, because there are so few studies and even fewer studies that meet the criteria to be reviewed in a Cochrane review. So that doesn't mean that. The data isn't out there in some form and I can definitely go into that a little bit more.
Carol: Yeah, actually, let's do that because I feel like I kind of come at it from I'm the person that you don't want to sit next to at the airport bar. I come at it with a lot of opinions and not a lot of real world experience. And there's probably going to need to be some unwinding here. But looking at this from a common sense perspective, ablation, which is using energy to burn off the lesions. And again, these lesions can be anywhere in your body, literally anywhere. And then excision, which is like kind of like taking about taking a mole out where you're going and you're cutting around the lesion and then you're going down to get the root of the lesion so that you have clean edges all the way around. So from a common sense perspective, excision would be the way that I'd go. Wouldn't take me long to make that decision.
Dr. Misal: Yes, those are excellent descriptions of the technique. The other points that I would make, and I talk about often with my patients who are considering surgery with vulgaration or ablation of endometriosis, you are relying on the surgeon surgeon's eyes to be a microscope, which we are not. So there is evidence out there that searches both under call, overcall missed call, what is an endometriosis lesion up to 25% of the time. So with ablation, you're never going to get that satisfaction that we treat it at all because we don't actually know that. And then the second downside of ablation is that if you have endometriosis over a very important structure such as the ureter, you can't burn the tissue overlying the ureter because you could damage it. Same if you have a large natural on the rectum. Not only is that going to inadequately treat the lesion, but you could also cause thermal injury to the rectum just by haphazardly ablating it. Which leads me to the third thing, is that with ablation, you will also not know if there's a deeper invasive component to the lesion because you just touched the surface of it. And then finally you need a histological diagnosis. To get the diagnosis of endometriosis, you must at least take a biopsy for pathology review. So to get a biopsy, you have to perform excision. Right. I would think ablation is faster, right? It is faster. So they might be comfortable doing the biopsy, but then choose ablation as the treatment option. Yes. And I'm going to bring up something that bugs a lot of us. The CPT code for ablation and excision is the same. So a physician, a surgeon is compensated the exact same amount for Ablation that maybe would be 45 minutes or less versus a six hour excision surgery for complex endometriosis. So from an economic and also just human nature standpoint, there is for some people less incentive to do the best surgery for patients. And just a little aside, there is the reason why I chose to practice in academic medicine, because my livelihood isn't one to one correlated to how well I am able to care for the patient, perform optimal surgical excision, and whether I lost money on the case because I did that.
Carol: Yes, we have to talk about it. We can't not talk about it. We have to talk about the numbers in every single aspect of gynecologic care, from research to the administration of care and everything in between, because the numbers dictate what our experience is like. And the idea that a physician would be paid the exact same amount of money for a 45 minutes surgery versus a six hour surgery, which is not only just longer or more complicated, there's also a greater chance of stuff to go sideways in a six hour surgery. I mean, that is intense. It makes no sense, except you can't logically unwind it. It always comes back for me and talked me out of it. Anybody, please talk me out of it. It comes back to bias, which makes my head break in half. I can't talk. Right? Okay, great. Here we go. We're all on the edge of the cliff, just thinking, like, God, really? I want to say, like, come on. We're actually kind of really cool. We're very complicated, exquisite systems, and you all should be more just generally curious about studying us and also sort of morally inclined to give us the best treatment possible. Right. And then supporting the physicians who have a choice of any practice area. First of all, they could also choose to go open up a restaurant with a really cool backyard bar and go work in hospitality. Nobody has to be a doctor. And I'm really concerned, really concerned about the shortage of gynecologists that we're looking at, which, of course, also means a shortage of gynecologic surgeons. And so when I hear things like CPT codes, which that for people don't understand, that's how the pay is set based on particular procedures, whether it's diagnostic or it's surgical, there's a structure in place that indicates that procedure is worth this amount of money. There isn't any rhyme or reason to it, at least not in this specialty.
Dr. Misal: It is a very, very complicated discussion for House. The value associated to each CPT code is determined, but very eye opening. When you learn more about it, all of the medical sub, specialties or procedural subspecialties, are competing for the same pie, if you will, of money. It certainly feels, as a gynecologist that we get the smallest slice of the pie, and then we have to distribute that money between all the different procedures that we do.
