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If you've ever been told your debilitating pelvic pain is “just a cyst” or left the emergency room without answers, this episode will change how you think about endometriosis and endometriomas. Dr. Jolene Brighten is joined by fellowship-trained endometriosis surgeon Dr. Amanda Chu, MD, for an evidence-informed conversation about why endometriomas deserve more attention, why so many women are dismissed despite severe symptoms, and what patients need to know to advocate for earlier diagnosis and better care.
In this episode, you'll learn why an endometrioma may be much more than an ovarian cyst, what happens when these cysts rupture or leak, why emergency departments often aren't equipped to diagnose endometriosis, and how quality of life—not just imaging—should guide treatment decisions. The conversation also explores emerging therapies, including Low-Dose Naltrexone (LDN) and GLP-1 medications, while emphasizing the importance of individualized care and informed decision-making.
Endometriomas and Endometriosis: What You'll Learn in This Episode
Whether you've been diagnosed with endometriosis, suspect you may have it, or want to better understand your treatment options, this episode delivers practical insights grounded in clinical experience.
You'll discover:
- Why an endometrioma is often considered the “tip of the iceberg” and what it may reveal about more extensive endometriosis.
- Can a ruptured endometrioma make surgery more difficult later? Dr. Chu explains what she observes in the operating room.
- Why so many women end up in the emergency room repeatedly without receiving meaningful answers.
- The surprising reason ovarian torsion is actually uncommon in many women with endometriomas.
- What you should do if the ER sends you home after ruling out life-threatening conditions.
- Why severe pain is never “normal,” even if imaging appears reassuring.
- How delayed diagnosis can affect fertility, quality of life, and future surgical complexity.
- The emotional impact of endometriosis, including fatigue, anxiety, depression, brain fog, and strained relationships.
- Why endometriosis contributes to billions of dollars in lost productivity through missed work and school, highlighting that this is a public health issue—not simply a painful period.
- Should teenagers and young adults be offered surgery sooner? Dr. Chu discusses how quality of life should influence treatment decisions.
- The role of patient advocacy and why asking for a second opinion may be one of the most important steps you take.
- Emerging conversations around Low-Dose Naltrexone (LDN) and GLP-1 medications, and why clinicians are paying attention even as research continues to evolve.
- How physicians can balance evidence-based medicine with listening to patient experiences, creating better partnerships in care.
If you've ever questioned whether your symptoms were “bad enough” to deserve evaluation, this episode offers both validation and practical guidance.
Understanding Endometriomas and Endometriosis: Why Earlier Recognition Matters
An endometrioma is a type of ovarian cyst associated with endometriosis. While these cysts are technically benign, Dr. Amanda Chu emphasizes that benign does not mean harmless. Throughout the discussion, she explains that when she identifies an endometrioma, she immediately begins thinking beyond the cyst itself and considers what additional endometriosis may be present elsewhere in the pelvis.
One of the most compelling discussions centers on what happens when endometriomas leak or rupture. Dr. Chu describes the inflammatory contents as creating an environment that can dramatically alter normal pelvic anatomy over time. As inflammation accumulates, tissues become scarred, surgical planes become increasingly difficult to distinguish, and future excision surgery may become significantly more complex.
Importantly, the conversation does not present this as settled scientific fact but instead shares Dr. Chu's surgical observations and explains why these findings influence her approach to patient counseling. Rather than adopting a “wait and see” strategy for every patient, she encourages individualized conversations based on symptoms, fertility goals, and quality of life.
The episode also explores one of the most frustrating experiences for patients with endometriosis: emergency room visits.
Many women seek emergency care because their pain becomes unbearable. Yet, according to Dr. Chu, emergency physicians are appropriately trained to identify immediately life-threatening conditions such as appendicitis, ectopic pregnancy, ovarian torsion, or pelvic infection—not necessarily chronic diseases like endometriosis.
This distinction is important. While the emergency department may successfully rule out dangerous conditions, that does not mean a patient's pain lacks a legitimate cause.
Dr. Brighten emphasizes that women should not internalize dismissive experiences. Objective physiologic signs—including elevated blood pressure, increased respiratory rate, and visible distress—demonstrate that severe pain is real, regardless of whether imaging provides a definitive diagnosis.
Another important takeaway involves ovarian torsion. Many patients fear that any ovarian cyst dramatically increases their risk of torsion. However, Dr. Chu explains that endometriomas often develop alongside extensive scar tissue. Ironically, that scarring frequently reduces ovarian mobility, making torsion less common than with other types of ovarian cysts.
The conversation then shifts toward prevention—not necessarily preventing endometriosis itself, but reducing unnecessary emergency room visits and empowering women to manage flares more effectively.
Dr. Chu recommends preparing an individualized symptom management plan that may include physician-approved anti-inflammatory medications, heating devices, TENS therapy, muscle relaxants when appropriate, and other supportive therapies discussed with a healthcare professional. Having a plan in place may help patients navigate severe symptom flares while continuing to pursue definitive specialty care.
Perhaps one of the strongest messages throughout the episode is that quality of life matters.
Endometriosis is not simply about pain scores.
