Maggie McKay (Host): Welcome to HealthWorks Here. Today we'll explore the realities of menstrual pain and how women are finding relief with Dr. Nisse Clark, Emerson Health, Minimally Invasive Gynecologic Surgeon, and Kelsey Magnuson, Community Benefits Manager at Emerson.

The majority of women experience period pain at some point in their life. For many, the pain is debilitating and affects their ability to enjoy life. Yet menstrual pain is often dismissed by some healthcare providers. Join us as we explore women and pain and ways women can find relief.

Kelsey Magnuson, MPH: Hi everyone. My name is Kelsey Magnuson, and I'm the Community Benefits Manager here at Emerson Health, and I'm so excited to be sitting here talking to Dr. Nisse Clark. I know you're a busy woman in your practice and in your home life with your three kids. I'm grateful that you're giving your time to share more information and tips to women who experience pain. Let's start with an understanding of what it means to be a Minimally Invasive Gynecologic Surgeon.

Nisse Clark, MD: Hi, Kelsey. Thank you so much for having me. I'm so grateful for this opportunity to share a little bit about what I do and hopefully demystify some of the conditions that can cause pelvic pain. I am a Minimally Invasive Gynecologic Surgeon. The abbreviation we use for that is MIGS. It's a subspecialty of OB GYN, a surgical discipline that really focuses on benign GYN conditions, things like endometriosis, adenomyosis, heavy bleeding, fibroids, some of the things we'll talk about today, and treats them with minimally invasive surgery, small incision outpatient surgery.

Kelsey Magnuson, MPH: All right, awesome. So there's a lot of big words in there and we are going to break it all down. As a woman and a doctor, you're a little bit of an expert on periods. So I want to go back to the basics and just kind of start with an explanation and an overview of the woman's menstrual cycle.

Nisse Clark, MD: Sure. Menses, you know, starts around age 12 on average continues till on average age 50. And throughout that time, people, women, experience menstruation in a variety of ways. It can have some normal variability, but on average is occurring every month. Anywhere from three and a half to five and a half weeks apart is normal as long as your cycle is happening, plus or minus seven days from the last cycle. During that time, there are various phases of the menstrual cycle, which I can just touch on briefly. Day one of the cycle is when menses occurs and you have bleeding, and that's the early part of the follicular phase when a follicle starts to develop and egg is then released during ovulation, and then that moves you into the second of half of the cycle, which is the secretory or luteal phase when the uterine or endometrial lining is again building up in anticipation of the next period.

So that's a very broad overview of the menstrual cycle, but during that time, there are symptoms that are normal and symptoms that are not normal, and that's what I hope we can touch on today.

Kelsey Magnuson, MPH: Yes, definitely going to get into that. I remember I understood at a very early age that having your period was uncomfortable and painful and have since experienced that discomfort on a regular basis. But, you kind of just said even that there's varying normalness in how women experience this.

So while we know that each person handles and experiences pain differently, it would help if we kind of provide a broad definition of what a normal period is or what normal discomfort pain is. So then we can get into some of those big words that you talked about earlier and break those down for people to understand.

Nisse Clark, MD: Sure. So I mentioned a little bit, you know, normal cycles happen on average a little under a month or over a month apart. They shouldn't last much more than seven days. But pain is also a symptom to be attuned to or to look out for. Because a little cramp or twinge of discomfort is fairly normal.

There are symptoms that go along with ovulation and menstruation that many women experience, but it shouldn't be to the point that your symptoms are really setting you back. That they're severe and causing you to lose out on opportunities or engage in life in the way that you want to. You shouldn't be missing school or work or other things because your period symptoms are that bad.

Kelsey Magnuson, MPH: I'm so glad that you mentioned pain during ovulation too. That's not something that is often talked about. And I know we're not going to get too much into that today. But, as you kind of go into some of the other severe or concerning symptoms, if you could just kind of touch on what happens around ovulation that causes discomfort, and then we can get into some of the other conditions that we were talking about.

Nisse Clark, MD: So, ovulation is that period of time, it's just a couple days or so when a mature egg is released from one of the ovaries, and in anticipation of that time, estrogen is rising. The follicles are developing until one declares itself mature and actually is released from one of the ovaries. And that process for some women is symptomatic.

Some don't know it's happening at all, but others might experience some pain, some spotting, maybe an increase in their temperature, which is actually happening at that time. A change in cervical mucus or libido. These are all symptoms of ovulation. If it's very painful, it might indicate some inflammatory disorder.

Certainly my patients who have endometriosis as an example, are more likely to experience pain at any point in their cycle and during ovulation at times.

Kelsey Magnuson, MPH: Great. So now that you mentioned endometriosis, let's go into some of the more severe or concerning symptoms that women experience and when they should get in touch with you or another provider.