Carol: Yeah. And that pie is equally as small when it comes to things like research. We don't get the funds. As we talked last week on the show about gender disparity and NIH funding, you see the trickle down the cascade of issues that it creates, both on the research side and the medical school side, that we have to fix things. We were talking earlier, before we started recording, we were talking about the idea of having an unstable foundation and then trying to build this really complicated house on top of it. And every time you add a floor, you just create the chance for greater calamity and it feels a little bit like that's where we are. But I don't want this to be a complete downer because I was thinking about this last night just to calm myself down after I read some data. It's like, you know what, this is like the Wild West. It's like the frontier time for gynecologic surgery and for gynecology in general. And there's a lot of really intense things going on. But at the same time, if we keep sort of churning at this and we shine a light on things and we take the time to understand how medicine is practiced, but I don't mean clinically, I mean sort of administratively or from a business perspective, we will be able to affect change. And I see it happening because we have people like you who are spotting it and then also talking about it publicly. You're talking about these problems that we have to fix as opposed to not addressing them, which I would imagine is a bit uncomfortable, especially if you were talking about it amongst colleagues who didn't agree with your philosophy.
Dr. Misal: Yes. On the positive side, to reiterate what you're saying, there definitely are things in the works that hopefully will improve the situation from the very specific level. The issue with compensation and the CPT code for endometriosis surgery being just the single one to reflect all the complexity of surgery, that's something that is being worked on by AGL members. There may have made some steps in getting more CPT codes added, which hopefully will lead to further change the fellowship and minimally invasive gynecology is becoming more and more popular, so there will be more specialty subspecialists available to the population. And the next step is that we just need to figure out how to get patients to the mid surgeon if they need them. But there are definitely some positive things, I think, that we are speaking up more about all the different layers that need to be improved upon.
Carol: Yeah, there's going to be change. And the majority of the reason why uterine kind exists is because of what you just said. There actually is the idea that there's a limbo that happens. People, they step on a path to try to address air quotes, bad periods, that's generally how it begins. And then they hit a wall and that wall could be like 10ft down that path or it could be about a mile down that path. But that wall is generally built of birth control pills and they slam face first into that wall and then they live in that limbo for a period of time and things change or maybe they get pregnant or what have you, but the conditions are progressing. And the other thing that's happening is that the person is becoming normalized to a quality of life that is significantly less than what they would experience if they were well. So I do want to touch on birth control pills because we've said it here a million times for birth control pills. The birth control pill is not the problem. It's when it feels like we're guinea pigs in a research study, but nobody's collecting data, they're just handing out meds. Right? Well, it's symptom suppression, right? My patients do really well on this. You should give it a shot. But there's been no discussion of a diagnosis or like, what's going on here? Can you speak to this idea of birth control pills being the backstop for every condition on the planet, being slightly facetious, but it's what it feels like.
Dr. Misal: It certainly can be true, particularly if the specific physician doesn't have a lot of surgical tools in their toolkit, if you will. But I totally agree that the first impulse will be like, well, not sure why you're having, say, dysmonorrhea or where the adenomyosis came from, why your fibroids are growing, but let's just stop your period and maybe everything will be better. Definitely see that attitude. One of the things that you were talking about before was, do we really understand what birth control pills are doing in the body? And really kind of the answer is no. We have a general idea, but the level of vagueness in terms of mechanism of action and downstream effects, it's kind of surprising how much we are willing to accept. And of course, separate topic, but the onus is often on people who can get pregnant to manage the whole situation. Whether that be experiment with five different kinds of birth control to see what is the most tolerable to them is kind of a wild and unfair. I do want to reiterate, I am pro birth control if it works for you. But it is very frustrating to particularly when I'm counseling options with patients, to be like, well, here are a bunch of side effects that could happen. I have no idea if they'll happen to you. Well, unfortunately, this will be an experiment. Do you want to do it or not? Right? It's really not awesome.
Carol: No, that sounds like shoe shopping. It's like, do you want to go for the three inch heels or do you want to go with like, a kitten heel? We'll see how it works for you and whether or not your feet are going to hurt. At the end of the day, I'm so glad I'm going to rewind this and listen to it a thousand times. And I recommend that everyone does because of what you just said, which was we don't really know how hormonal medications affect the body, right? Is that a fair,
Dr. Misal: in comparison to the way we understand other things in medicine? We're definitely not at that level. We know, okay, birth control suppresses ovulation. How we have a general idea. And I also apologize if there is, like, a basic science researcher or someone who's a contraception researcher who's like, but wait, or something like that. Well, in that case, that information is not trickling down to people in general practice. And I think that I keep up to date with research and new development. So if I don't know, then the average person practicing OBGYN probably doesn't know either, right?
