Endometriosis, HRT, and Menopause: Expert Answers on Surgery, IVF & What Really Helps| Dr. Melissa McHale

Dr. McHale: [00:00:00] Endo has no rules, does not have a textbook, and is often a disease that presents in the earlier years of life. But we do know that Endo can progress. We do know that adeno is often a disease that happens in what we consider the later reproductive years. It worsens over the course of the uterus, be that pregnancy or having surgeries.

Dr. Brighten: As an endometriosis patient, I will say the vast majority of doctors I have encountered have no clue that endometriosis can actually infiltrate organs and cause organ damage outside of the pelvis. So can perimenopause make endometriosis worse? And. So why are we not talking about this? 

Narrator: Dr. Melissa mc Hale 

Narrator 2: is a Johns Hopkins trained gynecologic surgeon who's changing the game in endometriosis care 

Narrator: with 

Dr. Brighten: advanced 

Narrator: fellowship training 

Dr. Brighten: and dynamic ultrasound and robotic assisted excision.

Narrator: She brings precision and hope to patients who've been dismissed for years now practicing in 

Dr. Brighten: the DC area. 

Narrator: She offers office-based evaluations and surgical expertise that actually treats the root [00:01:00] cause, not just the symptoms. 

Dr. McHale: Every patient's experience is different because sometimes someone has aggressive endo that for whatever reason, hasn't come to light, and if you have infiltrating endo and you're gonna lose a kidney in six months, if we don't do surgery and you're 42 years old, please don't wait for menopause, especially when for whatever reason their endo is causing more.

Dr. Brighten: Is IVF making endometriosis worse? And could it be sabotaging your chances of actually getting pregnant without you knowing it? 

Dr. McHale: This is a very controversial topic, and I will tell you. 

Dr. Brighten: Welcome back to the Dr. Brighton Show. I'm your host, Dr. Jolene Brighton. I'm board certified in Naturopathic endocrinology, a nutrition scientist, a certified sex counselor, and a certified menopause specialist.

As always, I'm bringing you the latest, most UpToDate information to help you take charge of your health and take back your hormones. If you enjoy this kind of information, I invite you to visit my website, dr brighton.com, where I have a ton [00:02:00] of free resources for you, including a newsletter that brings you some of the best information, including updates on this podcast.

Now, as always, this information is brought to you cost free, and because of that, I have to say thank you to. For making this possible. It's my aim to make sure that you can have all the tools and resources in your hands and that we end the gatekeeping. And in order to do that, I do have to get support for this podcast.

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Can perimenopause make endometriosis worse? And if so, why are we not talking about this? 

Dr. McHale: That's a really good question. I think this is one of those things where unfortunately we're living in a data free zone. Mm-hmm. Because people just [00:03:00] haven't been studying this, and generally speaking, there are sort of these like broad conclusions that we can make about things like endometriosis and adenomyosis.

Mm-hmm. Endo, depending on the person is, is often a disease that presents in the earlier years of life, not always. Right. We all know Endo is one of those things. It, it has no rules. It does not have a textbook does not follow the rules. Right. She does what she wants. Exactly. But, but we do know that Endo can progress.

Mm-hmm. We do know that adeno. Generally speaking, again, young people can have adeno, but it's often a disease that happens in what we consider the later reproductive years. Mm-hmm. It worsens over time, especially over the course of the uterus doing the various things it does over the course of a woman's life, be that pregnancy or you know, having surgeries or whatever.

All those things are risk factors for worsening adeno. So of course as time goes on, that's likely to progress. Then we know that people's hormones fluctuate significantly mm-hmm. As they approach perimenopause and we just don't know how much that [00:04:00] impacts these things. So this is one of those things where unfortunately I can't, I can't like quote a study or give you like a data driven.

Like yes, it happens. But certainly that is an experience that patients report to me. Mm-hmm. So why aren't we talking about it? I don't know. We're talking about it now. We're doing it. There's that. Yeah. Well, we should be, 

Dr. Brighten: I appreciate, as you just said, this is what patients report to me and I think. You know, something happened in the last like five years where people forgot that part of evidence-based medicine is the clinician's experience.

Mm-hmm. And taking the patient's data. And I always say when a doctor says, well, there's no study to support what your experience is, however the patient's experience, when we hear that time and again, it's how we know what to study and where to focus on. Of course. And it would make sense. So here's the thing, we're not studying perimenopause.

The average endometriosis patient is getting $2 per year towards research funding. So very [00:05:00] underfunded. But if you sit back and you think about the physiology. We've got progesterone declining, which we need to oppose estrogen, estrogen's, A, it's all about proliferation. Like let's grow tissues. And in perimenopause you might have months where it's like, oh my estrogen's low and I feel achy and just, you know, brain fog and not great.

And then you might have months where estrogen is way jacked up and we don't have the progesterone to oppose it. So I would imagine, and being an endometriosis adenomyosis patient myself, um, and just having messed with my own estrogen and progesterone that like. Of course it would make sense that some women's experiences that we're gonna see increase in these tissue growth, more inflammation and more of those endometriosis symptoms.

Dr. McHale: Yeah. And I think that, you know, to your point, everyone's experience of their hormones is different. Yeah. Right. And this is one of those things that I think. Is hopefully just now starting to come more into focus for a lot of clinicians, right? Because you will [00:06:00] find different women who will say, you know, I feel like a superhero when I'm on the pill.

Mm-hmm. Or, I feel amazing with a Mirena IUD, and they're gonna have to take it out of. And, you know, out of my body at the morgue. Right? And, and on the flip side, there are women who are like, my mood symptoms are unbearable when I'm on any kind of exogenous hormones, right? Mm-hmm. And, and of course it makes sense that two different people are going to have two different experiences of both their own sort of hormonal fluctuations and what we give them, right?

Yeah. Two people experience the common cold differently. Two people will experience, you know, any, you know, staying up all night differently, right? Some people re everyone responds differently to different things. Mm-hmm. And we, we haven't done enough to address that, and that's why. Even if, for example, you know, someone had surgery and they don't have any endo left behind, it may not necessarily be that, you know, flaring estrogen is causing new growth.

Yeah. So much as either there's adeno there or they just [00:07:00] have an inflammatory predisposition that is linked to something about their hormone response mm-hmm. That we just don't understand yet, and that's why they feel so terrible. And I think the really important thing, uh, you know, to, to what you were saying earlier is that doctors need to get to a point where they're not just saying, well, we don't have the data to support that what you're feeling is because of X, Y, or Z.

Yeah. And so I, you know, you're, you must not be feeling that way, right. Mm-hmm. Because obviously that's not true. Right. So, so, you know, use a little critical thinking and like, why is she feeling this way? 

Dr. Brighten: Yeah. And understanding that she's been living in her body for decades. She knows her normal and she knows something's off.

Right. I think this is one of the biggest frustrations when patients are like my, my doctor says my labs are normal, and with endometriosis, labs can be normal and you can still be having symptoms. Sure. 

Dr. McHale: And I, and I think that. Again, one person's normal is not another person's normal, right? Mm-hmm. [00:08:00] There could be an amount of estrogen that makes you feel terrible and me feel great, right?

Just like if you and I, you know, went out and climbed a mountain, we would have different physical experiences of that, right? Mm-hmm. And so I think that something where, you know, and patients do often ask me this, like, something feels off. Can you test my hormones? And I say to them, it's, it's not about what the number is.

I'm not here to chase a number around. I'm here to get you to feel better, right? Mm-hmm. And so that's why a lot of this just has to be tailored to how a patient feels. 

Dr. Brighten: Yeah. And what's interesting you're bringing up is that, so. You know, it could be estrogen driving growth, but you said like if everything's been excised, maybe there's no growth there anymore.

We know there's a connection between estrogen and histamine, and that endometriosis patients can suffer more from that. It's, you know, a histamine intolerance gets thrown around a lot. It's not even necessarily that. Mm-hmm. It's that your immune system, for whatever reason could be that it's. It's programmed that way or that it's been so over activated over the years having [00:09:00] endometriosis can respond with this, uh, excess histamine kind of symptom picture.

Totally. The other thing that's interesting is that another subset that we're not studying are neurodivergent women who tend to be much more hormonally sensitive. There's a whole hypothesis around this now of like, why are there certain women who go on the pill and their life is completely wrecked?

They go off the pill and it gets even worse than it was getting on the pill. And postpartum is hard and perimenopause is hard, and we look at them and there's a big subset that also has endometriosis and adenomyosis. So there's a lot of crossover happening here and it's too much to ignore. And yet for anybody listening, we, we don't have the data to say like.

This is the one thing this is, wouldn't be great if there was like one gene and we knew how to target it. It's not gonna be that though. It's gonna be environment meets, genes needs, you know, everything else that's been thrown in the mix. 

Dr. McHale: Yeah. And I think, you know, these overlapping, these sort of like the, the interplay [00:10:00] between different conditions and overlapping conditions is hugely important.

Mm-hmm. And, and that's one of those things that I really focus on as my, in my role as an endometriosis specialist because I do find a lot of women, you know, because there is increasing awareness about endo sort of come to me and they have this enormous constellation of symptoms. Yeah. And they've never seen anyone who thinks about pelvic pain in sort of a more global way.

And then we're having a conversation about hypermobility about. MAS about pots, about, you know, all the different now, like increasingly we're learning about all the different venous congestion syndromes that can lead to pelvic pain, all, everything with the pelvic floor. And, and so it's one of those things where we're now starting to realize people do have increasingly sort of overlapping and con what's called concomitant conditions.

And I think, you know, my job as sort of the, the endo specialist, like yes, I'm the gatekeeper for the endocare, but [00:11:00] now we're seeing a lot more specialists who are educated in all of these other pieces. I think historically there were a lot more endo surgeons where you would see them, they would excise your endo and then they would be like.

See ya. Yeah. Right. And, and patients would be like, wait a minute, wait a minute. I'm still having symptoms and, and you know, what about these other things going on in my body? And the specialist would be like, I don't know what that's from, but it's not endometriosis. 'cause your endo's gone. 

Dr. Brighten: Mm-hmm. 

Dr. McHale: And then the conversation would just stop.

