Dr. Rania Habib (Host): The Office on Women's Health estimates that 11% of women in the U.S., that is 6.5 million women, have endometriosis. What is endometriosis, how does it impact the lives of women, and what treatments are available? Let's find out on this episode.

Welcome to The Healing Podcast brought to you by MarinHealth. I'm your host, Dr. Rania Habib. Joining me today is Dr. Beau Park, a gynecologist at MarinHealth OB-GYN, a UCSF Health Clinic, who specializes in minimally invasive pelvic surgery. She is here to discuss everything that we need to know about endometriosis. Welcome to the podcast, Dr. Beau, and thank you so much for joining me today.

Dr. Beau Park: Thank you so much for having me.

Host: Let's begin by just a brief explanation about your background and credentials, Dr. Park.

Dr. Beau Park: Yeah. So, I am a new minimally invasive gynecologic surgeon here at MarinHealth. I grew up in Southern California, did my training at Chicago Medical School, residency at Emory University, and then I did a surgical fellowship at the Mayo Clinic in Arizona. Then, I practiced at Thomas Jefferson University in Philadelphia where I was the MIS surgeon there as well as the Director of the Fibroid Center and other things, and I'm happy to be starting in MarinHealth.

Host: That's amazing. Your credentials are wonderful. So, what got you interested specifically in minimally invasive surgery?

Dr. Beau Park: So, I enjoyed sort of personally the challenge of learning something new, doing something different every time, really maximizing my surgical skills. But as I was doing it and practicing it, I realized I really appreciate and enjoy helping women that have complex issues, whether surgically or medically, and being able to help them is really a great privilege.

Host: Absolutely. And obviously, you have the credentials to back that up. So, let's begin. Let's start on our topic of endometriosis. Let's start with an explanation of endometriosis, what is it, and how does it affect the body?

Dr. Beau Park: So, endometriosis is a condition where the endometrial cells, these are cells that typically line the uterine cavity and make the menstrual blood, they escape the uterus into outside, elsewhere in the pelvis. Most often, because we think that it escapes through the fallopian tubes, the first place they might implant is in the ovary and they can make a cyst in the ovary and the cyst is usually full of essentially menstrual blood, the gold menstrual blood that you're accumulating every month. But anywhere it implants, it can cause an inflammatory and pain response there. And that inflammation then causes adhesions to anything that is nearby. So, between bladder and uterus or uterus and rectum. And of course, then that causes more pain. So, it's this cycle, that's pain and inflammation.

Host: Okay. Now, I know you said it depends on where it implants that sort of affects the symptoms, but what are the most common symptoms, and how might endometriosis affect an individual's daily life and overall quality of life?

Dr. Beau Park: Endometriosis can present in almost any form of chronic pelvic pain. So most commonly, it would be very painful menstrual cycles. That almost everyone has that symptom. But more than that, it can cause pain with anything, for example, sex, having bowel movements, having urination, and that is described as both sometimes dull and throbbing pains. Patients have told me it feels like "everything's falling out." Sometimes it's sharp and stabbing, so imagine having sex and it feels like a stabbing pain. This is not fun. And that pain could be so severe that it causes nausea and vomiting. And obviously, if you have these symptoms, it affects your quality of life because you really can't do much during those times.

The other way it can present is infertility. If it causes inflammations, that can cause adhesions and scarring. And if it causes scarring in the fallopian tubes, which catches the eggs from the ovaries to the uterus, obviously that's going to cause problems with fertility. We talked about cysts in the ovaries, and that general inflammatory response in the uterus and in the pelvis can be very prohibitive to sperm motility and implantation. So, it can cause fertility issues. And that's sometimes the first way women find out they have endometriosis. And then, a small percentage OF women will be completely asymptomatic. They'll have no symptoms to this. So, it can present in really various ways, and it really depends on each woman.

Host: Now that you've described the symptoms, Dr. Park, who is most commonly affected by endometriosis? And are there any specific age groups or even risk factors?

Dr. Beau Park: So, women of reproductive age are the most commonly affected because this is when the endometrial cells and the uterus related to menstruation are active, when they're having menstrual cycles. And the peak prevalence occurs between women aged 25 to 35 years old, but it also has been found in girls who haven't yet started their menstrual cycles and even in menopausal women. So, it can present in almost anybody.

Host: And are there any risk factors that are specific to developing endometriosis?

Dr. Beau Park: If you have family history of it, you're at increased risk for it even though we don't have a known genetic mutation for this. Other risk factors include early start of menstrual cycles, late onset of menopause, heavy menstrual cycles, so really any situation where you're having a lot of menstrual cycles.

Host: Now, do we know what causes endometriosis, Dr. Park? And I know you said there's not specifically a genetic component. Are they on the lookout for any genetic components?