Nisse Clark, MD: Endometriosis, I'll just touch on what that is for those that aren't aware, it's a condition that affects at least 10% of women. I think that's probably an underestimate, but it's characterized by tissue, very similar to the uterine lining, the endometrium, so endometrium like tissue, existing in places beyond the uterus where it's not supposed to.

So that same tissue that builds up each month and sheds in the form of a period, exists elsewhere. Maybe it's on the ovary, on the surface of the pelvis, near to the bowel, the bladder, wherever. It can literally be anywhere. That tissue causes for most people, but not all, pain. And that pain is most commonly before and during menstruation, like as it's building up and as it's shedding.

 When the period would occur is when that pain is most pronounced. And typically if it's symptomatic, which again is for most, it's pain out of proportion. Meaning not just a minor cramp or, yeah, I have my period now and I'm using whatever sanitary product I choose, but actually I'm like doubling over at times.

I feel like, I can't do the things I'm supposed to do today because this is so debilitating. Some of my patients with endometriosis describe like a towel being rung out in their insides, or maybe it's just bloating and dull pain. It can present in a variety of ways. But that's very classic for endometriosis.

The other symptoms that can often go hand in hand, not just pain during periods, but like pain during sex, penetrative intercourse, pain during bowel movements leading up to the bowel movement or as it's passing through. Sometimes urinary changes, sometimes really vague, non-specific stuff like bloating, fatigue, joint pain. There's a whole slew of symptoms, but the hallmark is painful periods.

Kelsey Magnuson, MPH: Oh, that sounds so hard. And not enjoyable. So what encouragement can you provide to women who've maybe been dismissed or, that oh, they're just complaining about it, about these types of concerns, whether that be from family or friends, or even other doctors.

Nisse Clark, MD: Well, you know, informing yourself, listening to podcasts like this is so important. Just getting informed, being your own advocate is essential in today's world. And, not stopping at the first person to tell you it's no big deal, but, you know your body, if something feels off, dig deeper and find someone who will do that with you.

Meaning go back to your doctor and saying, Hey, that birth control pill you gave me isn't cutting it. Or, Hey, I do think this is a problem and I want to be referred to someone who can explore other possibilities. Seeing someone like our office, a minimally invasive GYN surgeon is one avenue, but in general, going to your PCP or your OB GYN and not stopping at this is normal or here's a treatment, you should be fine. Like don't leave it at that. Dig deeper if something does not feel right.

Kelsey Magnuson, MPH: Yeah. Thanks so much for saying that. And I agree that being our own advocates is so important and there's so many different specialties nowadays that sometimes it can be confusing to know where to start. So I'm glad that we are giving some of those tips and tricks, and helping people know where to go.

So with all this, you did mention birth control. What hope is there with medications or even lifestyle modifications to improve these symptoms?

Nisse Clark, MD: There are a lot of different treatments out there. There are not enough. There needs to be more. There needs to be more research into non-hormonal treatments for endometriosis, but in general, I'll talk about what exists and that's a broad spectrum. You have your least invasive. Diet and lifestyle things.

You have your medical interventions. And then on the other end is the surgical intervention, which is much of my work. We can start on one side and move to the other. So I often will kind of talk about the spectrum with my patients and you know, it starts with just awareness. Being aware of your body, of your cycle, of your symptoms, and there's a lot of ways to take a diary of that or use an app-based program to better understand what you're experiencing and then starting to look at diet and lifestyle changes that may be helpful.

Now, sadly, as with a lot of medicine, we don't have really robust evidence as to like this exercise or this food is going to change your life. I wish we did, but adhering to a healthy diet. Moving your body. Exercising has tremendous benefits for so many conditions, including endometriosis. What I mean by this is like a diet rich in antioxidants, fruits, vegetables, nutrient dense foods, maybe less meat, potentially less alcohol. We don't have any robust data, but I would encourage, or I do encourage my patients to really pay attention to a nutrient dense diet.

And then when it comes to movement, again, like no one exercise is better, but moving your body, improving your mental and physical health, increasing your oxygenation, your vitality is essential to reducing the symptoms of these inflammatory conditions like endometriosis. So that's a start.

And then there's medical treatments. Medical treatments so often are birth control. You'll hear a lot about that from any provider treating endometriosis with medication. There's a role for anti-inflammatories like ibuprofen, Tylenol, Advil. Those are important things to take. They certainly can take the edge off. For some that's all you need. But birth control is an extra step toward targeting the cause of the symptoms. Endometriosis is an estrogen sensitive disease, so it's fed by estrogen and birth control, which in its hormonal form always contains progesterone can oppose the activity of estrogen. Progesterone is anti-inflammatory, so birth controls, and there's no one that's better than the others when it comes to this. It's really what works for you, can greatly reduce or eliminate the symptoms of endometriosis.