It affects educational opportunities, careers, athletic participation, relationships, fertility planning, mental health, and economic productivity. Dr. Chu notes that many adolescents undergoing surgery are not seeking care because they have nothing better to do—they are seeking care because their symptoms have become impossible to ignore.
This shifts the conversation away from asking whether disease appears severe enough on imaging and toward asking whether symptoms are preventing someone from living the life they deserve.
The episode also addresses growing frustration surrounding misinformation.
Patients increasingly report receiving conflicting recommendations from different physicians, leading many to lose confidence in the healthcare system. Rather than positioning herself as having every answer, Dr. Chu advocates for intellectual humility. She encourages physicians to acknowledge uncertainty, stay current with evolving research, and collaborate across specialties whenever possible.
This philosophy naturally leads into a discussion of emerging therapies.
Dr. Brighten and Dr. Chu discuss Low-Dose Naltrexone (LDN), which has gained increasing attention in integrative medicine for chronic inflammatory conditions, as well as the growing interest surrounding GLP-1 medications. While randomized controlled trials specific to endometriosis remain limited, both physicians describe observing improvements in select patients when these therapies are used thoughtfully within a broader treatment strategy.
Throughout the conversation, they repeatedly emphasize informed consent, individualized care, and honest discussions about what is known, what remains uncertain, and how patient experience can guide future research.
Rather than presenting medicine as static, the episode highlights how clinical practice continues to evolve as physicians listen carefully to their patients while awaiting stronger scientific evidence.
For women who have spent years searching for answers, this conversation offers both hope and practical strategies for moving forward.
What This Conversation Means for Women Living with Endometriosis
One of the most powerful themes throughout this episode is that women deserve to be believed the first time they seek help. While the discussion centers on endometriomas, it ultimately becomes a broader conversation about delayed diagnosis, patient advocacy, and how medicine can better serve women living with chronic pelvic pain.
Dr. Brighten and Dr. Amanda Chu explain that one of the greatest challenges in endometriosis care is that symptoms often don't correlate neatly with what appears on imaging—or even with the stage of disease. A woman may experience debilitating pain despite relatively limited visible disease, while another with extensive endometriosis may have different symptoms altogether.
This variability is one reason why listening to the patient's experience is essential.
Rather than focusing exclusively on imaging findings, both physicians advocate for evaluating how symptoms affect daily life. Questions such as:
- Can you attend school consistently?
- Are you missing work every month?
- Has your pain changed your career choices?
- Has it affected your relationships or intimacy?
- Are you avoiding exercise because of pain?
- Do you constantly worry about your next flare?
These questions often provide a clearer picture of disease burden than imaging alone.
The discussion also highlights how endometriosis extends far beyond pelvic pain.
Chronic inflammation and persistent pain can contribute to fatigue, brain fog, anxiety, depression, sleep disruption, and significant emotional distress. Living with unpredictable symptoms may also affect confidence, financial stability, and long-term family planning.
For many women, years spent searching for answers become an additional source of trauma.
Repeated emergency room visits, normal imaging studies, or being told that symptoms are “just part of being a woman” can erode trust in the healthcare system. Dr. Brighten reminds listeners that these experiences are unfortunately common—but they should never become normalized.
Another important conversation centers on second opinions.
Rather than viewing another consultation as questioning a physician's expertise, Dr. Chu encourages patients to seek providers with extensive experience managing endometriosis when appropriate. Medicine continues to evolve rapidly, and no single clinician can be an expert in every condition. Seeking additional expertise is a proactive step toward making informed decisions—not an act of distrust.
The episode also explores the balance between evidence-based medicine and innovation.
Both physicians emphasize the importance of high-quality clinical research while acknowledging its limitations. Randomized controlled trials require years of funding, participant recruitment, and analysis. During that time, physicians continue caring for real patients with real symptoms.
This creates situations where clinicians may thoughtfully consider therapies supported by emerging evidence, biologic plausibility, or extensive clinical experience while maintaining transparent discussions about uncertainties.
Low-Dose Naltrexone (LDN) serves as one example discussed during the interview.
Originally used for entirely different purposes, LDN has become increasingly recognized within integrative medicine for chronic inflammatory conditions. Dr. Brighten shares that she has used it clinically for years in carefully selected patients, while Dr. Chu notes that she has incorporated it into her own practice more recently after observing positive patient experiences and learning from colleagues practicing integrative medicine.
Similarly, the conversation explores growing interest in GLP-1 medications.
Although large randomized trials specifically evaluating GLP-1 receptor agonists in endometriosis are still lacking, both physicians discuss observations suggesting some patients experience improvements in inflammatory symptoms while using low doses under appropriate medical supervision.
Importantly, neither physician presents these therapies as universal solutions.
Instead, they emphasize individualized care, informed consent, ongoing monitoring, and honest conversations about what is currently known—and what remains unknown.
This thoughtful approach reflects one of the strongest messages throughout the episode:
Medicine should continue learning from patients.
Listening carefully to patient experiences has historically driven important medical discoveries. Rather than dismissing observations simply because randomized trials have not yet been completed, clinicians can remain curious while simultaneously practicing safely and ethically.