Dr. Beau Park: What causes endometriosis? I can tell you we have theories, and we have about three main theories, and the first one is what we call retrograde menstruation. So during menstrual cycles, some of that blood actually flows backwards out of the fallopian tubes into the pelvis instead of all just coming out of the cervix. And we think that this is probably the main cause of endometriosis because when the blood flows, sometimes that endometrial cell can flow out with it. And that's how it gets implanted outside of the uterus and the pelvis.

Having said that, we've also found endometriosis in women who've had their tubes tied or their tubes removed. And so, then the next theory is, well, maybe there's a lymphatic distribution to this. And so, those cells are escaping the uterus by another way, maybe the lymphatic system, maybe the vascular system, so that is our second theory. But even in a smaller subset of women, and this is rare, but women who've had hysterectomies, they don't have a uterus anymore, and some have been found to have endometriosis.

So, our last sort of theory is what we call ceolomic metaplasia. That means that cells', in our body under certain conditions, for example, response to estrogen can turn into endometriotic cells.

And so, these are three theories that we have. And yes, there's no genetic mutation. I'm not sure if they're looking for a specific genetic mutation, but they are looking for certain markers that we can biopsy in the uterus, as an indicator for endometriosis.

Host: Okay. That makes a lot of sense. Now, you provided us with a really great background on endometriosis, what are the symptoms, who's most commonly affected. Let's move on to diagnosis. How is endometriosis diagnosed, Dr. Park?

Dr. Beau Park: Well, the gold standard, which is what we call the best method or test, is a diagnostic laparoscopy, which means we put a camera into your belly and look around. But obviously, it's not reasonable to put everyone through surgery to be able to treat endometriosis. So, as many conditions, we start with a very detailed history and physical exam. Chronic pain is often multifactorial, meaning there's more than one cause of pain, especially in the pelvis. So when I do an exam, I really try to palpate everything separately, right? I think, can I reproduce this pain on the exam? And if so, where is it? Is it the bladder? The uterus? The rectum? So, a detailed physical history and physical exam is very important.

We often get an ultrasound. Now, an ultrasound is not a very sensitive test, except when we see maybe a large cyst on the ovary that we described before the endometriomas. But it also helps us to rule out other causes of pain and heavy bleeding. So for example, polyps or fibroids and another condition called adenomyosis, which I call the cousin of endometriosis. So, these things can be seen on ultrasound and help us rule in or rule out other causes.

We sometimes get an MRI, and it's a little better than an ultrasound, but also not perfect. I will request it if I suspect that somebody has very extensive endometriosis, specifically bowel involvement. And if I'm planning for surgery, then it helps with surgical planning. So, we will get it. But the gold standard is a diagnostic laparoscopy.

Host: Now, Dr. Park, I know you mentioned that endometriosis can cause all these pain symptoms, but lets talk about how it impacts specifically pregnancy and fertility, because I know you mentioned it does cause some infertility. Could you provide a little bit more detail about that?

Dr. Beau Park: Right. So, that inflammation I talked about with those endometrial cells can cause scarring. Things are stuck to things that shouldn't be stuck to. And so, the tubes, the fallopian tubes, the ends of the tubes are very delicate and that can easily scar. And if that scars, then the tube is blocked. And obviously, if the tube is blocked, it will be very difficult to get pregnant. That is one way. The endometriotic cysts on the ovaries can disrupt or interrupt monthly ovulation, right? That ovary is supposed to make a small follicle each month, the egg comes in. But if it's overtaken by a large cyst, that function can be severely compromised. So, that's another way.

And the last way is the inflammatory response within the uterus and pelvis is often described as a hostile environment, which makes implantation of the embryo very challenging. And so, some studies show that up to 50% of women who present with infertility are actually diagnosed with endometriosis.

Host: Wow. That's a high percentage.

Dr. Beau Park: Right.

Host: Now, if a patient gets pregnant and they have endometriosis, are there any major risk factors or anything they should be on the lookout for?

Dr. Beau Park: No. Actually, pregnancy helps with endometriosis, because it suppresses that sort of estrogen fluctuation and so people actually feel better when they're pregnant. So, it's the getting pregnant that's more difficult. But once you're pregnant, that actually helps.

Host: Well, that's good news for the patients who are able to get pregnant, hopefully, their symptoms go away. Now, Dr. Park, how about later in life? How does endometriosis impact perimenopausal women and menopausal women?

Dr. Beau Park: So in general, the pain related to endometriosis does subside in menopause because they're no longer stimulated by the estrogen. but this is also again patient dependent because if they have the adhesions that we talked about earlier, that adhesion is not going to disappear in menopause. And so, that might still cause discomfort, but any kind of stimulation from the estrogen will be significantly improved in menopause.

Host: Now, we've discussed the symptoms in detail of endometriosis. Are there any lifestyle changes that can help manage those pain symptoms?