And I think it's great that we're starting to build that and you're seeing people building these networks and communities. Right. So, you know, when I see a patient I'm like, oh, it really seems to me like you have MCAS, this is who my patients see for MCAS, right? Yeah. Patients who are struggling with different, you know, clearly like vulva symptoms that are response to a, you know, years of being on the pill or something like that.

Like, this is who you need to see for that. And I think, you know, increasingly we're starting to see more and more crosstalk mm-hmm. Between these specialties. And so I think it, [00:12:00] there is hope for, you know, all of these different things being addressed at once. Yeah. 

Dr. Brighten: Well that is fantastic to hear and I think that's gonna bring a lot of comfort to a lot of patients when it comes to menopause.

Doctors will often tell women with endometriosis, don't worry about it. Like, Hey, we found your endo at 42 years old. You might be in menopause within the next 10 years. Once you're in menopause, your endometriosis journey's over full stop. Is there a truth to that? 

Dr. McHale: No, not really. Right? Mm-hmm. I think this is one of those things where, again, every patient's experience is different, right?

And so the first question is always, is there a safety issue? Mm-hmm. Right? And this is the first thing I always do with every patient, because sometimes someone has aggressive endo that for whatever reason, hasn't come to light. And you know it. If you're gonna, you know, if you have infiltrating endo and you're gonna lose a kidney in six months, if we don't do surgery and you're 42 years old, please don't wait for menopause.

Mm-hmm. Like this is a safety issue. This is a now problem. Right. So the first thing is. [00:13:00] Is there a safety issue? And then it's entirely a quality of life discussion. Mm-hmm. And for some people, those symptoms are going to persist in menopause. Especially when, you know, for whatever reason their endo is causing more fibrosis and more structural distortion, you know, for whatever reason.

Again, not fully understood if theirs is more hormonally active. And also, menopause is not a light switch, right? Like, we all know it's not just like one day you wake up and suddenly menopause has happened. Right. It's the, the commercials on TV are wrong. They're lying to you. Right? So, so this is one of those things where like.

I think, I think deciding type surgery for endometriosis is a very personal decision. Mm-hmm. Right? For, for any, any person with endo, right. Again, first question is always is, is there a safety risk? But after that, it's really like, this is your quality of life. This is what may happen, this is what may not happen.

Have I met women who went through menopause and then they were like, you know what? I feel 98% better. And to me it's not worth having a [00:14:00] surgery and recovering from surgery. That's their experience. Great. Mm-hmm. But I meet other women who are like, I still feel just as terrible today as I did, you know, 10 years ago.

And I think as long as doctors don't dismiss that, right? Doctors need to hear the patient experience and let the patient make a decision about her own body, you know? Mm-hmm. I always say to my patients, you know, you're here for a surgical consult 'cause I'm a surgeon and I'm gonna spend a couple of hours tops in your body.

You're in it for the rest of your life. So you have to feel good about whatever decision we're gonna make together. Mm-hmm. 

Dr. Brighten: So as an endometriosis patient, I will say. From the vast majority of doctors I have encountered have no clue that endometriosis can actually infiltrate organs and cause organ damage outside of the pelvis.

And I think that is where this dangerous misinformation around endometriosis happens. Mm-hmm. [00:15:00] Where they say it's just a period problem disease, therefore when your periods are gone, you're gonna be fine. Mm-hmm. So a patient listening to this now, you just draw, brought up like you could lose a kidney.

Like, um, if I put myself in their position, his alarms like gets freaked out mode. Yeah. So what should a patient know about advocating if their doctor says. This might be endo, but don't worry about it. You are gonna be in menopause soon enough. They don't really know where the endo is. Mm-hmm. What should this patient do first?

Dr. McHale: Yeah, totally. I think you are absolutely right. I, I remember once, um, I was talking to a pediatric neurosurgeon and he asked me what I did, and I said, you know, I'm a gynecologist, but I, you know, I specialize in surgery for endometriosis. And he looked at me like I grew another head. And he said, but isn't that just the fibromyalgia of gynecology?

Oh my God. 

Dr. Brighten: And I was like, you were like, sir, please sit down. You're embarrassing yourself. 

Dr. McHale: Like, well, well, one, let's not be dismissive of fibromyalgia like that. Yeah. But two, no, it's, it's not. [00:16:00] This is a structural problem, right? Mm-hmm. Um, but, but to your point about advocating for yourself, first of all, you don't owe your doctor anything.

Not a thing. Okay? If your doctor says something that demonstrates that they are ignorant, they are not listening to you, whatever it is. You don't have to sit through the rest of the appointment. Mm-hmm. Right. But I, like, I always tell patients, by all means, you can feel free to say like, thank you so much for your time, I just don't think this is a good fit.

Yeah. And leave. Right. Like, it's not your job to educate that doctor. It's Right. And eventually they're gonna figure it out when all of their patients are being dismissed and they just get up and leave in the middle of the appointment. Right. Yeah. But like you, you don't owe your doctor anything. Right.

They're supposed to work with you. You are the boss. Right. It's your body. And so if your doctor's not doing that, you need a new doctor. Mm-hmm. Right. You, I, I, people always say like, uh, I see a lot of the sort of, how can I convince my doctor to operate on me? Yeah. How can I convince my [00:17:00] doctor also? And it's like, don't Should you.

Yeah. Don't convince them. Right. Like, okay, if they don't believe you, they're not on your side in the first place. If they don't believe endometriosis is a surgical disease, then one. They're not gonna be looking in the right places. They don't have the skill to even recognize it. Mm-hmm. And they're not gonna be able to actually fix it.

Right. Yeah. Someone who doesn't believe it's a surgical problem, I guarantee you, has not pushed themselves to get the skills to excise endometriosis. It's hard, right? Mm-hmm. There's a reason, gynecology, you know, the, the average general gynecologist can't do excision surgery. It's not like they have, it's not like they have the skill and they're holding out on you.

They, they can't do it. Mm-hmm. Because they don't have the training, they don't have the skills, they don't have the knowledge. And so if they don't have the skills to do the job right, please don't have them try. 

Dr. Brighten: Please don't. How do you, so how do you know who has the skills and who doesn't because mm-hmm.

You know, this was actually a conversation. We were at dinner last night having Yes. Um, bringing up the fact that I take huge [00:18:00] issue and men do gynecologists get mad at me on the internet, but I. Still very much. Not everybody can just be in there excising. Agree. And just because your scope says that you can, doesn't mean that you should or that you have the skill to do it.

And there are lots of doctors out there saying like, oh, I do endometriosis surgeries, and then they're not doing imaging ahead of time. Mm-hmm. They're going in completely blind. They didn't even know the endo could be on the diaphragm. Right. They don't know that. Like there's bowel modules and like they need a colorectal surgeon to be there like Right.

It's very telling when you get into conversations of how little they actually understand endometriosis and they're in there with a scalpel, like mm-hmm. So how can patients find, I mean, obviously we'll link to you, they can come to you, but you're one person, right? So No, totally. How can they find a surgeon?

Dr. McHale: Yeah. I, I, I think that's a great question. I wish there was one good answer, [00:19:00] but there isn't, right? Mm-hmm. Everyone talks about all these different lists, but at the end of the day, even so the quality is not uniform on those lists. Mm-hmm. And they, they all, you know, they're great resources, right? That there are great, you know, resources out there on the internet, on social media for how to find a doctor, but none of them is perfect.

Dr. Brighten: Mm-hmm. 

Dr. McHale: And. In my mind there are sort of like red flags and green flags for if you're looking for the best person for you. For me, actually the number one green flag about a surgeon is if they are independently recommended by a different surgeon that I trust. Okay. Right. So like let's say you call me up and you, you know, we have a great phone conversation and I'm like, look, I, you know.

I do think you have Endo. I think it makes sense for us to work you up and do surgery. And you look and you're like, oh my gosh, you're in Washington dc I'm in Washington State. Like, shoot wrong Washington. Yeah. If I say to you, look, you know, if you wanna travel here for care, I'm happy to take care of you, but you're in Washington State, you should see Tristan Ville [00:20:00] or Cindy Moss Bruer, or one of those doctors.

'cause they're right down the block from you. Mm-hmm. I have no investment in recommending another doctor, doctor to you. I'm not gonna send you to some clown. 'cause like, what does that get me? Right? Yeah. And so when you see doctors recommending other doctors, that to me is often like a really good green flag.

Mm-hmm. Um, another I will say, you mentioned a big red flag, so I'm gonna, I'm gonna jump onto that one. Do it, which is imaging. Mm-hmm. Right. Your doctor should know what they're getting into. Right. And different doctors do this different ways. You know, at this point, a lot of us are doing high level ultrasound.

Mm-hmm. And, and that's great. Some people are doing MRI, that also works well. Whatever your doctor is best at and most comfortable with is what's most important. Right. I always tell patients when I'm scanning in the office, like right now, I'm building a mental map of what's happening in your pelvis. And I walk them through it.

Right. Your doctor should be able to point to things on your imaging. Yeah. And I, you know, I'll say like, look, here's [00:21:00] where your rectal wall starts, you know, at the back of your vagina, and I'm following that muscular wall all the way up to your pelvis, and I don't see any interruptions. Mm-hmm. Or changes in this wall that make me think that you have invasive endometriosis of the rectum.

Right. And so then when they ask me a question about, you know. Am I gonna need a bowel resection? This is gonna bring me to my next green flag, which is your doctor should talk to you like a colleague, right? Mm-hmm. If, if you say, do I need a bowel resection during my surgery? And your doctor just says, nah, you don't need that.

That's not a, that's, that's a red flag. Right? Okay. The green flag is when your doctor says, I personally stratify you as low risk for a bowel resection. Mm-hmm. Based on the imaging that you know, I personally reviewed, or I did, and we talked about based on your symptoms, based on previous surgical images of yours that I've reviewed, whatever it may be, right?

Your doctor should have a good reason for saying you're low risk or high risk for needing a bowel resection, and then they should say [00:22:00] low risk is not. No risk. Mm-hmm. We all get surprised, right? I can't image the small bowel. I can't. Right. And so sometimes I do get surprises where it's like, well, you didn't have rectal disease, but sure enough you did need either a bowel resection or some, some manner of, of bowel surgery.

