Welcome to the After Show! This episode is a continuation of our conversation from our last episode with urogynecologist Dr. Elizabeth Graul.
Welcome to the After Show!
Dr. Graul joins us for a freewheeling conversation that illuminates some good and not-so-good trends in uterine research, care plans, and how gynecologists are the go-to doctors for A LOT. Plus a sneak peek at next week’s expert guest. You’ll never think of menstrual blood the same again.
Send your Hear Me! Hear Me! questions to hello@hellouterus.com to be featured in an upcoming segment.
Join us back here every Tuesday for all things uterus, in service to you, uterinekind.
Until next week,
Your Uterinekind Team
Carol: Imagine you're at a party and you go up to the punch bowl, what is the cool thing now? Charcuterie. You go up to the charcuterie table and you're standing next to somebody and you start chatting. You ask them casually, oh, what do you do? And they're like, oh, I'm a gynecologist. And then you monopolize their time for the remainder of the evening. You and the gynecologist are in the corner by the plant. Their significant other can't get near them, and you're just peppering them with questions. That is Hello Uterus the After Show
Dr. Graul and I continue our conversation in Hello, Uterus the after show. We get into things like how people are conditioned to feel shame around their periods, how people can really identify with their uterus. But that identification is largely conditioned by the type of education that they have or have not received about the uterus. So maybe they think that the uterus is who they are rather than the uterus is a really important organ in the body and that the overall body is who they are. We also talk about attitudes and misinformation, about hysterectomies, super interesting and a trend that's happening now where other doctors, general practitioners, therapists, psychiatrists and psychologists, a wide variety of doctors are sending women to Gynecologists for hormone testing for depression. Dr. Graul gets in to what unwinding that is for her, which is, again, another complication as a result of lack of education and misinformation. Let's get back to our conversation.
We talked a little bit about research specific to fibroids, but I'd like to ask some questions about research overall, starting with something on the positive side. What are you hearing about that is currently being researched that you're excited about, or you think that they're onto something that will ultimately result in a positive impact on uterine care? Is there anything out there that we should know about?
Dr. Graul: I do not know of anything. Again, I feel like research is guided by where financial benefit can be gained. It's basically medications, not for prevention, but for treatment, and then treatment modalities that can be used once an abnormality is identified. We get little bits and pieces of maybe a new birth control pill now and then, maybe something new and hormone replacement, something big like assessor every once in a while there for a while, there was a lot of research going on with Pelvic prolapse, but the mesh problems kind of put a damper on that. So I really am not aware of any big issues in women's health that probably the biggest ones are cancer. But even there, I think that there's not a lot of money that's being used to research women's health in general.
Carol: How do we change that?
Dr. Graul: Like you said, the squeaky wheel. There are so many issues that are going on right now. I think it's really hard to bump our way up to the top of the list. And the only way to do that is by being active in the community and finding people that are running for office that are advocates for women's health and then moving up the line to your state elections and even national elections. Like you said, Vice President Harris, coming up with a bill to address something like Fibroids or issues in women's health, you'd never see that. No one ever talks about it when they're running for office. So right now we are way, way down on the list. But I will say, in fairness, you don't see men's health issues being talked about a lot either. I just think that people take help for granted when you can't get food to put on your table. And there are wars around the world. A lot of times health issues fall by the wayside.
Carol: Yes. We're going to have to learn a hard lesson around that, probably. Yeah. And with COVID, that was an opportunity to recognize that we need to listen to the experts and recognize that we have a small world now and what happens in other countries can affect everyone around the world. And we should work together on it. The idea that parts of the body, especially the uterus, something that is misunderstood and also is very important
Dr.Graul: Oh, yeah, carries life.
Carol: Yes, carries life and then also doesn't only carry life. Right. And so the carries life part seems to be really easy to understand. The uterus expands, carries life. Right. But the hard stuff to understand is what does this organ also impact? And that from a research perspective is something that I follow closely. Like, for instance, in our first episode, we talked about the research out of the University of Arizona Professor Heather BiMonte Nelson, on the cognitive impact of removing the uterus and leaving the Ovaries. Understanding this is so important. Right. Because then if you have a diagnosis where hysterectomy is the right option for you, then you go in understanding what the possible long term effects of that are so that you can recognize the symptoms. That takes us back to the conversation that we had in the Hello Uterus episode, recognizing the symptoms and connecting the dots. I think that's so important. Can we go back to that? How can we get better skilled at doing that? Because I've asked people to close their eyes and imagine their uterus and to describe it to me. And it's never what the uterus actually is. It's not in the place they think. It's not shaped the way they think. Some people say this is really actually kind of it's fascinating. And it's also a little bit scary. They picture a black hole because they have a complete lack of understanding, like they can't see anything because they don't know what to picture. Also, that could be impacted by the way they view the uterus.
