Pelvic Congestion Syndrome, Interstitial Cystitis, & Chronic Pelvic Pain (CPPS Disease): How to Finally Get Relief | Dr. Ana Sierra

Dr. Sierra: [00:00:00] Muscles are like a window to whatever you're feeling. Whenever your muscle reacts to something, this will cause pain because it compresses a nerve. The thing about our pelvis is that it has the same amount of nerve connection that your brain. In surgery, we sometimes do some nerve blockages in order for the patients to start forgetting the pain.

Dr. Brighten: IUDs. Endometrial biopsies, colposcopies, these very painful procedures in the United States, a lot of women aren't even offered pain medications. Why are women not getting adequate pain management for these procedures? 

Narrator 1: Dr. Anna Sierra 

Narrator 2: is transforming the field of pelvic health as a world class endometriosis surgeon and neuropelviology specialist.

Narrator 1: As a minimally invasive gynecologic surgeon with ISON Level 3 certification and a Master in Neuropelviology, she's one of the leading experts tackling chronic pelvic pain. 

Narrator 2: A trailblazer in her field, she's a published author and part of the team behind the first neuropelviology [00:01:00] paper out of Mexico. At the renowned Doyen Institute in Mexico City, 

Narrator 1: Dr.

Sierra uses cutting edge techniques to help patients overcome endometriosis, vascular compressions, pelvic floor dysfunction, and more. 

Dr. Sierra: If you have pain in your pelvis that lasts for more than three months, that is chronic pelvic pain. So there are several causes of pain. One of the most common ones are 

Dr. Brighten: When it comes to women's pain.

They generally have more recurrent pain, more severe pain, longer lasting pain than men because of medical gender bias. But how can women advocate for themselves when they are experiencing pain and their doctor's like, maybe you need to just go to a therapist, or maybe you're just drug seeking. They have to really understand their disease and they have to look for their best.

Welcome back to the Dr. Brighten show. I'm your host, Dr. Jolene Brighten. I'm board certified in naturopathic endocrinology, a nutrition scientist, a certified sex counselor, and a certified menopause [00:02:00] specialist. As always, I'm bringing you the latest, most up to date information to help you take charge of your health and take back your hormones.

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Don't forget to subscribe, leave a comment or share this with a friend because it helps this podcast get out to everyone who needs it. All right, let's dive in. [00:03:00] Dr. Ana Sierra, welcome to the podcast. Thank you so much for having me. Yeah, I am super excited for this conversation because we're going to be talking all about pelvic pain, different things that can lead to pelvic pain, but also very importantly, what we can do 

Dr. Sierra: about it.

Of course. Yes. Uh, I've been following you for so many years and I'm really excited to be here. 

Dr. Brighten: Oh, I'm so honored. You know, I'm very fun. I'm like blushing right now. That's just like so amazing because I found your work and now I am a huge fan because You just really advocate for women's health, for women's pain.

So often, women's pain is dismissed, and we know from the research, at a far higher rate than men. Yes. Why is that? They've 

Dr. Sierra: have, like, a lot of research has been made, and they have seen that whenever a man gets into a consultation about pain in the shoulders, the man is even half the time or even, it has been said like [00:04:00] 10 times, it's easier for them to get analgesics.

Yeah. For pain. But women, they get, uh, psychiatric consults. 

Dr. Brighten: Yeah. 

Dr. Sierra: So it's like really horrible, I think. Uh, there was a study made in a fertility clinic. Uh, the nurse stole the fentanyl. Oh yeah, I saw that. Was that in 

Dr. Brighten: Harvard? 

Dr. Sierra: I don't know. It was some Ivy League school and so 

Dr. Brighten: everybody was like double shocked because, you know, you just think Ivy League, like they must have higher standards.

Spoiler, they don't. In this situation, there wasn't enough checks and balance, but go ahead, like the, so stealing the fentanyl, right? They 

Dr. Sierra: stole the fentanyl and they change it for water. Yeah. So the, the patients were complaining about pain and the doctors were like, nah, you're, you're addicted to painkillers.

You're, yeah, you're just an old junkie looking for another fix or something. And they, it took them six months. to see that the drug has been changed for water and they didn't believe in the [00:05:00] patient's pain. That, that blows my mind. It's like, if the pain, if you can see the pain in the patient's eyes, I mean, you can see it.

It's really hard, like, oh, I don't know. We try really hard to advocate for patients that, even though, Pain for them is real, even though it's centralized and there is not another explanation and it's only that memory of the pain, but for them, the experience is real, so we have to listen to them.

Dr. Brighten: Absolutely, and that, um, that particular case with the fentanyl that you're talking about, that was post egg retrieval, so that is somebody taking a needle, going through the vaginal wall, which is a muscle, This is painful in itself and into the ovary and then sucking out all the eggs they can find on both sides.

I've had three. 

Dr. Sierra: Okay. My 

Dr. Brighten: third one, um, I will actually share. I woke up and I was in serious, serious pain and they took it very seriously. Immediately they were like, We have to do an ultrasound, like we have to see what's going on because we've given you pain meds [00:06:00] and I was thinking about that fentanyl study and I was like, did somebody here like steal my fentanyl?

Um, and as it turned out, like when I found out later, I had endometriosis and I had an endometrioma. I was like, Oh, well, this. This makes so much sense why it was so painful. Okay, when it comes to women's pain, they generally have more recurrent pain, more severe pain, longer lasting pain than men because of medical gender bias.

This is well documented, irrefutable at this point, but we're going to get into like all the things that cause pain and what women should be looking for. But right away, you know, you're like, doctors need to believe women. Okay. That's the first thing we need to change. But how can women advocate for themselves when they are experiencing pain and their doctors like, Maybe you need to just, you know, go to a therapist, or maybe you need to sleep more, or maybe you're just drug seeking.

Dr. Sierra: They have to really understand their disease. First, they have to really advocate for themselves, as you're saying, right? And they have to look for their best [00:07:00] doctors and the doctors that do care about them. There are a lot of lists of doctors that are really experienced. experience in the causes of pain, and they can look for them because not all of the doctors are like studying pain in patients.

And it's really weird because pain is the most often cause of consult in any specialty. Right? So, yeah. 

Dr. Brighten: Yeah. So lists, you got to find the right doctor. Any resources for people who are listening? 

Dr. Sierra: Well, in cases for endometriosis, we have the I Care Better lists. And there's also another list that it's only like.

patients, uh, only patients like writing their stories in that list is Nancy's Nook. 

Dr. Brighten: Yes. 

Dr. Sierra: Then you can also, uh, like look for your really good doctors there. And in Latin America, we have endolatum. We have doctors that are really vetted and that you can see the quality of the surgery. So you can look for the best.

Dr. Brighten: Yeah. And I know that some people have criticisms of things that are said in Nancy's Nook. And I think, you know, that's [00:08:00] totally valid. Especially we always want to. from the context of what's true for us. But what I love about that resource is that there are people sharing their stories. And so, you know, often when you go to like Yelp, Google, these review sites.

It's usually just angry people. It's usually like people leave a review when they're mad, but hearing like how people were helped, how they were able to advocate, advocate for themselves is really helpful. And I think for anyone listening, you know, these resources specific to endometriosis, this is one of the leading causes of pelvic pain.

If you find a doctor who is endometriosis literate, and understands that, they're going to be able to help you navigate a lot of other pain, but they are more likely to believe you, wouldn't you say? And 

Dr. Sierra: there are also patients advocates. We have a lot of, um, like, resources out there, and they do help people get the best doctors in their communities, so that's also another resource that they can find.

Dr. Brighten: Yeah. 

Dr. Sierra: IUDs, 

Dr. Brighten: endometrial biopsies, colposcopies, these very painful procedures. In the United States. [00:09:00] I don't know if it's true here. A lot of women aren't even offered pain medications. They're told the cervix has no nerve endings. They're not going, yeah, you got to laugh. I always laugh about it. They'll say like, Oh no, it has no nerve endings.

Okay. You're going to feel just a pinch, which is it? Is it a pinch or is it no nerve endings? Like why is this myth still perpetuated in medicine? Why are women not getting adequate pain management for these procedures? 

Dr. Sierra: Well, it has been done like many years ago and the doctors were only male and they've never experienced a pinch on the cervix.

So it's like, um, I used to be a medical student and I used to place many speculums and I do them a lot, a lot, a lot. But when I was in the residency, when I get my first pap smear, I was like, Oh, my God, this is what you feel. This is not correct. I mean, this is not a little pinch. Yeah, you can feel it. So you start placing yourself in the patient's place.

So [00:10:00] that's the way that your brain starts to change. And then you can say that is really painful. 

Dr. Brighten: Yeah, 

Dr. Sierra: medicine has been done for males. Uh, male doctors, and it's not a bad thing, but vagina, it's something that not many people talk about. Mm-hmm . And even patients, they, they don't tell their, their pat uh, their pain because they are like ashamed of it.

Yeah. Because why, if she, if he's telling me this is not something that is painful, why am I feeling pain? Mm-hmm . Something must be wrong with me or. I, I am feeling too much. I am hysterical. I am. It's me. I'm the problem. I'm the weird one. So yeah, we have to change the narrative and really start looking at the patients and asking for them if they need something for their pain.

Dr. Brighten: Yeah. 

Dr. Sierra: Yeah. 

Dr. Brighten: Well, and that's something I, you know, whenever people ask me, like, why did you get into women's medicine? So much of it is because I just had this epiphany when I was in medical school that, you know, So often women's medicine is done to them, 

Dr. Sierra: not 

Dr. Brighten: with them, not in consideration [00:11:00] of them. And it is very much as like, doctor is dictator.

And like, I know best, I even know your own body best. And that's where I was like, we have to change things. And this is why I'm so excited to have you here because you are literally changing the landscape for women. 

Dr. Sierra: We're trying to, yeah, there's like this meme, I don't know if you've seen it, like there's like this big doctor and it's like a woman there and he's telling like, well we have studies on fireflies and on rats, on rabbits, and on males, but yeah, they never occurred to us to do studies on females.

Okay, that's so true, right? Yeah, so many few studies, right? We've done properly on women and for women's health. So yeah, it's Yeah, 

Dr. Brighten: so when we're talking about pelvic pain, you know, we've got problems of doctors having their Even things like, you know, accusing people of being drug seeking. This is very common in the United States among black women, indigenous women, and Latinas, where doctors are like, well, you're different skin [00:12:00] color, so you must just be here for the drugs, which It's a huge problem in itself.

Your eyes are so big as they say that. So, you know, so there's the bias of it's just in your head that you're drug seeking and that, you know, being misinformed and then the lack of research as well. So I want to really help women in this conversation. I think the best place to go next is what are the common causes of chronic pelvic pain.

What is chronic pelvic pain and what's behind it? It's big. Yeah, 

Dr. Sierra: it's a really large answer. But okay, if you have pain in your pelvis that lasts for more than three months, that is chronic pelvic pain. That will be like the short, like the, yeah, like the capsule version. So there are several causes of pain.

One of the most common ones are muscle contractions. Muscles are like a window to whatever you're feeling because muscle contracts and react to the activities that you're doing on daily basis. Yeah. So that, yeah, that's a really brilliant 

Dr. Brighten: way to put that. 

