Endometriosis Symptoms vs Normal Period Pain with Dr. Patrick Yeung

Dr. Brighten: [00:00:00] For women listening right now, if they actually have endometriosis, what are the big red flags that doctors tend to miss? 

Patrick Yeung: If you're curled up in the fetal position on the floor during the period, that is not normal. 

Dr. Brighten: A lot of women kind have been told, just take the pill and that's gonna be the solution.

Patrick Yeung: That's a big red flag. 

Dr. Brighten: We've all heard the stat that endometriosis affects one in 10 women. 

Patrick Yeung: Hashtag one in 10 is a gross underestimate. Dr. Patrick Yung 

Narrator: is a fellowship trained, minimally invasive gynecologic surgeon 

Dr. Brighten: who has performed nearly 4,000 surgeries and spent 15 years in academic medicine at institutions like Duke.

Narrator: He founded the Restore Center for endometriosis with a singular mission, 

Dr. Brighten: relieve debilitating pain and restore natural fertility without defaulting to IVF. 

Endometriosis. Doesn't have to have surgery to get a diagnosis. What do we do if we think someone has endometriosis? 

Patrick Yeung: Patients who are suspected to have endo don't get a proper exam.

Imaging is very important and a pelvic exam is very important. [00:01:00] 

Dr. Brighten: Sometimes the doctor thinks they are an expert, but as it turns out they really don't have expertise in endometriosis. That's hard for a patient to navigate. What tips would you give them? 

Patrick Yeung: What patients really need to know? 

Dr. Brighten: Welcome to the Dr.

Brighton Show, where we burn the BS in women's health to the ground. I'm your host, Dr. Jolene Brighton, and if you've ever been dismissed, told your symptoms are normal or just in your head or been told just to deal with it, this show is for you. And if while listening to this, you decide you like this kind of content, I invite you to head over to dr brighton.com where you'll find free guides, twice weekly podcast releases, and a ton of resources to support you on your journey.

Let's dive in. Endometriosis is a full body inflammatory condition. So for women listening right now who need to reduce their inflammation, what are three tips you'd give them? 

Patrick Yeung: Yeah, great. I think you know, wellness and. And inflammation go hand in hand. So three things that you can do right off the bat [00:02:00] is have a good, healthy diet, a food, first diet.

We call it foods high in omega threes, that kind of thing. Second movement, exercise, mobility, that's really important. And then good sleep Recovery we know is more and more important for wellness and reducing inflammation. 

Dr. Brighten: Absolutely. I love that you brought up exercise, because there is a trend on the internet to tell women that they shouldn't exercise just before their period or on their period.

And if they are, it should be gentle yoga, just stretching. And something that when I was in the worst flares of my endometriosis and adenomyosis, I had to do intense exercise, lift heavy and go hard. And I knew if I could just push through in 10 to 20 minutes, I was gonna be feeling better. So even on my worst days, I was like, you just have to move and you will feel so much better.

Patrick Yeung: Absolutely. I totally agree with that. Move your body. Rev it up, get it going and it will do the work for you. 

Dr. Brighten: Yeah. The other thing is you, you brought [00:03:00] up mobility and I just have to share with listeners, I got one of the vibration pods. I should link that in the show notes, but have you seen those vibration pods?

People like are like, oh, they'll help with weight loss. They help with lymphatic flow. But what I actually found is that output myself in a position where it just shakes my pelvis and that like moves everything in ways that like endometriosis just disallowed, like would not allow movement. 

Patrick Yeung: Yeah, that's great.

I love that. 

Dr. Brighten: Yeah. I wanna ask you, so a lot of women listening, they've been told that peer pain is normal, that they can just take the pill and that's gonna be the solution. But for someone who's wondering right now, listening to this, if they actually have endometriosis, what are the big red flags that doctors tend to miss that patients definitely should pay attention to?

Patrick Yeung: Yeah. How much pain is too much pain, or what is normal? That is a great question. I love Padma Lakshmi's poster that she made. Killer cramps are not normal, but red flags are if you're curled up in the fetal position on the floor during the period, that is not normal. If you're missing [00:04:00] school or work that is not normal.

If you can't do your sports, your social activities, people plan their vacations around their period. That's not normal. If you're having to take not just high dose anti-inflammatories, but, uh, narcotics, now it's c, b, D, just to get through your period. That is not normal and a big one is, or you're gonna the ER all the time.

And they tell you, you know. After a while, you become a frequent flyer and they tell you, oh, you must have had a ruptured cyst. That's not normal. And a big one is if you take hormonal suppression or birth control pills for pain and do not feel better, your chance of endo goes up. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: That's a big red flag.

Dr. Brighten: I wanna talk about that cyst rupturing, because this is something women are given the pill for. They will have subsequent cyst rupture and their doctors will tell them, just stay on the pill. This was actually me at 19 in the emergency room on the pill for period suppression. Like the only way I could manage was just never getting a [00:05:00] period.

And the doctor was like, oh no, you just need to stay on the pill. And I was like, this just doesn't make sense to me. Like I'm on the pill. I'm having ruptured cysts, things are, are not. And nobody at any point was like, Hmm, maybe something else is going on. So can you talk to patients about that? Because OB GYNs will say time and again, the treatment for cyst is just to give you the pill.

Patrick Yeung: Yeah, the pill is kind of a way to induce or cause a chemical pregnancy by flooding the body with hormones. So it thinks it's already pregnant. So you don't ovulate. Well, not everybody likes to feel like they're chemically pregnant and it does nothing to. To do anything with the endometriosis. It doesn't diagnose endo, it doesn't remove endo.

It doesn't even prevent progression of endo. So the common belief or the status quo is you need to be on birth control pills or suppression. If we think you might have endometriosis until you wanna get pregnant and then try to get pregnant. And if you don't get [00:06:00] pregnant right away, then you know, go ahead and maybe have the surgery or get the endometriosis diagnosed and treated and then get pregnant right away within a year.

'cause it's gonna come back in two years. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Well, none of that is true and the birth control pills are not actually diagnosing or preventing or removing the disease. If you have endometriosis at all. 

Dr. Brighten: Yeah. We're gonna dig more into that, but we just covered the red flag, so we covered the extreme levels of pain, the discomfort, um, how it's in affecting your day-to-day life.

Somebody listening to this right now, they're like, okay, oh no, I think I have endometriosis. What would be their first step? 

Patrick Yeung: Well, you could talk to your doctor and, and tell them your symptoms and have them, you know, you can write, write it down so you have your story to tell the doctor and it is your story.

And there's a lot of similarities in people's stories, but every story is unique. And if you, you know, if you cannot live your life basically, [00:07:00] and you are out during the periods, you cannot function. That is not normal. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: My wife had painful periods. Her whole life thought it was normal. We ended up having infertility, you know, we can tell her story later or whatever, but when she got the endometriosis treated.

She had no pain. She was actually caught off guard. Mm-hmm. She didn't know that she was starting to bleed until she began to bleed. That's not always the case. But she would say after she got the endometriosis treated and removed, that no period should be the normal. Now, you know, a little bit of ibuprofen maybe during a period might be normal, but if you cannot live your life that is not normal, 

Dr. Brighten: you are gonna go to your doctor.

Your doctor's gonna say, period of pain is normal. This is just part of being a woman. There's nothing we can do if we think it's endometriosis. It has to be surgery. Take the pill. What can women do in that situation? 

Patrick Yeung: They can advocate for themselves. They can say, you know, I'm not able to live my life. I need help.

I need a [00:08:00] diagnosis. Women deserve answers. 

Narrator: Mm-hmm. 

Patrick Yeung: You know, again, they're guests let their whole lives, they're told that this is normal, that you just need to deal with it, be on birth control pills so that if you have endo, it's gonna prevent it from growing and you should be on birth control pills anyway.

None of that is true. So there needs to be other ways to, to diagnose it and deal with it. You know, you could use anti-inflammatories, you can use diet, exercise, different things to try to function or, or, or feel better. But if none of those things are working and you cannot live your life at some point, it requires, it deserves a, A diagnosis.

Dr. Brighten: Mm-hmm. Do we know why nutrition and lifestyle works for some women and not for others? 

Patrick Yeung: That is a great question. You know, we believe that endometriosis is a surgical disease. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: That to remove it. To treat it, you have to remove it, but there can still be this [00:09:00] inflammatory component that maybe is a cause and an effect.

You know, it's, it's, it's thought now to be more of a neuroinflammatory condition. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Not just hormonal. And even if the implants are removed, there still may be inflammation that lingers, that has to be dealt with in addition to or after surgery for endometriosis. So we don't know a lot about endometriosis, but inflammation is definitely a key part of what leads to the experience of the woman.

Dr. Brighten: Mm-hmm. I appreciate you bringing up the neuroinflammatory component to that, because even when things are excised, pain can persist. I think that's important for women to understand. We're gonna talk more today about taking more of that holistic approach because I know that you and your team are looking more at the individual and treating the person in front of you rather than just treating the disease.

But what I wanna ask you. We've all heard the stat that endometriosis affects one in 10 women, but you've said that's a major underestimate. [00:10:00] How many women do you really think have endo, and why is this number so misunderstood even in medicine? 

Patrick Yeung: Yeah. This is a big point that I try to emphasize a lot.

Hashtag one in 10 is a gross underestimate, 

Dr. Brighten: mm-hmm. 

Patrick Yeung: Of the rate of endometriosis. That might be true in the entire female population, most of whom do not have symptoms, but with infertility and no pain, it's about 50% patients who take. Hormonal suppression or birth control pills to feel better and do not feel better.

It's over 80%. 

Mm-hmm. 

Patrick Yeung: And in patients with both pain and infertility, it's over 90% from our database. You know, we showed that, and other, other data has shown that as well. So, and a lot of these patients are being diagnosed with unexplained infertility. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But they probably have endo and maybe other things affecting their fertility and their wellness.

So we would say in a patient with both pain and infertility, they have endometriosis until otherwise proven so, it's [00:11:00] so common. It, it's, I, I love the TED talk. That is the most common disease you've never heard of by Shannon Cohen. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: I love that title. Everybody knows somebody with endo. It is so common.

Dr. Brighten: Mm-hmm. But the American College of Obstetricians and Gynecologists say that it is wrong to say that endometriosis is a driver of infertility or one of the primary causes of unexplained infertility. 

Patrick Yeung: Yeah. That, that makes no sense. You know, the, the whole field of infertility, you know, has moved towards bypassing, trying to really focus in on and diagnose what the underlying factors leading to the infertility is.

Narrator: Mm-hmm. 