The conversation concludes with a message of hope.
Despite persistent gaps in diagnosis, increasing awareness of endometriosis has led to greater collaboration among surgeons, reproductive endocrinologists, pelvic floor physical therapists, pain specialists, integrative physicians, and patient advocates. As research continues to evolve, women have more opportunities than ever before to build multidisciplinary care teams capable of addressing both symptoms and long-term health goals.
Whether your priority is pain relief, fertility preservation, improving daily function, or finally understanding years of unexplained symptoms, education remains one of the most powerful tools available.
The more women understand about endometriosis and endometriomas, the better equipped they are to advocate for timely evaluation, ask informed questions, and participate actively in treatment decisions.
This Episode Is Brought to You By
A special thank you to our sponsor, Endo Global, for helping make this episode possible.
If you've ever wondered, “Could this be endometriosis?” or you've been told your pain is “normal” but you know something isn't right, you don't have to navigate it alone.
Endo Global offers a free consultation to help you:
- Understand whether your symptoms could be consistent with endometriosis
- Learn what your next diagnostic steps may be
- Explore treatment options based on your goals, whether that's pain relief, preserving fertility, or improving your quality of life
- Get connected with experienced endometriosis specialists and resources
You deserve answers, and the right guidance can make all the difference.
👉 Book your free consultation today
Links Mentioned in This Episode
- Amanda Chu’s Instagram: drchu_endodoc
- ESSE Care
Resources Discussed
- Low-Dose Naltrexone (LDN)
- GLP-1 receptor agonists
- What Is Endometriosis? 4 Surgeons Explain the Symptoms, Misdiagnosis, and Whole-Body Impact
- Urinary Incontinence Treatment, Pelvic Pain & the Problem with Just Doing Kegels | Dr. Diana Mendez
- Endometriosis Symptoms vs Normal Period Pain with Dr. Patrick Yeung
- Endometriosis and Painful Ovulation: Why Ovulation Hurts, Where It’s Felt, and What Helps
Frequently Asked Questions
An endometrioma is a type of ovarian cyst associated with endometriosis. While it is considered benign, it may indicate more extensive disease and should be evaluated within the context of a patient's symptoms, fertility goals, and overall health.
In this episode, Dr. Amanda Chu discusses her surgical observations that leaking endometriomas can contribute to significant pelvic inflammation and scarring, potentially making future surgery more complex. More research is needed to fully understand these mechanisms.
Not necessarily. Treatment decisions should be individualized and consider symptoms, cyst characteristics, fertility goals, age, and overall quality of life.
Severe pelvic pain frequently leads women to seek emergency care. Emergency physicians focus on ruling out immediately life-threatening conditions, which means endometriosis may not always receive comprehensive evaluation during those visits.
No. Normal imaging does not exclude endometriosis. While endometriomas may be visible on ultrasound or MRI, many endometriosis lesions cannot be detected with imaging alone.
According to Dr. Chu, torsion appears less common with endometriomas than with many simple ovarian cysts because scarring often limits ovarian mobility.
Beyond pelvic pain, endometriosis may impact work, education, relationships, exercise, fertility planning, sleep, mood, and overall daily functioning.
LDN is a medication increasingly used in integrative medicine for chronic inflammatory conditions. Drs. Brighten and Chu discuss its emerging role in individualized endometriosis care.
Some clinicians are exploring GLP-1 medications in carefully selected patients because of their potential effects on inflammation. However, more research is needed before routine recommendations can be made.
If your symptoms persist despite treatment, significantly affect your quality of life, or you have an endometrioma or suspected endometriosis, consulting a physician with expertise in endometriosis may help you better understand your diagnostic and treatment options.
Dr. Jolene Brighten is a board-certified naturopathic endocrinologist, a Fellow of the American Board of Naturopathic Endocrinology (FABNE), a Menopause Society Certified Practitioner (MSCP), a nutrition scientist, and a certified sex counselor through the Sexual Health Alliance. As a licensed physician maintaining an active DEA license and full prescriptive authority, her educational frameworks align with leading global standards, including ESHRE and The Menopause Society. She serves as a faculty member for the American Academy of Anti-Aging Medicine (A4M), acts as the Lead Researcher for the Brighten Essentials Research Division, and is currently directing ongoing scientific research initiatives to advance clinical care standards for women navigating complex endocrinology, neurodivergence, and tissue-specific hormone sensitivities.
Dr. Amanda Chu is a board-certified minimally invasive gynecologic surgeon specializing in endometriosis, chronic pelvic pain, and advanced excision surgery. She practices at ESSE Care, where she focuses on comprehensive, patient-centered treatment for endometriosis and related conditions. Dr. Chu serves as a Clinical Assistant Professor at the Zucker School of Medicine and has spent years supporting education and advocacy efforts through the Endometriosis Foundation of America. Her work centers on improving diagnosis, advancing surgical care, and helping women receive evidence-based treatment earlier in the course of disease.
Transcript
Dr. Brighten: [00:00:00] Ruptured endometrioma or draining it, can that seed more endometriosis lesions in the pelvis?