Dr. Sierra: So [00:13:00] whenever your muscle reacts to something, you can have a contracture muscle and these will cause pain because it.

compresses a nerve, okay? There's this fabulous quote from Dr. Posover, who is our professor in Neuropelviology, and Dr. Posover says, pain is not a pathology, pain is information that travels through the nerves. When I heard that, I was like, okay, yeah, this is not something that I have to numb. This is something that we have to study in order to find the source.

And then we can help people. And, uh, I've been like, really hooked on pain ever since. Now I think that it's not only information, that pain is also a whole body experience because whenever I talk to our patients, it's different experience whenever they're with familiars or whenever they're comfortable in their house, the experience of pain is completely different that When they are alone with no [00:14:00] support system, the experience of the pain changes, even though it's the same signal in the nerve.

Dr. Brighten: How does it change if you're with people that are your community versus not? Yeah, they 

Dr. Sierra: feel it less. I mean, the experience of the pain and everything's related to it. They, yeah, they don't feel it the same way. And they are more resilient when they have a strong support system. 

Dr. Brighten: Mm hmm. 

Dr. Sierra: Otherwise, in other patients that People don't believe in them.

Their family is left, uh, doctors don't believe in them. They feel alone. The pain, like, it feels like something like a burden, no, or something different. Yeah. So, yeah. 

Dr. Brighten: Especially because when you're in pain, it can be so difficult to take care of yourself. And as you were saying, it's easy to get in your own head about it, of like, something's wrong with me.

Why, why is my body broken? And, you know, start to have that negative self talk. But I love that you Out of this community piece, because I don't think there is any chronic health condition that isn't positively impacted by being surrounded by people you love. Not just [00:15:00] people in general, because some people, they're not great to be around, but having people who support you can make such a difference.

I'm curious, in terms of the role of hormones, what do you see as, in terms of hormones like influencing pain? 

Dr. Sierra: Well, okay, uh, hormones do make a huge role in female health. Mm hmm. We need hormones. I don't like the fact that some doctors, uh, try to numb our patients and try to take away their estrogen. So like Lupron.

Dr. Brighten: Yeah. Um, 

Dr. Sierra: I'm not really like really into that because they don't explain exactly the secondary effects. And I don't like, like our patients getting with osteoporosis or higher rates or having, uh, A vascular infarction, a cardiac infarction. Yeah. So heart attack. Yeah. Heart attack. For the layperson. Sorry. I 

Dr. Brighten: know it's so hard though.

This is like, there's doctor brain and you're in doctor mode and then you're like, wait, but [00:16:00] people listening to this, they might not know what an infarction is. It's okay. Yeah. I'm your medical translator. Thank you so much. 

Dr. Sierra: And also, uh, dryness in the vagina, that, uh, everything about the brain changes with your hormones.

Yeah. So the experience is different whenever you're with the hormones and without them. 

Dr. Brighten: Yeah. And I think, you know, that's a little bit what's troubling is that so often if women report that there's cyclical pain, then the answer is just shut down the cycle with the birth control pill. 

Dr. Sierra: Yeah. 

Dr. Brighten: And as you were saying, pain's information.

We have to find the root of it. Where is it coming from? And not just numb it out, so to speak. 

Dr. Sierra: Yeah, because, well, there's only, there's not only, like, cyclical pain. It's not only explained by endometriosis. Vascular causes of, like, congestive, congestive pelvic syndromes or congestive pelvic compressions.

They do have cyclic pain. During their menstrual cycle, and they are so often confused with endometriosis. I have so many patients that come with us, uh, for a condition, a pelvic pain condition. [00:17:00] And for example, um, it was a 20 year old, uh, she was on, uh, Lupron since 16 because she has endometriosis. But you're not 

Dr. Brighten: supposed to do that longer than six months.

Dr. Sierra: And then Somebody call that 

Dr. Brighten: doctor. 

Dr. Sierra: No, well, and then I will. You 

Dr. Brighten: don't have to. 

Dr. Sierra: because she has some bleeding in their period through her urine. So they suspected they have endometriosis in the bladder and the ureter and in the kidney, you know, because if you have pain and it's cyclic and you have irregular bleeding something, it has to be endometriosis.

There's another condition called nutcracker syndrome, in which you have the venous Uh, the venal, uh, the, all the kidney vein, and then you have another artery, it's called the mesenteric artery. So it's got, it's, it does, the angle is like a little bit like shortened, so it compresses the vein. And have you ever seen like the cartoons when you compress a tube and they compress like a hose, I don't know.

Yeah, yeah. And it builds 

Dr. Brighten: up. 

Dr. Sierra: So it started [00:18:00] building up the pressure and it affects the gonadal, the gonadal, yeah, the gonadal vein. So that's the vein that goes into the ovary. So it starts there. It's provoking pain during menstrual cycle and also bleeding through the urine. So this girl, we have to stop all of this medication.

And they did a surgery to correct the malformation. And that was it. That wasn't endometriosis. She did not 

Dr. Brighten: have endometriosis. And yet they set her up for osteoporosis, dementia, Lupron. I'm big mad right now. 

Dr. Sierra: And they didn't, like, explain the secondary effects? And they only tell them, uh, tell her, Oh, well, this is endometriosis because you have cyclic pain.

Mm hmm. So that's the thing. You have to understand what is the cause of the pain because, yeah, it has, it could be muscular. It could be vascular. It could be also additions or something that's caused because of previous surgeries. 

Dr. Brighten: Yeah. 

Dr. Sierra: Because whenever we touch something inside of the body, your body is going to react.

Yeah. And [00:19:00] sometimes it reacts making like some forms of additions or some forms of. scarring because they're protecting themselves. So also additions from previous surgeries and some doctors, uh, for some surgeries are needed to do some instrumentation like leaving, um, mesh or tackers. And sometimes these, uh, clamps don't get, uh, like really attached and then start moving and then start compressing some of the nerves.

And this also can cause pain. So that's another cause of chronic pelvic pain. And it's not endometriosis. 

Dr. Brighten: And we're going to talk about even more, you know, I have lots of questions for you today. So when it comes to pelvic pain, it can be musculoskeletal. It can be endometriosis. from the intestines. It can be gynecological.

How do you start to differentiate that? 

Dr. Sierra: We have a neuro pelvological algorithm. So the first thing that we have to rule out, is it a visceral pain or is it a [00:20:00] somatic 

Dr. Brighten: pain? 

Dr. Sierra: They are very different. Visceral pain is really numb. Like the patient is going to tell you like everything, like where does it hurt?

It hurts like here. It's everywhere. Yeah. Because visceral, uh, well, all of your pelvic gut, everything that is inside of you, like get It's, it start to make, uh, relevos, how do you say, um, uh, like making move. And so I give you some information and you pass the information to the next and to the next station.

of pain. Yeah, something like that. Playing 

Dr. Brighten: that game of pass it along, pass it along. So, 

Dr. Sierra: uh, whenever, like you have pain in your intestine, in your uterus, in your ovary, all of that information. gets mixed up and gets into the superior hypogastric plexus, which is right here, uh, between your lumbar and your sacral region.

Yeah. So sometimes So 

Dr. Brighten: between, between the low back and then before you get to the tailbone, so your sacrum. Okay. A little triangle is what I'm trying to make with the sacrum. 

Dr. Sierra: Yeah. So that's why some of the patients say, Oh, it's really hurting here [00:21:00] because all of that information of pain goes there. And then it goes to your brain.

But the same information from your ovary and from your intestine goes to the same nucleus in your brain. So for your brain to say, Oh, there's a pain in the ovary, it's a pain in the intestine. No, I don't know. So everything is in pain. So that's visceral pain. And it's also accompanied by some other symptoms that are called epilepsy.

vegetative symptoms and which are like diarrhea, nausea, vomiting, getting a really pale skin. 

Dr. Brighten: Yeah. 

Dr. Sierra: When you have an activation of the sympathetic system, you're gonna see the pain on your patient. 

Dr. Brighten: I 

Dr. Sierra: didn't believe this until I started seeing my patient's eyes and they have really widened pupils. So when I was seeing that, I was like, Oh my God, the guy was right.

You can see the pain in the patient. And these are ladies who have been like tested for drug abuse and stuff. And, but they are really having an experience in which their autonomic system is not longer regulated. So they [00:22:00] have a lot of response because of the chronic pelvic pain. 

Dr. Brighten: Yeah. 

Dr. Sierra: So that's visceral 

Dr. Brighten: pain.

Dr. Sierra: The other one is the somatic pain. Somatic pain, your patients can tell you with. It hurts here. It hurts here. So it's usually a compression of one of the nerves and it causes pain. The thing is that whenever we have to think about it, like, When you go to in Christmas and you have like circuits of lights Yeah, and sometimes like one of the whole a whole bunch of lights go back go black So you have to change each of the bulbs or you have to check if the wire is 

Dr. Brighten: correctly 

Dr. Sierra: Please don't 

Dr. Brighten: tell me it's that difficult with pain Like if anyone's ever taken out one of the bulbs and no, 

Dr. Sierra: but you have to check The wire that connects the mo.

Yeah. So that's the thing that we have to do in neurobiology. We have to take all of the symptoms of the pain that our patient is presenting, and then find the wire that connects them mo mm-hmm . So we can find the, the source of the pain. Because the thing about pelvic pain is [00:23:00] that the place that. Patient, okay, the next question is in terms of a short term.

So, if 

Dr. Brighten: you 

Dr. Sierra: tell me you're going to do it, I'm going to make it short term. that's what I would say. if it's a long term and you want to do it, you have to think about it. If the patient is, you know, the patient is telling you that it hurts, pain, and the place when the nerve emerges. So all of that, by the way, you have to think about where can the nerve be compressed.

Dr. Brighten: Yes. And so for people listening, Dermatone is basically like the mapping of the body that the nerve follows down. So, and when you say where it emerges, it's coming from the spinal cord. So where is it coming from there? 

Dr. Sierra: Thank you for translating. Yeah, no, that's, no, and it's 

Dr. Brighten: fantastic. We have a lot of clinicians who listen as well.

So they're going to be like right there with you. But I want to make this accessible to everybody, especially because I feel like when you're in pain, you're also really irritable sometimes. And you [00:24:00] have, you have short patience. And, you know, So I just could imagine listening to this being like, what are you talking about?

I'm in so much pain. Um, you've, uh, you've mentioned neuropalviology multiple times. What is that? It's 

Dr. Sierra: a discipline created by Dr. or Professor Mark Pozover. It involves, it no longer has to be a subspecialty of gynecology. You can do it like as a urologist, as a coloproctologist, you can do it as a trauma surgeon.

You basically are going to. study the nerves of the pelvis. That's why we're calling neuropelviology. Yeah, 

Dr. Brighten: which is super specialized and specific and I think probably the most beneficial specialty to pelvic pain for women. You are the only woman in the world, correct? 

Dr. Sierra: Uh, there are like levels of certification between our community and there are three levels of this certification and we have eyes on level one, two and three.

Okay. And [00:25:00] I'm the first woman that who's has achieved level 

Dr. Brighten: three. 