Patrick Yeung: And to seek a treatment after very minimal workup that is really bypass treatment, which is IVF, and, and, and the funnel to get to IVF is so quick. And if you stay focused on trying to find the problem and fix it, what are the factors that are leading to the infertility you [00:12:00] will find. One, if not multiple things.

And it's often, again, endometriosis. Mm-hmm. So I think we need to stay focused on what are the root cause issues affecting one's fertility. 

Dr. Brighten: I wanna underline for the listeners what you had said before, though. Silent endometriosis, this is what this is called. So you have infertility and no pain. What is that rate that you have?

Endometriosis, 

Patrick Yeung: I would say it's at least 50%. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But I had a colleague, uh, Dr. Naomi Whitaker, who really challenges me to, to say maybe silent endo does not exist. So. You know, there's the top five symptoms of endometriosis, pain with periods, pelvic pain with periods, pelvic pain without periods, pain passing, stool pain with intercourse, pain, uh, or bladder symptoms, infertility.

But there can be a lot of other symptoms as well. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: You know, fatigue, bloating, all these other [00:13:00] symptoms. And so if you actually delve deeper into. How a patient is doing and asking symptoms, you will often find something so it, it may not be so silent as we think. 

Dr. Brighten: Mm-hmm. I appreciate you saying that.

So I kind, I kind of beed you there 'cause I was like silent endometriosis is what this called, it's not silent. It's because the whole entirety of medicine has decided that endometriosis equals pain. And in the absence of pain it could not be endometriosis. And that is certainly something that I went through and many of my listeners have gone through as well.

And I was someone, fortunately I decided that my special interests would be nutrition at a very young age. And so after I came off the pill and my periods were like horrific all over again and it was like, it, it feels, you know, I'm not being light when I say it feels like PTSD in terms of what you go through your younger self with your periods.

And then to have to go back into that a decade later. And I was able with nutrition, lifestyle, [00:14:00] herbalism, like everything that I practiced to be able to get rid of period pain. Which is, you know, you're just supposed to be impossible with endometriosis. However, when I look back at my excision surgery, which oh, it's like my anniversary in a couple of weeks of my excision surgery, one of the most startling things that happened is that two weeks later I was down like two dress sizes.

Like I just shrunk and I had thought like, oh, you know, I need to exercise more. And like, I've been on this IVF journey and all this stuff, and I realized like I was carrying so much inflammation. So, and when I look at my face before and after, I'm like, wow, that is not even something we ever talk about with endometriosis.

So I think that there are far more symptoms than pain that we are just not discussing, we're not acknowledging, and that a lot of doctors are gaslighting, 

Patrick Yeung: you know, I just kind of thought of it right now. I mean, unexplained a woman who's trying to get pregnant. And who knows that their [00:15:00] body is designed to get pregnant and it's not happening.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And then to be told, you have unexplained infertility after very minimal workup is insult to injury. That is a slap in the face. Women know that they should be getting pregnant. Yeah. That that is what their body is made for. In a similar way, again, this is what just came to me, you could say there's unexplained unwellness is not normal.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: If you can't function, you know, a young woman should be living their best life, you know, out there doing whatever they need to be doing. If they can't function, why is that? There should be a reason for that. It's not just they're lazy or you know, this is the way it's supposed to be and you're supposed to be down and out during your periods.

That is not normal and women know that. And if there's. You know, they're not able to function. There should be a reason for that. 

Dr. Brighten: Mm-hmm. I wanna play two truths and a lie with you. Okay. So I'm gonna make three statements and you tell us which one's the lie. So I'm gonna go through 'em first, and then you can tell us which is the lie.

So number one, endometriosis can be diagnosed [00:16:00] through imaging or clinical evaluation, not just surgery. Number two is IVF is the best line treatment for infertility caused by endo. And number three is most women with endo experience symptoms for over seven years before diagnosis, which is the lie. 

Patrick Yeung: The lie is the second one.

Dr. Brighten: Okay. IVF is the best first line treatment for infertility caused by endo. You're saying that's a lie, 

Patrick Yeung: correct. 

Dr. Brighten: And why? 

Patrick Yeung: Well, IVF is seen as the best that medicine has to offer. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But really, again, people are funneled to IVF very quickly with very minimal workup. And really, the best way to summarize IVF is to say that it's bypass therapy.

Narrator: Mm-hmm. 

Patrick Yeung: Really, it's really a failure of medicine or evaluation to find the problem and fix it. And so then you have to bypass the pelvis, the, the anatomy, the the patient to try to get pregnant. It really [00:17:00] is not the best that medicine has to offer. It's a failure of medicine to find the problem and fix it and find the root cause issues involved, infertility.

And at best, it's last chance. The last resort, but it should not be seen as the best that medicine has to offer. That doesn't make any sense. 

Dr. Brighten: Why do you think it is? Doctors will say that IVF is the treatment for endometriosis. 

Patrick Yeung: It's very interesting. Back in the day, 80% of doctors who treated fertility, infertility, reproductive endocrinology, and infertility specialists were surgeons.

Now it's exactly flipped. Only 20% are surgeons. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And somewhere along the line, all the focus went to doing IVF. So I like to tell the story. I went to go visit an IVF center and just to see what they do, and the director of the IVF Center said to me, who do you think is the most important person [00:18:00] in the IVF clinic?

Okay. You get the answer? 

Dr. Brighten: Yeah. Well, that'll be the patient. 

Patrick Yeung: You would think, okay, first off, it's not the doctor who got into med school, went through med school, did residency fellowship, and then now runs and owns the IVF Center to the IVF Director. It's not that doctor, and it's not even the patient. The answer.

She posed the question and then gave the answer is the embryologist. 

Dr. Brighten: Ooh. Yeah. 

Patrick Yeung: That to me was mind blowing and really was a paradigm shift to really highlight that. That's where the action is. It's in the lab. That is true bypass therapy and the patient, you could even make an argument, is really just there to produce the gametes or the eggs for the lab.

And then the IVF director really just transfers the embryo back to the patient. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But the action's all in the lab, so the whole focus has gone to the lab. That's where the [00:19:00] research is, that's where the money is, but. You know what happened to find, trying to find the problem and fix it and stay focused on that, which is what we're taught in every other field of medicine, is to find the problem and fix it.

Dr. Brighten: Okay. So I had asked why do doctors think that IVF is a treatment for endometriosis though? So you said the embryologist is like the most important, but why are doctors under this assumption? Because we know that IVF doesn't treat endo. 

Patrick Yeung: It doesn't, so it's basically bypassing the pelvis, it's bypassing the endometriosis, it's creating the baby in a test tube and then putting it back into the patient.

So the point is they're, you know, they call it treatment, but they're really not. Focused on trying to remove the disease or treat the disease, they're just gonna bypass it. 

Dr. Brighten: And does IVF make endometriosis better or worse? 

Patrick Yeung: Well, it can make it worse 'cause there's a lot of hormones involved. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: You know, you're trying to hyperstimulate the ovary and to do that you have to give a lot of [00:20:00] medications.

And, and, and oftentimes, again, we think endometriosis is hormonally activated and a lot of these medications used in IVF can activate endometriosis, in fact, treating endometriosis. Will not only give the chance for natural fertility, but will also improve IVF success rates. So if you go and look for and treat endometriosis, it's win-win.

Dr. Brighten: Mm-hmm. So let me ask you then, because you have said, when it comes to IVF and endometriosis as a whole, you and I, I saw you say this. So endometriosis is one of the biggest examples of how big pharma and big fertility profit off of women's suffering. Tell us more. 

Patrick Yeung: So, well, I would say the usual, the status quo way that we treat the two main symptoms of endometriosis mm-hmm.

Which are pain and fertility is on the one hand bandaid therapy, I call it, for pain, which is hormonal [00:21:00] suppression, which is usually chemical or medications like. Birth control pills that induce a state of chemical pregnancy. But now it's even worse. The newer FDA approved medications for endometriosis associated pain are actually causing a state of chemical castration.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And I use that term deliberately for dramatic effect, but also, you know, they're all oral forms of Lupron. Lupron being a medication that is used as a puberty blocker. Lupron being a medication that is used, uh, to in prostate cancer for men. And they're giving this now as a pill to young women and saying, this is great for your endo pain, but they don't tell you what it's actually doing.

And you can have very serious side effects, the least of which are menopause symptoms, things like. Like serious mood changes, like going crazy. And so it's all bandaid therapy based. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And you know, that's, that's big pharma. They say that you need to be on suppression to up until [00:22:00] you get surgery to keep the endo from growing or after surgery from coming back.

And either, actually neither of those have been proven. 

Dr. Brighten: What's the long-term consequences of hormonal suppression? 

Patrick Yeung: Well, you can have very serious side effects. It's, it's not suppressing the actual disease from growing. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So it could be growing while you're on the suppression long-term. In fact, again, there's a common belief that you need to be on suppression until surgery to keep the endo from growing.

But in fact, the opposite might be true. There was a series of studies done by Chapon Etal in 2006 showing that the earlier. A woman had to be on birth control pills for pain, or the longer she was on it as an adolescent, the rate of deep endometriosis was higher Later in life. So they actually concluded that the need for suppression earlier and longer as an adolescent in their younger years could actually be a marker for more advanced disease later.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Meaning it's not actually preventing progression. [00:23:00] 

Dr. Brighten: Yeah. Raises hand if everyone's watching the YouTube, that was me at 14. I was offered birth control pills. My parents were like, no, no, no, we're not putting our teenage daughter on birth control pills. And I didn't really wanna be on 'em either. It didn't sound like a good time.

Like I remember my aunts and my cousins and everybody talking about how sad they were and they cry all the time. Their breasts hurt. And like, I'm like, well, I would want, what do I want? Any of that. But then like, you know, not being able to go to school and vomiting from your period. All of that also not great.

Um, and when you think about that, not such great options that women are being faced with, but when I got my diagnosis, so it was, uh, stage four deep infiltrating endometriosis, which I know in the endometriosis community love their stages. They kind of don't mean anything though because. I didn't have pain until IVF, then IVF was like, just rocked my world.

Um, but my ENION score, I mean, it was literally everywhere. And you know, to your point, you call Lupron Chemical castration. Yes. I did it, I did it to for two months. [00:24:00] Um, it was the scariest, darkest place I've ever been with my mood. I was completely dysfunctional. It was during the holidays. I was crying all the time.

I felt like, I mean, it was just so awful. And I say this all the time, the more I read the research about the benefits of women's hormones for their brain, the more I regret. Ever having done Lupron. And that was just two years. There are women who, or excuse me, two, two months is what I was gonna say. Yeah.

But there are women who are doing this for two years. So we, we know that there's the mood symptoms, so there can be severe, severe mood changes. The menopausal symptoms you were talking about. So women can have hot flashes, they can stop sleeping. The first of this podcast, you were like, you need to sleep to get inflammation down.