And so they should be able to say, it's not no risk. And so if this happens in the or, this is the person I'm going to call, this is their experience level. This is how frequently we work together. Mm-hmm. Okay. If the doctor says like, yeah, that'd be really unfortunate, we're gonna have to bring you back in a couple of weeks or months and finish the surgery, then da, da, da.

No. Right? Because your doctor should be prepared, right? Your doctor should be prepared to handle whatever's gonna happen. And your doctor should, should respect you enough to not ask for a blank check. Mm-hmm. Right. To not say like, yep, we're gonna figure it out when we get in there. And like, maybe you have zero endo and maybe you'll wake up with an ostomy.

I don't know. Yeah. See you on the other [00:23:00] side. That's not fair. Right. That's not fair to the patient. 

Dr. Brighten: Well I think, you know, the other thing about imaging from the patient perspective is that it provides you a more complete informed consent. Mm-hmm. Which reduces anxiety greatly. Of course. So, you know, before my endo surgery, I underwent the gel MRI.

It had ultrasound. We looked at everything that we possibly could, got the Eine score, sat down and went through, um, everything. As I told you, the, I freaked out like a few days before and I was like, if a nerve gets cut and I can never have an orgasm again, like I, like, I'm panicking over that. And so I ro Cabrera, who we were at dinner with last night, and I will link to his episode.

I messaged him and was like, I'm having all these anxieties. He's like, let's get on a phone call right now. He got on like three phone calls with me before my surgery, which another friend of mine who's an endometriosis surgeon, she's like, yeah, before I went through my surgery, like I had a panic attack on the OR table.

Like, I was like, she's like, that's totally normal. But then, [00:24:00] uh, Dr. Anna Sierra was like, I reached out to her and I was like, I just need you there. Like, I just need the nerve specialist in the room with me. Mm-hmm. Even though nothing is showing nerve involvement on the off chance that it happens, I need to know going into this that like, you are there and you've got my back and I think.

Knowing what I know, I know how to ask for these things, but other patients don't. And that's where hearing you say like, your doctor needs to say like, this is who will be there, who's gonna help out. Mm-hmm. Like, and your doctor's completely prepared for it helps ease the patient's anxiety, but it also ensures that they get the best outcome.

Dr. McHale: Mm-hmm. No, totally. And, and. I think that just brings back to the, the doctor should treat you like a colleague, right? Mm-hmm. There's no, there's no instance in which, right? Like, they, they took your concern seriously. Nobody said to you, that's not gonna happen. Yeah. Right? No, that, that's not an appropriate answer.

That, that's the kind of thing that makes a patient more anxious, right? Mm-hmm. If you give patients [00:25:00] information, I think information really makes, makes us feel in control of a situation, right? Yeah. Because then you are making choices about your body based on the best information. You know, I very frequently get asked, you know, am I gonna need an ostomy?

Dr. Brighten: Mm-hmm. 

Dr. McHale: Again, don't say, nah, you're not gonna, like, don't worry about it. Right. What's 

Dr. Brighten: ostomy for people who don't 

Dr. McHale: know? Sure. It's, um, we do them, um, usually they're temporary in endometriosis surgery. Mm-hmm. Where you, um, we either. Pull up a loop of small bowel or large bowel and the stool empties into a bag for a period of time so that the intestines can heal after surgery.

Mm-hmm. It's really uncommon in endometriosis surgery in most places. Um, I think it happens a lot more in Australia and so Interesting. So, um, and so, you know, people talk, it's one of those things that gets talked about a lot on the internet. Mm-hmm. And so people often ask me, am I gonna need. Am I gonna need an ostomy?

Yeah. And instead of saying no, you say the circumstances in which a patient having surgery like yours needs an ostomy [00:26:00] are if there's an ultra-low infiltrating endometriosis nodule, right? Mm-hmm. Like within five centimeters or less of the anus. 

Dr. Brighten: Mm-hmm. 

Dr. McHale: Or if you know there's a complication, right?

Something, you know, something like a leak happens and then we have to have to re-operate later and that intestine needs time to heal. Right? These are both really uncommon scenarios and we can also say to the patient, like, I've imaged your entire entire rectal wall from your anus to five centimeters up.

I don't see anything. So it would, you know, nothing's impossible, but it'd be extremely unlikely in a situation like yours for you to need an ostomy. I've never personally seen it, right? Mm-hmm. And when you can say that to a patient, I think it gives them a lot of reassurance because they can tell that instead of just dismissing them, nah, you don't need that.

You thought about it? Yeah. You were like, here are the reasons I can reassure you that in my experience, that's really unlikely to happen to you. Mm-hmm. 

Dr. Brighten: I wanna go back into adenomyosis because you mentioned [00:27:00] that this shows up later in a woman's life and it does progressively get worse in most cases.

Mm-hmm. In perimenopause through menopause. If you can explain what's going on there, why does it get worse, and is birth control and hysterectomy the only options? 

Dr. McHale: Sure. This is one of those things where it really depends on the person, right? Yeah. Some people, it's bad early and it stays bad. Some people it grow, you know, it progresses quickly.

Some people it doesn't, right? Mm-hmm. And, and this is something that I think a lot of doctors struggle with when they see a patient with adeno and the patient says, you know, how is this gonna get? Get much worse before I go through menopause because, you know, for some patients who have adenomyosis after menopause, it's, it's better.

Yeah. Not everyone, but many. And so, you know, and, and unfortunately the answer is like, I, I don't have a crystal ball. Right? Like, yours could progress a lot, it could progress slowly, I'm not sure. Right. But, um, at the end of the day, I think, um. You know, the treatments for [00:28:00] adenomyosis are really challenging.

Mm-hmm. Right? And, and this is one of those things, again, imaging's really important because in some cases, if the adeno is focal or it's concentrated to some parts of the uterus that can be surgically managed, right? Yeah. And so it's not always a situation where it's like adeno, nothing to do, right?

Mm-hmm. Um, but in most cases it is that diffuse adeno that doesn't have a surgical intervention. And in those cases, the things, you know, it, the, the most important things are to really sort of drill down on what are the symptoms, right? Mm-hmm. Some patients with a, who I see with adeno, they're predominant complaints is actually heavy bleeding.

Yeah. Right? And that is something where, okay, if your primary complaint is heavy bleeding and hormonal management isn't working for you, tranexamic acid's a great option for you, right? Mm-hmm. It's a non-hormonal treatment that decreases bleeding and has a very, very. Favorable side effect profile, right?

Mm-hmm. And so why not offer that to patients as opposed to just saying like, well, if you don't want the birth control, you have to have a hysterectomy at the end, right? Yeah. Like, come on, think about what the symptom [00:29:00] is and how to address it. At the end of the day, some people have both the heavy bleeding and that, you know, I, I call it the hot bowling ball feeling.

Mm-hmm. Like at the end of the day, a lot of my patients just talk about this heavy throbbing, hot bowling ball in their pelvis. And that is something where unfortunately, we are really limited in terms of treatment options. Mm-hmm. You know, hormonal management does work for some women. And hysterectomy is, you know, unfortunately the other option for a lot of people, I 

Dr. Brighten: saw a study and I, I am.

Not gonna quote the statistic perfectly. However, I remember my jaw dropping that the estimate was that I believe it was more than 60% of hysterectomies in the United States weren't actually warranted. So they were not medically necessary and the patients were not receiving an informed consent. So there's women who are like, when I bring this up, they're like, women have a right to have a hysterectomy.

Absolutely. It's your body. If you wanna undergo this surgical procedure, [00:30:00] then that is your choice. However, it was that the patients actually didn't get informed consent, they didn't get treatment options, their doctor was pushing them into surgery. Why are we seeing that happen so often? 

Dr. McHale: That's a hard question to answer.

I, 'cause I, I get tripped up often on medically necessary. 

Dr. Brighten: Mm-hmm. 

Dr. McHale: Because. Who defines medically necessary, right? I, I find particularly with endometriosis, right? Like if, if something's causing pain, in my opinion, it's medically necessary, right? Mm-hmm. If you want it done to your body, it's medically necessary.

And so, you know, I, I'm not sure who it is deciding, right? If the indication was pain, did they, did they feel it wasn't medically necessary? Because like, or like if a woman's heavy bleeding wasn't so bad that she needed a transfusion. Is it medically necessary? Yeah. Well, like, yeah. If she can't, like live her life for two days a month because she can't leave her house 'cause her bleeding so heavy, like, uh, you know, that to me that's medically [00:31:00] necessary.

Mm-hmm. And so I, you know, I, I struggle to sort of make heads or tails of, of that particular statistic, but at the end of the day, I think the counseling is what's most important, right? Mm-hmm. And I, you know, I really. Sort of try to drill down with patients exactly. Like why are you here and exactly what do we need to do to fix it?

Because sometimes, like, you know, on an ultrasound, if touching someone's adenomyosis, adeno, myotic ute with a u 

Dr. Brighten: hmm. 

Dr. McHale: Adeno, myotic uterus with, with, you know, very gently with the ultrasound probe, if they're like, yep. That right there, like you have low level reproduced the pain that brought me into my office.

Dr. Brighten: Mm-hmm. 

Dr. McHale: That's one of those things where like, if your uterus hurts, at the end of the day, the most likely way to give you relief is to remove it. Mm-hmm. Right. But that, like, it's not, it's not in my [00:32:00] body. It's in your body, right? Yeah. And so you're the one who should be making the decision about how much is this symptom affecting your life, right?

And so I will tell you like, here are your options, right? Here are your hormonal options. Here are your non-hormonal medical options, which are unfortunately very limited. And then here are your surgical options. And, and that's, that's what you have. I'm not telling you, you have to pick any of them. Right.

You have to decide what's right for you. Yeah. 

Dr. Brighten: Well I think that's, that's really what the issue of the study was pointing out is that it wasn't the doctor saying, I need you to decide what's best for you. It could have been a situation where you had a fo fibroid and they're like, well, it's easier to just take out the uterus.