Dr. Sierra: Which, 

Dr. Brighten: you know, great that this all exists, but like, we need a lot more women to be at level three and in this field, especially because I think there's a lot of great male doctors, but sometimes it does take somebody who can understand, have that true empathy of what it's like to be in your position.

And also, I think Sometimes women are just more comfortable seeing women as you were saying, you know, with patients and how sometimes they won't want to tell their doctor about pain. We know from the research that women, they may be less inclined to share about sexual dysfunction, pain with sex. So even the more intimate levels of things, and yet those symptoms are really crucial to know about.

They're less inclined to share in general, but certainly if it's a male doctor and certainly culturally speaking. Thank you. I mean, uh, machismo. It's alive and well among the Hispanic community. I'm actually talking at a conference today. I'm going [00:26:00] to be talking about how like, even if as a doctor you've done all your work so that you don't have those biases and you're open and you can support the patient, the patient may still still hold that.

And so it can be another barrier to overcome. Um, and so you're, you're one of 15 in the world, but when it comes to women, you are the only one at level three. And so I just think that is so incredible and even more special to have you here having this conversation with us. I'm curious, how often is IBS diagnosed rather than the proper cause of pain?

Dr. Sierra: I don't have like any data, but it's really common. Yeah. Because if you have any pain and bloating, you have IBS, right? So, but there are a lot of causes of IBS. And I don't think that is like really some thought placed into it. Even during our formation as female doctors, we start seeing patients as hysterical before we start understanding them.

[00:27:00] So I think This information has to change, and we start trying to change this with our fellows, so they have to see it. Like the way it is, like sometimes we have our own like shock, like resistant of coping mechanisms. So you can send your stress to your skin or you can send your stress to your bowel.

Yeah. And that can affect your bowel. But it's, that's not the only cause of irritable bowel syndrome. So we have to really look into it. Mm hmm. And it's really not often, not, not often. Unlikely often? Oh, well, not really often. Yeah. Yeah. It's really common to have confused with another like something IBS.

We have a lot of, uh, gastrointestinal surgeons that send us the patient when they have IBS and they can't find the cause. Yeah. So it's like, yeah, I'm not longer with her. It's all yours. 

Dr. Brighten: Like, okay, thank you. Which is fantastic because sometimes Because the gastroenterologist will call it IBS and then they're done.

Yeah. And they won't refer. And [00:28:00] I think there's so much power in that referral. And I love a doctor who's like, what is the cause? Because you know, we, I've had gastroenterologists on speaking on the podcast and they've said like IBS is just the diagnosis of, you know, we don't know, like we haven't figured it out yet.

It's like the stepping stone. It shouldn't be the last place that we end because as you were saying, you know, it can be related. to what's going on in the pelvis. It could be related to infections in the intestines. Like it could be all of these things which have a root and have a different treatment.

Dr. Sierra: Yeah. The way that the gut moves is it's regulated by an autonomic system. So we have a compression, for example, in the materials is that we have a uterus sacral ligaments that are like just a folding in the, in one of the facias of the pelvis. Yeah. So we have a lot of nerve endings there. Yeah. And if you have a compression in that level, it can affect the way you empty your bladder.

You have sexual intercourse and the way your bowel moves. All of these [00:29:00] symptoms are autonomic symptoms and they can be regulated by the inferior hypogastric plexus. So yeah, yeah, you can have a lot of symptoms by one tiny little compression, like four millimeters. It can affect the way that everything goes.

Wow. 

Dr. Brighten: Four millimeters is all it takes. 

Dr. Sierra: Oh, or even less. Sometimes we used to. Do well. There's a test called your dynamic study. We didn't used to make in any of our endometriosis patients. unless they have a B3. That's a compression of the uterine sacral ligaments wider than three centimeters. But then we started seeing some of the studies done in endometriosis patients, and we've seen that even 50 percent of the patients that doesn't refer any problems with their way that they empty their bladder or do poop, they do have changes in the your dynamic study.

Dr. Brighten: This 

Dr. Sierra: study, you can see the way that the patient feels about getting water into their [00:30:00] bladder 

Dr. Brighten: and 

Dr. Sierra: it's starting filling up. And then they can see when they do want to empty their bladder. 

Dr. Brighten: And 

Dr. Sierra: then they measure this by milliliters, but they're in the meantime, they're doing an electromyography. So they're seeing that there's an anomaly in the contractions of the muscles of the pelvic floor.

And there's also an anal manometry. So they can see if there's any spasms in the sphincter. So we have a whole set of circle with this information, and it helps us so, so much. 

Dr. Brighten: So 

Dr. Sierra: now whenever there's anything of compression in the utero sacral ligaments, we always perform or ask our neuro urologist to do a, a urodynamic study.

Dr. Brighten: Okay. And can you explain these ligaments to people? Like where do they run? Why are they important? Yeah. Why did they end up in pain? 

Dr. Sierra: Yeah. I don't know if everybody is familiar with, uh, compression ligaments. contact paper. It's like a plastic that self adheres to surfaces. So imagine that you stretch this contact paper and you stuck it into the pelvis.

So it's going to [00:31:00] cover your bladder. It's going to cover your uterus and it's going to cover your intestine because everything is connected in the pelvis. But sometimes when you are like handling this contact paper, you, uh, you don't do it like correctly and it's for, it folds a little bit. 

Dr. Brighten: And it's so frustrating.

Dr. Sierra: Yeah. Okay. So this Foldings into this fascia, the endopelvic fascia. It's called a uterus sacral ligament. It's not really a ligament. It's just a folding into the endopelvic fascia and it connects the back of your spine, like in the sacral and the uterus. So it's a uterus sacral ligament. Well, perfect. 

Dr. Brighten: And for people to understand that There's actually lots of ligaments running in the pelvis.

I mean, there's those that are holding the ovaries in place. I mean, if you've ever wondered why is it you run and your uterus doesn't fall out? Thank your ligaments. Thank all of this connective 

Dr. Sierra: tissue for being president. Of course, yes. It, it does do a lot for us. And sometimes we have a pathologist like EL that you [00:32:00] have like this hyper mobility.

Mm-hmm . You have hyper mobility and I have, but I don't have s 

Dr. Brighten: Yeah. But you neuro divergent as well. Yeah. So I want people listening, if you are autistic or you've been diagnosed with ADHD, pay attention to this moment right now. Tell us about the hypermobility Ehlers Danlos Syndrome, if I can get that out, and what happens with the connective tissue.

Dr. Sierra: Well, it does, it is one of the causes of the pain. We have like this, Talk with a lot of rheumatologists that do know that when you have hypermobility, the, they start to move the structure inside of you. Mm-hmm . So some of the blood vessel can compress the nerve even so slightly. And this is one of the causes of the pain.

Dr. Brighten: Yes. 

Dr. Sierra: So some of the patients that do have hypermobility do have chronic pelvic pain. Mm-hmm . And nobody can explains it to them. Mm-hmm . So we really have to once again look for the cause. of this pain. Yeah. 

Dr. Brighten: Do you see an [00:33:00] increased incidence in those who are neurodivergent having conditions like endometriosis, painful bladder syndrome, other causes of chronic pelvic pain?

Dr. Sierra: No, I think there's, uh, there's a lot of doctors that treat endometriosis that are neurodivergent. But for patients, uh, the only like, um, we have, there's a thing called this autonomy where whenever you're, uh, you're there, there are two systems. in your brain, like the autonomic system and the system that you can regulate.

Like when the autonomic system is doing its thing, it's making your heart beat. It's making your lungs breathe. That's the autonomic system. And sometimes it dysregulates. So you're standing up and then you're like feeling dizzy right away. So like pots. Yeah. Yeah. Okay. So, uh, this condition will, we have a lot of patients having endometriosis associated with this condition.

Dr. Brighten: There 

Dr. Sierra: hasn't been a study that makes like a straight line [00:34:00] between them. 

Dr. Brighten: Yeah. 

Dr. Sierra: There's not, uh, yeah, but, uh, they are really commonly associated. 

Dr. Brighten: Yeah. It's 

Dr. Sierra: like the, uh, the cat in the. And in this, uh, in the, uh, in the ceiling, you have seen this, um, there's this analogy when there's a cat in a roof where it's like a metal roof.

So the metal roof is like really a hot 

Dr. Brighten: tin roof. Uh, yeah, I think 

Dr. Sierra: it is, but it's a roof and it's really like with a widened, like, uh, with a bump. Yeah. Something. Yeah. Yeah. Yeah. That's it. And the cat is sitting there. So because the cat is sitting in something in the roof, it doesn't mean that the cat make a dent in the roof.

Ah, I get what you're saying. I don't 

Dr. Brighten: think I've ever heard this analogy, but it makes a lot of sense. So yeah, 

Dr. Sierra: it's something, it's something, it's causality. It's something that it, that the cat caused the dent in the roof. Yeah. That's not the cause, but they are associated because are in the same place at the same time.

Yeah. So the only thing that we can can see is that POTS and, [00:35:00] well, some of the dysautonomias, uh, can be associated with patients with ENDO. 

Dr. Brighten: Yeah. I just was wondering if you've seen any research because, you know, we know the neurodivergent diagnosis usually comes with a lot of comorbidities. Yeah. Excuse me.

Uh, so, you know, you can see POTS, you can see, uh, connective tissue disorders. There can certainly be increased incidences of PMDD. So we know that autistic women, they've found that, you know, there's an association of it's over 90 percent experiencing PMDD. So the extreme, extreme of PMS. And so, uh, it's something that I have seen neurodivergent patients.

having pelvic pain, having endometriosis, having these other conditions. And so I don't think we're there yet in the research. And that's why I was just curious because it's, and it's exactly what you said. It's not to say that, uh, you know, being autistic caused these things or that having endometriosis caused autism or anything like that.

It's just that there's just, you know, a [00:36:00] pack of like kids that like to hang out together, like these conditions, like, you know, they attract each other. It's interesting that you say there's a lot of neurodivergent doctors treating endometriosis. Why do you think that is? 

Dr. Sierra: I don't know. Uh, maybe because we go into hyperfocus or we, no, that's what I would get.

Or we challenges or I don't know. But yeah, some of my best friends that are neurosurg, well Endos surgeons mm-hmm . Are also neurodivergent. Yeah. As are I. So yeah. I'm also 

Dr. Brighten: neurodivergent. Okay. And I will say something that whenever I meet other neurodivergent practitioners, they're always the ones who get the.

I have to ask why until I know the answer like I can't sleep. It is all I think about and it's why like, you know when we talk about root cause medicine and stuff anyone who's obsessed about I have to get to the root of this and some of the best doctors I know they're neurodivergent and it's because their brain is like I will not let this go.

I must know and if you get If it becomes a, you know, somewhat of like what sometimes people call a special interest, like [00:37:00] it's something that like really excites you and lights you up, like hormones did that for me. Like I can see pathways in my head and I'm like, yes, this is so fun. I think that it's so much easier to make it your passion.

So, um, I just, that's a nice little side tangent we took there. It's very interesting. You brought up the fascia. I'm wondering, um, have you seen myofascial releases? therapy being beneficial for people? 

Dr. Sierra: Yes, I send all of my patients to physical therapy. It's a must. Sometimes they have to do it two weeks prior to surgery.

Dr. Brighten: Sometimes 

Dr. Sierra: they don't even need surgery, but they do need physical therapy. 