Patrick Yeung: Yeah. 

Dr. Brighten: And you know, there's the effects on, you know, nobody's even studied like do, are we setting people up for dementia when we give them Lupron? We don't know. Huge question mark. But we do know we're setting you up for osteoporosis. And we do know that. Like you can have vaginal atrophy, like vaginal dryness changes in [00:25:00] the microbiome.

Like there's so many problems. But you said something I think a lot of listeners wanna hear, and it is that even while you're suppressing your hormones, this disease can progress. Why is that? 

Patrick Yeung: Well, it's not removing the implants, and again, we think estrogen might activate it. And maybe produce symptoms and you might feel better at best, which is why we're calling it bandaid therapy.

Narrator: Mm-hmm. 

Patrick Yeung: But it's not actually preventing the implants from being there or even progressing. It doesn't always progress, but it can progress even in the presence of suppression. But I wanted to get back to that one point about it being chemical castration. The urologist who gave me this idea, this phrase that, that Lupron is really a form or inducing a state of chemical castration the following year, said to me, it's actually worse now.

So in the 

Dr. Brighten: wait it's worse than chemical castration. 

Patrick Yeung: Well, 

Dr. Brighten: because I'm like, what's worse than chemical is castration. I'm on the edge of my seat here. 

Patrick Yeung: It's, it's being used in [00:26:00] prostate cancer as adjuvant therapy. So after you get the surgery for prostate cancer, you then are put on Lupron to keep it away, to keep it from coming back.

That's adjuvant therapy. Well in the updated guidelines for prostate cancer, they're now saying that six months of Lupron post-op is as good as long-term Lupron. Well, what does that mean? That means short-term Lupron is having lasting effects, and now they're giving the same type of medication, the same class of drug in pill form to young women saying, this is great for your endo pain, but it could very well be having lasting effects that we're not aware about.

Only we'll find out later. 

Dr. Brighten: Sir, I did not need to hear this this morning. I'm sorry. I mean, I mean No, it's so good to hear. And it is something that, um, I will say before choosing to go with Lupron, I got three opinions. I saw three different doctors and I did not wanna do Lupron. And I, I remember taking the medication home, I was supposed to start it, and [00:27:00] then I, I, I delayed it like a whole other month.

I was like, no, I just, I don't feel right. And I contacted these three doctors again and they all were like, no, this is the way, this is what you have to do. And I'm like, okay, okay. And then now I look back and I'm like, that was after three opinions. And this is what I think is so exhausting for women with endometriosis.

You don't have the energy. You are in pain and you have to advocate with yourself for yourself. And then you see people and you see three different people and they're saying the same thing because medicine does a lot of parroting where they just parrot what they heard exactly. Rather than actually updating themselves thinking about it.

And I am like often. You are hard pressed to come across an endometriosis patient, someone who's been living with this their lifetime, that doesn't know more than your average ob gyn. 

Patrick Yeung: And you really, I mean, this is why I love what you're doing to get the word out. You really have to be your own best advocate these days.

So kudos for you and for what you're doing. But yeah, we, I talk to patients all the time about this idea of root cause treatment. If you have these implants that are [00:28:00] not normal, remove them to avoid the need for long-term suppression, basically because the disease is gone. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: To optimize the anatomy and to lead to natural and recurring fertility and for the hope of one and done surgery.

Patients get it, they're on board, they're tracking, but then you talk about that to other doctors and it's been amazing, the resistance for that. And again, I think it's a lot of big pharma, big fertility, you know, that is where. The money is for a lot of the medical industry, we'll call it, 

Dr. Brighten: whenever you say big pharma and big fertility, there are always people that immediately are like, this is a conspiracy theory, so let's break that down because it's not a con.

Capitalism is not a conspiracy theory, like return on investment of, you know, drug trials is not a conspiracy theory. All of these things are well documented, but I think, you know, what people don't understand is what's happening in big fertility right now. 

Patrick Yeung: Yeah. I mean, I like to think the best of people.

I think people are well [00:29:00] intentioned, but that's all they know. Like you say. I mean, that's what they've been taught. That is the status quo. You know, you write a script for, for pain, you refer them to IVF for fertility. It's easy, you know, I decided early on to be good at surgery for endo to remove it, that I couldn't do it.

Part-time or delivering babies at night and trying to do good surgery during the day. 

Dr. Brighten: Thank you for that. 

Patrick Yeung: And so 

Dr. Brighten: that for people listening, good sleep makes a good surgeon. 

Patrick Yeung: Yes. And so I kind of went all in with surgery for endo, but it, it takes someone dedicated to removing the disease to avoid the need for long-term suppression.

Again, basically because the disease is gone to lead to natural and recurring fertility and for the hope of one and done surgery that. Is a very different surgical mindset on behalf of the surgeon, I think. And I think we've shown a very different surgical outcome for the patient. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But it takes that kind of [00:30:00] focus to do that.

Dr. Brighten: Yeah. And for people listening, I think it's important to understand that when infertility rates went from one in four to one in six in couples private equity groups saw that this was going to be very luc lucrative and profitable, and they stepped in and I think the estimate is around 70% of fertility clinics in the United States, like doing the most cycles are owned by private equity groups.

And so it's really important for people to understand, you know what I'll do, I'll link to, um. Dr. Justin, uh, his episode, he is a male physician, so he treats men for infertility, and he was talking about how less and less fertility clinics are actually referring men to him now, because the name of the game is how many cycles can we put a woman through, so they're not even working up men anymore to put women through cycles.

So there's. It is not the doctors, and this is where I think people are always like, doctors are evil and they're greed. That's what's going on. That's not what's going on. Doctors are often stuck between [00:31:00] like pharmaceutical influencing insurance, insurance influencing pharmaceutical. And now we've bought private equity who stepped into the arena and doctors, every single one of them went to medical school because they wanted to help people.

And that is the driving mission. And then they get stuck in, well, I have to pay back my student loans and I have to feed my family and I have to like keep my job. And there are these puppet masters pulling the string, so to speak. 

Patrick Yeung: Yeah, striving for one and done surgery I joke, is really not a good business model, you know, to, to have a patient on long-term suppression from being a teenager onward, or IVF, you know, 20, 30,000 per cycle.

That's recurring. That is a much better, if you're talking about just business model. So, you know, I, I believe I am still the, or have the only center of endometriosis that does not offer or refer to IVF [00:32:00] and does not rely on postoperative suppression to cut, kind of try to suppress whatever endo we don't get.

That gives us a focus to try to remove the disease again instead of bandaid therapy, big pharma instead of bypass therapy, IVF. And again, that, that gives us a focus to try to remove the disease and optimize the anatomy. And I think we're showing great results. 

Dr. Brighten: I love that. But I know the argument's gonna come.

Any doctor who's not referring women to IVF first, they're anti IVF, they're part of the Christian nationalist agenda, or they're trying to like harm women. What do you say to that? 

Patrick Yeung: I've heard patients say that they were recommended to try up to five cycles of IVF who had known endometriosis, and if that didn't work to have a baby then do the surgery for endometriosis.

This, this seems totally backwards to me. You know, again, women want answers, but women also want [00:33:00] the disease removed. To be made whole again and to feel better in addition to having increased chances for pregnancy. Again, my wife had endo and she would say, you know, a part of her journey, her healing journey, her journey to be restored again, restore Center for Endometriosis, that is her name that she came up with because that is her journey.

It was such an important part of the process to ha to get those answers, to have the disease removed, to be restored and kind of made whole was so important for just peace and, and resolution and feeling better and chances of pregnancy. Also, you know, there was a thread, I believe on Nancy's No get one point where women with known endometriosis and debilitating pain and periods went and got IVF to get pregnant.

And they felt great when they were [00:34:00] pregnant and maybe even breastfeeding, but as soon as that was done, the pain came roaring back. 

Narrator: Mm-hmm. 

Patrick Yeung: To the point that they had a hard time not just taking care of the child, but even bonding with the child. And there was this whole discussion or sentiment that maybe they should have had the endometriosis addressed first before trying to get pregnant.

Dr. Brighten: That is such a powerful point. And is someone who has lived with endometriosis and, you know, going through IVF putting me, you know, my life, man, my life was very different before IVF, but by my third egg retrieval, I couldn't get outta bed for three weeks, three weeks, three weeks of my life, like almost an entire month.

I missed out, couldn't go to the park with my child, couldn't get up and go to dinner like with my husband. Like there were all these things I looked at missing out on. And I think that in medicine we often forget the quality of life of the individual. And I think especially in reproductive [00:35:00] medicine, the end goal is get a baby in your arms because it's so heartbreaking when you want a baby and you have pregnancy losses and, and you don't have that baby in your arms.

But I think what you just said is so powerful of thinking about and what's the long-term outcome for this patient as well. So with, you know, you, you are a big advocate for this one and done surgery. I wanna start from the beginning because I, when I did the two, two truths and a lie, I think some people are gonna be like, hold up endometriosis doesn't have to have surgery to get a diagnosis.

So I wanna start from that place. First step, what do we do if we think someone has endometriosis, we've done an intake, they've got all the symptoms. What does it look like for imaging next? 

Patrick Yeung: So imaging and an exam. I'm amazed how many patients who are suspected to have endo don't get a proper exam. 

Dr. Brighten: What do you mean by exam?

Like a, 

Patrick Yeung: like a pelvic exam. But the chance of endometriosis comes from talking to the patient again, the [00:36:00] numbers that we gave are just by talking to the patient of the, of the chance of having endo. But for surgical planning to know how much endo or to be able to plan for the right surgery, imaging is very important in a pelvic exam, is very important.

So those two things allow us to look for evidence of more advanced disease to plan for the right surgery. So endometriosis starts off on the surface when it's just surface disease, early stage endometriosis, you can't really see or feel it. You can have it. So a, a normal ultrasound and a normal exam in no way rules out surface endometriosis.

Dr. Brighten: Mm-hmm. And when you say surface endometriosis, where are we talking about? 

Patrick Yeung: So endometriosis is by definition cells in the wrong place. Cells, which are normally found in the lining of the uterus and shed during the period found outside the uterus implanted on the wallpaper of the pelvis, I call it, or the peritoneum.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So it's these implants along the wallpaper of the pelvis. So you can't really see or [00:37:00] feel that with imaging or an exam, but you can have surface endometriosis and it's well documented that the amount of disease and the amount of symptoms do not line up well. You could have just early stage surface endometriosis and a lot of pain and have it affect fertility and have it treated.