You have endometriosis and we know there's a lot of doctors out there promising to, you know, take away your period pain by having a hysterectomy. And it's like, well, yeah, now you don't have a period, but that doesn't mean the pain's gone away. Absolutely. You, you brought up hormones. I wanna talk about this 'cause there's new research showing that, uh, [00:33:00] estrogen only HRT has nearly tripled the risk of ovarian cancer in women with endometriosis.

So the question is, why is unopposed estrogen still being prescribed in endometriosis patients? And what should women be asking their doctors for instead? 

Dr. McHale: I'm gonna, I'm gonna lead with, I am not the expert in this. Okay. And so I, and I, I really like to stay in my, in my lane on this. Mm-hmm. And truthfully, when I have patients who need, like, complex or long-term HRT management, I don't do it myself.

Dr. Brighten: Mm-hmm. 

Dr. McHale: Because there are a lot of people who have really great expertise in this, and I, I happen to have a co like, access to a couple of them in my area. Yeah. And so it's really, you know, it, and this is one of those things where, again, I, I really believe in doing what's best for the patient. Mm-hmm.

Which is why like, you wouldn't want them doing your endosurgery, but at the same time, like, you don't, you don't want me doing this management for you going forward. Mm-hmm. That said, I think we just [00:34:00] need more data. And that's, and of course that's hard, right? Because you never wanna be the person who's like.

Here I am participating in the acquisition of data. Like we'll see what happens. Right? Yeah. You know, we do, you know, from the women's health study, we do know that there, there are significant risks that you know are associated with the progesterone component mm-hmm. Of the progestin component. Yes, you are right.

You 

Dr. Brighten: are right. The progestin component, but they did report it as progesterone, but once you get into the methods, it's like, no, that was progestin, which is right. You know, I think the, the slippery slope that we've fallen into in, um, in medicine overall, like a woman says, I had adverse mood symptoms when I was on the birth control pill.

The doctor says, well, clearly you can't do progesterone. And yet it was the progestin that's more closely linked to that. It's been very interesting to see a studies come out, um, how much estrogen got a bad rap for everything progestin actually did. 

Dr. McHale: Yeah, I, I mean, again, I think this is one of those [00:35:00] things where we need, we need more data, right?

Mm-hmm. We can't just keep re-analyzing the same data from the women's health study over and over. It's, and it's a great study. We learned a lot, but. We just need more information, right? Mm-hmm. And, and at the end of the day, also, I think I'm, I'm hopeful that we're also gonna do a lot more to assess a woman's baseline risk for things Yeah.

When we're making these decisions, right? Mm-hmm. Some people are really high risk for breast and ovarian cancer. Some people are really low risk for breast and ovarian cancer. We don't stratify when we're making these recommendations. Mm-hmm. And so I think we have a really long way to go in, in how to get this right.

Dr. Brighten: Yeah. So the, the study, what was interesting is they found when you combine estrogen and progesterone, then there was no risk of ovarian cancer, like compared to anyone else. But it's about the endometrioma. And that's something that when my audience is like, why did you decide to have these excision surgeries?

I'm like, well, I had bilateral endometriomas. The risk of ovarian cancer goes up slightly. [00:36:00] However, I want to be on estrogen hormone replacement therapy in the future, and I would rather have an excision surgery at 43 than 53 because unfortunately, it was the age. It's harder to recover from surgeries. But that was part of my decision making as well, is that I know that I want to have my brain health and my heart health and my bone health and not lose my mind.

Um, I did Lupron for two months, so I already have a insight into a window of like. How freaking bad it's gonna be to go cold Turkey without estrogen, right? Um, and so that was part of my decision process as well is knowing I had endometriomas and knowing that if I do HRT, that because of that predisposition I can incr that might increase my risk of ovarian cancer.

However, what often happens is that the doctor took your uterus, uh, you know, once upon a time, can't even be the same doctor that is, uh, doing your HRT and they'll say, well, because you don't have a uterus, therefore you don't need progesterone. [00:37:00] But in endometriosis patients, that's a very different situation.

Progesterone isn't just about protecting uterine lining. Also, I would argue that like progesterone's also good for your mental health and it has a lot of other benefits as well, but it's that unopposed estrogen. And I think about it like at no other point in a woman's life would we ever be okay giving unopposed estrogen, knowing she had endometriosis.

Dr. McHale: I think. Again, the issue in terms of assessing someone's risk for these things. Mm-hmm. Again, it's there, there are, the landscape is changing so fast that we haven't caught up to understanding it. Right. Yeah. At this point, we know, for example, 60 to 80% of ovarian cancer start in the fallopian tubes. Mm-hmm.

Right? And so, and, and so of course like your baseline ovarian risk, you wanna talk about something that changes it significantly is whether or not you had a salpingectomy, either if you had a hiss at the time of the hiss, right. Or some, what is that for? People who Dunno, I'm sorry. [00:38:00] Hysterectomy. And a salpingectomy is removal of the fallopian tubes.

Yeah. Right. They have one job. They don't have a hormonal function. All they are is a highway from the ovary to the uterus. As far as we know right now, 

Dr. Brighten: this is true because it's very interesting to like, I feel like, uh, the fallopian tubes are kind of like the appendix of once upon a time where we're like, it doesn't do anything like it, it, or it's got like one job.

Although I think. We thought even less of the appendix in the, in the past, but it's, uh, I just bring it up because women who have their tubes removed, there is actually entire groups talking about the hormonal hell that follows that and like all of the symptoms that they're having. And so it just makes me wonder what we'll know, hopefully in our lifetime about.

Are they doing anything else? Like, you know, how are they involved with the microbiome of the reproductive track? Like there's big question marks around this. 

Dr. McHale: I think I would be much more concerned about the technique of the salpingectomy. Mm-hmm. Because everything's very close together, right? Yeah. And the blood supply is [00:39:00] important.

And of course the ovary does have a lot of collateral blood supply, and so depending on how the salpingectomy was done, your ovaries may well just be in shock because if they previously were getting a lot of blood supply from those same vessels that the surgeon took during the surgery mm-hmm. Then the ovaries may take more time to recover from that.

But I think, you know, at the end of the day, I'm, I, I'm not here to tell a patient what their experience is. Of course. Right? Yeah. Yeah. But, um, I think that there are a lot of different variables into why that could be. But certainly I wouldn't want a woman to miss out on the opportunity to have her fallopian tubes removed.

Totally. If she's not gonna use them. Because if you wanna talk about an intervention that is, you know. Uh, that without removing the ovaries is most likely to, to impact her, um, or decrease her ovarian cancer risk. It's, it's that procedure, right? Mm-hmm. Um, and I think a lot of endometriosis surgeons don't do a good job talking to patients about their fallopian tubes before surgery.[00:40:00] 

The reason being, it's a really long conversation. Yeah. My, every time, you know, and I, I have this conversation with every patient I take to the operating room. Whether they want to get pregnant or they don't want to get pregnant or they don't know is how am I gonna handle your fallopian tubes in different scenarios?

Mm-hmm. Right. On the one hand, if you're not trying, if you know you never want to get pregnant, then you should be offered an oppor, what's called an opportunistic salpingectomy. Mm-hmm. Which means we take your tubes out, even though that's not the objective of the surgery. Right. The reason I'm going in is not a tubal, but I will offer it to you if you'd like to have it done at the same time, because that's your right.

Dr. Brighten: Yeah. 

Dr. McHale: And then on the flip side, if you either are currently trying to get pregnant or you are planning to do so in the future. What if one of your fallopian tubes is really damaged from endometriosis? Mm-hmm. Right. What if it's dilated? What if you have a hydrocele? Pinks? What if you know, what if, what if, what if, if it's one tube, but the other one's fine.

If it's both tubes, how do [00:41:00] you want me to handle those scenarios? And of course, I counsel the patient like, this is what I recommend. Yeah. For these reasons. The alternatives are this, and what would you like me to do? Right. And the patient, you know, again, I'm just here to give you information. You make the decision about what you want me to do during your surgery.

And I think that a lot of surgeons don't do that because at the end of the day, it's, it's a long conversation and it's pretty weighty. 

Dr. Brighten: Mm-hmm. And 

Dr. McHale: often it's unnecessary. Right. You know, the majority of the time when the tubes look totally normal on imaging, they're gonna be totally normal when you get into the operating room.

Dr. Brighten: And what type of imaging are you doing ahead of time? So you know about the health of the tubes? 

Dr. McHale: Ultrasound or MRI. 

Dr. Brighten: Mm-hmm. 

Dr. McHale: Um, not in HSG. Mm. Okay. No, because I can do that intraoperatively Okay. Is, is one reason. But also, you know, HSG, like tubal spasm can happen. Those kinds of things can happen. It's an invasive procedure.

Mm-hmm. It's really unpleasant for the patient. And [00:42:00] so, you know, I'm not, I, I'm not gonna do it just so that I can sort of. Shorten that conversation with the patient, right? Yeah. Like, you shouldn't have to experience a painful procedure just so that I can like, you know, save 15 minutes going through all these different scenarios with you.

Right. So that procedure's more than 15 minutes, I had it done Right. And well, and it's, it's terrible. 

Dr. Brighten: Right? And so, yeah, I have to say that, um, I think because I thought it was gonna be so terrible. It wasn't as terrible. Okay. You know how, how that goes sometimes where you like, yeah, you build it up, you build it up.

And, but also like, I mean, they had me on like scopolamine. They were like, they were, they drugged me up for this procedure, I will say. So I had this done in Mexico. Their pain management is very good, right? In women's health. Um, like when I had to have an endometrial biopsy and it was like, I'm gonna be put under for this, right?

And they're like, of course, why wouldn't you be? And I'm like, let me tell you a story about the US And my doctors were shocked. They're like. They do biopsies. Well, you're awake in the us. Yes. I'm like, [00:43:00] yeah, they do. Yeah. It's not fun. So I'll say that like anyone listening, if you're like, my HSG was hell, and you're like, why was, why was Dr.

Brighton's fine? Uh, drugs? Um, I was medicated and I think that was a big part of it. Um, and I just, I also had an entire team of women and they were very, very much like, we're checking in. How are you? Let's do deep breathing together. Like, it was a, it was a very pleasant experience, uh, from the perspective of my team being very invested in my comfort.