Carol: I mean, I guess I can sort of see how it happened. It's like, oh, my gosh, birth control, hallelujah, right? And everyone's just like yay. And then some decades go by, which is what it seems like for people who are dealing with these hard to pinpoint symptoms. They're even hard for the people living with them. They're hard to discern. They're hard to sort of capture in action. I look back on my time on birth control pills and then dealing with a chronic condition with fibroids, but without being diagnosed. I did not know that I had fibroids until after. And psychologically, it messed with me. Maybe I'm weak. Whatever. I don't know. But I'm just saying, psychologically, it absolutely messed with me. I thought that I was broken, gross dirty, and my moods were really chaotic when I was on birth control and then getting why was I on birth control? Because I had bad periods. Why did I have bad periods? Because I had fibroids. Did anybody tell me I had fibroids? No, not until I was pregnant. There was a big, giant fibroid in my uterus along with a child, which could have complicated my pregnancy and could have resulted in a miscarriage. Actually, I want to stop saying miscarriage could have resulted in a spontaneous abortion because miscarriage just feels way too blaming for me. So anyway, I think I had a light experience. I've talked to people who have been sent off the edge on hormonal medication. In an ideal world, how would you handle using hormonal medication in your practice?
Dr. Misal: When discussing I guess I would back up to first we talk about what are your symptoms? And to call back to what you're saying, sometimes people don't really know. It takes someone outside of them to say, you know what? That's not normal, what you're experiencing. The number of times I've told someone your periods are not normal. Like, that heaviness that pain is not normal, or pain with intercourse that you're having not normal. We only have our own bodies to compare to. So over time, you get used to things like, well, that's just how my body is. And sometimes it takes someone else pointing out like, well, I've identified a problem that could be fixed for you. But anyway, so we'll talk about symptoms and then talk about goals, because everyone's goals are different. My job is to find options, if there are any, that work for you to achieve that. So for some people, they do need contraception, they do need some period management. Surgery isn't or they don't want it to be an option right now. So maybe that is the way that we go. There are so many things available out there that don't often get talked about that could be a good fit for somebody. I get very excited to be able to tell folks about a non Hormonal option for managing heavy bleeding, which is traniccemic acid. Again, not for everybody, but it's non Hormonal and people never heard of it before. That can be amazing. Of course, transcendic acid, since it's non Hormonal, I don't anticipate that it will do anything for Dysmenorrhea or very painful periods, but then we try something else. Maybe we do a progesterone IUD with tranic semic acid. There is some creativity even though there are not unlimited options. But to get back to your question for the right person and symptom profile and goals, it can be the right answer and sometimes it's not. How familiar are you with the recently approved my fembrary for endopane and for fibroid bleeding? Somewhat familiar. It's funny that you bring that up. I just somewhat recently prescribed it and that's a whole other topic. But had the insurance company deny it with the most interesting of reasons. So my fembre is religolex with Add, back estrogen and north and Drone, I believe, and it got denied because the patient had not tried religiolix yet, which is not FDA approved for that indication. It's only FDA approved for prostate cancer. It was just kind of a hilarious waste of time. Peer to peer explained, I cannot prescribe religolics for this patient.
Carol: That's one example of one thing in a day with 30 to 40 patients and people having babies and surgery, and you have to get on the phone with an insurance company and defend like it's your thesis. The choice that you're making with regard to your impatience, it's madness.
Dr. Misal: It is draining sometimes when you have a lot of fees to deal with. But as far as my fembre, I mean, it's fairly new. I don't know if I would call it innovative, though. It's sort of a repackaging of things that have already been around. And that, of course, goes back to the problem with treatments for endometriosis fibroids heavy periods that were kind of it feels like the pharmaceutical companies are kind of like, well, we've got this. We can repackage it and remarket it and sell it and it's really unfortunate. That isn't to say that again, like My Fembre or other similar products, I call it a product because it kind of is might be excellent for somebody, obviously for the person I prescribed it for. We came to that choice as part of an overarching plan, but it's not new. It's the same.
Carol: Yeah, and it seems like it feeds into that monster that we've identified here, which is that if you have a group of gynecologists that don't have surgical tools in their toolkit and their only option for treatments are medications, and then you have a pharmaceutical industry which is not wanting to spend a lot of money to do progressive research and development of new products for uterine health. So they're looking to get additional indications for already existing compounds that they know are going to be approved, because they've already been approved. Then we get into studies and this is how your brain probably is fine on this, but this is how my brain starts to cry. The studies are done in support of the pharmaceutical company getting approval for that indication. So it's not like, oh, my gosh, look at all these studies. No, that study literally exists to get that drug approved. And why do we want that drug approved? Well, because it's already been approved and there's this huge evergreen population of people experiencing these chronic conditions. It's an absolute billion dollar opportunity, so let's go for it. That gives these other doctors that's why I asked you about my fembre, because to me, it's a danger. I understand that there are good reasons for it, but it's a danger if it becomes another pill that can be given, that can be prescribed by a doctor who is not going to refer a patient to surgery. On the positive side of it, I would imagine that from what I've read, it benefits people who have multiple and large fibroids because it can shrink them prior to surgery, which I think is a really wise use of a medicine to support treating the root cause ultimately. So it just feeds that same problem, which is concerning.