Have both improve feeling better and chances of pregnancy, you could have advanced endo and no symptoms. My first case of stage four endometriosis was in a patient whose only symptom was infertility. And really infertility should be seen as a symptom, not a diagnosis, but the amount of disease and the amount of symptoms do not line up well.

You could have a little bit of endo and a whole lot of pain or a lot of endo and no pain. We've seen multiple examples of both, but doing the, we call it a surgical planning visit with a a mapping ultrasound, which is standard now, and an exam to look for more advanced disease to plan for the right surgery is so important.

Dr. Brighten: You [00:38:00] just said a mapping ultrasound is standard. Do you know how many doctors slide into my dms or pop into my comments telling me I'm absolutely wrong to tell women that they should ever have imaging first. It's not standard for some doctors, but it's standard for you. And I'd say the ones who are doing things right.

Do you ever do MR MRI as well? 

Patrick Yeung: There was a time when I would order a lot of MRIs for patients coming in from out of state. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And we'd order a local MRI that they would have done. But MRI is really dependent on the protocol that is done or used to perform the MRI and who is reading it. So mapping ultrasound has been shown to be as good as MRI and the benefit of the mapping ultrasound is we can do it ourselves.

We can see the images, we, you know, measure everything and get a good idea of what to expect so we can plan for the right surgery. But when I say mapping ultrasound, that is not the usual ultrasound. That is not the usual pelvic or transvaginal [00:39:00] ultrasound, which really they're looking at the uterus. And the ovaries for the one type of advanced disease, which is endometriomas or chocolate cysts is another word for it.

In the ovaries 

Dr. Brighten: way, it ruined chocolate, right? Medicine just really ruined it for us. 

Patrick Yeung: But mapping ultrasound is more than just looking at deep endometriosis in the ovary. It's looking at deep endometriosis behind the uterus, in the bowel, and in other areas. And that's what I mean by a mapping ultrasound consensus guidelines came out for that international consensus guidelines.

About a year ago. And so now it's becoming standard, at least among centers of Endo to do a mapping ultrasound to be able to plan out the surgery. 

Dr. Brighten: Mm-hmm. So the MRI is only as good as the radiologist who reads it. I experienced this, I had an MRI done, the radiologist was like, there's no endo, there's no, and there's no adenomyosis.

I'm like, I'm looking at this and I can see my adenomyosis. Like, and this is not, this is not my [00:40:00] job. This is your job. Yeah. I'm like, I told my doctor, have him read it again. He's like, she's just being dramatic. She's attention seeking. And I was like, yeah, bye. Okay. So I sent and I contacted a friend of mine.

I'm like, I need to send this MRI to someone else. He's like, I got a radiologist. Radiologist is like, damn girl, you got hella endo in here. So it matters greatly, but I So does the ultrasound. So how does someone find someone competent to do this type of ultrasound? The mapping ultrasound you're talking about?

Patrick Yeung: Well, first off, just to say, I mean, I. I love that you have so much lived experience. I mean, it's, I guess it's good and bad. I don't, but it's so powerful, your story and it, it echoes so many other women's stories. And so, you know, I think things are not gonna change. The status quo is not gonna change until women tell other women that there's another way and that, you know, they've been gaslit their whole lives.

And it's not gonna change until women demand better anyway. [00:41:00] In terms of imaging, you know, people say that endometriosis should really only be treated by centers of endometriosis or centers of excellence, or centers really focused and dedicated to treating this disease. Because if it's early stage disease, it's just surface.

It can be really subtle. It can be really atypical. And it requires somebody who's looking closely, carefully, and systematically for all the different implants in all of its forms, which can often be missed by A-A-G-Y-N who's not used to looking for it. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Or if it's advanced. Then it takes a team, a team approach to deal with advanced disease, deep endometriosis, deep infiltrating endometriosis that can be involving not just the ovary, but the bowel, the bladder, the ureter, other organs, vital structures.

So it takes a team so that whether it be endometriosis along the entire spectrum of early and superficial to deep should be addressed by [00:42:00] centers dedicated to treating endometriosis. But these are the, are the places that should have their imaging. Kinda worked out, whether it be MRI or mapping ultrasound to be able to plan for the right surgery.

Dr. Brighten: Mm-hmm. So how does someone find that kind of surgery center? Because there are certainly, you know, we see this a lot happens in medicine. I mean, we're hearing a lot about it in perimenopausal care where people are advertising that they, they do hormone prescribing and then the patient gets there and they're like, I only give SSRIs like it's false advertising.

And I think the same thing. Well, I know the same thing happens in endometriosis as well, where where sometimes the doctor thinks they are an expert, but as it turns out they really don't have expertise in endometriosis. That's hard for a patient to navigate. What tips would you give them? 

Patrick Yeung: Again, I think it's hard for a general GYN who's still delivering babies, has a busy office practice for well woman care and [00:43:00] doing endometriosis surgery every now and again to be good at treating this disease.

Again, in my story, I really felt like I had to focus on treating endometriosis and do it well. And so I guess it's important to look for a place where they're really focused on treating this disease. They have a high volume practice. We know that volume matters in terms of surgical outcomes. 

Dr. Brighten: What do you mean by volume?

Are we saying 50 surgeries a year? A hundred surgeries a year? 

Patrick Yeung: Oh, well at least 50. Okay. That would be a minimum. Okay. You know, a hundred to 200 would be better. But this is something they're doing weekly or, or on a regular basis? Not every now and again. Again, most centers of endometriosis that are actually focused on treating endo, that is the majority of what they do.

And that would give, gives them the focus and the experience and the volume to be good at it. And that's what you want to, to look [00:44:00] for. And, and again, what is their philosophy? What is their focus? So are they focused on trying to remove the disease and optimize the anatomy, or are they relying on this postoperative suppression to suppress whatever they don't get, which really makes them say they don't have to get it all?

Mm-hmm. It's always a red flag to me when a patient says, oh, my doctor said they got all they could, but by the way, they really should be on Lupron for six months after surgery that that tells me they know they didn't get it all, and they're trying to use Lupron or some kind of postoperative suppression to suppress what they didn't get.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Or you know, they didn't need to go to IVF. They're not trying to really optimize the patient's own anatomy. You want somebody who can, who is really focused on doing that. 

Dr. Brighten: Okay. So you had said before that endometriosis are cells similar to the uterine lining that are outside of the pelvis, or excuse me, outside of the [00:45:00] uterus.

But tell us how those cells respond differently to hormones and how they act differently because they aren't, they are not following the rules of the endometrial lining. 

Patrick Yeung: Right. So it's, it's, they're similar cells to the cells, uh, found in the uterine lining, but they're also different. So it's ectopic endometrium is kind of the medical phrase that is used to describe endometriosis, which is cells in the wrong place.

We do think that. They're activated by hormonal stimulation. 

Narrator: Mm-hmm. 

Patrick Yeung: So that estrogen can activate it or make it more symptomatic. And so all of the kind of status quo approach is to try to block estrogen stimulation, either by medications that induce a state of chemical pregnancy, like birth control pills, which are all progestin based or progestin dominant, progestins being synthetic progesterone, which is the counter hormone to estrogen, or to shut down the entire [00:46:00] axis all together and put the patient in the state of chemical menopause.

Or again, as we're saying, chemical castration, to try to take away the stimulation of those implants. But again, we're understanding more now that endometriosis is more than just a hormonally activated disease. There's a whole neuromodulatory or neuroinflammatory component of it, either in its cause or effect that also has to be addressed in addition to or after.

The surgery. 

Dr. Brighten: Mm-hmm. And we see that there can be prostaglandin production, there can become histamine imbalances, and so there's a lot more going on. You mentioned progestin, everyone I will link to show notes. We've done EPIs episodes on why progesterone and progesterone are not the same, but what is the role of progesterone bioidentical, like oral micronized progesterone or using it vaginally with endometriosis?

Patrick Yeung: Right. So you can take progesterone to try to block [00:47:00] estrogen or, or reduce estrogen dominance. You can take it throughout the cycle. That's what a birth control pill does, basically. But you can also take it time to the cycle. Mm-hmm. You can take it when your body would naturally produce it in the second half of the cycle and you can use bioidentical progesterone, which is the same compound that your body makes and just support the the cycle.

At the time that the body would normally make it, and sometimes that helps symptoms. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Absolutely. 

Dr. Brighten: So we want to keep going on our journey of, you know, someone who may be going for excision. So we first do the mapping, do the surgical consult. I assume that's so that you can get all the right team members in place and give the true informed consent that patients deserve.

Now, when it comes to surgery, what are you recommending women do to prep themselves before going into surgery? 

Patrick Yeung: That, that's very, that's a great question. The healthier the patient can be going into surgery, the [00:48:00] better the outcome after surgery. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So, getting in the best possible shape or wellness you can be getting your, your supplements all kind of tuned up and, and being active and, and all of that's gonna help you or recovery from surgery.

It was interesting. So, so for fertility. You know, remove treating the endometriosis is kind of the surgical part of it. And then there's a whole non-surgical optimization that can happen for fertility, for best chances that can happen after surgery. But there's a doctor who's been sending a lot of patients to me from dc, Dr.

Margaret Dwayne, and she tells me, I, I, it's kind of unbelievable, but all the patients she sent to me in the past year, which is maybe 10 or so patients have gotten pregnant within six months of surgery. 

Narrator: Mm-hmm. 

Patrick Yeung: This is kind of unheard of. And I think a lot of that might be happening because she's doing a lot of the non-surgical optimization before surgery.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So I think [00:49:00] that's helping the outcome after surgery in terms of wellness, but also fertility. So yeah, the more that you can do to, to prep for surgery, the better. 

Dr. Brighten: Are there particular supplements you recommend for women with endometriosis, especially in the consideration of they're gonna go the excision route, 

Patrick Yeung: there's a list, you know, vitamin D's important to, to, to have optimized.

Um. Oma Omega threes can be helpful in, in endometriosis, although you don't wanna be on omega threes at the time of surgery 

Dr. Brighten: for the blood thinning effects. 

Patrick Yeung: For the blood thinning, 

Dr. Brighten: y'all, we don't want you bleeding. 

Patrick Yeung: So that has to be stopped by by two weeks of surgery. Yeah. We, we offer patients a whole functional medicine guide mm-hmm.

With a whole list of recommendations on all of that. 

Dr. Brighten: Perfect. And I would imagine you also want their ferritin optimized as well, so making sure we don't have any blood level anemia level. Yeah. Yeah. Are there particular screening labs you think are important for patients to have before they're, they're going into excision surgery.