If they view the uterus as the problem rather than something that is impacting the uterus, then they have sort of a hate relationship with a part of their body. And that makes me sad. Can't that negatively impact somebody's overall wellness?
Dr. Graul: Well, of course, I think any negative sense about any of our body parts can be a problem. But for women, I think the uterus is kind of central to identity. And if you have a negative sense of that body part, I think that then translates into a negative sense of your identity. On the other hand, I think that there are women that even if it's a positive sense of their identity, the uterus is primarily a carrying vessel that does not make hormones. It does not do anything other than provide a safe growing space for children. So I have patients that when they are faced with a hysterectomy, psychologically, it's very difficult for them because for them, that is their identity. They are women, and women become pregnant and carry children, and the uterus represents that. And so somewhere there's got to be a balance in understanding what the role of the uterus is, but that it is not who we are.
Carol: Right. The other end of the spectrum is the person who has the bottle of champagne in the refrigerator. They're like 28, and they can't wait to get a hysterectomy because their periods have been horrible because of the lack of data that we have. It seems to me like cheering on a hysterectomy or I don't know what the word would be. It's misinformation, I guess.
Dr. Graul: I think so, too. It's like so many things in our society. It's what they view as an easy fix. And I think that often there are many other options available to them that maybe they haven't explored. And I don't think they understand all of the impact that they might experience by having that surgery, especially at such a young age. And I will tell you, the paradigm in the last ten years has been so different in our younger patients not wanting to bear children, not wanting to keep their uterus, not wanting to have periods. And we're getting inundated with 25 and 26 year olds that want their tubes tied or even more want hysterectomies, not because there's any pathology or abnormality. They just don't want that part of their body. They don't want children. And it's a very different mindset than what I experienced 2030 years ago.
Carol: Wow. I expected you to say the opposite.
Dr: Really?
Carol: Yes, I did, because I assumed that people in that age group would know how to navigate toward data that they are more informed about, even just searching on the Web to find accurate information. And I guess what it suggests is that the information that is out there and it's just a small amount of information. But that one study that I referenced about the cognitive issues that occur. This is a study in rat models on the various types of hysterectomies and how removing just the uterus is one that creates issues from a cognitive standpoint. And then there's a study that we talked about coming out of the Mayo Clinic on the cardiovascular complications that happen, especially with hysterectomies that are performed before 35 years old. So that's wild because I assumed that people in that age group would access that information. Well, they do it based on the emotional choice of not wanting children. That's the driver. And I think that that's reflective of kind of where our society is. It's scary, and they don't want to deal with raising a child and then that. So removing an organ that's been described as not having other conversations in the body, that's sort of how I look at it. We don't know. Right. We don't have super, definitive conclusive data. This is exactly what happens. We've studied this, and people we don't have that. But the human body, to me is I often describe it as an exquisite communication system, because what it does on a second by second basis is mind blowing. And then so to take out the uterus and assume that there isn't going to be some disruption in that communication system seems fairy tale to me. Like, we don't have the data definitive, hardcore data. We have some studies that suggest that it does disrupt the communication system. And so that goes back to what you said at the top of our podcast episode and what you and I talked about before, the need for education and education that is accessible. They can understand the information. It's thorough, and it's not. Dr. Google a myriad of variety of takes on things, some of which can include, like spinning under the sun on your head and spinning wooden nickels. I don't know. But we need to get a handle on that. And you're right. Doctors have been the ones who we look to to educate us. But how much more could you possibly do in a day, Dr. Graul, how much more could you do in a day? How many patients do you see in a day?
Dr.Graul: My schedule is probably a little lighter than most. And because we don't do obstetrics, it's much lighter than a regular OBGYN. But I see around 18 to 22 patients a day
Carol: because it makes me think I think this is really important for people to make correlations between experiences. Like, imagine if your significant other came to you 18 to 22 times a day to complain or make you aware of, like, how bad their periods are. You're a gift in this sense, because you hear them. But I hear from people all the time who say that their doctors don't hear them. And I get why. Because if that's happening 100 times a week, you're going to hear white noise. As soon as you hear the words my periods, you're probably already writing you're beyond that, you're at the end of that consultation because you're like, I've heard this ten times in the last hour. How do you keep yourself present with each and every one of the patients?