Dr. McHale: Yeah. And I, I think that that's essential. Mm-hmm. Um. And, and thankfully we are seeing this change in the us right? Like, I have a list of providers in my office, like if someone wants an IUD or like, needs any kind of procedure of the people who will give them pain management during that, that office procedure.

And so we are seeing that more and more in the us. Yeah. And again, advocate for yourself. If your doctor doesn't do it, ask them who does. And if they say that they don't know, then go looking because there are mm-hmm. There are, you [00:44:00] know, increasingly more and more practices offering that. Um, but, but back to that, the, the conversation about sort of fallopian tubes, right?

Mm-hmm. Like, I'm not gonna put the patient through a procedure just to, to truncate that conversation. Yeah. I'm just gonna say, you know, if this is what I find, how would you know, what, what would you like me to do if this is what I find, what would you like me to do? And, and I think it's really important because no one can make that decision for you in, in the OR.

And I say that to my patient's, like, look. I, I'm, I'm not comfortable with anyone consenting on your behalf to have a reproductive organ removed. Yeah. And so the only scenarios in which I remove a reproductive organ without someone's consent would be like, you know, if it's sort of a life or death situation, right.

Like surprise cancer or like surprise, you know, a bleeding event that, you know, couldn't have been foreseen, this has not happened to me. Mm-hmm. 

Dr. Brighten: But 

Dr. McHale: that's, you know, people ask me like, is there any scenario in which you're gonna take my ovary out? Like, yes, I would do [00:45:00] it to save your life. Those are the only, that's the only time.

Yeah, yeah, yeah. That it's appropriate for me to do that without your consent. And I've seen this where women have a surgery, like an endometriosis surgery, and then their doctor wakes them up and says. Your tubes are totally dilated and damaged and you know, I'm sorry, you're gonna have to do IVF and you're gonna have to have the tubes removed before you can do IVF.

Mm-hmm. Right. And on the one hand, that patient is entitled to be mad at the doctor because they've already, like, they're, they're still in the PACU from the surgery they just had and they're being signed up for another surgery. 

Dr. Brighten: Yeah. 

Dr. McHale: Because the doctor didn't talk to them about it. But on the flip side, if your doctor takes your tubes out without having asked you ahead of time and then just says.

Sorry, I had to take your tubes during your surgery. That's also not appropriate, right? Mm-hmm. Like, it, it, it's, I think informed consent is growing with surgery, but it's challenging because your doctor has to have the time to do it. And so yeah, as doctors get squeezed with shorter and shorter appointments, you know, it's harder and [00:46:00] harder to do.

The longer counseling. Yeah. 

Dr. Brighten: I went through a punch list with my doctor and, uh, he also had, you know, fellows in his office, which was nice because, um, they could, he could be like, I'm gonna go through this stuff with you, and then I could have conversations with them as well. But I basically was like, I wanna see the list of what we think's going, and then I wanna, I wanna make a list of what might be going, and then I wanna make a list of like, holy shit, we didn't see that coming like this.

Like, and, uh, and it sounds like I just like, am so grateful that my team was like, really patient with me because not all doctors are patient. Mm-hmm. And I get where they're like, you're being, you know, well, I would call it being hypervigilant. Maybe that would be like the worst term I would use, but they would be calling it hysterical.

Like, you're, you're going on, you know, above and beyond. And yet. It's something that I'm like, I need to know this to mentally prepare for these things. And I think having the tubes on the list is a really important thing for [00:47:00] patients listening to this to be like, okay, I go in and talk to them. Right?

Because everybody's concerned. Like, I don't want bowel resection. Mm-hmm. That's, nobody wants to recover from that. Not, no. Nobody wants to bowel 

Dr. McHale: resection. 

Dr. Brighten: Yeah. Um, and so I think there's like the big scaries, and yet it's like, maybe you're not thinking about like, mm-hmm. Well, what about, uh, the tubes? You know?

I was like, we please make sure you're gonna check my diaphragm. Like, even, even though everything looks at just go peak up there, please, like, course look at my diaphragm. Like, and even though I knew what. You know what, what the plan was. I was like, I need to know you're gonna check my peritoneum. Like I just need to hear it.

Yeah. I need to hear that we're going through the list and that like all of these things are gonna be checked. 'cause I never ever want another surgery again if I can help it. Of 

Dr. McHale: course. And I think that this is one of those things where again, like information, like you are entitled to all of the information about your body.

And so, you know, my OR team always teases me that I'm trying to win the Pulitzer and photo gynecology because I take so many pictures in the or. I mean I walk out [00:48:00] with a stack of pictures, like here are all of the before pictures and then here are all of the after pictures. Mm-hmm. And my patients are entitled to that.

But also I think a lot of doctors hand a family member a stack of pictures and say everything went well. I got it all the end. And then they just kind of walk away. Yeah. And then the patient, you know, I see a lot of patients in my office who had a prior surgery and you know, very helpfully, they bring the pictures from their last surgery.

Then they sort of say like, can you, can you tell me what's happening? Oh. 'cause no one ever told me what's happening in these pictures, right? And so I'm going through all the pictures of the old surgery. And so, you know, and this is one of those things where also like, it's really hard to remember, right?

Mm-hmm. I'm sure you know, you remember in your family, remember, surgery is a really overwhelming experience. And when you're in an experience like that, it's very, very hard to take like detailed mental notes mm-hmm. Of what's happening. And so when I bring that stack of pictures out, I sit down with my, um, you know, whoever came to the hospital with my patient and I say, take your phone out.

Take a [00:49:00] video of me. Yeah. And I take it and they, they take a video of me going through every single picture that I took saying, this is a picture of this, this is why I took this picture. You know, this is normal. This is not normal, blah, blah, blah, blah, blah. This is what I did after here's, you can see here's the edges of the areas that I excised, whatever it is, right?

Mm-hmm. And I think then. You know, first of all, I don't contribute to like anybody's, you know, inter, inter-family drama of like, what did she say? Yeah. When they're waking up from surgery, but also, you know, you're entitled to have that information in a digestible way mm-hmm. That you can keep, right. You need to have that information because you may, you may have questions about your surgery.

Two years from now, five years from now. Yeah. Again, you're living in your body for the rest of your life. You're gonna take that surgery I did with you for the rest of your life. Mm-hmm. And so I think, you know, that's why like you've got that video, you can look back whenever you want about exactly what happened.

And it's not just an op note that's written in medical jargon that no one who's not a [00:50:00] doctor can possibly understand. Yeah. And pictures don't lie. I've read a lot of op notes where the op note says one thing and I look at the pictures and I'm like. That does not, that does not appear to be what's happening to me.

Mm-hmm. Right. And so I think that that's, that's really important is for people to have that information. 

Dr. Brighten: Yeah. In Mexico, they're required to record the surgery and provide a patient with a video of the entire surgical procedure. And then in your post-op, they sit down and they go through the entire video.

And I had my husband record 'cause I was like, I wanna be present for it. And then the moment I saw them, like pop a black pearl outta my ovaries was just an endometrioma. I was like, Ooh. I'm like, I'm not a squeamish person, but when it's your own body, I'm like, oh my goodness. Um, so just for people listening, I say that because sometimes people are like, that's hardcore.

I don't wanna watch it. It's okay if you get squeamish, but get it, collect the data. 'cause you never know when you wanna go back and revisit it. I wanna talk about. When it comes to endometriosis surgery, hysterectomy, tubal removal, um, [00:51:00] all these surgical procedures, why can the wrong surgeon leave you worse than before?

And what do we know about repeat and the necessity of repeat excision surgeries? 

Dr. McHale: So that is a really important question because we see this super commonly, especially in the US mm-hmm. Because, you know, increasingly you're seeing the specialists are all out of network, or a lot of them are out of network or have very long wait times.

And then you'll see a patient who is. You know, really suffering. And she says, you know, I can't afford it. I can't wait that long, whatever. And, and, um, so I'm just gonna have this like surgery with my local GYN now. Mm-hmm. And that'll like buy me some time before I can have the right surgery. And no surgery is better than bad surgery because, say that again?

Because I think people need to hear that no surgery is better than bad surgery. Mm-hmm. Because there's, there's a number of different things that can happen during bad surgery that no surgeon can undo. Right. [00:52:00] If someone does nerve damage in your pelvis, no one, no one can unring that bell. Right. Yeah. And a lot of people say like, well, it's okay 'cause you, you know, for a lot of the, the functions that are not like sensation or motor function mm-hmm.

You know, things like, um, being able to hold your urine, being able to empty your bladder, things like that. You do have nerves on both sides. And so if you get damage to one side, in theory. The other side still works. Mm-hmm. Which is true, but if you had bad surgery on the side, that actually, like those nerves could have been preserved and then you have invasive endo on the other side, and the bad surgeon was like, well, I'm not gonna touch that because I know I can't.

I can't fix that. Then to actually get that out, suddenly you've gone from having collateral to having. Nothing. Mm-hmm. Right. And that's when we really end up in trouble. Um, fibrosis is an enormous problem with endometriosis surgery, right? Because when when you're doing it, you're really opening up all of these spaces that are below the peritoneum, right?

Yeah. That sort of [00:53:00] protective plastic wrap that we have throughout the abdomen. When you get in there and you start doing things, you cause fibrosis and scarring, right? Mm-hmm. Just like if you've ever had a scar on your skin, you know that when it heals, it's not the same as it was before. Yeah. The same thing does happen to a certain extent on the inside when it's done right.

We reduce that fibrosis when it's done multiple times. That's your highest risk for having a lot of that fibrosis, which can entrap your nerves and do all kinds of things that are painful. Right. Retroperitoneal fibrosis can cause pain. Mm-hmm. And that's a thing that, you know, it. It's, it's hard, if not impossible to undo that depending on the level of fibrosis that someone has.

And so we, you know, we really struggle with that. And the other thing is, sometimes the worst, the worst patients to re-operate on are good surgeons who know nothing about endometriosis. Oh, okay. That is my nightmare because Right. Like I'll see people, it's like he's a great cancer surgeon. [00:54:00] But he went in and he opened up all the spaces and then he left all the endometriosis there.