Patrick Yeung: We want to know their blood level before surgery. Um, 

Dr. Brighten: so A-C-B-C-A-C-B-C 

Patrick Yeung: or [00:50:00] blood level hemoglobin. I often do recommend if we're going to potentially be operating on the ovary and removing an endometrioma or doing a cystectomy. Just to get a baseline measure of their ovarian reserve before potentially operating on the ovary.

Dr. Brighten: So an A MH, 

Patrick Yeung: it could be an A MH or a cycle three. Day three FSH. 

Dr. Brighten: Okay. 

Patrick Yeung: The anti mulian hormone. Yes. 

Dr. Brighten: Do you also do follicle count? 

Patrick Yeung: You could, you know, but the blood death is probably just as good. Okay. The, the antral follicle count is kind of. Measuring what the blood test is measuring. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: There there're two ways to get to the same idea.

Dr. Brighten: So I'm just curious. A-M-H-F-S-H, is there a level where you're like, no, we shouldn't do excision. Maybe if you're gonna go IVF you should do a retrieval first. Or, you know, how that's, um, actually, you know, helping you in terms of guiding the patient. So if they've got a high A MH things look great or a low a MH, what is like the route?

Patrick Yeung: So, that's a great question to, to [00:51:00] highlight the idea that a MH, the anti mullar hormone is really the modern day blood test for ovarian reserve, which is really a predictor for IVF success rates. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: It's really not a very good predictor for natural fertility. What we did before A MH is the cycle day three FSH, which is, which is a much better predictor for natural fertility.

So there are patients who could have a low or poor A MH and thereby not very good. Outcomes or predicted success with IVF, but have a normal or good cycle day three FSH, they might actually have a better chance at natural fertility than IVF success. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So that's interesting. 

Dr. Brighten: What FSH are you looking for?

Patrick Yeung: We want it under 10 or single digits would be ideal. 

Dr. Brighten: Mm-hmm. And so for everyone listening, when you get into double digits, like 25 or more, that's when we're like, oh, this is looking like perimenopause. Or depending on your age, primary ovarian insufficiency. [00:52:00] So if somebody has an optimal FSH, how does that influence the removal of an endometrioma?

Patrick Yeung: Well, so that's been looked at, what is the best way to treat a chocolate sister endometrioma? Do you just drain it or do you cut out the entire cyst wall? So in multiple well-designed trials, randomized controlled trials, removing the entire cyst wall is better for the outcomes that matter to the patient, including reducing pain, reducing recurrence of that cyst and natural fertility.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: It has been shown that. Reducing the the, or cutting out the cyst wall can reduce A MH, which again is worse for IVF success. So there is a debate, an ongoing modern day debate of it's thought that if you have a small endometrioma and the cutoff is usually three centimeters or less. The plan to get pregnant is to do IVF, then maybe it's better to just avoid surgery altogether, go straight to IVF.

Narrator: Mm-hmm. 

Patrick Yeung: And that the small endometrioma would not affect the stimulation protocols, [00:53:00] but if the goal is to feel better or for natural fertility, then it's been clearly shown that cutting out the entire cyst wall is better for feeling better. And natural fertility. 

Dr. Brighten: Isn't there evidence that an endometrioma, however, because of the inflammation it's creating, can actually affect the quality of the eggs that are being retrieved during a fertility cycle?

Patrick Yeung: Absolutely. So patients have been sent to me to have their endometriosis or endometrioma endometriomas removed for the sake of IVF. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Because yes, we know that IVF outcomes are worse in the presence of endometriosis. And again, a large endometrioma is often prohibits IVF. 

Dr. Brighten: Mm-hmm. So we, we talked about the CBC or the hemoglobin, uh, getting your vitamin D levels up, F-S-H-A-M-H.

Any other labs patients should consider having done before going for excision surgery? 

Patrick Yeung: Not really. Those are the main labs to, to be done before surgery. 

Dr. Brighten: Okay. And [00:54:00] then are you checking things like clotting disorders and like the usual run The gamut of, uh, you know, making sure someone is a good candidate for surgery.

Patrick Yeung: We're not doing that if, if it doesn't come up in the, in the history screening of somebody who has issues with bleeding. 

Dr. Brighten: Okay. 

Patrick Yeung: If somebody's had recurrent miscarriage then, and the usual definition, full, recurrent pregnancy loss or recurrent miscarriage is more than three losses. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But you could absolutely.

Start a workup earlier two or even one. Or if somebody's, you know, using a method of fertility awareness and their charting is not normal, you can measure all those hormones even before the the first miscarriage to try to get ahead of it and support the progesterone timed properly to the cycle, even before the first miscarriage.

But those hormone levels can all be looked at and addressed as well. 

Dr. Brighten: Mm-hmm. Okay. So somebody is going into surgery, what should they know about going into excision surgery? So we've talked [00:55:00] about doing the imaging first, how to find the right kind of surgeon. Now they're going into surgery. What do you think people should know about that?

Patrick Yeung: So I would say the surgery for endometriosis, the goal I call it is anatomy optimization. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So that actually has two parts. So very few, as we're saying, are very focused on removing all the disease. To avoid the need for long-term suppression and to avoid the need for IVF to kind of optimize the patient's own anatomy for wellness and fertility.

Optimal excision I define as cutting out whatever is suspicious for endo in whatever form and wherever found so very few can achieve that result. Well as it is. But even if you can do that, that is still only half the battle. The other half is preventing adhesions. Mm-hmm. And even fewer do that. Well, and that was very important in our story.

So again, my wife had painful periods. Her whole [00:56:00] life thought it was normal. We tried to get pregnant from day one. After about a year of trying, she said, maybe I have endometriosis. I said, no way. She had bad endo, she had giant bilateral endometriomas. She had one surgery to remove the endometriosis, and then multiple surgeries for adhesions.

She's now pain free. We've had recurring fertility. We're trying to pay that forward. That is the bottom line. But preventing adhesions was really important for our story and for her. So we are very deliberate about preventing adhesions where things can stick after surgery, and that is often overlooked.

Or, or people focus on one or the other. People try to remove all the endo, but then aren't deliberate about preventing adhesions. Or some people are very focused on preventing adhesions, but don't remove all the endometriosis. 

Narrator: Mm-hmm. 

Patrick Yeung: I really believe both are important. You should remove all the endometriosis, do whatever it takes, and then prevent adhesions, do whatever it takes, and one should not compromise the [00:57:00] other.

And I think we've shown that is, or I would say that is how we're getting such good results. And the hope of one and done surgery is by combining the best of both optimal excision and adhesion prevention. 

Dr. Brighten: I love that you told your wife No way. And then she was like, bet and, and there it was. But I think like the, the biggest thing, and I, I have two sons I'm raising and I'm like, never dismiss a woman's intuition.

She knows her body better than anyone and if she says, I think it's this. It probably is, and that I would say I've learned through medicine, but I've also just learned to listening to women in my life that like women are rarely wrong about what's happening in their body, but I wanna get into, you had a study you showed endo can be one and done if done right, you can do this surgery and it can be a one and done procedure.

How are you achieving that when other people are not 

Patrick Yeung: Okay? So I just wanted to kind of go off or [00:58:00] re-emphasize about your point about women know their bodies. That's exactly what I say. I, I continue to learn from my wife. 

Dr. Brighten: Good man. I'm gonna stay married long time 

Patrick Yeung: and, and I really do think that women know their bodies.

So in our story, my wife had the surgery for endo and then a couple of surgeries for adhesions. It was actually three more surgeries already for adhesions. And we did get pregnant. I praise God. And then had a couple of miscarriages and she felt stuck. She felt like she wanted to have surgery again. 'cause she felt like the adhesions were back and I was actually kind of against it because she had gotten pregnant multiple times 

Dr. Brighten: mm-hmm.

Patrick Yeung: With her current pelvis. So, but we went ahead and did the surgery, found adhesions, and then she had multiple pregnancies after that and she was absolutely right. So I absolutely agree with the idea that women know their bodies, but, 

Dr. Brighten: and I [00:59:00] just wanna say, to be fair, a husband being like, I don't want you going into surgery again, is a very valid thing.

Yeah. Because all surgeries carry risk, especially when you're a surgeon and you know that. 

Patrick Yeung: Yes. So you have to choose the right surgeon that that is true. In terms of the outcomes. So this idea of one and done surgery is kind of triggering for people and it's controversial and no one's perfect. There is no cure.

I never guarantee that they cannot ever have to need to have surgery again. But I would say based upon our study, that one and done surgery is possible. So this was a 10 year study showing a very low rate of repeat surgery. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: It was under 5% and the majority of patients did not take any long-term suppression post-op.

They were either trying to get pregnant or didn't like the side effects of the suppression. So the majority of patients took no long-term suppression post-op. We told them if we felt like we achieved our goal of removing at all. There was no known or suspected endo left behind. They didn't [01:00:00] have to take the long-term suppression post-op.

And again, most didn't. And still such a low rate of repeat surgery. So we're saying one and done surgery is possible. In many, if not most patients, and without the need for long-term suppression. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Two, at least one and done surgery should be the goal of what centers of endometriosis are striving for.

Even surgeons sometimes who treat endo feel like they don't have to remove it all because again, whatever they don't get, they're gonna put the, or recommend what everybody recommends, which is to put the patient on postoperative suppression to suppress whatever they don't get. They don't have to get it all.

Narrator: Mm-hmm. 

Patrick Yeung: Or again, for fertility, they're gonna bypass the pelvis and refer to IVF. They don't have to optimize the patient's own reproductive anatomy or just come back and do it again in two years, which is the expectation versus trying to optimize the anatomy, remove all the disease, to avoid the need for long-term suppression post-op, basically because the disease has all been removed.[01:01:00] 

To lead to natural and recurring fertility and for the hope of one and done surgery, that is a very different surgical mindset on behalf of the surgeon, I would say. And I think we've shown a very different surgical result for the patient. 

Dr. Brighten: Mm-hmm. And how are you preventing adhesions? Because I think that's gonna be a big aha moment for a lot of people listening.

Patrick Yeung: So adhesions is a very common, longstanding surgical challenge, you know, to prevent things from sticking and after surgery. And some people are just really prone to adhesions like my wife. And so we're doing things to help prevent adhesions, which can involve. Different substances or fluids to float things apart.

Products made from amniotic membranes, suspending ovaries. Now we're using PRP or platelet rich plasma. What 

Dr. Brighten: works injecting that into the ovaries? 

Patrick Yeung: Well, PRP can be used to help ovaries work better and you can inject them into the ovary. Mm-hmm. But we're actually now [01:02:00] using it where after we've cut out all the endo and you have these kind of deep peritoneal areas or these areas where you had cut out the endo, you can coat all of that area, all the pelvis, all the wallpaper with PRP.