Dr. Graul: Well, I have three or four areas of expertise. And so in a given day, I will probably see some period problems and some bladder leakage problems and some prolapse problems and some menopausal problems. But I think that every time I walk through a door, that patient is an individual. I have learned to probably too well, compartmentalize. So I am able to say, okay, my focus is here. I'm not going to worry about running late. I'm not going to worry about what's happening at home. I'm not going to worry about the arguments that are happening in the office. My focus is here, and she and I are just going to have a conversation. I try to have most of that conversation be her talking and me listening.
Carol:That's excellent listening. Right. Because it's a simple thing. We are all asked to do it. And it's something that patients talk about over and over again is that the doctor isn't hearing them. And there's something else that you brought up that I want to point out that I think is interesting. You don't do Obstetrics like if you were making your own healthcare choice, your own choice in terms of a provider, when cetrix is no longer part of your picture, would you personally change doctors to somebody who was not focused at all on Obstetrics and instead on care from that point through the duration?
Dr. Graul: Absolutely. We started this practice for that very reason. When you do Obstetrics, which is a wonderful experience, it controls everything in the practice because you can't schedule when babies are going to be born, the complications are often you're talking about your patient's life and a baby's life. The schedule, the focus, the energy is all really dictated by the Obstetrical side. And if I were in my Obstetrical years, that's what I would want from my Obstetrician. We opened our practice in 1998, and the women that come so appreciate a that we run on time because we're not delivering babies in the middle of the day. But two, they're not sitting in a waiting room with three or four pregnant women. And then that gives us time to focus on surgery skills and new techniques and ways to treat patients for these other issues that don't have anything to do with being pregnant. And I think that's very important. At some point, I wouldn't be surprised if the residency splits and we start seeing Obstetrics separate from Gynecology. I don't know. I think that might not be a bad thing.
Carol: I agree. And I'm already sort of revising what I would suggest to someone based on your information. It's not so much that you would need a Gynecologist after Obstetric years, but perhaps you seek out an OB when you become pregnant or if you're having difficulty becoming pregnant, that even in your twenty s you ought to be with a Gynecologist who is not focused on Obstetrics primarily.
Dr. Graul: Well, we have lots of patients who we now see their daughters that are in their twenty s and need birth control and might have bleeding or period issue. So I think that, again, any doctor that you have, the more focused they are on your specific problem, that's going to be a better choice for you.
Carol: Yeah. And as women, we've kind of mushed all of our health care underneath an OB GYN. Right. You guys are now responsible for our entire bodies. Did you know that, Dr. Graul, when you went to Med school? Absolutely. I mean, we have many, many patients that want us to be their primary care physician. Yeah. That's sort of how, as a matter of fact, my primary care physician, I have celiac. And my primary care physician. Just a little story here. I had moved to California and I had to get a new doctor. And back in Philadelphia, I was seeing a dermatologist. And oncology dermatologist, I'm a redhead really required. And I have been getting a symmetrical rash all over my trunk. And I thought it was related to my period because I think that we think everything is if something goes bad in our body, we're like that uterus. So for 20 years to zero, I was putting steroid cream on my trunk, all over my trunk. Giant, giant part of my body. Right. And this doctor who I felt very comfortable with, I knew personally as well, so I could push for something. This is back in the mid two thousand s, doctor. Google was not a thing. It was my first Google search and really kind of my only Google search for a health condition. I searched symmetrical rash, trunk, and wheat because I had a feeling it was after a pregnancy. And when I came home from the hospital, I had welts on my body that were a foot long. It was out of control because I had been craving wheat because we crave what we're allergic to. Right. I don't understand that. So I did that. And of course, the very first it's probably the one and only time that, like an accurate symptom search. Really nailed it. It is a form of celiac that Nordic women acquire, and it presents around the age of 25, which is when mine started. And it has herpes in the name. It's some sort of like a herpes style thing, but it's celiac disease. It just presents differently. So I take it to my doctor. I'm like, hey, look at this. And he was like, Whoa, really? And then before I went to my appointment, I'd stopped eating wheat. My rash went away immediately. It was a very easy thing to prove out it was an elimination diet. Instant confirmation. Fast forward to move to California, walk into my new GP. He sits at the computer and gives me some side eye and says, okay, so celiac. And his first question was, who diagnosed you? Okay, what's the passive aggressive thing there? The who diagnosed you, right. Not how are you feeling? What are you doing to deal with it? Do you have challenges here? No. Who diagnosed you? And I said I did. And he rolled his eyes. And Dr. Graul, that was the last time I went to my general practitioner five years ago. But I still can tap into the feeling that I had there, which was like he was shaming me for taking control of my health when I had been putting steroid cream on my body for two decades. This little story there on Harolds that one can encounter when they're talking to a GP and then how we end up in the hands of our gynecologist. Right. Because I feel like people who gravitate toward that practice are, by and large, super compassionate, empathic people. And I don't know what we'd do without you because there are so many patients, they don't have any place to turn beside their gynecologist. It's where they feel most cared for and safest.