Dr. Misal: Yes. For endometriosis, as we've alluded to before, there is usually a long delay before people are diagnosed because we try to potentially mask the symptoms with different types of hormones or contraceptive methods. I totally agree with you. I believe my fibre you can take for up to two years, similar to eligolax or lupron. So in a sense, it's kind of a bandaid, unless you're prescribing it for a specific reason, as part of hopefully a stepwise plan. But I also want to zoom out a little bit. Surgical removal of fibroids, for example, or my Amactomy, I would say generally is very good treatment. But is it really solving their root problem? Because at the end of the day, we don't know why this patient has quality of life debilitating fibroids causing bulk symptoms and bleeding, and this person has cute little fibroids that they didn't even know about, and this person doesn't have any fibroids. Why? We don't know that. Yes, I love a good myomeectomy and I will do, but I sometimes would have to remind myself that I still don't know any better than the person who prescribes the medication to what's really going on. And I can't really give someone that basic science level answer because we're studying it
Carol: right? We're not studying it. We absolutely have to. I want to be cognizant of your time, but I have one other question for you. How are you? Because you've come off of covet and slid headfirst into the repeal of Roe v. Wade, and you work in Ohio. This is just a very troubling, very upsetting, and I would imagine for you a very complicated situation to be in, given that you are practicing uterine health medicine.
Dr. Misal: You are so kind to ask. I'm doing okay. But, yes, there are a lot of things going on. For my surgical practice, for example, there's just a lot of need. And I have been sometimes feeling a little overwhelmed that I can't keep up. But if I say I need to see fewer patients or I need to operate less, what good does that do? So kind of finding the balance of providing the best care for the most people without burning out. And then as far as the environment that I practice in, yes, I am in Ohio. And one of the things that I have such other people is what is particularly exhausting is that I'm not a lawyer. I shouldn't have to know about subtleties nuances and a lie. I shouldn't have to think about how my care plan for a patient, whether it's legal or not, what's difficult is, and I think others have certainly said this more eloquently than me, but there's no law or legal writing that can address all the complexities of reproductive healthcare. And so it just seems inappropriate to me that there are things that exist. And that's just like, one more reason that it's harder to practice as a gynecologist right now, because we have these external forces that we need to be aware of and weigh pros and cons of all the choices that we make.
Carol: That brings us right back to bias, because I don't see it happening anywhere else. It's like abortion is a word, first of all, power of words, and represents a wide variety of situations of complex medical conditions that people can experience. It is not a one thing, and it also has been demonized, but let's call it what it is. Abortion is a procedure that treats numerous complications in reproductive healthcare. Right? Yes, it's essential health care. It's essential healthcare. And then we have people who don't have a uterus or a medical degree. They have neither.
Dr. Misal: I think a lot of these lawmakers have revealed very clearly that they do not understand basic biology, how anything works when it comes to health care, but unfortunately have the ability to make laws.
Carol: Yeah. I am amazed at your grace and how you are navigating this. We can kind of understand they're not burdens, but responsibilities that you have. Right. Like, to me, it's almost like having it's like being a matriarch over 100 kids or something you have all of these patients and they all have very significant needs, and the type of medicine that you're practicing is complicated. And so I'm just in awe, actually.
Dr. Misal: Thank you. That's totally how I feel. One of the things that I just kind of wanted to throw out in the world, actually, is that maybe people don't realize is that I think about my patients. I think about you on Friday night. You had surgery three weeks ago. How are you doing? Or I think six months ago, you pop into my head and I hope you're doing well. And we worry. We care all the time. It's really not a nine to five. And even medicine is more like six to six, but it's not even that. It's 24/7.