Dr. Brighten: Yeah, 

Dr. Sierra: as we were saying that a muscle are part of one of the causes of chronic pelvic pain. So yeah, muscle muscle contractions. I did some time with a physical therapist, only pelvic physical therapist. You have to really look for the ones that understand pelvic pain.

Because some of these physical therapists, they, I only trained, uh, to see [00:38:00] patients in postpartum, which is really good that they have to strengthen the pelvic floor or in patients that have incontinency. So they have also to strengthen their pelvic floor. But if you're going to a consult for chronic pelvic pain in a physical therapy, and they, they make you do, uh, kegels.

Yeah. 

Dr. Brighten: Yeah. 

Dr. Sierra: That's wrong. 

Dr. Brighten: Why is it wrong? I'm glad you said it. It is. So I'll ask you up and I 

Dr. Sierra: will tell people why. Okay. So if you have a contraction in one of the muscles, I mean, one, uh, bulgarianos muscle is, uh, there are a lot of muscles in the pelvis. There 

Dr. Brighten: are, there's a lot. 

Dr. Sierra: And if you have a contracture muscle there.

and you add more pressure to it, it's gonna screw everything up. Like, yeah, you're not going to be able to pee, you're not going to able to have sexual intercourse. And in patients that have chronic pelvic pain, you have a disconnection, they start to stop losing or stop feeling the way that the pelvic floor feels.

Dr. Brighten: Yeah. 

Dr. Sierra: So some of the most common causes that we have of [00:39:00] pelvic floor misinformation or something that it's not connecting. I start asking our patients, do you have any pain? Why? While you're like doing urinating? They're like, no, there's no pain. Okay. How often do you go to the bathroom? Oh, I have this tiny little bladder and I have to go like once every hour, every two hours.

I'm like, yeah, that's not normal. And do you wake up in the middle of the night? needing to empty your bladder? Yes, of course. Two or three times. Yeah, that's not normal. So yeah, that's, it's talking about maybe a compression in this autonomic pelvic system into the inferior hypogastric plexus, but also it can tell us about a contracture pelvic floor 

Dr. Brighten: muscle.

And so doing the Kegels is just going to reinforce that dysfunction. And then maybe you're up six times being at night. That's like very bothersome because we know not getting adequate sleep. sleep can also be a factor that contributes to pain, but also pain can be the reason why you're not sleeping.

What do you see [00:40:00] in terms of like, you know, sleep disruption and people's pain? 

Dr. Sierra: Maybe not sleep disruption, but anxiety. People, uh, well, uh, endometriosis patients, uh, only 70 percent of endometriosis patients have pain. The other, they don't really do, the first cause of the, yeah, the first thing that, bothers them is that 90 percent of people with endometriosis have anxiety, depression, and fatigue.

Yes. So those are the most common symptoms. Anxiety, 

Dr. Brighten: depression, fatigue. These are the most common symptoms of endometriosis, you're saying. 

Dr. Sierra: Not pain. 

Dr. Brighten: Not pain. 

Dr. Sierra: So yeah. And whenever you are sleep deprived, you don't function well. We know this. And we do need to get more focus into this. sleeping patterns into the whole, uh, getting back your life without, uh, getting into drugs.

There has been studies that you can see that, uh, there's like this amino acid deficient in some of [00:41:00] our patients that it's called tryptophan. Yes. So you can, uh, add tryptophan in order to get more senotenin. Tryptophan, it's like, uh, the basic, uh, well, some of the prime materials that you use to build serotonin.

So if you start adding tryptophan to some of our patients who are deficient in it, 

Dr. Brighten: you 

Dr. Sierra: save them from having another kind of medications that also have secondary effects. 

Dr. Brighten: Yeah. 

Dr. Sierra: So I use it rather regularly. 

Dr. Brighten: Yes. And so people know the pathway is tryptophan. 5 HTP, serotonin, and then to melatonin. And so one is making you feel happier, your brain works better, you feel more motivated.

And then you get into melatonin, that's going to help with sleep. Interestingly enough, um, there have been studies questioning those women who are on the pill, how their tryptophan pathway is actually disrupted. And they believe it's in part maybe due to nutrient depletion. completions that are happening, but also [00:42:00] neuroinflammation.

And so they'll make more, they'll make less neurofavorable metabolites. And so in those instances, that's when we'll circumvent with 5 HTP and skip that step. If anybody's listening and you're on an SSRI, do not take tryptophan. You have to talk to your doctor first because serotonin sick syndrome is nothing to mess with.

You will not feel good. Yeah, but that's a really helpful tip talking about tryptophan, you know I think number one is like we've got to get you out of pain But sometimes, you know You you have to do things that help with sleep or will help with pain management as you were saying We don't want to just numb it But that, I assume that doesn't mean you never use an analgesic, a pain medication.

No, we do. 

Dr. Sierra: We do. Yes. We do use, we do use some of the medications that are used as neuromodulators. In surgery, we sometimes do some nerve blockages in order for the patients to start forgetting the pain. The thing about our patients. pelvis, it's that it has the same amount of nerve connection that [00:43:00] your brain.

Dr. Brighten: So I 

Dr. Sierra: think it's really amazing that, and you have also a laterality. So for example, I'm left handed, so my right brain is my dominant brain. And also probably my pelvis, it will be my dominant side. Yeah. So if somebody ever does a surgery in my pelvic nerves, I hope they do it on my left. side. Because if they screw my left side of the nerves, I have my dominant side and they can make new nerve connections.

This is mind blowing. 

Dr. Brighten: Okay, like say more about that. So the, the pelvis is operating in the same way as the brain, if I'm hearing you correctly. So if you're left handed, the 

Dr. Sierra: same amount of connections. Yeah, but 

Dr. Brighten: not, but in terms of like, if you're left handed, then the right side of the brain and the right side of your pelvis is dominant.

Yes. I've never heard this. before. Yeah. This is fascinating. Why does this matter to people? Why do they want to know 

Dr. Sierra: this? Okay. Because of this, I mean, you can have a better recovery if there's like a nodule or there's a tumor in your, for example, in my left, uh, I'm left handed. So I hope [00:44:00] if I ever have a tumor in my nerves, I hope it's in my left side.

So my dominant side will be clear and they can establish new nerve connections. 

Dr. Brighten: Okay. And so, and will you presumably maybe have less pain, better recovery? No, better recovery. 

Dr. Sierra: Okay. Yeah. The pain will be the same, but the recovery will be better. Okay. Like the pain's the 

Dr. Brighten: same. 

Dr. Sierra: Sorry, I didn't mean 

Dr. Brighten: to break it to you.

You have brought up, we've talked about urination and pain with urination several times. I want to talk about painful bladder syndrome, also known as interstitial cystitis. Let us know first, what is that? What are the symptoms someone experiences? 

Dr. Sierra: It has to be like the last. Of the, in a list of diagnosis, you have to, so it is 

Dr. Brighten: the end of the diagnosis train.

Like we've tried everything, we've worked everything out. Yeah. You have to try 

Dr. Sierra: everything. And then you have to do a lot of testing in order to diagnose interstitial cystitis. Mm-hmm . You have to do a cystoscopy, you have to do a biopsy, and you really need to, uh, understand the way that the cells are com, uh, yeah.

[00:45:00] Are behaving and that you really are finding this inflammation between the cells. Okay. So, yeah. The cells lining the bladder wall. Yeah. 

Dr. Brighten: Okay. 

Dr. Sierra: So, uh, before that, you can start ruling out the nerves that, uh, connect the bladder. Mm hmm. And how they are, uh, managing the way that the nerve, the, the bladder relaxes or contracts.

Yeah. So, uh, we have, uh, into the autonomic system, we have the sympathetic and the parasympathetic, and they're like, uh, two brothers wrestling all day long. So whenever the sympathetic is winning, you're gonna have your detrusor muscle is going to get relaxed, and your internal sphincter is going to contract.

And whenever the parasympathetic system is winning, the, the detrusor is going to contract, and the internal sphincter is going to relax. So that's the thing, when, when you're, whenever you're struggling, uh, you're struggling with somebody, you're doing like forces arm wrestling. Yeah. Arm wrestling. Yes. And, uh, you're doing like a mischief and then you move like [00:46:00] this, the other guy is going to fall.

Yeah. So if you cut, for example, the sympathetic system, the parasympathetic system will start to hyper activate mm-hmm . So the, the STR or muscle is going to have hyperactivation and you're going to have a hyperactive. bladder. So that's the thing. You have to understand the way that the nerves control the bladder in order to understand why is this bladder painful.

Dr. Brighten: Okay, so there are foods, though, that people will eat and they notice that it makes their bladder more achy, they urinate more, things like coffee, sometimes spicy food. Yes. What's the connection there? 

Dr. Sierra: Well, they do react to the salting, to the lining of the wall. Uh, yeah, but, uh, there's like, um, no coffee, a caffeine do start to make, um, your kidneys work even more and then you urinate even more, but there's like into a connection that there are foods that make your bladder more painful.

I really don't know like that an exact line, but [00:47:00] you've seen it. 

Dr. Brighten: Yeah, there's definitely recommendations that if you have painful bladder syndrome to avoid these foods, they're like some of the best foods to like citrus as well. And I think, um, you know, people just are always very curious of like, why is that?

And, you know, with interstitial cystitis, when we get to that end diagnosis, what's really behind it? What's causing that painful bladder when it's the lining of the cells that are irritated? 

Dr. Sierra: The, it's, it's been attached to like, uh, an autoimmune system because of your own cells are attacking the cells into your, uh, the bladder lining.

Yeah. So that's what it causes pain. But why are your cells reacting into your own cells of your own bladder? We don't know. 

Dr. Brighten: Yeah. Any tips, things that people can do to help if they're struggling with painful bladder syndrome? It sounds like first, make sure that's exactly what is going on. First, 

Dr. Sierra: that would be the first thing.

And the other one, you have to stop the train of inflammation. Yeah, we've talked [00:48:00] about this a lot with our nutritionists. that do, uh, when diet, when you change the way that they, they eat, they start like diminishing the inflammation. Even when irritable bowel system, uh, it's syndrome or whatever, like inflammation does build up whenever you don't have a really good diet.

So if you're changing some of the way that you eat or some of the way, even the way that you think can cause inflammation. 

Dr. Brighten: Would you say an anti inflammatory diet is helpful for everybody struggling with diabetes? chronic pelvic pain or is it more individualized? 

Dr. Sierra: Yeah, more individualized because it, you cannot say that something can cure everything.

Yeah. There's like no, there's no, there's no magic there. You have to work for your diagnosis, start with the diagnosis and they're still building up. And also the anti inflammatory diets are different for every patient because not everything works for you. Yeah, we cannot say like, stop eating gluten, everybody knows sometimes it wouldn't be great if it was that easy, though, easier.

But yeah, we have to study the [00:49:00] patient and see if gluten is really the cause of the inflammation. Maybe it's lactose. Maybe it's another thing that they're eating into daily basis and they haven't figured out what, which one is it. 

Dr. Brighten: Yeah, we were, I was talking with your colleagues. So there's another episode all about endometriosis, Dr.