Right. And it's great. Like, great. Now he made these like deep dissections and then like just seeded the endo into these deep dissections. It's so much harder. What does, does that mean? Seed, the endo. So, I mean, either they didn't remove it, so it's still there, but when it heals, it just gets tucked in. Right.

Or like an endometrioma gets. Sort of tucked into the sidewall 'cause they didn't remove it completely. These kinds of things where it's now, it's much deeper and much harder for me to go in there and dig it out, right? Mm-hmm. And similarly with that fibrosis, it makes it much harder for me to dissect the, you know, essential structures in a way.

Like, okay, now I know these are over here, they're clear, they're safe, I can operate here and remove the endo. And, you know, again, it's, it's not just like, it's harder for me. Like, don't, don't cry for me. I'm, I'm up to the challenge, but Yeah. Yeah. But it's one of those things like, it is more dangerous for you, right?

Yeah. I was just gonna say, if it's harder for the surgeon. Exactly. And it's harder on the patient too. Right? [00:55:00] Exactly. That, that's, that's the point I'm trying to make. Trying to make is, it's, it's not about, you know, how hard it is, right? It's about the, the more complex the surgery, the higher the risk of complications.

Mm-hmm. Regardless of who's doing the surgery. We all have complications. Every single surgeon who's doing high volume endosurgery has complications because these surgeon surgeries are challenging. Right? Mm-hmm. The anatomy is no longer where it's supposed to be, and Endo has no respect for where it's supposed to be.

Whacked. That microphone, that's fine. 

Dr. Brighten: It's very endo of you, 

Dr. McHale: endo wha endo has no respect Yeah. For where it's supposed to be. And so we really end up in these situations where like, we're going, we're going hi and ya to look for that. Mm-hmm. Please don't let some other doctor, like, make it, make it even harder, right?

Mm-hmm. Don't, you don't want your endo to have like a teammate in getting it where it's not supposed 

Dr. Brighten: to be. Totally. And the, the thing that you'll hear often is that doctors will say, and even, you know, women will also say [00:56:00] this as well, 'cause that's. This is the truth to their experience is that excision surgery isn't gonna take care of endo.

It's just gonna come back. You're gonna have to have five or more surgeries. Like you'll hear these stories. But that really, from my understanding, and I know there was a recent study coming out, showing that if you're a surgeon knows what they're doing, they are an endo specialist, it's, you're looking around like less than 5% chance of recurrence.

If they imaged first, they get in there, they get, they get everything that they can. Of course, we're not perfect because we're humans, but why do you think we're not talking enough about that endometriosis specialists exists in surgery and that that is the patient's best bet in managing their endometriosis?

Dr. McHale: Yeah, I, that's an enormous problem. That data is still coming in, right? Mm-hmm. We're still collecting it. We're still learning a lot about recurrence. Right. And the hardest recurrence is exceedingly hard to study. [00:57:00] Because so many of the people who have been doing surgery for so long on endo are leaving it behind.

Yeah. So it's not recurrence, it's residual, right? Yeah. And so our biggest challenge is differentiating recurrent and residual endo. But now we're starting to get series of patients who had what we know to be complete excision surgery, and the numbers are much lower, right? Mm-hmm. There's a range, you know, 5%, 20%, 10%.

We're seeing different numbers. But they are much, much lower than what we're seeing for all comers having endometriosis surgery. Mm-hmm. So we know it's that outcomes are much better. You know, we know which types of recurrences are more common. Endometriomas, for example. Right. Ovarian endo is the most common site for true recurrence.

Yeah. And so these are the kind, the kinds of information we're starting to get. And hopefully the basic science is gonna catch up with us and help us figure out why. Mm-hmm. Like why is that a place that we know recurrence is, is a significant risk, whereas other places it's not as high risk. Right. 

Dr. Brighten: Yeah.

Dr. McHale: Um, and then you were asking [00:58:00] about why, I'm sorry. You were asking about why I think we let people do these surgeries when they have no idea what they're doing. Well there's, that's really, I think everybody wants to know like 

Dr. Brighten: why the hell is rookie hour front and like they know what they're doing. Right.

And like cutting into women's bodies, but absolutely. Also just not like the. That like endometriosis, excision, surgeons, they specialize in, it's their life. They exist. If this was mm-hmm. Any other kind of surgery going on, but something about it's a woman's body and it's endo. We just let anybody get in there.

Dr. McHale: Yeah, and I think this is something, you know, this is sort of like my. One of my favorite soapbox to climb onto. So like, stop me when I get out. Let's go. I think I, I already was on this soapbox yesterday, but you know, we know for certain types of complicated surgeries, people have better outcomes if the person doing the surgery does a high volume and has advanced training in that thing.

Mm-hmm. Right. And so for example, with hospitals, when you apply for privileges at a hospital, you [00:59:00] have to say, you know, okay, if I wanna do this thing that's considered a subspecialty, I have to be able to demonstrate to you that I was trained to do it. And I have a high enough volume of that procedures to have kept my skills up.

Right? Yeah. So, for example, if you wanna do a suspension procedure for prolapse, you wanna be putting meshes in people, that kind of thing. You have to be able to demonstrate somebody taught you how to do it. Mm-hmm. And you do a high volume of it. The reasons being mesh complications are serious, and people who do, a lot of them have fewer mesh complications.

Yeah. And. You're much less likely to have the surgery fail if the person doing it knows what they're doing. Right? So, um, uh, a urogyn who does a high volume of them is less likely to have recurrent prolapse than somebody who, you know, doesn't do a high volume of this. This is why I like to say I don't mesh around.

Dr. Brighten: So 

Dr. McHale: when I have a patient, when I have a patient who needs like a, a, a suspension procedure, I say, fantastic. I have a wonderful Urogyn colleague. Mm-hmm. We're gonna [01:00:00] coordinate. We're both gonna be there in the or, I will take out all of your endo and they will do your suspension, right? Mm-hmm. But um, and same thing with GYN cancers, right?

I do not have privileges to operate on cervical cancer. There's a reason I don't treat cervical cancer, so my outcomes will not be as good. Right? And to that end. Endometriosis should be that way. Mm-hmm. Right. You know, Joe, why is it not though? No one knows. I mean, no one knows. I don't know. I think, I think the real reason is, you know, gradually there's this erosion into general gynecology of like, okay, now you guys probably shouldn't be doing this 'cause it is a subspecialty field.

And okay, now you guys probably shouldn't be doing this. 'cause you know, there are people who, who can do it better than you. And I think at the end of the day with endometriosis surgery, a lot of people feel like they can do it. Yeah. And so they don't want that taken away from them. Mm-hmm. And obviously the skill of the surgeon, like this is something that's very variable, you know?

Yeah. Um. At the same time, also, there are general, general gynecologists who really don't [01:01:00] believe in what I do, right? Mm-hmm. There are people who believe, like, you should take out the endometriomas, you should take out the cys. But like, that's some Easter 

Dr. Brighten: Bunny stuff over there. 

Dr. McHale: Like, I, I don't know why you're doing these big dissections and taking out all, you know, all these nodules and peritoneum, the patient's not gonna feel better, so why are you doing this?

And then we feel better, right? And then they're like, oh, that's just placebo. I mean, I, it's increasingly, this is changing. Yeah. This mentality is changing, but it's not changing fast enough, right? Mm-hmm. And so I think really what we need is more data. Yeah. On people who are having high quality surgery to show that.

Sure enough, if you have surgery with someone who has advanced training in this and only and does a high volume of this, your outcomes will be better, right? Mm-hmm. Because at the end of the day, you know, and this is like the sad truth about medicine in America, but a lot of it's about money, right? Yeah.

And your insurance company would rather pay for you to have surgery once than for you to have surgery annually, right? And so we have to demonstrate to them like, no, no, like there's value to what I do, right? [01:02:00] Mm-hmm. I know there's value to what I do. 'cause I, I change people's lives by taking their pain away or helping them get pregnant or whatever.

I, you know, whatever it is that their goals are. But, um, I think that, you know, unfortunately corporate medicine needs to see that value in the form of a bottom line. 

Dr. Brighten: Yeah. Well, and speaking of money, I wanna talk about IVF because I saw you post on social media, something that I have echoed. A lot because of my own personal experience.

So let's talk about, is IVF making endometriosis worse? And could it be sabotaging your chances of actually getting pregnant without you knowing it? 

Dr. McHale: So this is a very controver controversial topic. Mm-hmm. And I will tell you. The endo specialists I know debate about this among themselves. Yeah. Okay. So this is not something where someone can give you a definitive yes or no answer, right?

Mm-hmm. I think the things that we know right now are that, [01:03:00] um, it really depends on an individual case. Yes. Right? And so. You know, we, we do know for sure that when you give someone that stem, if they have endo in their body, it's going to flare. Yes. Their symptoms are going to get worse. So for people who 

Dr. Brighten: don't know, the STEM is doing FSH and LH injections that causes your body to produce its own estrogen.

And you're trying to get, you're trying to like, uh, uh, Dr. Amy, the egg whisperer, the way I, I love that she frames it. You're trying to save all of the eggs that are there. You have all these follicles. So you're trying to basically go on a rescue mission and get mm-hmm. As many eggs as possible. So as you're That's a good way of thinking of it.

Yeah. As you're saying. Um, so the stems, the, the stimulation that's going on that can flare your endo. Why is 

Dr. McHale: that? Because endo is hormonally responsive. Yeah. Right. So when you do that, like, you know, a lot of patients tell me like, that experience was terrible, right? Mm-hmm. And that is true. It's absolutely true.

This is one of those things where. Theoretically, if [01:04:00] hormones cause endo that's there to progress or spread or sort of causes, you know, lesions that were previously microscopic to then become macroscopic, right? Mm-hmm. The theory is that of course that's possible, but at the end of the day, nobody has done like a, you know, laparoscopy look at the lesions, leave them behind, do IVF, and then go back and look at the lesions and see if they look different, right?

Yeah. Because that would be awful for the patient. But it's also, but it's happening 

Dr. Brighten: to us all the time. Yes. Like you said, it's awful for the patient. And yeah, I think about how I went for retrieval, retrieval by the third retrieval. I couldn't get outta bed for three weeks and I was like, something is seriously wrong with me.