Dr. Brighten: Interesting. I haven't heard that yet. Yeah. Is that, are a lot of people doing that or is that something that like, that's 

Patrick Yeung: relatively new. 

Dr. Brighten: Yeah, 

Patrick Yeung: and to be fair, so my wife had Gore-Tex twice. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And 

Dr. Brighten: can you explain that for people who don't know what that is? 

Patrick Yeung: Yeah. So Goretex is what they make jackets out of.

Nothing sticks to it. But after you cut out a cyst, you can wrap the ovary. Well, we always reconstruct the ovary, so that's another thing that we do. Many people we're taught as residents that you don't have to reconstruct the ovary, you can leave it open and it will just heal. Well, you have a, a raw open ovary, it's gonna be more prone to sticking.

Mm-hmm. So we suture it close so it's smooth. We can suspend ovaries temporarily. We suture that absorbs, so it's lifted off the sidewall [01:03:00] and can't stick to the sidewall. But then you can wrap it in Gore-Tex, like a piggy in a blanket. And we published a landmark study showing that Gore-Tex doubled the pregnancy rate in patients with infertility in a cyst.

Dr. Brighten: Nobody would think that putting like the lining of a jacket, like something that like probably has PFAS, um. In the pelvis would actually increase fertility. 

Patrick Yeung: Yeah. Actually it, it's really interesting because when we, whenever we study an adhesion prevention strategy, we look at second look laparoscopy scores.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Which is, you know, you do another surgery and then count adhesion scores. But really like a MH, that is a secondary outcome. That's not the primary outcome that matters to the patient. What matters to the patient is pregnancy. 

Dr. Brighten: Yeah. 

Patrick Yeung: Or maybe feeling better or quality of life, or maybe even rate of repeat surgery.

So this was the first study that was published looking at any adhesion prevention strategy and pregnancy, which is actually easier to ask about, and it doubled the pregnancy rate, but the [01:04:00] downside is it requires another surgery to remove it. 

Narrator: Hmm. 

Patrick Yeung: So I usually only talk about it or offer it in patients who have both infertility and cyst.

It did work for my wife. But now it turns out that in the last surgery she had no adhesions before in the, the surgery. Before that they removed Gore-Tex, but then coated everything in PRP. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So that got me back onto looking at PRP and interested in it. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Again, they're calling it liquid gold.

It's being used across specialties in ortho spine, ENT, plastics, hair transplants, facials, and now we're applying it to GYN. You can use it in the uterine lining for endo, for chronic endometritis. You can use it for premature ovarian failure and help the ovaries work better, and now we're using it. On the peritoneum or the wallpaper to help prevent adhesions.

Dr. Brighten: Mm-hmm. I'm a big fan. I've had PRP in several places in my body, but when I was going for my excision surgery, I asked to have my [01:05:00] ovaries injected and they were like, yeah, we can totally do that. I'm like, thank you. Um, and then also for my, um, embryo transfers, I always went in and had, because though a lot of times they're gonna do a practice run of like, oh, can we get the catheter in and place the, um, you know, embryo?

And I'm like, let's practice with PRP while we're there. And my doctor, that's like totally what he does. He is like, yeah, instead of just wasting your time with like, you know, a speculum and inserting a catheter, let's put some PRP in there as well. So I think there's a lot of utility in that for a patient who's like.

Sign me up. I want to prevent adhesions. Can do you feel like what you've explained here, they could go through and ask their doctor, like, how do you prevent adhesions and see like, you know, are they using Gore-Tex? Are they using, um, TRP? Are they using, um, you, I believe you said the, uh, amniotic membranes as well is another route to go.

Patrick Yeung: Yes. So yeah, patients should be asking their doctor, you know, what is your focus? What is your [01:06:00] volume? What is your goal of surgery? How do you prevent adhesions? All of those are, I think, are very reasonable questions that the patient can have for the. Surgeon 

Dr. Brighten: mm-hmm. 

Patrick Yeung: That the surgeon should be able to provide answers for if they don't have a plan to prevent adhesions options, strategies.

That's important to know. 

Dr. Brighten: You said that you do not do suppression post-op. That is gonna be news to a lot of people. So why are you not doing suppression in, what are you doing instead? 

Patrick Yeung: So, I, I'm very deliberate in what I'm saying. I, I say if, if we have achieved our goal of optimal excision, cutting out whatever is suspicious for endo in whatever form and wherever found, they don't need to be on suppression for the sake of preventing endo from growing or coming back because basically there's no visible disease left behind.

I'm very specific about saying that they don't need to be on suppression for the sake of suppressing the disease. [01:07:00] Again, it has not been proven that suppression does anything for the actual disease in terms of preventing. Progression or recurrence of the disease. There's this common belief that, you know, you need to be on suppression up until surgery to keep the endo from growing or after surgery from coming back.

Neither have been proven. It has been shown that you might feel better longer. The interval to have a repeat endometriosis or endometrioma might be longer if you're on suppression post-op. But in terms of the actual disease, it has not been proven to prevent progression. We talked about that. Studies have shown that the, the need for suppression earlier and longer as an adolescent could be a marker for more advanced disease.

We do stage four endo every Thursday, at least every, you know, week in, week out. And most of those patients have been on years of suppression, years of no periods. And here we are with advanced disease affecting the bowel, requiring a bowel resection. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So it's [01:08:00] not been proven to prevent progression.

And then post-op again, you might feel better longer, but it's not been proven to actually prevent. The rate of recurrence of the actual disease. 

Narrator: Mm-hmm. 

Patrick Yeung: So we would say the best way to prevent it from growing or coming back is to remove it. 

Narrator: Mm-hmm. 

Patrick Yeung: And to, to be really focused on that and again, achieve this goal of optimal excision, which is clearly defined as, again, removing all visible disease in all of its forms and wherever found.

Dr. Brighten: Mm-hmm. You know, something that Dr. Bro Cabrera, who I had on the podcast said is that he feels that when women are put on birth control and not investigated for endo, and that's allowed to go and, and they're told, just wait until you wanna have a baby, or wait until things are bad enough, that increase the risk that they will have progressed deep infiltrating endometriosis.

Do you agree with that? 

Patrick Yeung: Yes. We, we would say that the best [01:09:00] prevention. Is early diagnosis and removal. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Again, you can't be doing surgery on everybody. No one's saying that. But we went through our list of red flags. You know, if, if the story is, is classic for endo and you know, especially if suppression has failed, the chance of endometriosis goes up and the earlier we can re remove it, then the better for the patient.

And in fact, again, with our 10 year study showing a very low rate of repeat surgery, it's not proven. But if you can remove it early and have a low rate of repeat surgery in 10 years, maybe we've done something early to help preserve. Later fertility. 

Dr. Brighten: Mm-hmm. Do you have an age cutoff? Like as in terms of like you have a 15-year-old who has extreme endometriosis pain.

Is that someone you would do surgery on, or would you Wait, is there any reasoning behind that? [01:10:00] 

Patrick Yeung: So people would say, teenagers cannot have endo. That is really 

Dr. Brighten: what, who says this lies? I'm no guy. It's me. Hi. I'm her. 

Patrick Yeung: Exactly. So teenagers can absolutely have endometriosis and again, you know, in, in the right setting a surgery would be reasonable to look for and treat endometriosis even in a teenager.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Again, teenagers are at the prime of their life. They, I would think or would believe that are the first to want to live their best life. If they're saying they can't function, they can't go to school, they can't attend the social activities or sports that they want to do, something is wrong. That is not normal.

That should be looked at sooner than later. 

Dr. Brighten: Yeah. I'm curious, after excision surgery, are there key things that can help determine long-term success, like pelvic floor, physical therapy, anti-inflammatory diet? Are there any things that you recommend patients do? Because often I [01:11:00] think doctors are like, just have a surgery and then you can have another surgery and another surgery.

And I think women with endometriosis want to be proactive in their health and want to be working towards how to have that best quality of life. So if we've done excision surgery, what else should be coming next? 

Patrick Yeung: That is such a great point. So I like to say, you know, we remove endometriosis or treat endometriosis as a disease for pain.

For fertility or both. But there can be other sources of pain that have to be addressed in addition to or after surgery for Endo. And there can be other things that have to be optimized for fertility after surgery. So absolutely for a kind of, kind of a comprehensive approach, there can be things that have to be done on the pain side and the fertility side.

In addition to, or after the surgery, we're focused on just optimizing the anatomy and the surgery. Mm-hmm. But we collaborate for the non-surgical pain and the non-surgical fertility. 

Dr. Brighten: And what does that collaboration [01:12:00] look like? 

Patrick Yeung: Well, pelvic pain centers or there can be other sources of pain. There's the evil twin to endometriosis with is, which is interstitial cystitis.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Which. The classic story is it feels like a bladder infection, but it's not. Two thirds of patients with endo have ic. The treatments are not, uh, antibiotics. It's things to help reduce inflammation. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: The evil triplet is the muscles or physical therapy, but oftentimes the physical therapy is not optimal until the underlying pain generator, we call it, has been dealt with like endo or see.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So, but these terms, evil twins, evil triplets, just convey the idea that there may be other things that have to be addressed in addition to or after the surgery for endo, same thing on the fertility side. There can be the need for optimizing the hormones, the targeted hormonal evaluation and support, we call it.

If you're going to measure and support the hormones, it has to be properly timed to the cycle because the hormone levels change throughout the cycle. So using a method of fertility awareness to know where you [01:13:00] are in the cycle, to properly measure and then support the hormones properly timed is very important.

Optimizing cervical mucus, optimizing ovulation. All the functional medicine piece there, all those things can be important and helpful in best fertility chances. And again, they all, they are related as well. I, I really believe that wellness and fertility go hand in hand. Mm-hmm. The better the patient feels, the better her chances of fertility.

Dr. Brighten: Let's talk about optimal timing for labs, because the number of times I have seen a progesterone of 0.2 and I'm like, what? And they're like, my doctor says I need progesterone. I'm like, when did you they do this? Oh, I was on my period. I'm like, right, okay. Uh, you're not gonna have progesterone. That's fantastic.

I'm so glad not to see progesterone. But a lot of doctors will order these tests. They don't know when to order them correctly at the right time in the cycle. And they also don't know how to interpret them always, but, but they're not doing it because, you know, they're, they're trying to do a disservice [01:14:00] to the patient.

They're like, okay, maybe this can help. And the patient's asking, so let's help patients advocate for themselves. When should they have testing? And what are we looking for? 

Patrick Yeung: So the dominant hormone in the first half of the cycle is estrogen. The dominant hormone in the second half of the cycle is progesterone.