Rom, um, Cabrera. And he was like, broccoli might be the problem. And I was like, shut your filthy mouth. Like I love broccoli, I'm obsessed, but he's right. Like it can be very individualized. And so I appreciate you saying that like diet does play a role, but you also mentioned the way that we think can be inflammatory.

Say more. 

Dr. Sierra: Yeah, it's because we've seen it in our patients when they are getting their recovery. If they fix it themselves on how bad do they feel their recovery is like really slow. And we start seeing and we start strolling with them. And we have to convince their brain that, you know, They can do better.

So yeah, I think we are not only one uterus and one ovaries. You have to treat the patient as a whole. 

Dr. Brighten: Yeah. 

Dr. Sierra: So if they're not convinced that [00:50:00] this is going to work, believe me, this won't work. Yeah. Yeah. For even though we do that. perfect work. If the brain is not there, you have to get into it. 

Dr. Brighten: I love that you bring up the mindset because people are more powerful than they think.

Interestingly enough, there was a study, and I think we need more studies on this, uh, that, Even just negative self talk, so saying mean things to yourself, raised cytokines, these chemical messengers that are inflammatory, that are causing that immune chaos. So, so we've talked a little bit about diet, we've talked about seeing pelvic floor physical therapists, uh, I call it talking pretty to yourself.

That's another strategy I'm hearing from you. How do you, medications like muscle relaxers, um, you know, antidepressants fit into the framework of managing pain? 

Dr. Sierra: Antidepressants, I use them, but in conjunction with a psychiatrist. I never prescribe them myself. Muscle relaxants, [00:51:00] when the cause of the pain is a muscle.

You have to understand that, uh, which one is the cause of the pain. Is it the nerve that is like only this polarizing? Okay. Then you have to provide something that makes the lining of the nerve more thick. Mm hmm. if the cause of the pain is muscle, you need a muscle relaxer. But sometimes, for example, they start doing Botox therapy for love, for all of the muscle pain.

And that's not the answer, because if the patient has incontinence and you add Botox, she's not going to be able to pee. So, uh, there are a lot of things that you have to, like, really, So we need to establish an adequate for the patient and not start doing like everything can do for him. No, we don't have like a perfect prescription or like a cooking recipe like, Oh, it hurts here.

You need this and this and this. Like, yeah, we're not chat GPT yet. We need to like get more into the thought process that this goes for this and this go for that. 

Dr. Brighten: So again, I'm hearing [00:52:00] from you a very individualized approach. We might use muscle relaxers, we might use SSRIs, we might use Botox. But. Yeah.

Used in the wrong patient for in the wrong way for the wrong condition, they can do more harm than good. Yes. Yeah, that, like, that has me worried for how many people have been, um, you know, you, I see a lot online where people are like, oh, I had pain, and I just, you know, went and had Botox, and, uh, which, you know, might have helped for them, but I think people should consult with an expert about it to make sure they're not doing more harm than good.

You've mentioned pain with sex. I, for people listening who experience that, what are some of the common causes? 

Dr. Sierra: We study dyspareunia in three thirds of the vagina. So we have the outer third, the middle third, and the inner third. So where you're, when you're experiencing pain in the outer third of the vagina, you're talking about superficial things like infections like tearing during postpartum, like some scarring tissue that could have been ended up there.

Dr. Brighten: If 

Dr. Sierra: you have pain during [00:53:00] intercourse in your middle portion of the vagina, that can be caused for an increasing of the tone of the muscles. It could be a contracture muscle or it can only be, remember that muscles are the way that you react to something. So sometimes you can trigger some memories.

intercourse and your muscles are going to react even though you're not causing it even though you think you have gotten over this. You talk about memories, you're talking about 

Dr. Brighten: things like sexual trauma, trauma in general. 

Dr. Sierra: Yeah. Pain sometimes is a memory of the pain, not something that it's going away.

stimulating right now or right at that moment of the patient. So we have to really sometimes figure out that before we give a diagnosis. And also, well, last on the list, uh, and, uh, most, uh, deeper inner third of the vagina, we're going to think about vascular compressions. We're going to think about additions.

And we're going to think about nodules, for example, like a tumor or endometriosis. [00:54:00] Yes. 

Dr. Brighten: So endometriosis could be behind that, you could have nodules, you can have, you can have several pathologies that could be behind it. Yes. So we don't want to ignore pain in the sex, but sometimes you're in a position, someone knocks your cervix, it's a one off and you have pain.

Should anyone be concerned about that? 

Dr. Sierra: Well, if it's like sometimes there's an orgasm in the cervix and some of the patients do enjoy them 

Dr. Brighten: Yeah, and 

Dr. Sierra: some others they don't like it. Yeah. Oh, yeah, it's not a bad thing. So it's just a preference thing 

Dr. Brighten: Yes, you just said there's an orgasm in the cervix. Yeah, I've actually written And it's in my book.

Is this normal and I have had doctors say no, there's not this is women just imagining it. So I'm just I want, I want, I think, okay, so I want to talk about pelvic pain today. I think you're going to have to come back for a second episode. We're going to just do a sex episode. Okay, yes. But I want you to talk about that because I'm not that big of a tease.

Uh, so go ahead and, uh, let us know. cervical orgasm. What is that? 

Dr. Sierra: Well, uh, you [00:55:00] have a lot of nerve endings in the cervix. And when you stimulate the right point, you can have an orgasm. It's as simple as that. Like, you don't need, like, there are a lot of spots in the women and you have to study them. But, uh, there isn't a cervical orgasm and they, you can see it, uh, like for the lubrication and all of these nerve endings that you can stimulate and they do came to an arousal and by the end of it, an orgasm.

Dr. Brighten: Yeah. Yeah. We'll talk, we'll have you back and we're going to talk a lot more about it because there's been interesting studies on like paraplegics rerouting their nerves, being able to have orgasms in different ways. Like I think we should nerd out on the neurology of orgasms. Okay. We're going to come back and do that.

But for people who are experiencing pain with sex, so we've got at the introitus at the opening, we've got mid. So, so if you're somebody listening, you're experiencing this trying to identify where is it and if it's. It's deep. Who should they go see? Because usually it's going to be their gynecologist who might not be [00:56:00] that educated on this.

Dr. Sierra: Yes, that's the thing, uh, you have to, or even, uh, Well, some of the physical therapists are really amazing, and they do know about physical therapists. Yes, yes, they do know about these causes, and they do ask for their right studies. And if there's an organic cause of it, like a tumor or endometriosis or something, they do send them to us.

appropriate doctors. But even though any doctor that does understand this, you have to do your research and start seeing the way that your doctor speaks and the way that they do publish in order to find the way that are causing chronic pelvic pain. Mm 

Dr. Brighten: hmm. 

Dr. Sierra: I think 

Dr. Brighten: that's the great thing about social media is that people can kind of get a glimpse into their doctor and see what's going on.

But also, you know, Going back to, you know, even Reddit can be such a great place for women. I had no idea until a patient was like, Oh yeah, no, I like found your name on a Reddit group. And I was like, Oh, okay. But women are telling their stories, [00:57:00] talking about what doctors they've seen. 

Dr. Sierra: It can be a really good source, I think, but I've never been on Reddit.

So I don't know. I try 

Dr. Brighten: to 

Dr. Sierra: stay off of it. 

Dr. Brighten: Yeah, I try to limit any, any toxic interactions online. And sometimes it can be that way. Yeah. Um, So we want to talk about lifestyle changes people can make to help alleviate chronic pain. I, I do, you're going to, I still have other questions for you about certain conditions, but just in general, you know, we've, we've only talked about, I think a few things, but what kinds of things in someone's lifestyle, if they're dealing with chronic pelvic pain, can they start to examine and really check in about, do we need to modify this?

Dr. Sierra: Okay. You have to start seeing, uh, the pattern of your pain. I think exercise can be good for everybody, but you have to really know the cause of your pain. 

Dr. Brighten: Yeah. 

Dr. Sierra: Whenever you have a vascular compression, you're gonna feel, uh, this limitation on the way that you do your exercise. Uh huh. So you have to really check that one out.

Uh, the way that you perform the exercise, you can do, like, um, first, well, with the physical therapist, we have a lot [00:58:00] of, uh, people doing Pilates without having any problem and Pilates are really hard. I mean, yeah, have you ever been into it? 

Dr. Brighten: I love that you bring this up because there are some haters online of Pilates and they're like, you should just lift heavy weights.

And if women are doing Pilates instead of like weight training, like that, that's a, like, you know, that's not what you should be doing. And I'm like, well, It depends, and certainly with pelvic pain, that's one of the ones that, especially when people disassociate, Pilates demands you know your pelvic floor.

Anyhow, you can say more about Pilates and how fantastic it is, but I just want to shout out to people doing Pilates. 

Dr. Sierra: In patients that do need like to strengthen the muscles also, Pilates is like a really good other choice. There are people who don't like to move weights, but weights are really important in order to preserve your bones, for example.

So you can mix and match some of this, but you have to like really find the place that it makes endorphins for you and you are enjoying this. Yeah. [00:59:00] Because it shouldn't be like a punishment. Because sometimes you take exercise like, yeah, because I have to fit into this pattern or in this body. And that's not the way that you're supposed to do it.

Yeah. You're supposed to do it like a celebration of what your body can do. If it doesn't feel like that, you're not supposed to do it like that. Yeah. You really have to find the place that you're comfortable and you're enjoying your time that is going to help. so much more because of the endorphins and the way you're, you're releasing pressure and that's going to do wonders for your pain.

Dr. Brighten: Yeah. And the endorphins are something that I think, you know, it's easy to forget about when you're in pain. So someone with endometriosis, when my period comes on and if it's been a month where I have not managed things well enough and I'll wake up and I'll be in pain. And it's so easy to be like, I just, So, um, I don't know, I think you should listen to your body and give yourself permission, but [01:00:00] I, and so I appreciate you saying that's valid, but I always have to like remind myself, like, But if you go lift weights, those endorphins will kick in and your pain will be so much more manageable today.

And it's always that way, but I forget about those endorphins all the time when I'm in pain. I'm like, what, what are endorphins? I don't even know. I just want to lay here. And I love that you say finding what you enjoy because on the days that you have pain that you're not feeling well and you feel like, oh, well, I'm supposed to lift weights or I'm supposed to go to like, like spinning class.

Like go do that. The bicycle, like I'm supposed to do these things, then you're less motivated. But it kind of just like compounds like more shame, more judgment, more guilt of yourself. And if instead it's like I get to go for a walk, I get to play tennis with my friend. I get to do something that I enjoy with my body.

I think it's a good mindset shift. And knowing that. With exercise, I mean, we, it's irrefutable, all women should be lifting weights, sure, but that doesn't mean that it [01:01:00] has to be every day, and I think when it comes to this chronic pelvic pain conversation, as you were saying, if you've got issues with the blood vessels, that might affect how you're able to lift weights, how you're able to exercise, so listen to your body, listen to your doctor, you're going to get better.

Less than you listen to influencers online is what my takeaway 

Dr. Sierra: would be. Yeah, stick with your diagnosis and really start getting really lectured into it. I've met so many patients like these last years that we have like gotten more into the community of endometriosis and they do know more. that most of the doctors about their disease, they're like, Oh my God, you know this.