Dr. Amanda Chu: At certain sizes, they can leak, and they can leak all of that inflammatory fluid all over the pelvis. It is inflammatory glue, and it starts to glue things. That's what actually makes the surgery challenging.
Narrator: Dr.
Amanda Chu- Is a leading endometriosis surgeon and longtime advocate through the Endometriosis Foundation of America- On a mission to break the stigma, challenge misinformation- And help women get the care they deserve.
Dr. Amanda Chu: Stage IV endometriosis didn't just sprout up yesterday. It started throughout your whole life.
A large percentage of the patients who are young, who are adolescents, who are in their 20s that get surgery, they have endometriosis, and they have it to the degree where it's impacting their life.
Dr. Brighten: How often does ovarian torsion occur with endometriomas?
Dr. Amanda Chu: Honestly, most of the endometriomas are-
Dr. Brighten: Ruptured endometrioma or draining it, can that seed more endometriosis lesions in the pelvis?
Dr. Amanda Chu: We talk a lot that at certain sizes they can leak, and they can leak all of that inflammatory fluid all over the [00:01:00] cul-de-sac, all over the pelvis. I always feel like that is, like, you know, not surgical glue, but it is inflammatory glue, and it starts, it starts to glue things together, right? Yeah. That's destruction of, uh, surgical plane spaces.
That's what actually makes the surgery challenging. When you have unruptured endometriomas, you can actually tell, like, when you open endometriomas, younger endometriomas that have been there for a shorter time, the, you know, sort of the fluid consistency is, is, isn't as thick. Um, the, the cyst wall isn't as, like, fibrotically scarred into the ovary.
So just knowing these, like, physical characteristics, it makes it so hard for someone like myself to leave something in there that I know at some point may cause a problem.
Dr. Brighten: It's very common for endometriomas to land people into the ER. When it comes to going into the ER, what should the, an ideal scenario look like for a woman getting assessed for an endometrioma?
Dr. Amanda Chu: I mean, unfortunately, it's, it's almost never ideal. When you are a woman going to the emergency room for pain, they are [00:02:00] thinking pelvic inflammatory disorder, ap- appendicitis, you know, if you're pregnant or not. Um, and, you know, I mean, maybe an adnexal mass or torsion. They're thinking about the twisting or a ruptured cyst, right?
And so they're thinking, you know, "These are, these are my emergencies." They kinda don't really view endometriomas as emergencies-
Dr. Brighten: Mm-hmm ...
Dr. Amanda Chu: still. Um, I think sometimes they're thinking more endometrioma in the context of could they cause something like a torsion, could they cause something else? But the endometrioma in and of itself is never really viewed as an emergency, even though the symptoms you are feeling I think have brought you to the emergency room.
I think what we always sort of forget for patients, and I, I always remind myself, nobody wants to see you, okay? I, I mean, I think I'm a nice person, but nobody really wants to come see me. They're seeing me 'cause they're in pain. They're seeing me because they have problems, right? Doubly so, triply so if you're going to the emergency room.
So I would say It is go- always going to be hard [00:03:00] because you are, you are probably not gonna have an advocate with you. I would, I would hopefully bring someone with you to the emergency room that can help you vocalize and be your advocate there to be like, "Hey, no, I really think something is wrong."
Narrator: Mm-hmm.
Dr. Amanda Chu: The issue here is that you probably do not wanna be getting your surgery or any intervention in the emergency room. You wanna come away, you know, hopefully with resources, having your pain controlled, um, with, you know, any imaging if they're able to do it for you. MRIs are excellent. They sometimes won't do that for you in the emergency room.
Um, but just to say, you know, that is not ever an ideal place, and it would be very, very rare for you to get the best care there. Mm-hmm. Make sure none of those other things are happening that you would need immediate care for, um, like I said, like the over- ovarian torsion. But I would say with whatever information you have, you know that something is wrong.
You didn't bring yourself to the emergency room because everything was great that day. So if they have ruled out scary things like appendicitis, then you [00:04:00] can say, okay, you can take that diagnosis and be like, "Okay, I have, you know, well enough information or well enough, you know, symptoms and issues that I should be seeking appropriate care now."
Dr. Brighten: Mm-hmm.
Dr. Amanda Chu: Um, it's very interesting. For some reason, people... Y- you know, the psychology of endo I found so interesting is, you know, when do you realize that your symptoms are abnormal? When do you seek care? When do you feel like you deserve care? It's, it's so interesting. And so I would just basically urge anyone, if you're going to the emergency room, um, and they are not finding anything, you should really be considering endometriosis, right?
That, to me, that's a big problem.
Dr. Brighten: Mm-hmm. Yeah. But if you do go to the emergency room, they happen to do ultrasound or MRI, any kind of imaging, that is good data. You- That was like, even if they just say, "Go take some Tylenol," get the imaging 'cause you can take- Yes, exactly ... that elsewhere. I'm curious, how often does ovarian torsion occur with endometriomas?
Are we looking more at, like, a size of an endometrioma that puts you at risk?
Dr. Amanda Chu: Yeah, [00:05:00] honestly, pretty rarely, Mm-hmm ... I would say, because most of the endometriomas are associated with scarring. So scarred ovaries don't twist that much. So i- I mean, they can happen, but I see them much less frequently than with any other type of simple cyst 'cause those you have, you need mobility.