Back in the day, and it's going outta favor because it's not accurate. People would measure the day 21 progesterone. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Which is the proper time to measure the progesterone peak? If the woman had a 28 day cycle and she was ovulating on day 14, which is maybe a third of women, a third of the time, 

Dr. Brighten: maybe.

Patrick Yeung: Maybe you need to know when you ovulate and then measure the progesterone peak seven days after. Or even a whole curve of progesterone, but timed properly to after ovulation. So having a method of fertility awareness or knowing where you are in the cycle when you're ovulating is really important to properly time and [01:15:00] measure.

And then support the hormones. And you know, we've often looked at progesterone as the dominant hormone and what the levels are and, and supporting deficient progesterone levels in the second half of the cycle. But we're also knowing now that estrogen is not just important in the first half of the cycle, but also the second half of the cycle.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And it might be that the progesterone or estrogen to progesterone ratio is important and other things. So, but knowing where you are in the cycle is critical. 

Dr. Brighten: So seven days post ovulation, what are you looking for in an estradiol and a progesterone in terms of levels? 

Patrick Yeung: So we would like it 16 to 20.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So, but people will say, oh, if it's over three, that means you've ovulated, 

Dr. Brighten: no it'ss 10. 

Patrick Yeung: That's an ideal. That's 10 friends. So it's very different to say, confirmation of ovulation versus what is an ideal level. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: For pregnancy support. Or even feeling well. Okay. So I don't know if we had planned to go there or you wanna go there, but, [01:16:00] but PMS, 

Dr. Brighten: yeah, let's do it.

Patrick Yeung: What is the first line treatment now for PMS? 

Dr. Brighten: I don't even know. Is it SSRIs at this point? I don't treat with that. Yeah. So it 

Patrick Yeung: used to be birth control pills. 

Dr. Brighten: Yeah. 

Patrick Yeung: But now it's antidepressants. 

Dr. Brighten: That's what I thought. Yeah. I feel like I wrote the book Beyond the Pill and then I kind of disrupted things in terms of pill prescriptions because women took that information.

They demanded better. But then I'm like, it's now switching to SSRIs. That's not what my go-to is not at all. 

Patrick Yeung: So as a woman, I mean to say you're having mood changes that occur before the period that get better with the period, but to say you need to be on an antidepressant to feel better from that makes no sense.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: That's kind of a slap in the face, I would think. But if you properly. Measure the progesterone levels or hormone levels properly timed to, to the cycle and support the levels properly. Timed patients can have a dramatic improvement in PMS symptoms. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: They're like, [01:17:00] thank you for giving my life back.

Husbands are like, thank you for my wife back, and so it is not disproven. That progesterone support can help PMS and in fact, if it, it, it has to be properly timed to get the benefit of progesterone support for PMS. 

Dr. Brighten: Mm-hmm. And so for progesterone support, what are you doing? 

Patrick Yeung: Progesterone can be given in different ways.

It can be given orally, vaginally, injections. You know, you can find what is needed and what works for you in the most streamlined way. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But it can be given in different ways. 

Dr. Brighten: Yeah. And for people listening, if you're not trying to get pregnant and I see like progesterone is, so let's clarify. If your progesterone is three, yes, you probably ovulated, but your corpus lium, it just failed the test and it's not making enough progesterone and that matters if your progesterone is 10.

That's what I'm like, yes, ovulated, yes, Corpus Lium is trying to do its job, but as you said, I look at 15. If you're not [01:18:00] above 15, that's when we look at progesterone replacement, especially if you're, you're wanting to get pregnant, but doing things like vitamin C, keeping your stress low, vitamin B six and even Vitex can be really helpful for supporting that corpus luteum.

Once you're in your forties, those things are less helpful because the, you know, the ovaries are. Aging out of the reproductive years and deciding to make their transition. So we talked about doing the day 21, uh, you know, uh, testing. That's not the gold standard anymore. We wanna be looking at five, seven days post ovulation to get that peak.

Then you manager, uh, you mentioned FSH on day three, I'm assuming you probably test an estradiol then as well as you're collaborating with people to make sure that this patient has optimized hormones. And I think that's a good takeaway here is that you are not just being like, let's just do a surgery and hope and pray that you get pregnant.

It is, let's optimize the person in front of us and we need to [01:19:00] excise the lesions. Why is excision so important on the outcomes of pregnancy? So not just getting pregnant, staying pregnant, but also the postpartum experience 

Patrick Yeung: to mention kind of big picture like again, when you're. Properly measuring and supporting the hormone levels to treat PMS and patients are feeling better, then they also have better chances of pregnancy and reduced chance of miscarriage.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So again, just this idea that the better you feel, the better your chances of pregnancy, that wellness fertility absolutely go hand in hand, whether it be pain with endo or mood and PMS. Well, okay. We know that endometriosis, even as surface implants is associated with pain and fertility, infertility, but how is it doing that when the cells are not deep enough to be in the nerves?

Mm-hmm. Or without distorting tubes and ovaries is a great question. We don't [01:20:00] fully understand that. We just know that by treating even surface endo, quality of life, sexual functioning improves, and fertility chances go up. A patient with endometriosis. We will have the quarter, quarter of the rate of the chance to get pregnant per month.

But by treating endometriosis, it doubles that baseline rate. Mm-hmm. At least. So we know that treating endometriosis improves, even surface endometriosis, helps pain, quality of life, sexual functioning, and fertility. The whys may be less well understood. You know, modern day theories or theories include reducing, uh, the, what it's, it's causing a toxic environment in the pelvis, or there's this inflammatory component in the pelvis that is causing infertility or affecting somehow the sperm and the egg.

Increased central sensitization to pain from [01:21:00] inflammatory factors, things like that. So there are theories about how, what the link is to, of the implants to pain and fertility. But we do know that surgery does improve both. 

Dr. Brighten: Mm-hmm. And it's been interesting, I think, you know, we can learn so much from patients and I've seen women who are like, I did a histamine pro protocol, H one m, H two blockers, and I was able to get pregnant.

Or women who have endometriosis. Using GLP ones, not even women who are, um, overweight. And I know there's an argument of like, well, they probably have visceral adiposity. Maybe we didn't do a DEXA scan on this person, but there's endometriosis patients being like, I'm gonna use two point or 0.25 milligrams of ozempic.

And my inflammation is dropping and my CRP goes down. I'm feeling better, I'm functioning better. And I think it's, this is, I bring all this up not to tell people run and take antihistamines or run and take, uh, GLP ones, but I think it lends insights to exactly what [01:22:00] you're saying when I hear so many endometriosis specialists saying is that there's more to it.

There's more to the immune system going on. This is not just a infertility condition, this is not just a pain condition. This is a very complex, as you said, neuroinflammatory condition, and we have to be going deeper. Where do you think the future of endometriosis is headed in terms of treatment with the really excited, uh, flooding the system of PRP, um, and preventing adhesions?

That's exciting. Are there other things on the horizon? 

Patrick Yeung: That's a great question. You know, I really have said for a long time that I think that. Cancer research and treatment is like 30 years ahead of endometriosis. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: Research and treatment, or at least endometriosis, is 30 years behind cancer research and treatment.

So in the world of cancer, you have networks of excellence, of cancer centers focused on treating cancer that collaborate, that do research, and the treatment plan is [01:23:00] now tailored to the patient. We talk about individualized, personalized treatment plans that can involve surgery, but then maybe you send off some of that tissue to figure out what type of cancer you have and what chemotherapy agents might work for your cancer after the the surgery.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And then other comprehensive treats or modality treatments or modalities after surgery. To, to comprehensively treat that cancer. I think that's gonna happen, or can happen with endometriosis where surgery is one part of it, but there's a more comprehensive approach to the treatment of this whole body condition, which is endometriosis that involves surgery, but then other things, maybe the surgery even by, by having the tissue diagnosis can, can inform what other treatments might be beneficial to you.

But you can lead to a personalized and individualized treatment plan. [01:24:00] 

Dr. Brighten: Do you think endometriosis should be classified as a cancer? 

Patrick Yeung: It, it's, it's been called a benign cancer and no one really likes that. Neither in the endo world or the cancer world. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But I would say it's at least underdiagnosed.

Undertreated. It's not on the radar. It's so much more common than people think, and it needs to be looked at for what it is, which is a very common disease that affects millions of women. And it needs to be researched and treated with the same. Intention and deliberateness as cancer. 

Dr. Brighten: Mm-hmm. And for people listening, because when you say a benign cancer, people are like, well, the disease is not benign.

It's benign in the sense of cancer categories. And so that I think is what patients who don't really understand, uh, you know, benign versus malignant cancers, uh, and then have it just being called benign. It doesn't feel benign when you live with it. Right. It feels very [01:25:00] confusing. And I think, you know, that's where it's like, it's, it's not on the patient to understand the jargon of medicine.

Women have been saying that when they can't find an endo excision specialist in their area, they go to a cancer surgeon instead. Why do you think that is? 

Patrick Yeung: Well, it can be that level of surgery. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: It can be that complexity of surgery, and again, when it's advanced and it's affecting other vital structures, bowel, bladder vessels, ureter, it can be that level of.

Surgery and complexity of surgery. So oftentimes it is the cancer doctors who deal with advanced endo that requires a team. But the problem with cancer doctors is they're not very good at preserving fertility or even preventing adhesions. So it really should be its own specialty where the surgery is focused on removing the disease, but also preventing adhesions to preserve or optimize or restore fertility.

[01:26:00] That's a very different surgical focus. 

Dr. Brighten: You say it should be its own specialty. Do you think that it's serving patients to allow the general ob gyn to do excision surgeries? 

Patrick Yeung: I decided early on to be good that this should kind of have to focus on it. You know, it has been said that you should not follow your heart or follow your passion.

You should do what you're good at. My wife and I were having this discussion and then she goes on to say to me, you know, and you're kind of OCD and you like to finish what you started. And even the bowel surgeon that I work with, that I've worked with now for 10 years, I think over the years, again, we're doing stage four bowel endo cases week in, week out.

I think he's done some of the most bowel endo cases in the country. I joke that when he graduated residency, he got the, they roast you, he got the OCD award. That is the guy you want for treating your endo. 

Dr. Brighten: Yes, 100%. 

Patrick Yeung: So, you know, it takes [01:27:00] somebody with that kind of focus, I think, to do a good job. And again, I, I really try to stay in my lane 

Dr. Brighten: mm-hmm.

Patrick Yeung: And do what I have been doing for over 15 years and be good at that and, and, and work on focusing on. Optimizing the anatomy and then I collaborate for the nonsurgical part. But I think having that focus is really important. 

Dr. Brighten: Bowel, endo, what is that? For people who don't know, 

Patrick Yeung: that's endometriosis. So endometriosis again is these cells that are implants on the wallpaper of the pelvis, but it can sometimes are often even go deeper than just the surface and involve other structures.