Uh, and they were like, more NSAIDs and like more this and that. And I was like, no, like it's not working. Right. So as you're saying, like it'd be horrible for the patient and yet. It's the, it's the reality right now. 

Dr. McHale: Oh, of course. I, I, um, I just mean we, like, we don't do a surgery to look No. Yes, yes. As a surveillance then.

No, no. And then do IVF and then just look again, [01:05:00] right? Yeah, yeah. Um, no, I would say imaging, I would say I would 

Dr. Brighten: advocate for imaging, not, 

Dr. McHale: not surgical procedure, but, um, I, I just use that as an example to say like, we can have these things that like. Scientifically, theoretically makes sense. Mm-hmm. However, you know, we can't nec we can't say definitively.

Right? Yeah. And I, I, I try very hard to not make definitive statements when we, we don't fully know yet, right? Mm-hmm. Because I think that that's happened so long with endometriosis that people say like, oh, like it's retrograde menstruation, case closed. And then that like shuts down scientific thought about that issue for many, many years.

And so when we don't really know, I think it's really important to keep an open mind, right? Mm-hmm. And because now, of course, like we're learning. That obviously retrograde menstruation does not make sense. Yeah. For, you know, a lot of endometriosis cases and so that, that can't possibly be the explanation, right?

Mm-hmm. And obviously we know now [01:06:00] that endo happens more than one way. Yeah. Right? Yeah. And, and so you were asking about IVF, um, for example, when we do endo surgery and we take an endometrioma out of an incision, some people get endo in the incision. That's how we get abdominal wall endometriosis. It happens, obviously, like that's not something that was laid down before she was born.

It's, it's surgically seated. 

Dr. Brighten: Yeah. 

Dr. McHale: And so. That both supports the endo has to happen more than one way. Mm-hmm. But it also supports the, the theory that if you do IVF for example, someone has an endometrioma and you're like more IVF, more IVF. If you, if you're poking an endometrioma with a needle and then the needle's going in and out of the patient's body, you're going to be seeding endometriosis.

Yeah. And so like, yes, we do see seeded endo from from IVF. Is it necessarily going to happen? No. Right. And plenty of cases it doesn't. Um, and at the same time also. Knowing that risk doesn't mean it's the wrong answer. Mm-hmm. And, and again, this is [01:07:00] extremely patient dependent. And I, and, and I wish that, you know, and I hope someday we're gonna have algorithms for like, what is the right answer in terms of should we do surgery first?

Should we do egg retrievals first, right? Mm-hmm. But I think there's so many factors. Does the patient have endometriomas? How old is she? What is her a MH? How many children does she want? Has she done a previous retrieval? Has she had a previous surgery? Like, no, no. Two patients are alike. Yeah. Right. And so making that, that recommendation is very nuanced and it also, a lot of it plays into what are her symptoms, right?

Mm-hmm. I counsel a patient. Differently if she doesn't have symptoms. But, you know, she's like, I don't have symptoms. And, and you know, a lot of people would say, well, you're just not asking the right questions. Yeah, maybe. But I, I do believe truly there are some women who don't have symptoms. I wish I knew why.

Mm-hmm. But I don't. And, and for those patients, I'm gonna counsel them differently than the patients who were like, yes, I've been miserable my whole life. And just now [01:08:00] that I can't get pregnant is when I'm finally getting answers. Yeah. Right. For someone like, like the second scenario I just described, she needs to have surgery.

Mm-hmm. It's just a question of when. Yeah. Right. And so that's something where, again, you're really, you're looking at all of these different factors so that you can help her achieve both her family goals and mm-hmm. Her, her own, like health goals. Right. You, you shouldn't, you shouldn't be unable to take care of your newborn because you're in horrible pain trying to have a bowel movement, right?

Yeah. Like, this is not the right scenario and so we really need to think about the whole person. 

Dr. Brighten: Mm-hmm. 

Dr. McHale: Um, and this is why I, I bother the. The reproductive endocrinologists in my area constantly like, hello, here I am again. Again. 

Dr. Brighten: Yeah. Dr. Cabrera and I sat down and we were talking about when to time, like doing another eight retrieval and something that he had tried to institute here in Mexico is actually trying to develop an algorithm.

Mm-hmm. Um, [01:09:00] and then start collecting data on it so that it can be verified. And so he very much was like, it's a great idea. Yeah. Right. And like, can we just, everybody get on board with that? Mm-hmm. Um, and what, you know, so if people are interested, like what he said to me is that 43 years old, if you're a MH is less than one, we should definitely consider getting you in for another egg retrieval.

Mm-hmm. Before doing the excision surgery. If your a MH is, uh, greater than one, we can go excision surgery, do ovarian PRP, and then go egg retrieval afterwards. My A MH at 43 ended up being 2.4 and I was like, what? I called lab, I was like, you messed up. Are you sure? Messed up. And I like when I, but you know, it can fluctuate, right?

Just so people know. Amy is like, it's not like a definitive number, right? Correct. And trends matter, so it's a lot more nuance to it. Um, but with that, I elected, I was like, well, 2.4 we're looking at, you know, possibly 20 plus eggs. Like, let's just do it. And [01:10:00] I also decided I'm gonna go through an egg retrieval because I do wanna actually flare my endo before going into surgery because I want it to be apparent.

Because I was afraid after three egg retrievals, when I woke up from that third one, I was in the most excruciating pain to where I was like, I don't think you gave me pain meds. Like, I was crying and like I wanted to scream. I was in so much pain. And they immediately were like, we have to do an ultrasound, like something's wrong.

It was incidental later that I had a full body MRI that was offered through Pvo. They comped it. They were like, uh, make a post, do this thing. I was like, sign me up. I would definitely want that. And they were like, you have what appears to be endometrioma. It looks like you have endometriosis, aosis. We're not diagnostic.

You need to go follow up. And I'm like, holy hell. And the IVF clinic I was with were like, oh yeah, we saw your endometrioma. We saw your adenomyosis. I'm like, why didn't you ever say anything to me? And they're like, it. I see that all the time. The bro, man like broke up. We broke up so fast. He has like head spin because, [01:11:00] because he was like, adenomyosis is just the new trendy diagnosis like a DH, ADHD and women all think they have it.

And I was like, well I have freaking a DH, adhd. So like you're also telling me this is not real. Like Yeah. Um. We're over. See you later. I went to a different clinic. They've been like super fantastic. But I share these stories because if I had known then what I know now, it would've saved me so much pain.

Mm-hmm. So much heartache. I would've been holding the baby in my arms so much earlier, most likely. And so I share this because I think it's important that we share our stories because if I'm further on the road ahead and I'm like, girl, there is a pothole and I can help you not fall in it, like why would I not do that?

Oh, totally. That this happens so much in IVF clinics where endometriosis is very profitable for an IVF clinic. Private equity groups have been buying up IVF clinics and really it's how many cycles can you get her to go through? But what I wanna talk about in this moment is that there's a consideration for a quality.

We know that [01:12:00] endometriosis can negatively impact a quality. And some women who know they have endo might be 32 thinking, well, I'll just be 38 and or, you know, when I try or my doctor said I can have IVF, there's different considerations. Correct? Mm-hmm. 

Dr. McHale: There are, and this is one of those things that, again, like it's very person dependent.

Dr. Brighten: Mm-hmm. 

Dr. McHale: And, uh, you know, there are certain things that. No. You know, even the best doctor in the world does not have a crystal ball and does not have a magic wand. Totally. Right. Like nobody can tell you how fertile you are. Right. And so when I see someone who's, you know, 32 years old, and she's like, I know I wanna have children, but I'm not ready now.

Mm-hmm. And we know she has endo. Okay. We have to be strategic about this. Right. And, and I often tell people like, this is a question of priorities for you. And, and a lot of it, again, you're making decisions with information you don't have. Some of those people, if they went and tried to conceive right now, they would be pregnant and other people.

Whether they tried, if, [01:13:00] if they tried now, they wouldn't be successful. So if they wait another six years mm-hmm. Certainly I don't expect their fertility to, to improve. Yeah. Right. Without intervention. And so it's really one of those things where you say to them, look here, you know, here's your, your A MH, here are your options.

Here's how I, you know, what I expect, um, to be going on with your surgery. And again, another factor, for example, is do they have endometriomas, right? Mm-hmm. Are there ovaries accessible for, for retrieval? You know, some people have like a big, you know, this gets into the types of endometriomas, right? For example, a type one endometrioma is.

Smaller, but it's much more fibrotic and it's a lot harder to peel it out. A type two endometrioma is a lot easier to peel out, but they can get much bigger. Mm-hmm. If you have a big type two endometrioma, we can't even access that ovary, then that's obviously gonna change your IVF outcome. And that's when we talk about, um, you know, whether it makes sense to have surgery first so that we can actually use that ovary during your IVF retrieval.

Right. Yeah. And this is something where I think collaboration is really important and there [01:14:00] are. Fan. You know, I'm, I'm not here to, to knock IVF docs. I think they're great and I, there's a lot of really good ones that I work with in, in my area and very frequently, you know, whether they saw the patient first or I saw the patient first.

We'll both see the patient, then we'll get on the phone, right? Mm-hmm. Often with the patient there, right? Well, like one of us will call, call the other on speaker and be like, here's what I think, here's what I think, you know, and, and we sort of hash it out, the three of us, and say like, here's, here's what the game plan should be in your case, based on all of these different factors.

Mm-hmm. I think that that's really important, right? Because again, we can't tell the patient, you know, if you have surgery first, then it will improve your egg quality by this much, but decrease your ovarian reserve by this much. And on the flip side, we can't say like, oh yeah, like I know that if you do a retrieval now you're gonna get however much.

So we just have to talk about her individual factors. Mm-hmm. And then how that impacts her outcome. Yeah. 

Dr. Brighten: A daily pill to shut it all down. What should we know about the [01:15:00] new endometriosis drug and should we be cautious about it? 

Dr. McHale: We're talking about my fbri. Yes. Yeah. So I mean, yes, a hundred percent. We should be cautious about it.