Carol: Yeah. Now the care is ratcheting up. It's like when your child first gets their license, it's like you cared when they were 16, but now they're 17 and behind the wheel of a car. And your care is now like this monster because it's like you're simultaneously caring and thinking about all the things that can go wrong. And so you have pregnant patients, right. Every one of those people who's pregnant is in a position where they could be risking their lives and their freedom. That is a lot to carry around every day while you're working in such challenging environments. So thank you for doing it, and I hope that a lot of people are inspired by the way you described how you practice with your patients to go and try and find physicians that are like you and also what you've helped do today. It's kind of like getting a mini consultation with you for free, which is awesome. So thank you from the bottom of my heart for everyone listening because what you just provided is so insightful and it clears up a lot of the chaos that somebody is staring down when they are already feeling vulnerable. So they can now say, oh, okay, so maybe if I go to an association's website, I might have a better chance of finding a physician who's trained in something that I need or I know, a question to ask now that I didn't know before. So I just want to thank you from hello uterus and uterine kind. We're really glad that you took time out today to talk to us, and I have 100 other questions, so I hope you'll come back.
Dr. Misal: Of course have to, any time.
Carol: Excellent. All right, well, we're going to take a quick break, and when we come back, we're going to end on a high note.
We had some tough news to start us off, and honestly, I chose the less intense options, and I did. I was like, oh, I don't want to bring this big of a hammer to the show today. We're going to have to tone this down a little and toning it down a little. Ends up with Tylenol can contribute to ADHD and insomnia and serotonin uptake inhibitors can turn your genitals into stone. And, you know, those are the easy ones. But now, in ending on a high note, we're going to dive in to some awesomeness who wants herpes? I'm serious. Who wants herpes? If you have cancer, say yes. The Institute of Cancer Research in London reports a new genetically engineered virus has delivered a one two punch against advanced cancers. In initial findings from a phase one trial, researchers found that RP two, which is a total missed opportunity because it could have been called r two, p two, and then we'd all remember it. But anyway, enough about me and naming stuff. RP two, a modified version of the Herpes simplex virus, showed signs of effectiveness in 25% of patients with a range of advanced cancers. Patients on the trial had cancers, including skin, esophagal, head and neck cancer. And all of these patients had exhausted all other treatments, which means that they were in a precarious situation with their cancers. The genetically engineered RP two virus, which is injected directly into the tumors, is designed to have a dual action against the tumors. It multiplies inside cancer cells and bursts them from within, which is just so cool, right? It's like, take that, you little cancer cell. And it also blocks a protein known as CTLA four, which is like it's a protein that slows down your immune system. And this blocks that protein, fueling the immune system and increases its ability to kill cancer cells. So that's why they call it a one two punch, right? Goes inside, gets injected into the tumor, goes inside the cancer cells, and then multiplies within the cell, just basically breaking them apart, like filling a water balloon with too much water. And then has a protein that assists in also killing cancer cells, I guess maybe the ones that don't burst. And this is super exciting. I mean, 25% of people where all other treatments were not effective have gone on to live months and months, 1214 months after receiving this treatment. And this is just phase one so they can optimize it, study it more. It's incredible. This is what happens when stuff gets funded. See, it's what happens when you fund research. You get incredible stuff like this. So we're going to stay on top of their progress as trials expand and keep you looped in on herpes good side. Whoever thought that Herpes was going to be like the coolest? I don't know. It's so warming. It's such a high note. So thank you, Dr. Masal, for your time and insights today. And thank you, angel and Mariel, for producing hello, uterus and the Uterine Kind team back at headquarters, along with our technology team in Ukraine who are building an app that will change the experience of uterine care for everyone. We thank you, especially our team in Ukraine, whose passion for uterine kind health and wellness has been amazing. And we know. That you are under extreme pressure right now with the war in Ukraine. And we are so grateful that every day you show up and bring your agame and you're delivering an incredible app to people that will change the way they experience uterine care. So we're super thankful. The app launches in mid November and along with it, we will announce the beneficiaries of our commitment to fund research on uterine adjacent conditions. We aren't just going to shine a light on the lack of research like we've done today. We are going to fund research because otherwise, personally I'm going to go insane. Because you know how, like you learn about stuff and you learn about stuff and then it builds inside of you and then if you don't take that energy and go and use it on something, then much like after herpes gets inside of a cancer cell, you feel like you're just going to explode. And that's how I feel right now. So I'm super excited that Urn Kind is going to be able to participate in the funding of research and that we are going to help change the way everyone experiences uterine care. Because you're worthy of living your best life and nobody should tell you otherwise. We'll be back next week with another episode of Hello Uterus. Till then, be well, be cool, be kind.
Angel: The Hello Uterus Podcast Is For Informational Use Only The content shared here is to not be used to diagnose or treat any medical condition. Please speak with a physician about your health conditions and call 911 if it's an emergency. And thank you, Uterine kind for listening.