So it can involve the bladder, it can involve the bowel. You can have a nodule of it where it's got some depth, uh, to it and it's kind of invaded into the, the bowel or the bladder or the ureter or whatever. You can get a ball of it in the ovary, that's an endometrioma, but you can technically have endometriomas or nodules [01:28:00] in other places also.

Dr. Brighten: Mm-hmm. Yeah, I think it's really important for people to hear that because so often, you know, I, I've seen a lot of doctors who don't know endometriosis lately on podcasts and clips coming out and them saying things like, oh, it's just gonna be found on, on the uterus. That's where you find endometriosis.

Or there's no reason to have imaging and, and for people to understand that it really can affect any organ in the body. It's rare to leave the pelvis, but it's not unheard of to lead the, to be leaving the public. So I think it's really important for people to understand that like there are other organs involved, which is why you are bringing in specialists for that when necessary.

And I think that is one of the things I tell people all the time, get imaging. Because the best guess at who you need in the room is better than opening you up and realizing we got the wrong team in place. We don't have the right people in the room, and now [01:29:00] you gotta come back. We've gotta do this again.

Or sometimes they're like, we'll take a little bit out and then you're gonna come back in six months and do the surgery again. And I think that is part of what you are doing to get to that one and done as often as possible with patients. 

Patrick Yeung: Yeah. So when these consensus guidelines came out for the mapping ultrasound, the people that that promote, that, that advocate, that say you should be able to plan for the proper surgery.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: You should really never be surprised or should be rare with the proper imaging. You can know what to expect and plan for the right surgery. But to answer your question about, you know, what is the surgical focus or what is the point of surgery, even just to put it simply as. Oftentimes the trans of asthma ultrasound is looking for a cyst, and they might see a persistent cyst that is suspicious for an endometrioma, and then they go in and do surgery, which is really focused on just dealing with the [01:30:00] endometrioma.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But two things happen with an endometrioma. One, they almost for sure have surface disease, so if you just deal with the endometrioma, you've not done anything to the surface disease. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: That needs to be treated because again, stage one and two or surface endo can affect both pain and fertility.

Or they'll release the endometrioma with the ovary from the sidewall and deal with the cyst, but not deal with the sidewall disease. That's often over the ureter that made it stick in the first place, and again, is also endometriosis that has to be treated on the other side. If you have the form of advanced disease that's now in the ovary as an endometrioma, that puts you at risk for the other form of advanced disease, which is.

Maybe a nodule in the bowel. And that's where the mapping ultrasound comes in to look for that. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So you really need to be comprehensive to look for and treat all the different forms of endo for best results. 

Dr. Brighten: When did imaging [01:31:00] become available to patients? And for providers to be able to really understand the extent of endometriosis.

Because I will hear from patients who will say things like, well, 20 years ago nobody told me I could have an ultrasound or have an MRI for this, but this is not something, so I don't want anyone to feel bad or feel like, well, I should have known better. So when did imaging actually become at the forefront in endometriosis care?

Patrick Yeung: Yeah, that's a great point. It's been years in the making. Um, you know, we have really only been incorporating these guidelines, these standards on mapping ultrasound in the past few years ourselves. MRI and ultrasound can be as good as each other. But again, it is really a specialty in its own focus. And you need somebody who is following consensus guidelines or standards to know how to do the MRI.

There's certain [01:32:00] protocols or the ultrasound, there's a protocol. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And then how to read it. So it does take specialized training and experience to do imaging well and properly. And those guidelines and those standards have only been in the last few years really become standardized and become more the norm, especially among centers of endo.

But we're at a good time now that, that this does exist. 

Dr. Brighten: Mm-hmm. When you say certain protocols, are you doing a gel? MRI? 

Patrick Yeung: So people who do MRIs do involve often rectal gel. Mm-hmm. Yes. Now I. We've chosen to go the route of the in-house mapping ultrasound, which we can do ourselves. We can see the images ourselves, and that involves a rectal prep.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: So it's an enema an hour before the ultrasound to empty the very end of the rectum so that we can see that bowel better. 

Dr. Brighten: Mm-hmm. Okay. So that's how you're doing the ultrasound in-house. [01:33:00] Most surgeons that I would ever recommend people to, I are doing the, they're either in-house doing the ultrasound or they're doing in-house ultrasound with a gel, MRI, and they have their radiologist that they work with.

But it's very much tightly regulated in like, this is how the protocol works, this is how we do things. It's not a, you just pop into your o ob gyn, they do a quick peek and then you're on your way. And I think that's important for patients to hear. You know, I've, um. I just had somebody send me a message the other day and they were devastated because they went in for their surgical consult and they were told, well, you have advanced Adenomyosis, adenomyosis.

I think in the US I talk to people all over the world, there's no consensus on this name. So with that, um, they were like, my surgeon was like, you are probably looking at a hysterectomy. And they're like, but my OB GYN said my uterus looked perfect. And I'm like, [01:34:00] your o ob GYN should have been able to see that.

They should have been able to see if it's that advanced. And I would also just get a second opinion from another surgeon, like, just get a second opinion and make sure that you, you know, what's going on. In the case of adenomyosis, you know, in terms of imaging, what are you doing to diagnose that? 

Patrick Yeung: Well, just to make that point, I mean, endometriosis is by definition outside the uterus and.

All you do is remove the uterus. You've done nothing to the endo. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And people think that you know, if based upon an outdated bad theory, the retro administration theory of Samson, that if you remove, which is basically the backflow theory, that when a woman is having her period, she's bleeding backwards through the tubes and those cells implant that if you remove the uterus, you're somehow removing the source of endo.

So you can't have endo without a uterus. That is absolutely 100% not true, especially if you've left the ovaries again, which can produce hormones to activate the endo. [01:35:00] People have said the number one thing that we can do to help women with endo is get rid of this bad theory. But you can absolutely have endo without a uterus.

In fact, we had a case the other day where she had no uterus and no ovaries, but a giant nodule that went into the back of the vagina and the bowel. So she, she had advanced. Endometriosis in nodules in both the back of the vagina and the bowel after surgical menopause. And she not only felt better after surgery, but was so validated in being diagnosed with this disease, these nodules, and having it removed.

Narrator: Mm-hmm. 

Patrick Yeung: And again, that the importance of the exam. I've had several patients where they've had exams by GYNs, multiple GYNs, and over years we do an exam and there's not only a giant nodule between the uterus and the bowel that you can feel, but it's actually [01:36:00] sometimes coming into the back of the vagina and you can see it on speculum examination.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: And it's like, how was this missed? I remember one patient in particular where, you know, you could see it on speculum examination, you could feel it. I told her, you have advanced endometriosis based upon the exam alone. And she began to cry. I said, I'm so sorry. And she was crying because she was so validated.

Dr. Brighten: Mm-hmm. 

Patrick Yeung: She was happy that she had been given a diagnosis of advanced endometriosis when she's been told for years. This was just all in her head. 

Dr. Brighten: Gynecologists supposed to be the vagina experts. How are they missing this? How is endometriosis being missed so often? 

Patrick Yeung: It's, it's unbelievable. Again, it's so important for the surgical planning to do imaging of some kind and an exam to look for advanced disease to be able to plan for the surgery.

Narrator: Mm-hmm. 

Patrick Yeung: So, yes, so imaging can be used as well to look at kind of a form of advanced disease in the uterus, which is adenomyosis, which is [01:37:00] where the cells, which line the uterus, have made their way into the muscle of the uterus. It's kind of like endometriosis of the uterus, but MRI and ultrasound can suspect adenomyosis.

Now, if it's normal, it doesn't rule out adenomyosis. Clinically, I suspected when somebody has had a patient, has had optimal excision, had the endo removed, but they still have significant midline symptoms, whether it be pain with periods or heavy bleeding issues, or deep pain with intercourse, then maybe we say it's coming from the uterus itself or it's from adenomyosis.

Mm-hmm. That's how I suspect it clinically. It really is a tissue diagnosis like endo really is. You diagnose it not by looking at it, but on tissue after the specimen has been removed, but we can suspect it or look for it on imaging. Yes. 

Dr. Brighten: Mm-hmm. [01:38:00] In cases of infertility, what can be done about adenomyosis?

Patrick Yeung: Well, sometimes adenomyosis, it can consolidate as a ball of it or a mass of it in the uterus, and we can remove that mass. To debulk the uterus and increase chances for fertility. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But if it's just diffuse and it's not consolidated, then there's no great way to treat it for fertility. Mm-hmm. People have tried to suppress suspected adenomyosis with suppression for fertility.

I, I'm not convinced that that is very helpful to do that. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But if a patient does have suspected adenomyosis, I will say it does not rule out feeling better or chances of pregnancy or, or getting pregnant. So. My wife and I, my wife who had stage four endometriosis was told that she would not get pregnant, but through IVF [01:39:00] because of having advanced disease and likely adenomyosis, and that's not true.

We have a baby board in the office of babies that were born after surgery for endometriosis, and many of them had stage four and we're told the same thing. They probably do have adenomyosis and yet got pregnant after surgery. So having adenomyosis does not rule out the chance for feeling better or pregnancy.

Dr. Brighten: Mm-hmm. If a woman listening today finds the right team takes this root cause approach, you've been talking about, treats the disease instead of suppressing it, what could her life look like in the next five years? 

Patrick Yeung: When patients have their disease, their endometriosis diagnosed and treated, they're so validated in getting answers, but they also can get their life back.

Their sexual functioning can improve. They have improved chances for fertility. They can result in a. Baby and their life, their, their journey can be totally different. I, I, like, I use my wife's phrase often that, you [01:40:00] know, I, I just work here. You know, God is the ultimate divine healer, but to be a part of helping a patient get their life back or get pregnant has eternal value.

And I mean, patients, the, the number one sentiment or emotion that women, women have after getting their disease removed and feeling better are often saying, you know, I wish I had done that sooner. 

Dr. Brighten: Mm-hmm. 

Patrick Yeung: But to get their life back, to do what they need to do, to live their best life or to have the gift of pregnancy, you know, there's, there's nothing better to be a part of that.

And for the patients, it's a whole new lease on life. I always say my, my job is. I just feel like I work here and my job is to optimize the anatomy or set the table and then offer it up. 

Dr. Brighten: Mm-hmm. Well, thank you so much for taking the time to sit down with us today and share your expertise and for everything you're doing for women everywhere, 

Patrick Yeung: and thank you so much.[01:41:00] 

You're doing great work for women. 

Dr. Brighten: Thank you so much for joining the conversation. If you could like, subscribe or leave a 

 

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