If for no other reason, then you can only take it for two years, right? Mm-hmm. But ignoring all of the other, in my opinion, large problems with this medication, if I could pick one that really bugs me, it's, you can only take it for two years. So like, okay, you're 25 years old and someone's like, here, this is gonna help you.

You're gonna feel great. Great. What happens in two years? Mm-hmm. What's the plan? Right? Like, and, and so if, if your doctor can't tell you what the long-term plan is going to be mm-hmm. Then like, something's not right. Right. For, for something that's a chronic condition, a medication that maxes out at two years makes no sense.

Yeah. Especially when that max is because of the health risk, that health risks that it carries. Right. Um. You know, ultimately, like patients, [01:16:00] patients don't tolerate these medications well. Mm-hmm. They really, the side effects are miserable. Let's talk about 'em. One of the side effects people should know about, I mean, the most common ones of course are the, the menopause ones we were talking about earlier when you were talking about your experience with Lupron.

Right? Yeah. Not a nice person. Not nice person on Lupron that add back therapy. Yeah. Like it really doesn't mitigate those side effects enough for us to be able to say like, oh, you, you couldn't do Orissa, but this is gonna be totally different. Like, no, you're still gonna have horrible mood side effects.

Mm-hmm. And you're still gonna feel really tired and miserable and hot flashes and sleep disturbances and all the things, you know, people, people really don't feel well and the cure should not be worse than the disease. Yeah. And the case, the case can be made that those medications, the cure is indeed.

For some patients worse than the disease. Mm-hmm. The only scenario in which I have used one of those medications is when someone has a major life event that is less than three months away. Mm-hmm. And they're like, look, I'm getting [01:17:00] married and we picked our wedding date two and a half years ago and my wedding's in three months.

I can't have surgery between now and my wedding. Yeah. And I'm in so much pain that like, is there anything we can do to try to control it now? Mm-hmm. And I say like, look, this is an option you can see if it helps. Right. Take, you know, we, we can trial it now. And you can see if you feel better enough that you think like, okay, this is the difference between being able to dance on your wedding day and not being able to dance on your wedding day.

Dr. Brighten: Mm-hmm. 

Dr. McHale: Let's do it. And then we plan for surgery after the major life event. Yeah. Right. Is it a perfect, is it a perfect fix? No, absolutely not. Right? Mm-hmm. But in my mind, like because of that time limit it is that if someone has a short term like limitation that they can't have surgery, that's the only scenario in which I have ever found it to be like clinically useful for me.

Dr. Brighten: Mm-hmm. 

Dr. McHale: Um, doesn't work for everybody for that, but for some people, you know, it can get them through that [01:18:00] major life event. Mm-hmm. 

Dr. Brighten: We're seeing more and more women online talking about how they don't trust their doctors. Mm-hmm. Reporting medical gaslighting is rampant in the endometriosis community.

Mm-hmm. What do you think we do to move forward to rebuild patient trust? 

Dr. McHale: I mean, I think the, the doctors who are good, there's an expression in medicine of meeting people where they are, right? Mm-hmm. And I think 10 years ago, a lot of people were like, oh, those doctors on social media, like, you know, they can't be real doctors.

Yeah. Um, and, and I think that now there's a big shift of doctors saying like, no, no, no. Like you should have access to health information mm-hmm. In a place that's accessible for you. Right. Like, I, I'm not here to gatekeep health information from you. You shouldn't have to come see me in the office. Yeah.

To be able to learn my opinion about how to treat something right. Mm-hmm. And I'm a big believer that like if you get to know a doctor [01:19:00] through. Social media through patient reviews, through whatever it is that they're doing, you know, speaking that they do locally. If doctors make themselves more accessible in that way to patients, the patients feel like, okay, this is someone I could gel with, right?

Like, I'm not the right doctor for every patient. And similarly, you know, someone else isn't the right doctor for patient who may get along great with me, right? And I think we have to just accept that patients like are going to find the right doctor for them and embrace that, right? Mm-hmm. Like let patients get to know you.

Let them know your treatment philosophies and what kind of person you are, and then patients are gonna trust you. Um, I think. People respond differently to different things. Right. I'm very blunt with people, right? Mm-hmm. Like with my patients, I'm like, this is what I think. This is what I would do. Here are your alternatives.

They may not be very good alternatives, but like, this is what I got. Right? Yeah. Some patients love that, but not every patient is gonna love that. Mm-hmm. They should get to make that choice. 

Dr. Brighten: Mm-hmm. [01:20:00] In 2025, what do you wish endometriosis patients knew more? 

Dr. McHale: That's a hard one because it's meant to be hard.

It's okay. I know I have, I said that with every question that you asked me today. No, that's a hard one. No, you ask good questions. This is this, but the thing about this is, um, endometriosis is such a unique disease in a lot of ways, but especially in the enormous variability in patient understanding of their condition.

Dr. Brighten: Mm-hmm. 

Dr. McHale: Right? I find when people get like, like. A diagnosis like a cancer. Right? They go and they learn everything they can possibly learn about that cancer, right? Mm-hmm. And so when someone comes in and says, I'm a breast cancer patient, you're not sitting down explaining to them what is breast cancer?

Yeah. Right. But with endometriosis, there are some patients who have no idea they've, they have it, they've never heard of it, and [01:21:00] you know, they hear the word, they don't understand what it means. And then there are patients who know more than 99.9% of doctors mm-hmm. About endometriosis. Right. And that, that gap.

Is I think what I would like to, to close mm-hmm. In terms of what patients know about it. Right. Like, I, it's not so, you know, so many patients are so well-informed that like, they talk about endometriosis and I'm like, 10 out of 10 no notes. Yeah. Add for you. But for the other, like, my, my wish is to get the other people to catch up more.

Right. To, to, to bring them along and educate other women about it. I mean, I was doing the math in my head and now I'm gonna like, betray how bad I am at mental math. But like, if you assume there's, I think there's about 50,000 OBGYNs in the us mm-hmm. The last time they surveyed them, like 60% of them were women.

Right. That number is increasing now. You know, 85% of BGYN residents, at least are women now. Mm-hmm. But say 60% of practicing OBGYNs are women. So 30 women, [01:22:00] 30,000 women have, um, uh, 30,000 OBGYNs are women. And then you assume, you know. 90% of them lack a sort of baseline understanding of pelvic pain and endometriosis.

And then you assume between one in 10 and one in seven of these women have endometriosis. Yeah. You're looking at somewhere between 2,704,000 something. 

Dr. Brighten: Mm-hmm. 

Dr. McHale: OBGYNs who are gaslighting themselves about their own endometriosis because they don't even know. So true. Like there are, there are mathematically.

There must be thousands of general OBGYNs all across America who like have endo. Yeah. And they see a patient and the patient's like, I can't go to work because of my period. And the OBGYN's like, girl, me too, we're unlucky. Yeah, it's you're like. 

Dr. Brighten: Ah, that does happen a [01:23:00] lot. Um, and you also seeing a lot of ob gyn saying like, well, I'm a fan of menstrual suppression, so I just recommend that I do that and I recommend it to everyone.

Right. And I'm like, you don't get to be a fan of something and then decide like you're, what is this, the MLM of medicine? Like where you're like, I'm a fan. Hey girl, hey, like, this works so great, so everybody just get on board and let's do it. It's like, well wait a minute. Like, what if the patient doesn't wanna do that also?

Totally. We don't have long-term data to understand. When we put women through menstrual suppression from 14 to 44, like we don't actually know. It's a huge question mark. Is it bad? We can't say, is it maybe good? Possibly, but we really can't say. 

Dr. McHale: Yeah, I, and I think. I think the transparency about a lack of data is important, right?

Yeah. Saying like, we don't, there's no known health risks now, right? We haven't seen any. If it works for you, that's great, right? Mm-hmm. There's, there's risks to everything and humans are terrible at [01:24:00] calculating risk for anything. Right. And statistically speaking, this is one of those things where, again, when we give somebody numbers like, this may slightly increase your risk of this type of cancer, if you take this medication.

And it's like, okay, compare that statistically to like how likely you are to get hit by a bus on your way to work, right? Yeah. Like humans really struggle with calculating these, these relative risks, and I think as long as the patient has access to that information mm-hmm. That's what's most important.

No patient, like, no doctor should be making a recommendation based on their own personal experience. Mm-hmm. But just like, I wouldn't say, aha, I had one patient and she liked, liked the Mirena and so every patient forever will have a morena. You can't do that, right? Yeah. But it happens. It does. It does. But it shouldn't, 

Dr. Brighten: right?

Yeah. How do we close the gap? So you're, you keep saying, you know, there's this information that patients need, information that doctors need. Like we, we have this big gap of information. In a perfect world, your biggest wish can come true. How would [01:25:00] you close the gap on endometriosis education? 

Dr. McHale: You know, I think educating people early, right?

So I think if, if, you know, I know people try to reach out to, like school nurses for example. Yeah. Right. Health class. I think those kinds of things are really important. College campuses, places where young people are giving them access to this information. Mm-hmm. Happily, one of the places young people are is also like TikTok.

And so you see a lot of doctors who are on Instagram and on TikTok and talking about this kind of stuff. I think that that's, that's how we start to bridge this gap. Mm-hmm. And so, and, and I think it's a great movement, you know, patient education, patient advocacy is really coming from patients and from advocates.

And I think the doctors who are getting on board with that. Are, I think it says a lot about them, right? Mm-hmm. When a doctor says like, yeah, like you lead the way, I'm here to support you. I'm here to give you like what information I have. I don't have all the answers, but like, I wanna be a resource for this.

[01:26:00] I think that speaks volumes about someone's sort of collaborative nature when doctors are like, ah, TikTok, like, those are the doctors. You really don't, you don't wanna engage with those doctors. 

Dr. Brighten: Totally, totally. Well, this has been a fantastic conversation. Anyone who wants to find you, we're gonna put links to your social, to your clinic.

Thanks. Um, so that people can reach out. I really appreciate you taking the time to share your knowledge, your expertise, and forgetting online and being. Just brutally honest about the state of endometriosis. It's super refreshing. 

Dr. McHale: Awesome. Thanks so much for having 

Dr. Brighten: me. Yeah, it's been fun. I hope you enjoyed this episode.

 

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