And it's so amazing that you're a patient and you really know and you can advocate for yourself. So it's like showing up for yourself when this exercise matters. Like, what do you need right now? Because you do need to take a day off. Okay, it's a good thing. But tomorrow, what are you going to do? Like, uh, you cannot like cuddle and like, [01:02:00] um, get fatigue every time.

Okay, you're going to feel fatigue. But where this fatigue is coming from? Is it coming from a place in which your brain is not working properly? Do you need any medication? Do you need to sleep? speak to somebody. 

Dr. Brighten: Yeah. 

Dr. Sierra: Where is this fatigue coming from? Or is it that you're taking so many things at the same time?

You really need to lay a little bit back into the work, family and everything around you. So you have to find this sweet spot, right? 

Dr. Brighten: Yeah. Finding the balance is hard when you're dealing with chronic pain. Why? Right. As women who are working and families and all of that. But I think sometimes Especially when you're dealing with pain, it is so much of this, like, I'm not doing enough.

There's gotta be more. There's more that I'm doing. I've gotta, you know, restrict my diet more. I need to work out more. I need to, and it's just, sometimes it feels like you need to do more and sometimes the answer is no. to do less. Maybe just like understand that just being with your community and spending that time that day might be the most nourishing thing for yourself.

Yes. I 

Dr. Sierra: [01:03:00] think, uh, I've seen this post sometimes in the, um, it used to say, uh, there is no balance. Uh, when you come like women doing work, like working moms and stuff like. It, it was about the surgeon and she said like, uh, there is no balance. Like being, um, a surgeon makes me a better mom and being a mom makes me a better surgeon.

So there, you cannot like change or make a space for everything. Sometimes you're going to fail at everything, right? 

Dr. Brighten: I definitely have had those mornings. Not this one. I made it. Thank goodness. What about things like Chinese medicine or acupuncture? Have you seen those being helpful? It helps a lot. I do 

Dr. Sierra: work, um, he's, uh, he's a really amazing, uh, acupuncturist.

He's like a 10th generation acupuncturist. Like, yeah, he came from Taiwan. He's, he's a really amazing doctor in Querétaro called Sergio Lin. If you ever want to chat with him. It's [01:04:00] amazing. Um, here's like a 10th generation and he is like, their parents are from Taiwan and, uh, he knows so much thing about nerve connections because he also studied the general medicine.

So after studying medicine, he dedicates to acupuncturist because he knows everything because of their family and the traditions and stuff. And I've seen so many patients get better with acupuncture. So it does help. 

Dr. Brighten: Oh, that's fantastic. Yeah. 

Dr. Sierra: With chronic pelvic pain. Some of the patients we have to send them.

Mm hmm. Mm hmm. Because, yeah, he treats, like, nerve endings and, uh, depolarizing nerve endings. Yeah. So it's part of the same, part of the team. I mean, you have to have one, uh, acupuncturist into the team because it does work. 

Dr. Brighten: You have a very holistic approach and you take a team approach to pelvic pain. 

Dr. Sierra: Yes.

Dr. Brighten: What types of team members So you said acupuncturist on the team. Who else should be considered? Well, 

Dr. Sierra: I have a physical therapist [01:05:00] and we have a pain management. Uh, he, uh, well, she's an anesthesiologist with regionalist approach and also a pain management. He does all of these blockages for pains with patients with, for example, cancer or something like even chronic conditions like even wider or in cases of chronic pelvic pain because of the pudendal nerve entrapments or something that she can block.

So we have that in our team. There's like an all female team at which I work in Greta. We have a coeloproctologist, a female urologist and anesthesiologist, um, our nurse, and that's me, and that's it. And I also work here in Instituto Allianz. It's part of like the same thing. 

Dr. Brighten: Yeah. And you also have a nutritionist.

Yes. I'm a nutritionist as well. Yeah. I'm shouting out your nutritionist because I think Yeah, she's really great. That's really unique. I mean, not everybody gets It's that team approach, [01:06:00] and so I wanted people just to hear like, who are the types of members that we should be considering on a team as we approach pelvic pain, and to understand the limitations of doctors.

I think it's sometimes frustrating when you go to the doctor and you're like, why can't they solve all my problems? Well, they're very good at specific things, but I always say it's like, it's like going to the ice cream shop and asking for a sandwich. They don't have the capacity to make you a sandwich, you gotta go to the sandwich shop for that.

But the ice cream's still good. It's like. The ice cream's still good, but like, you just need to see the right provider for what you need, and that can be sometimes hard to navigate. 

Dr. Sierra: Also, pain has so many levels, so we have to treat every level of the pain, so there's not only like one cause of your pain that you can like swipe a little wand and everything is going to get better, right?

Dr. Brighten: Yeah. 

Dr. Sierra: You really need to get into the causes of the pain and treat them as a team if we want our patients to get better. 

Dr. Brighten: I wish we had a wand, but until then. That would be so amazing. In the team. Yes. Pelvic congestion syndrome. You've brought that up a few times. And so I want to talk a little bit more [01:07:00] about what that is.

Dr. Sierra: When your blood vessels are not working properly, okay? So they start to build up pressure and this pressure compresses the nerve and they start to provoke pain. Mm-hmm . So, uh, there are a few syndromes that are like most common for the example, the Nutcracker syndrome that we were talking about. Also may Turner syndrome, which is uh, also a blood vessel compression in which an artery compresses.

Um. A vein? Okay, I'm not going into a lot of details, but we have a lot of those. The thing is that whenever there's a blockage in the way that the blood vessels take blood back from the legs to your heart, if there's a blockage, they're, they're going to start to look for another pathways. Yeah. And these pathways, as they are like new, they are not built up with the same technology.

Whenever you're doing something really fast and you don't do it, like, correctly, they're like aberrant the way that the, the, these blood vessels are formed. And these malformations [01:08:00] of blood vessels start compressing places where they don't fit very well. 

Dr. Brighten: Because they were never designed to be there to begin with.

Yes. 

Dr. Sierra: So this blood compression starts to build up and this pressure starts to build up and it causes more pain. Is it always 

Dr. Brighten: a blockage? 

Dr. Sierra: Sometimes there are malformations that they do, were born like this. But when they are kids, they don't move as much blood. So it start building up the pressure as their years go by.

Dr. Brighten: Okay. Mm hmm. And with this, how would somebody know that this is something they're struggling with? Can they, do they have symptoms that are pretty obvious? 

Dr. Sierra: Pretty common. Like you can, if, if I told you that it's this menorrhea, like pain during your menstrual cycle with symptoms like having painful urination, painful defecation, painful intercourse, uh, pressure in your belly and sometimes pressure in your legs, you're going to think about endometriosis first.

So, but those are the same symptoms for conjecting pelvic syndrome. 

Dr. Brighten: So 

Dr. Sierra: yeah, the thing is that you have to go to [01:09:00] a doctor that does know the difference between these two causes. 

Dr. Brighten: And the 

Dr. Sierra: test that we do is an ultrasound Doppler. And then we see the widening abdominal, no, uh, vaginal. And then we measured the, uh, the uterus.

The, the uterine artery and the ovarian arteries and the veins, and we see if they are dilated. Mm-hmm . So that's, that's the way that we start thinking. I work with also an, uh, vascular surgeon also in the team. . Yeah. . So you have to buy them. Yeah. 

Dr. Brighten: And, and, and tell people how the doppler is different. So you can't just get a regular ultrasound and see the blood flow.

Yeah. Explain that. 

Dr. Sierra: The Doppler is like, there's a Doppler effect that we can, that you've seen it because of whenever you're hearing like a siren to go like, you think that the siren is coming closer because of the way that sounds comes closer to you. So that's the in, in the way that they apply this into the ultrasound that they can see if the [01:10:00] blood is coming towards to you or getting away to you from your transducer.

So, the way that you can find a blood vessel is with this coloring that you can find or you can add to your ultrasound. But with this technology, we can measure the widening of the, of the, yeah, the widening of your blood vessels. So you can see the arteries and the veins, and then you can see if they are abnormally enlarged.

Mm hmm. Who's most at risk for this syndrome? Um, patients that do have something in their, like, uh, varicose veins in their pelvic, in their pelvic. legs, they're usually attached to something in their pelvis. Those will be like one of the things that you can find. If you see somebody who has like little, uh, worms or little snakes in their legs, or and not so, uh, so, uh, like, uh, horrible cases, but sometimes you can see little spiders in the little 

Dr. Brighten: legs.

Dr. Sierra: Yeah. Little spider veins could also be a sign that there's something wrong in their [01:11:00] pelvis. 

Dr. Brighten: If people have a family history, so let's say their mom, their dad had varicose veins, is this something that should be on their radar? 

Dr. Sierra: Yes. Okay. Yeah, especially if they have chronic pelvic pain. 

Dr. Brighten: Okay, and it's definitely something they should note to their doctor.

Yes. Actually, my grandmother, she had these varicose veins, or my mom. Yes. Okay, that's good for people to note. What is the treatment for this? 

Dr. Sierra: It depends on the cause. If there's a malformation that we have to, like, get a surgery on it, there, you can transposition the blood vessels in order to stop the blockages.

Dr. Brighten: But 

Dr. Sierra: sometimes they have to, like, eradicate the, these abnormal blood vessels. So they don't follow this pathway and they follow the proper pathway. And what does that look like, eradicating abnormal blood vessels? They go to, uh, like a surgery, into a flibography. So they go into their femoral. This sounds awful, but They go into their arteries, but it's endocatheterization.

So everything is [01:12:00] into their blood vessels. Yeah. So it's, it's a nice thing that they don't have a very good, very large scar. 

Dr. Brighten: Yeah. No, I'm just like, Oh, this sounds awful. Just like, I'm like, I know what this procedure is, but for people to know I, I have a looming blood draw today. And so like, even like, I immediately started thinking about like, You know, taking that catheter all the way up, I'm like, get out of your head, get out of my 

Dr. Sierra: own head.

What can 

Dr. Brighten: people do 

Dr. Sierra: to 

Dr. Brighten: prevent this? 

Dr. Sierra: No, and it also can be as easy as taking a pill in order to make your blood vessels more strengthened. Okay, so back, this is the treatment still. I got ahead of you. Interrupting. Only that thing, and then we can, yeah. Yeah, so you can take a pill. What's this pill? Uh, there's, uh, there are some medications that make the blood vessels, uh, stronger.

Strength, like, uh, it strengthens their walls, and that's the only thing that they need in order to not have any more pain. Oh, that's fantastic. So it can be as easy as that. So you really need to know the cause to treat it. 

Dr. Brighten: Okay. 

Dr. Sierra: What about prevention? Prevention. Uh, exercise does help, uh, yeah, uh, sometimes [01:13:00] swimming does help a lot, but if you have a malformation as much as, as much as you swim, maybe you're going to stop the pain sometimes or the, stop the, the newest connections because your blood is going to draw very well backwards, but you're going to still have a malformation, so yeah.

Dr. Brighten: Yeah, we can't out exercise a malformation, but what types of exercise can people do if it's not due to a malformation 

Dr. Sierra: swimming? Swimming helps a lot because it doesn't add any more pressure to it. 