There are other medicines too. I'll just briefly mention, there are GNRH medications, aromatase inhibitors, other ones you'll hear of. But we usually start with birth control and then only up the ante medically if it's not working or a patient doesn't want to move to surgery. But that is the end of the line, surgery. Taking that next step to now surgically address the disease.

Kelsey Magnuson, MPH: Yeah, so thanks so much for going through those. I know it's always hard to know exactly how much time one needs to figure out these, but, sometimes time is what people need. So about how long do you suggest that people give, whether that be, lifestyle changes or the medication until the next step is needed?

Nisse Clark, MD: I mean, the average like time to diagnose of endometriosis is tremendously delayed. It's like some seven or more years until many women will finally get a diagnosis despite experiencing these symptoms. So it should not take that long, and that's why awareness is so important. But diet, lifestyle changes should be implemented throughout.

When it comes to medical treatment, I usually have patients give it a go for like three to six months. I don't think it needs to be a tremendously long time. I don't think you need to try every medication under the sun, but a trial, at least a few months is reasonable before saying this is or is not working.

Kelsey Magnuson, MPH: Great. I think that's super helpful because oftentimes we want the fix overnight and it doesn't always come to that. So we have to give it a little bit of time, but appreciate that it's not years before taking the next step. So in thinking about taking that next step, surgery kind of being the final stop or so, take us through, you know, what surgery looks like and how that might provide the ultimate relief from pain.

Nisse Clark, MD: So surgery. Surgery is really the right next step for those who have not found success with medical therapy. There's also an increasing number of women who just don't do well on hormones. They have various side effects for which they've tried it and it's not really an option for them. So for those patients, for those who are not able to take birth control because they're trying to get pregnant, that's a very common indication, or other reasons they pursue surgery.

And surgery is most often done laparoscopically when it comes to endometriosis. I can talk a little bit about that if you'd like.

Kelsey Magnuson, MPH: Yeah, go into it a little bit more. I think people might be interested.

Nisse Clark, MD: So that's what I do. That's my bread and butter. I'm in the operating room every week doing laparoscopic surgeries for various reasons. Many of them are endometriosis. This is an outpatient surgery through small incisions, and that is great for you and great for your surgeon because you get to go home the same day. The incisions are small and the recovery is half the time of a large open incision like a C-section cut.

As a surgeon, it gives me a really nice, magnified view of the pelvic structures, the abdominal structures. We have a narrow rod lens, which is inserted through these tiny incisions, and that image is projected on a screen in the operating room. And then your surgeon, myself, we're using long, narrow instruments through the other tiny incisions to dissect tissue and cut out disease. Endometriosis when treated laparoscopically, nowadays, the standard is increasingly to cut out the lesions or excise the endometriosis. So through this minimally invasive, laparoscopic procedure, we're looking and surveying for any and all endometriosis, even that very subtle, hard to see lesion or that very obvious deep lesion, and we're cutting it out with fine dissection and then allowing you to go home later that day and recover for anywhere from a couple weeks to a month's time.

Kelsey Magnuson, MPH: Wow. That definitely does not seem as scary as what we typically think of with surgery, of going under the knife or long recovery time. So thank you so much for all that you've been able to tell us today. Lastly, I just want to ask, why did you become a MIGS surgeon and what do you want people to know about your work?

Nisse Clark, MD: I chose minimally invasive GYN surgery as a subspecialty of OB GYN because I love the technical aspect. I thought it was amazing what you could do through these small incisions We still take really complex procedures. You know, those who have had a lot of past surgery, those who have a very large uterus, those who have endometriosis, that's really changed the anatomy or led to a lot of scarring and were able to do their procedure and when it's all said and done, there's just these teeny tiny little bandaids on your abdomen and the recovery's. It's a recovery, but it's a lot better than a more major procedure. A more invasive procedure, and that was really awesome. And then as I've been in practice, I think I've gotten to really know my patients and hear from them.

And it's so apparent how under-recognized these conditions are. We're getting better, like there's more and more awareness, but endometriosis, adenomyosis, which is endometriosis in the uterine muscle and fibroids, these benign tumors of the uterus, these are conditions that are really common, like fibroids affect 80% of people, and bringing awareness and helping people experiencing symptoms from those conditions is really gratifying.

Kelsey Magnuson, MPH: Yeah, I agree. I've had a great time talking to you and learning more. Even though I've had decades of periods and I've gone through two pregnancies and births myself, I find there's always more to learn about the female body and how we all experience things different. I'm so proud to work at a community hospital that can provide this specialized care and help all people find relief from pain.

So thank you very much for our time together today.

Nisse Clark, MD: Thank you so much for having me, Kelsey. This is great.

Host: Thanks for listening to Emerson's Health Works Here podcast. Make sure to catch the next episode by subscribing to the Health Works Here podcast on Apple Podcast, Google Podcast, Spotify, or wherever podcasts can be heard.

And call Dr. Clark's office at (978) 287-2936 or visit emersonhealth.org for more information and to make an appointment.