Dr. Brighten: And this is endometriosis is surviving, right? Because I need my little hormone factories to keep me here. So let's go- Yeah, it's not gonna
Dr. Amanda Chu: try to cut you off
Dr. Brighten: Yeah. It's
Dr. Amanda Chu: gonna, it's gonna wanna keep, keep everything flowing there.
Dr. Brighten: So I'm gonna preface this next question that I was severe period pain for years.
Finally, I'm like, "Get on the pill," and I think this is gonna be my savior. And I went into the emergency room over and over again for pain, and it wasn't until almost 25 years later that I remember, 'cause, like, everyone listening, I was, like, 17 when this started, they're like, "Chocolate cyst is rupturing.
Chocolate cyst is rupturing." Nobody used endometrioma. No one said endometriosis. And all my time on the pill, I still had rupturing of cysts. [00:06:00] What are other things women can do to prevent trips to the emergency room?
Dr. Amanda Chu: That one is tough because, you know, just like, you know, contraception, it's just not 100% perfect.
Dr. Brighten: Mm-hmm.
Dr. Amanda Chu: Um, I don't think we have anything that's 100% perfect unless you remove ovaries, which is not something we're ever gonna do. A 17-year-old-
Dr. Brighten: Yeah, 0%
Dr. Amanda Chu: perfect at 17 0%. Okay, that is 0%, right? And so, um, the things you can do are, I always tell a lot of my patients to have, like, a little go pack or something with them because if they're out, you never know when you might have a flare or you might have something happen to you.
Um, so whether that is, you know, a portable heating pad, whether that's a portable TENS unit, um, I know, you know, p- patients are using, like, little red light therapy machines. Some of them are all combined into one. You can have some anti-inflammatories. You can have ... I use a lot of muscle relaxers. I do things to try to prevent you from ending up there, um, because that is n- again, like we said, not the place that you really wanna go to seek, um, [00:07:00] probably the, the treatment that you need- Mm
um, at the time. So I think those are the best ways to prevent, um, sort of unnecessary ER visits. Unfortunately, I've had a lot of patients just tell me, "Well, I just don't go anymore 'cause it doesn't help me."
Dr. Brighten: Yeah.
Dr. Amanda Chu: And I think that that's, that's, that stems from experience.
Dr. Brighten: Mm-hmm.
Dr. Amanda Chu: Right? So they wait a long time.
Um, they get the same ultrasound. They have the same interaction. Um, and if anything, at some point it does more harm than it does good, just from a, you know, psychologic perspective, especially when you can't see it. So again, we're talking about endometriomas, which you can see, but for every other patient, if they can't see it-
Dr. Brighten: I wanna ask you, you know, somebody going to the emergency room, why is it the ER doctor never says, "This could possibly be endometriosis.
You should meet with a specialist. You should take this to your gynecologist"? I, I want people to understand what is going on in their minds, and that their doctor isn't necessarily just [00:08:00] being a bad doctor here. They are actually doing their job.
Dr. Amanda Chu: I think two big things. One is the emergency room is like, 'We wanna keep you alive,' right?
Are you having a STEMI? Are you having a heart attack? Are you having a stroke? That's sort of like th- you know, how their mind is structured and how they were trained, and I think we've spent a long time talking about, unfortunately, the, the deficiencies within OBGYN training. Well, these are emergency room physicians.
Yeah. Think about their training in endometriosis. So unfortunately, so many of our patients get labeled as pain-seeking. I'm hoping, again, now the narrative is shifting, and they're starting to understand that if somebody is coming back repetitively to the emergency room, they should be questioning, uh, what that is, right?
Especially if they're never finding any pathology. Because again, I think, too, you know, you get so into your own space and the narrative you think that, you know, you wanna see, but this is not normal. They- Mm ... they don't wanna see you either. Right? And so I think those are the big things here is that they are, their focus is slightly different.
It's not on [00:09:00] your psychosocial, uh, wellbeing. It's not on your quality of life. It's not on your fertility at this moment.
Dr. Brighten: And I would also add, you know, I, I think it's really easy to internalize these messages of medicine, and they'll say, like, "You're drug-seeking, and you're being dramatic. You want attention."
There are objective findings. Your blood pressure changes. You're sweating. You're, you know, we have objective findings. Your respiratory rates are up that show that you are truly in pain and distress. And when your doctor says You're probably just drug seeking. It's probably something else. That's a bias.
That's not reality
Dr. Amanda Chu: I mean, I think if you have an endometrioma, you should at least get a consult, right? Mm-hmm. A consult does not always mean surgery. It just means understanding what that endometrioma can do, um, and is currently doing, and to understand all of your options, right? Just like the things we talked about, and whether you would prefer to take a non-surgical route at this moment.
I think more information always helps. Like I said before, to me, an endometrioma is tip of the iceberg. It means so much more for you and has the potential, and for someone to spend the time [00:10:00] and to ask about your fertility goals, I think that that is, is a gift that, you know, we should try to, try to give to more young patients found with endometriomas than told just to, just to monitor, or, "It's not a big deal.