Dr. Brighten: Okay. And so any, like, type of swim? Is it like, do you need to be against a current? Is it like anything special?

Yeah. You 

Dr. Sierra: just tried water or something? Yeah. You're trying water. Yeah. Training water. And that your heart rate increases. So you're doing exercise. Yeah. 

Dr. Brighten: Okay. And what about things that, you know, we know can help with blood vessels? So, uh, antioxidants, vitamin C for supporting connective tissue, vitamin A, like nutritionally, are there things that people can be adding in to support their blood vessel integrity?

Dr. Sierra: Yes, but they [01:14:00] haven't like they a lot of studies that support this like into the medical community that I can Tell to you like I haven't read anything that has enough like information so I can recommend this Yeah, maybe I need to read more. 

Dr. Brighten: No, I appreciate you, you know Letting us know, like I just haven't read into that and also I think we know nutritionally things that can help and I think that's all great, you know, preventatively for like keeping your body healthy overall, um, but I just want people listening to know that not necessarily as a treatment, especially if there's a malformation, you have to address what the actual cause is.

Yes. I want to move on into fibroids because Okay. They are quite common, uh, well let me first back it up and say, can you define what fibroids are for us? 

Dr. Sierra: Okay, uh, have you ever eaten steak? Yeah. You can see, uh, the muscle cells, like you can see like these little stripes. Mm hmm. So those are muscle cells.

Dr. Brighten: Yeah. 

Dr. Sierra: And sometimes one muscle cell goes like rebel [01:15:00] and goes like into a little ball, it rolls itself into it. And then another one rolls himself into it, another, another one rolls himself into it. So you stop having like a roll of muscle tissue. So it's. It's tissue, muscle tissue, that is like wrongly placed.

This is the tumor, a benign tumor, the most common benign tumor in females. It can add to cancer in really rare cases, like 0. 02%, like it's really rare that a fibroid goes into a sarcoma. But it's one of the most common tumors that females have. And 85 percent of the females that do have fibroids have endometriosis.

So there's a strong association between fibroids and endometriosis. 

Dr. Brighten: Yes. And what usually comes first? Is it usually a young teenager, 20 something is experiencing endometriosis, then like 40s, 50s she develops fibroids? Or what, is there a typical pattern you see? 

Dr. Sierra: No, there's not a typical pattern because [01:16:00] endometriosis, you're born with it.

So these cells can trigger pain in whatever the autoimmune system starts triggering itself. 

Dr. Brighten: Yeah, so 

Dr. Sierra: that's the thing. And the fibroids, I've seen them in patient as young as 18 years old. Yeah, so there's not as, as we grow up in age, like we are making more diagnosis because more female patients are getting into making an ultrasound.

I've met patients that are in their forties and have never had other undergone an ultrasound unless they're pregnant. Yeah. So sometimes they don't have the the that they do need, like, in order to see that their uterus is normal. 

Dr. Brighten: Yeah. But we do see that the majority of women are going to develop at least one fibroid by the time they get near the age of menopause.

In terms of, I'm just curious, in your patient population, because in the United States we see that black women are at the highest risk, do you see the same? Or [01:17:00] What do you see in your practice? 

Dr. Sierra: We don't have like that much of, uh, changes or like we, we attend a lot of Latino patients where we, we don't have like a lot of black women coming here.

So we don't have that, uh, gender or ethnicity, uh, studies that we can support. Yeah. Yeah. Not as much. 

Dr. Brighten: And it's so quite common in your patient population. 

Dr. Sierra: Our patient population is really common. Okay. 

Dr. Brighten: What. Is it that, you know, can help someone identify that they might have a fibroid? So maybe it's, you know, incidentally found on an ultrasound.

But what are the symptoms that they might experience? 

Dr. Sierra: They might experience pain during their menstrual cycle, but also heavier menstrual cycles. And sometimes they can do having like I'll start having like irregular spotting or irregular cycles because of the pressure. We have to remember that the endometrium, there is like the inner lining of the uterus, does bleed because it unattaches themselves whenever [01:18:00] you're not pregnant.

So it, it heals itself. And it has like this natural anticoagulant that makes that blood flow really easily. But when you're, uh, bleeding from the muscle that, that's where the fibroids are. Mm-hmm . There's not anticoagulant, so you're going to have heavy, heavier bleeding. It's sometimes with coagulants.

Mm-hmm. So that's one of the, the clots. Thank you. Yes. Where that's one of the tips that you can see that you're bleeding from your muscle. You can have either adenomyosis or fibroids because you're having clots. 

Dr. Brighten: Okay, and anemiosis, fibroids, heavy bleeding and clots, let's quantify that. How much blood are we talking about would be abnormal?

Dr. Sierra: Well, we know that the normal blood period of bleeding, it'll be 80 milliliters for the whole week. So that's the thing. Some of my patients are like using the menstrual cup. 

Dr. Brighten: And we have 

Dr. Sierra: to remember that the menstrual cup, the small one can be 10 milliliters or 15 milliliters. And sometimes they're getting into a cup every three hours.[01:19:00] 

And like, are you measuring how much are you bleeding? It's like, this is not normal, right? You have to really measure and see how many towels are you using or how many tampons are you using. But if you don't want to count it, if you have to change your towel in less than an hour. When you say towel, 

Dr. Brighten: you're talking about pads.

Yeah. 

Dr. Sierra: Yeah. Yeah. Yeah. Sorry. Yeah. Pads. You're totally fine. Yeah. Or a tampon. If you have to change it after one hour, that is not normal. 

Dr. Brighten: Yeah. If 

Dr. Sierra: you're having too much. Clots that are larger than a quarter or a Oh, you're saying quarter ? Yeah, quarter A coin or a synco peso coin. Yeah. Yeah. That's not normal either if you're having pain.

Mm-hmm . That's not normal. 

Dr. Brighten: Mm-hmm . Mm-hmm . So you're saying pain is not normal during the menstrual cycle? No. , there's so often I will say that, um, online that period pain is common, period of pain is not normal. And women will say, well, everybody's threshold for pain is different. Yes. So it might be normal for some people.

But what would you say to that? 

Dr. Sierra: If it's making you cancel plans, if it's making you not going [01:20:00] to your regular things that you do every day, that is not normal. Menstrual cycle are not supposed to make you don't live your life. Yes. 

Dr. Brighten: Or make you vomit or cry. All of those things. You might cry because of the hormones, you know, or a sad TV commercial.

But if you're in so much pain that you cry or you're, you're finding, you know, there's a lot of women who are like, Oh, I'm taking Midol. I'm just taking pain meds. So I'm taking, you know, NSAIDs and I'm just taking them all the time and they barely touch the pain. That's problematic. No, and that's oftentimes where, you know, I'll say I think someone's missed your diagnosis of endometriosis because heavy, painful periods, cyclical pain, like happening around ovulation, these things, and you can't get it controlled with pain meds.

Like we've got a problem. Yes. Yeah, so talking about fibroids What role do environmental toxins play? 

Dr. Sierra: There are a lot of studies that do like have something backed [01:21:00] up, but there's not like a straight line into whenever you're taking some toxins into your, I don't know, the bottles or the water bottles or something.

And there's a straight line into how you, how fibroids develop, like they have been studies that do take environmental toxins into more women having fibroids. But I don't know the exact exact physical pathological mechanism of how do they cause them. That's it. Yeah. 

Dr. Brighten: I haven't seen studies saying environmental toxins cause fibroids, but that they can be contributors.

Basically, you're already going down that pathway. And because there are laden with endocrine disruptors, they have the ability to stimulate cells in the same way estrogen might, um, to actually block receptors to cause the, at the DNA level for your cells to misbehave when it comes to, you know, estrogen, that that can be a contributor.

Because fibroids are related to hormonal issues, correct? 

Dr. Sierra: They're also, yes, to a hyperestrogen, the [01:22:00] higher estrogen in your blood vessels. Yeah. 

Dr. Brighten: Yeah. Yes. And so that makes the case of coming back to exercise again so that you are helping with those hormone levels and diet as well so that we can move that estrogen out.

Yes. Um, in terms, so in terms of medications, sometimes doctors will recommend various medications for fibroids. Others will say like it needs to be a surgical intervention. What would you say to that? It 

Dr. Sierra: depends on the size and of the willing of the patient. Yes. And if the symptoms of the patient, sometimes they have a six millimeter fibroid that it's not making any, any problem with them.

They don't have any pain. They don't have heavy bleeding 

Dr. Brighten: and you 

Dr. Sierra: can check them every six months and the, that's not growing up. So you can leave it there. Are there ways that we can prevent fibroids? Prevent them. Okay. Well, if you have like this genetic pathway into the way that your muscle cells are going to roll into a little ball.

it's really [01:23:00] hard to really do prevent them. You can stop the train of inflammation and the train of estrogen hyperstimulation and then can These make not be like, you have hern, hern, see, there's something that you inherit and there's also the environment. And sometimes if you don't give the proper environment, some pathologies won't develop.

So this is one of the theories about fibroids, that if you don't give them this hyper estrogenism and you don't give them this Uh, muscle or like endocrine, like these regulators, they won't happen. But in the little experience that I have, some patients do have this inheritance and they do have, even though they do everything correct, they inherit these fibroids.

So yeah. Some 

Dr. Brighten: people can do everything right. And that they can prevent fibroids and some people can do everything right and they'll still get fibroids. So I would still make a case for even if you develop a fibroid and you've been doing everything and it feels right, you're doing a lot more for your body.

Of [01:24:00] course. Beyond that because I think sometimes when we focus on just one condition and it's like Oh, I failed because I developed a fibroid, but you forget that you also nourished your heart, you nourished your brain, you nourished your skin like you were taking care of your entire body. Of course. And it is unfortunate that sometimes, you know, surgery is necessary or they develop anyways.

Do they ever go away on their own? Have you seen that? No, 

Dr. Sierra: I've never seen that. They don't go on their own. Wouldn't that be lovely? Oh, yes! That you can take a pill and they, everything can disappear, like, that would be amazing. Or the doctor that discovers how to get rid of adenomyosis or, I think that would be amazing, that to offer something to our patients.

It's something different than rather take, uh, hormones or take a surgery. That's I hate that. Yeah. 

Dr. Brighten: But it is good that we have those options for when we need them, but I'm with you. And so it would be nice if we could just like, again, our magic wand or make things go away naturally. 

Dr. Sierra: Yeah. 

Dr. Brighten: Fibroids and fertility.

What should women know? 

Dr. Sierra: Okay, uh, [01:25:00] fibroids have been discovered to be embryo toxic. Sometimes the environment of having a fibroid make the fetus doesn't implant in the right place. And also because of the mass effect, they do push certain places. And for example, if the fibroid is in in the lining of the uterus, like a suvmucosus, like, or a suv, yeah, a suvmucosus, a type 1 or type 2 fibroid, like, they're really into the lining.

If your fetus attached there, there won't be enough blood to supply to the fetus, so you are probably going to miscarriage. So it can be one of the causes that you have infertility. 

Dr. Brighten: Mm hmm. And that's something that can be discovered via ultrasound. Yes. So if you have had a miscarriage I always encourage women if you've even had one Go to a doctor get some imaging get worked up because sometimes doctors They'll follow an algorithm that says not until you've had three miscarriages.