Dr. Graul: I think that a lot of physicians will push their patients towards us as well, because if they have something that they don't understand or they don't know what's happening, I can't tell you the number of patients that come to me and say, my doctor wants you to test my hormones, and they're going to blame all of the problems that the patient is having on their hormones. And so that's a very frustrating situation, because if their doctor is sending them for that, then that reinforces to them that this is something related to hormones when it probably is not. We get that from therapists, psychiatrists, dermatologists, all the specialties. And that's a difficult situation to be in.
Carol: Wow. That puts you in a very difficult position because what percentage of those referrals do you think are as a result of either misinformation or a prejudice around the way women are expressing their symptoms? That seems really judgy to me.
Dr.Graul: Yeah. I think that in most cases may be judgy. I think the prejudice. Absolutely. And then I think just maybe a lack of information of what hormones really do and what they don't do. Again, we're back to there are a lot of things we just don't know. It's very difficult in that situation to say, well, there are many hormones. I'm not sure which ones your doctor had in mind. I think almost always they're referring to to reproductive hormones because those are the ones that have the reputation of making us crazy or unbalanced or whatever the term might be. And that's a difficult we are then stuck with.
Carol: Okay, we've got to not only reverse this education, but then reeducate to say without saying, well, I think your doctor was completely wrong trying to say, well, maybe there's another way we can look at this. Yeah. Let's start from the beginning, perhaps a way to avoid what I would want to say, which is your doctor is completely wrong. Can I have your doctor's phone number so I can call them and tell them exactly how wrong they are. I want to place those phone calls. So can you give me an example of an experience like that where somebody referred a person to you because of hormone issues, when, in fact, it wasn't that so that people listening can look for similarities and something that they're experiencing?
Dr. Graul: I can't think of a specific example. I think the most common thing that we see it with is depression. The problem with that is that hormones are so they fluctuate literally within a day and from day to day. If that physician has done a very accurate tracking of symptoms and can say, look, it really is correlating with hormonal fluctuations with menstrual cycles in that situation, I think that it may be valid to look at some things, but to just say, oh, I think this is hormonal and you need to go to your gynecologist and have your hormones checked. I just think that that's a way to dismiss the reality of what's going on and to maybe say it's a way that you don't have to say, gosh, I'm sorry. I really don't know what's going on. And so I'm just going to send you to someone else and see if they can figure it out.
Carol: Everybody gets sent to the gynecologist telling you, my head hurts. You need to go see a gynecologist right away.
Dr. Graul: Oh, yeah. Well, we've definitely had headaches and in for hormone checks. That's valid because you can have menstrual hormones, but there needs to be some evaluation before that determination is made.
Carol: Yeah. Especially I'm seeing like a perfect storm here in our conversation going back to when we were talking about symptoms. If someone can't connect the dots with their symptoms and they're under the impression that their period is normal, so they bring that with them and they're depressed, so they're bringing that with them. Do you think maybe depression would occur if someone felt extremely sick for a third of the month, was also in a self talk cycle of hating a part of their body. They're being gaslit, perhaps by people around them who are dismissing their symptoms and they're mortified because they bled out in the conference room.
Dr. Graul: Oh, yes. Seen all of those scenarios.
Carol: Yeah. And also walking around with your period and thinking that you smell and you can't ever I remember I'm 56, so I'm beyond those days, but I remember really sending anger directly to my pelvic region. I can just remember that sensation of hating a part of me that has a negative impact. And, Gee, I would think I mean, I definitely can look back and say I was depressed. Who wouldn't be right?
Dr. Graul: Exactly. It's a chronic illness as far as you're concerned.
Carol: Exactly. It is. It's a chronic illness, and it's one that we have been conditioned to feel like we can't address publicly. I mean, we are still in a time period in 2022, where we can't talk publicly about periods without people getting mad.
Dr.Graul: Yes. It's not appropriate conversation.
Carol: Right. So I can see how the depression is a result can be a result of all of those things happening at one time. Maybe also throw on the fact infertility if you're bleeding half the month and you feel like crap the other half and whatever the sort of manifestation of that chronic debilitating health condition is, I could see that impacting fertility, even if it just means less sex.