We'll, we'll deal with it later."
Dr. Brighten: Mm-hmm.
Dr. Amanda Chu: Um, because I've seen that to be so damaging in so many situations.
Dr. Brighten: We talked about, you know, addressing endometriomas sooner. The fact that if your surgeon is draining it or y- he's rupturing, that could lead to the progression, the seeding of endometriosis. ACOG currently is like, you sh- you shouldn't be addressing endometriosis via surgery in younger patients.
I find it hard to reconcile that as somebody who didn't get diagnosed until their 40s, having stage IV DIE, like acronym is, is, is that acronym for a reason. But I look at my surgical video, and I often question these over, this over and over rupturing that was happening of these cysts over a decade of time, how much worse [00:11:00] did that make my endometriosis, and could I have prevented it?
And so I, what I'm curious from you is that what, what is your thought on, you know, teenagers, 20-somethings doing surgical intervention for endometriomas?
Dr. Amanda Chu: I think if it's inf- impacting your quality of life, you should absolutely be offered surgery. I always say it's amazing that we have so many endometriosis advocates.
My goal for, you know, Endometriosis Awareness Month is to actually have less advocates, okay, out there. The whole reason you are advocates is because you have suffered, okay? And so the prevention aspect of this is huge. I say at stage IV endometriosis didn't just sprout up yesterday. It started, you know, throughout this, throughout your whole life, right?
And so, um, you know, you went from stage I to stage II, to stage III, to stage IV. So really, stage IV endometriosis is a fail- failure of our system if you were talking about it back then, right? Mm-hmm. It has been linked to absenteeism in school. Um, [00:12:00] you know, a large percentage of the patients who are young, who are adolescents, who are in their 20s that get surgery They have endometriosis, right?
Um, and they have it to the degree where it's impacting their life. They're skipping school, they're skipping sports. Um, actually a 20-year-old is, is the exact population. They have a million other things they wanna be doing, and I, you know, I'm in New York City, so there's a lot of things they should be doing and would want to be doing other, like I said, than seeking care, going to emergency rooms, seeing gynecologists.
Mm. So that should be an absolute red flag for, for providers.
Dr. Brighten: When you say quality of life, what kinds of things are we talking out- about other than missing school, work, or sports activities that for women listening they should know this isn't normal and you deserve better?
Dr. Amanda Chu: I mean, I think it also impacts their careers, right?
Sometimes it impacts what jobs they think they can take. Um, so the loss to the workforce is incredible. You know, they estimate I don't know however many, you know, billions of dollars lost secondary to [00:13:00] endometriosis and chronic pain. Um, so it's not just a loss to their personal lives, which it is, it's a loss to society.
Um, it puts stressors, you know, with your family, with partners. Um, it's very hard for partners to understand, especially when they're young, right? Mm-hmm. So, um, I, I think it can impact every part of, um, a person, and we talk a lot about things like, uh, fatigue, anxiety, depression, um, brain fog. You know, it just, it, it really extends well beyond, uh, physically the, you know, the body, but also mentally.
Dr. Brighten: Mm-hmm. When I was asking people to send questions about endometriosis in, in advance of Endometriosis Awareness Month, and I had my team put together the clusters, the question, one of the biggest questions that I didn't expect and was shocking to me-
Dr. Amanda Chu: Hmm ... is
Dr. Brighten: patients asked, "What can we do to end the misinformation that is primarily spread by doctors?"
Dr. Amanda Chu: Ooh, this is a [00:14:00] hard one. Um- I think it's different messages, and these are gonna be different doctors, and I think that it is hard because there's not a lot of societies, I would say, that we trust, right? Just I think going through the ACOG guidelines is just one example of that to say this was a very shallow understanding of this disease.
Um, I think we talk a lot about endometriosis myths, right? Uh, myths and misconceptions, and I just would say to hope, unfortunately, we are seeing more information coming from things like ChatGPT and, and it's basically loss of provider confidence. It's really hard to, to completely answer that and to be like, "How do we restore confidence?"
I think you need to find providers that you trust. I always tell my patients it's like probably like if I were to go into a car dealership, you could tell me anything about anything, and I would be like, "All right, sure." And then I like I'm Googling on my [00:15:00] phone 'cause I really don't understand. And so you already have a sense of like, well, um, you know, you know, like you're the provider, and so everything you, you know, you say should be right.
Um I think that providers that don't encourage you to research on your own to get a second opinion, um, I think a lot of their information we should, we should question here too because it's so individualized. Like you, I think you could say something for one patient, have it be true, and it would not be true for the next patient too.
Mm-hmm. So, um, I think until even we know more, it would be so challenging to say 100% everything. That is medicine. Um-
Dr. Brighten: I think that question that came up is really born out of the fact that patients are tired- Yeah ... advocates are tired, and the thing that they bump up against, and I'll see this all the time, is that a doctor will clearly be spreading misinformation about endometriosis, and an endometriosis advocate, [00:16:00] someone who is living with this disease, comes in and says something, and immediately people are like, "Well, what are your credentials?