Will we actually investigate? 

Dr. Sierra: Yes Yeah, no, I think I've seen patients like after even after [01:26:00] one miscarriage, they blame themselves so much. Oh, so true. Yeah. So yeah, you need to find the cause if there's any, sometimes there's no cause, but you have to find something. 

Dr. Brighten: Yeah. Mm hmm. adenomyosis or denomyosis as you call it here.

You've, you've brought that up a few times. We talked about the symptoms of it. What is it specifically? 

Dr. Sierra: It's when, it's like, uh, the relative to endometriosis. Endometriosis can happen anywhere in the body. 

Dr. Brighten: Yeah. 

Dr. Sierra: But whenever there's endometrial like cells into the muscle of your uterus, it's called adenomyosis.

So it's like the same thing, but in another place. Yes. 

Dr. Brighten: And how about that impact? We talked about the impact on menstrual cycles, but for fertility as well, what should women know? 

Dr. Sierra: Yeah. 50 percent of the patients that do have adenomyosis are going to need any, some sort of, um, uh, therapy, like helping getting pregnant, like at IBF.

Or, uh, some form of help into getting [01:27:00] their fetuses in the right place. Especially if they have diffuse adenomyosis, they're going to have more trouble, uh, having their, uh, baby insert in the uterus. And also keeping the baby because of this, uh, endometrial like cells, like, they're like little, uh, Lakes in between the muscle.

Mm-hmm . So the baby's living through these blood vessels, and if they don't attach to the correct blood vessel, they're going to have maybe miscarriages or they can have, uh, like, uh, during the, during the pregnancy, they can have contractions. 

Dr. Brighten: Mm-hmm . Or 

Dr. Sierra: after the baby is born, the uterus doesn't contract as well, and they end up in the hysterectomy after the pa the apart.

So it's not. 

Dr. Brighten: Yeah. Why, why did they end up with a hysterectomy? 

Dr. Sierra: Because the blood, the muscles, yeah, you, you strengthen the fibers so much. And if you have a lake of this, um, endometrial like cells, they don't contract again. [01:28:00] So if your uterus is not contracting, it's going to have so much bleeding that you can die.

So they need to take away. And this is not 

Dr. Brighten: something Pitocin can help with. It's an emergency operative. Yeah. 

Dr. Sierra: Sometimes. I mean, sometimes Pitocin can help. Sometimes we have to do. Another drugs that are heavier and then we have to, like, um, tighten the uterus, like to wrap it up with some sutures in order to help.

But sometimes with adenomyosis patients, this doesn't even help. 

Dr. Brighten: Okay. You said diffuse. What does that mean for people listening? 

Dr. Sierra: There are three types of adenomyosis. It can be mixed up with a myoma. That's an adenomyoma. That can be the only focal that it's only on one point of the uterus and we can take that little part out and it's up.

That's the best scenario. And the other one, diffuse. It's in all of your uterus. Yeah. So yeah, that's the one that we don't like. 

Dr. Brighten: And going back to your red meat, your steak analogy, that's the marbled meat with the fat all throughout. That's the diffuse. 

Dr. Sierra: But instead of that. fat that's [01:29:00] endometrial like. Yeah, 

Dr. Brighten: so fat, it's lakes.

I like the lake analogy. Okay, who's most at risk for um, adenomyosis? 

Dr. Sierra: Patients that do have endometriosis. 

Dr. Brighten: Okay, full stop. If you have endometriosis, you're at higher risk. It's also, you'll hear from a lot of fertility doctors who say women in their 40s, it's much more common to see this. 

Dr. Sierra: Yes, but uh, I think that because they are going to a fertility clinic, that they are diagnosed in the north, right?

Maybe you have a, like a bias. Yeah. Because you are looking for patients that didn't, uh, weren't able to, um, procreate or have their babies before. So maybe it's something. Because we have to think about, like, 50 percent of these patients are going to have problems. Some of them don't. You can see them, uh, they, they have the diagnosis of an adenomyosis even after three kids.

Dr. Brighten: Yeah. 

Dr. Sierra: And they never occurred to them that this can be a factor. 

Dr. Brighten: Mm hmm. 

Dr. Sierra: Oh, yeah. 

Dr. Brighten: And for some women, they're going to enter into perimenopause and they're going to start [01:30:00] having disordered uterine bleeding. How many of these women can anticipate that they might likely end up with a hysterectomy because of adenomyosis?

Dr. Sierra: It depends on the doctor. It depends on the patient and how much are they bleeding. Okay. If you're getting anemic because of your heavy bleedings, yeah, this can be a cause. But if you have endometriosis and your irregular bleedings are like spotting two days before your menstrual cycle and it's getting fewer and fewer and fewer, you don't need a hysterectomy, right?

So, yeah, it depends on a lot of causes. 

Dr. Brighten: Yeah, because I think that's what a lot of women get concerned about. And we certainly know with endometriosis. For a long time, it was generally accepted to do a hysterectomy and there are still those doctors practicing and there's still the, the doctors who were trained by those doctors practicing who tell women, you can just cure your endometriosis with a hysterectomy.

Dr. Sierra: No, endometriosis is not the endometrium. That's one of the things that we try to shout every time we [01:31:00] get a microphone because, uh, this lining of the endometri, the endometrium is different to endometriosis. Yeah, the name doesn't help us a lot. I know. I think that 

Dr. Brighten: we need like, we need like, uh, like rogue cells, but in a different language that sounds really cool.

Like, cause that's what I feel like. I'm like, rogue cells is what I want to say. This just infiltrates different parts of your body. 

Dr. Sierra: But, and they have done, they have gone rogue and they are going elsewhere. But yes, um, if you cure, if you do a hysterectomy, you're going to take away the adenomyosis. But for endometriosis, if you have a nodule in your colon and you take away your uterus, you're still going to have a nodule in your colon.

Dr. Brighten: Yes. 

Dr. Sierra: So you're not eradicating endometriosis, taking away your uterus. Because the cells doesn't come from the uterus. They are implanted there. From the moment you were born, from the moment you were an embryo, those cells didn't migrate[01:32:00] 

placed elsewhere. Mm-hmm . 

Dr. Brighten: We see a lot of pelvic pain issues come up during perimenopause and menopause. What's going on there? 

Dr. Sierra: There are a lot of causes there. Uh, it can be the estrogen mm-hmm . That is going, like you, we, we know that in perimenopause is going like upwards and backwards. Yeah. It's not our second adolescent.

I know. 

Dr. Brighten: And a lot of people often are like, oh, I don't have any estrogen. I'm perimenopause. I'm like, not until you're about to cross the threshold of menopause. Until then, it's that hyper estrogen. state or what some people will call estrogen dominance, where estrogen is very high and progesterone is like, I don't even care anymore.

Just do your thing. Yes. So there's the high estrogen component. What else would you say women should be thinking about? 

Dr. Sierra: Maybe something that they do have. prior to it, like into, well, not in every perimenopausal women, but they go more prone to have feelings in your body and they start getting these flashbacks from when they were teenagers.

[01:33:00] Yeah. So I think one of this is one of the coming back to it and they have been gone through a lot of things during their life. They can also have additions from, uh, something infectious beforehand. So these additions can do cause. more pain. And they are making, um, their ovulation is like not the best standards.

So they do have more pain. So I don't know, the body changes a lot. 

Dr. Brighten: Yeah. And you know, as we talked about, so there's the painful bladder syndrome, there's the pelvic congestion. I imagine You know, pelvic congestion, having lived a full lifetime, we know that blood vessels, they're not made to last forever.

So now as we are entering into the middle age years of things, there's, this is the other reason where I'm like, let's come back and let's have a sex talk, because we could totally talk about vaginal atrophy. We can talk about vaginitis, the loss of estrogen and how that contributes to it. to, you know, pain with sex.

We know that any time there's pain there, the body [01:34:00] remembers. So even if you take away the pain, pain can persist. Can you talk about that a bit? 

Dr. Sierra: We're, we're doomed to memorize things and to learn about our medium. So if you're repeating an experience, your brain will learn, but also your nerves will learn.

So, uh, whenever you're showing your kids flashcards and you're saying like, this is a cat, this is a cat, even whenever you're recollecting information, the more times you're recollecting information. the quicker you're going to give a response. So that recall is going to 

Dr. Brighten: actually solidify the neuronal pathway.

Dr. Sierra: So if you're having chronic pelvic pain, you've gone through this nerve pathway so many times that it's really easy for your brain to remember the way that the pain feels. 

Dr. Brighten: Yeah. 

Dr. Sierra: So when there's a centralization, that's when the things goes really hard for us to, for treat our patients in order for them to forget about the pain.

As we were telling beforehand, um, there is no difference for our patients for [01:35:00] a centralized pain that for a pain that it's an acute pain that it's causing them discomfort in the, in that moment. So we have to treat them as they are. equals, because for the patient, the experience is the same 

Dr. Brighten: and 

Dr. Sierra: you cannot tell them it's only in your brain.

There's nothing that you can do about it. You have to treat about the cause of the pain and start doing new nerve connections. That's why we do sometimes nerve blockages in order for them to stop thinking about this because they don't do it like consciously, but their brain is like, this is so easy.

This is so easy. And this makes me, this is protecting myself. So it goes and goes and goes. So we have to. stop the strain of inflammation and this nerve pathway in order for them to start doing new nerve connections and start forgetting about the pain. 

Dr. Brighten: Can you explain to people what a nerve blockage is?

Like what is it? How does it help in this situation? 

Dr. Sierra: There are some peripheral nerves that we can block in order for our patients to stop feeling pain. [01:36:00] And sometimes, uh, like as much as we start studying, the more that we study, the less we do surgeries. So sometimes even in the nerves. whenever you perform a surgery, you can injure the nerve even more because of the additions that comes afterwards.

So sometimes for patients, for example, um, they performed a C section like 10 years ago. So they elongate some of these nerves and the addition start to build up for like 10 years. So they have, they have this pain. pain in the ovaries, that it's not in the ovaries, it's in the, in the, in the fascia, in one of the nerves, the denitrofemoralis nerve, in the iliohypogastric, in the ilioinguinalis, that those nerves got elongated during their surgery.

Yeah. So if you take It depends on the compression, but sometimes if you perform a blockage, it could be diagnostic and also therapeutic because you can diagnose that this was the nerve that was compressed and also therapeutic because the pain will go away. [01:37:00] And some of this sensitive nerves can get a blockage with Botox also and they're going to stop feeling the pain.

And when you're saying block, you mean numb it out? Numb it out. Yes. To attach a needle in the surroundings of the nerve and place some medication. Sometimes, uh, a local anesthetic can perform the function of a neuromodulator that is going to modulate the way that the pain signal is getting transmitted.

So that's a good thing. 

Dr. Brighten: Yeah. Yes. Well, this has been a fantastic conversation. I'm definitely going to have you back for everybody listening. You guide these conversations. So if you have questions about pain with sex, definitely drop them so I can start compiling my whole new list for you and have you back.

But thank you so much. This has been so very insightful. I know it's going to change a lot of lives out there. So I appreciate you taking the time to share with us today. 

 

Dr. Sierra: Thank you. Thank you. It's been amazing. Thank you so much.