Dr. Graul: Absolutely. That could be depressive.
Carol: Does anybody get that outside of a gynecology office?
Dr. Graul: Probably. I think that that's not as much medical training as being a compassionate human being. Maybe it helps to be a woman just because you've been through it a little bit. But my experience has been until I actually experience something for myself, I'm not nearly as empathetic or compassionate. Just being female doesn't make me that having experienced something directly really helps in my understanding of what someone else is going through. And that's an unfortunate reality of any kind of health issue is that unless you've experienced it for yourself, it doesn't matter how many times you've seen it. You can't quite grasp the magnitude of what that patient is experiencing. And I don't think there's necessarily an answer for that. But I think that you've got to acknowledge it, especially to your patients, saying, oh, I understand. You really don't. Right. It's like being empathic enough to communicate to them that you hear them, but that you also acknowledge that you're not in their shoes. Exactly. That's a tough balance.
Carol: Yeah. I call it the compound fracture situation. Like if you're watching a football game on television and someone breaks a bone, but you have no clue. Right. Because you don't see it. They're essentially just not putting, let's say, perhaps pressure on their foot because they broke their ankle, what have you. They carry them off the field. You continue on with your day and your celebration and what have you. But if it's a compound fracture, none of us forget that. Right. Like, we're trying not to get sick. People are like, oh, my God, when I think about someone trying to communicate to their boss or to their partner that these hard, round muscle balls that are crammed inside a three by two by one inch space are like the equivalent of a compound fracture. Maybe that's what we need to do is to just make it as violent an explanation as possible so that they get it. These other physicians that are sending or therapists that are sending you their hard to heal cases can have a little bit of a different take on what might be causing depression or PTSD even. I took my kids sledding one time and led out on a sled Hill in front of my whole community. Yeah, it was super fun. Super fun on snow. Right? And I had just changed a tampon. Just put it on my pad, everything. But it was like at that time period in your 40s where you feel like you are literally bleeding out. And, yeah, that's PTSD. I mean, I haven't been sweating since. That's not true. Actually, I have. But these are the things that I think we think about when we're trying to live with these conditions. And it's tough. And I just have to say that because of people like you, Doctor Graul, who get it. You get it. I can't think of any person who would walk into your consultation room and not have an empathic experience because of what you just shared with us, that you understand that even though you're a woman, you can't necessarily identify with what they're experiencing. And I just want to thank you for being there and for taking it upon yourself to stay on top of new technologies and to add them to your toolkit and to advocate for the right treatment based on that patient's experience. That is something that I think is rare.
Dr. Graul: Well, it shouldn't be.
Carol: Yeah, I agree. We're going to try to make an impact on that. So thank you for being here. I really appreciate it. Doctor Graul, what is the name of your practice?
Dr.Graul: Phase two, center for Women's Health.
Carol: Phase two. Center. I love that. Phase two. Yeah. After the baby years.
Dr. Graul:You got it. Yeah.
Carol: Excellent. In Salt Lake City, Utah, if you are close to Dr. Graul, you are one of the most fortunate people on planet Earth. And Dr. Graul, I hope that you'll come back to talk to us about some of the other conditions that you treat. You mentioned incontinence, and I know that there have been some advancements in treating incontinence, and that condition can have just as much of a negative impact on people's lives as horrible periods can. So will you join us again?
Dr.Graul: Love to. Yes. Thank you so much.
Carol: We really appreciate having you here, Liz. Well, thanks so much, Carol. This has been great. Thank you, Dr. Graul. We have 100 more questions. Actually, I think it might be a million, really and look forward to having Dr. Graul back on the Helen Uterus podcast. Thank you for tuning into the after show. We'll be back next week for another episode of Hello, Uterus. Our expert is going to talk to us about the importance of analyzing menstrual blood. You want to hear this? Thank you to angel for producing the heck out of this podcast. We really appreciate your efforts. And thank you to everyone who's listening. Shining a light on the Uterus chronic conditions that impact it. The lack of research and the realization that money is driving all of this. Money is driving how we access Uterine care. Money is driving how much research is performed on the Uterus and the conditions that impact it. So our commitment is that we're going to put pressure on the people who have the money to fund the research and then we're going to bring you the information because you're not going to find it on CNN you're not going to find it in USA today. You're going to find it at hello, uterus we're really happy that you're here. Please send your questions for hear me. Hear me our Q and a segment to hello at hello, uterus.com and visit hello, uterus.com to subscribe for updates on our progress with uterine kind a platform that's going to revolutionize the way uterine care is experienced by everyone. Thanks. Have a great week.