'Cause this person has credentials." Every time I'm like, "I just hate to break it to you, but the credentials don't mean that they're accurate." You have to be humble in medicine- Yeah ... and you have to recognize that you entered into a field where you can never know everything and your, your information is always evolving and you- Yeah
must always update yourself, and then you must listen to people who understand this, their field of expertise.
Dr. Amanda Chu: Yeah, I think it's, it's okay to be a provider that says, "I don't know," and it, it might be something says, "I don't know. Let me find out and see if I can talk to colleagues that maybe know better that can help us in this context."
It might be that this is out of my field of expertise. Sometimes I have patients ask me incredible things about things that I r- I really don't know about, and just because I think we have a baseline trust, right? So I, I don't wanna lead them astray. Um, and so I th- I think, you know, it's okay to say, "Hey, you know, I, I said [00:17:00] this thing five years ago.
I am learning. You know, I, I am human. I am a, I'm a provider, and a lot of how I, I deliver my care is, is through experience, lived experience, and a lot of how you receive care is through your lived experience, and I'm just trying to connect with you here and make sure that I don't do any harm, make sure that I am as up to date as I can."
Um, you know, I don't have PubMed in my head, right? So, so if a new article came out and someone brings it to me, amazing. Great. Thank you. I will take that, right? And so I think that is part of the give and take now because we have so much data, so much information. It's almost too much, right? And so now that's what you're experiencing.
You're having people who are, you know, influencers come in. You have people that are pseudo-credentialed. You have people that are credentialed, but p- potentially don't know. So it is, you know, it has so many benefits, but then we're seeing basically all of it. We're just in a different society now. Mm-hmm.
And so I, a lot of my patients actually come to me from their [00:18:00] own Google search, right? And so that is, is rough to hear because they've maybe seen 10 doctors, and any one of those doctors could have at one point been like, "Hey, maybe you should see an endometriosis provider." Um, but through the internet they were able to find me.
And so I don't know how to answer your question. That is, it's, it's again, everything we have, um It's sort of amazing the technology, but we're dealing with, uh, different things like I'm not gonna comment on the IT band 'cause I don't know IT. I was like, I'll let the PT, and I have a group of great PTs, so I'm gonna let them comment.
Dr. Brighten: Well, that's exactly ... I mean, when this person left that comment for me, I was like, "Thank you so much," because it's so easy- Yeah ... to repeat the things that you have learned in the past- Yeah ... and not be updated- ... when it's not your field. And so you jumping in and saying that to me, that updated me, and I'm really grateful, and it's also why I refer to PTs because I'm like, I know some things, but what I know- Yeah
mostly is then when it's time to refer.
Dr. Amanda Chu: Well, I know this has come up a lot, so we had been talking about GLP-1s in the [00:19:00] setting of endometriosis, and so we are just talking about it because of course there's no RCT with GLP-1s and endometriosis. We're just talking about mechanism here, and I think if you, you know, had reasons to be on it and then you concurrently have endometriosis, people were noticing things, right?
And so, uh, I think even from just patient experience, we're learning, oh, it seems to w- be working better, ah, people are mostly using really, really low doses because we are sensitive, and, you know, certain things, so you're, you know, you're having patient experience sort of speak for itself and obviously do those in monitored settings.
It's, it's tough. You have to be creative. That was never written anywhere, but it's just to say- Mm ... okay, like, you know, the things that you're talking about a lot, you know, I think a lot of us use things like low-dose naltrexone. Like, it's just, it's used in the integrative space. You know, I think that that's sort of that big field that, oh yeah, we do need doctors to put it all together 'cause we have, you know, a doctor here that is treating our endometriosis.
We have a doctor over here that, you know, is treating your migraines, things like this. So, um, I think that's, that's the, um, you know, hopefully where, where it's moving towards [00:20:00] in the endometriosis thing. Are you
Dr. Brighten: using low-dose naltrexone and GLP-1s in your practice?
Dr. Amanda Chu: I don't prescribe GLP-1s 'cause I do think it takes monitoring.
You know, I wanna ... You know, I think it comes with, you know, nutrition and a treatment plan and- Mm-hmm ... and ways to do it correctly, but, um, I absolutely support them. I will try to put them in touch with either ways to get it, um, on label, um, if they have any indications, or off label. So I definitely have referral sources for that.
Low-dose naltrexone I do prescribe. Um, so and, and again, that was more recent I think in the past few years that it's started to become, uh, more prevalent, I think because our integrative partners were also using it. Mm. And so, um, you know, it's tough to make everybody go to every different doctor for every little thing, so I think I just started doing that for ease of patients.
Dr. Brighten: Yeah.
Dr. Amanda Chu: Um, but yeah, I'm, I'm curious too 'cause I think you come at it from a different perspective in what you, what you've experienced. I don't know, have you even tried, you know, have you tried those things? I'm sure you have.
Dr. Brighten: Yeah. So, uh, with patients I've used LDN for a very long time, um, approaching endometriosis as if it is [00:21:00] autoimmune- adjacent.
Yeah ... um, because we know LDN works really well for autoimmune disease. So I've used that in endometriosis, and it was in the last couple years when people started reporting GLP-1s. I'm like, "Let's try .25 of Ozempic. That's a starting dose." Yeah. Like, we never have to go higher there, and I find really good results.
I see hsCRP drops. We see- Mm-hmm ... um, and this is like, we don't see, like, major improvements in, like, insulin or a- any of those kinds of changes, but the way they feel is better and their inflammation drops. And it's interesting to me because I talked to an obesity medicine doctor, and she was like, "Well, yeah, of course it will work 'cause they had hidden visceral adiposity."
And I'm like I don't think that's what's going on here Mm ... because some of these people are very lean. I've had people who are athletes. Like, I've had people who've had DEXA scans. They don't have m- like marked, uh, visceral adiposity, so I don't think that's what's going on. I think that there is an actual shift in their inflammatory state, and that these peptides are affecting [00:22:00] the immune system in a positive way.
I've also seen post-excision surgery 'cause p- post-surgery for everyone listening, your inflammation is always gonna go up. It's part of the healing. But when people... Some people's immune systems just have a hard time coming back from that, and they're doing anti-inflammatory diet, they're doing, you know, for all intents and purposes, everything right.
GLP-1s for, like, a few months helps- Mm ... drop that inflammation and reset the system. And so, you know, we're using it off-label and people are always... You know, whenever you say that, people are always like, "You can't be using medications unless the FDA has approved them." I'm like, "Tell every PCOS patient on spironolactone that, okay?"
Like, we do this all the time in medicine, and- Yeah ... it is something that when patients tell you something is working, you need to listen. And when you start seeing the pattern of it, you're like, "Let's try it," and you just be very honest with patients of, "We don't have data on this." Mm-hmm. "This is, like, how I think it works.
This is how we will use it. If you have these side effects, we're off of it." [00:23:00] Yeah. Um- That's ... but yeah, I think that it's exciting to see the other treatments that have come. I think when you look at autoimmune disease, we've seen lots of people with autoimmune disease getting better with, uh, GLP-1s as well, seen histamine issues- Yeah
get better with those. So, you know, the other things is that, um, patients that have concomitant, uh, endometriosis and PMDD, trying H1, H2 blockers and then noticing their period pain is much better. We know that- Mm-hmm ... these lesions are propagating histamine. There's histamine involved in your uterus, and so, you know, it's, it's, you know, one of those things where it's like we're piecing together what patients are saying, and then being like, "Okay, we're smart enough that we can figure out some of these things without waiting for the randomized control trial and get people relief now."
But the reason we have to talk about it is because the randomized control trial lets us know who do we use this with, who is it safe for, who is it dangerous for? Like, we get better data, and we can be [00:24:00] more precise in our medicine, and I think that's important for people to understand. I always say, like, you shouldn't have to wait for a study to believe your patient, and I am always floored when doctors are like, "Listen to her," like, "She's saying you don't need research to believe your patient."
Yes, you do, and I'm like, to believe the person living in their body who says to you, like, "This is my experience in my body," I don't need a research paper to validate that. I just need to get curious and be like Well, tell me more. Let me try to understand this, and if I can't understand this, then I'm calling colleagues and being like, "Help me understand this.
Have you seen anything like this?"
Dr. Amanda Chu: I mean, I think really, like, the idea of evidence-based medicine was really, like, drilled into our skulls- Mm ... as trainees, and, you know, everything has to be evidence-based. And, and I mean, it probably came from an era where sort of, like, it was like the Wild West. Doctors were sort of doing, you know, what, you know, whatever they wanted.
Um, but, you know, it's very hard to do those studies, and there, there's a lot of restrictions and a lot of challenges to do them, so. And they're
Dr. Brighten: very expensive.
Dr. Amanda Chu: Yes.
Dr. Brighten: And we're not [00:25:00] getting funding.
Dr. Amanda Chu: Yes. A million percent. So I think just like what you're saying, you can see... You know, you, you have a, a background to understand some of these things.
You, you treat this disease enough. You, you know, this is informed consent. You tell patients what you know, what you don't know. You, you wanna help them. You know, these are, these are our limitations here. You have to be a little bit creative, and I, you know, for myself, it was challenging to sort of leave academic medicine.
I had a moment where just in this, you know, recent, you know, few months I thought, you know, would I go back? And I actually decided to stay, you know, outside, just because I didn't feel like it necessarily offered me anything different, and I still now... You know, I get to practice the way I wanna prac- practice the way I wanna practice, right?
And I think that has always been the most important for me. So it's not to say academic medicine is bad. It's just to say, you know, it's, it's a little bit different, and you're gonna have different providers within that. But just because you go to an institution doesn't mean that that, you know, every single department within that institution is, you know, everything and knows everything.
Does that make [00:26:00] sense?
Dr. Brighten: Yeah. Well, thank you so much for taking the time to sit down with us today. I really appreciated this conversation.
Dr. Amanda Chu: Yeah, absolutely. Um, thank you so much. Thank you so much for having me.
Dr. Brighten: Thank you so much for joining the conversation. If you could like, subscribe, or leave a review, it helps me so much in getting this information out to everyone who needs it.
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