Dr. Beau Park: This is another really good question, because there isn't a great answer to this. But acupuncture has been shown to help with pain with menstrual cycles so not specifically related to endometriosis, but the painful menstrual cycles that people have can be help with that.

There aren't any dietary modifications that have been proven to help with endometriosis pain. But some studies have shown that maybe the intake of vitamin B or Ds can help with the painful cycles. In theory, if we try to avoid foods that mimic estrogen, which stimulates endometriosis, it might help. So, this would be like soy products or flaxseed. And we call these phytoestrogens. They kind of mimic estrogens in our body. So in theory, it might be helpful. I always tell patients anything that is safe and sustainable and helpful that they want to try, I'm okay with it, I encourage it because we're probably also lacking in research, right? We don't know everything about all the modifications that we can potentially do. So, I actually learn a lot from my patients from just their experiences.

Host: Now, I know you mentioned a couple vitamins that might help with the menstrual pain, but are there any specific medications that treat endometriosis?

Dr. Beau Park: Because endometriosis are the cells that are stimulated by estrogen, our best therapy is to suppress them with the hormones. Our first line of therapy is usually birth control pills, which actually have estrogen themselves. But what they do is they suppress our own body's production of estrogen and we try to avoid those high peaks that we have every month.

Now, not everybody tolerates birth control pills. And so, another option would be a progestin hormone. Progestin hormone in our body kind of counteracts the effects of estrogen. So even though their body still has these fluctuations of estrogen, we're trying to not let that stimulate those cells by giving the progesterone. We're trying to counteract the effects of estrogen there.

People with really bad endometriosis, we have something called GnRH agonist and antagonist. These are medications that act a little higher up in our brains and our pituitary and they suppress everything. It's essentially medically inducing menopause, which can be pretty harsh symptomatically, so it's not always well tolerated. But in the last couple of years, there have been new medications that are GnRH agonist and antagonist with a little bit of add back therapy, so a little bit of low-dose birth control with it to help that harsh side effect of inducing menopause. So, these are some of our medical options.

Host: Now, Dr. Park, as we know, you're a minimally invasive surgeon who is specialized in pelvic surgery. So, let's move on to the surgical treatment options. I know you mentioned earlier in our conversation that a diagnostic laparoscopy is how we diagnose endometriosis. So, what different procedures are available and when is surgery the best option?

Dr. Beau Park: This is a very long conversation I have with my patients, because there are a lot of options. And the most important thing for me is being clear, both myself and the patient, on what are the goals of surgery. So, for example, if someone has had pain for 20 years with endometriosis, and they just want everything out, right? They're not worried about fertility. Their main goal is pain control. They want everything out. And that might entail a hysterectomy, which is a removal of the uterus. They might even want their ovaries out so that nothing stimulates any potential recurrence or residual endometriosis. This might involve even bowel surgery if there's bowel involvement. But if this is what they want, if this is their goal, in terms of pain control and reducing the risk of any recurrence, that might be the best option for them.

If it's someone like we talked about trying for pregnancy and their goal is to maximize pregnancy outcomes rather than pain control, then it might just be about do we remove the cyst on the ovary? Do we try to remove some of the adhesions by the tubes and the ovaries? And of course, this would be a bigger conversation with their fertility specialist, but that would not be the time when we're doing aggressive surgery.

And some people just want a diagnostic laparoscopy, right? They're not trying for pregnancy, but they've been in pain, and they've had ultrasounds and MRIs, and everything is negative, and they just really need to know, do I have endometriosis or not? They want to rule in or rule out this diagnosis so that they could make a decision about the next steps, right? And that's very reasonable as well. And so then, we discuss, okay, our goal is just to kind of see. And that's not the time, even if I find endometriosis, to do aggressive surgery. But then, we can actually talk about that as an option next. So, it really depends on each situation.

Host: I love that you're really taking the patient's interest in having these long conversations, because it's really important to make sure that you and the patient are on the same page.

Now, Dr. Park, you have shared a wonderful just realm of knowledge from diagnostic all the way through surgery options. And we're wrapping up this episode. So, is there anything else that you'd like to share or you wish that more people knew about endometriosis?

Dr. Beau Park: I think endometriosis and chronic pain in general is so complicated. Even though, like you mentioned, it affects about 10% of the population, it affects them quite greatly. So, in my experience, I feel endometriosis is both the most overdiagnosed and underdiagnosed condition. Anytime somebody has painful periods, it's often attributed to endometriosis, without any further workup. But really, with endometriosis or chronic pain in general, it's part of a pain syndrome.

Most people with endometriosis will actually have one or two other diagnoses that can cause pain such as interstitial cystitis of the bladder, IBS of the bowels, pelvic floor myofascial pain. So, it really needs a holistic, comprehensive approach to this. And without that, I think it'd be a very frustrating experience for women. So, it takes time and the right team, not just a gynecologist often, but a urologist, pelvic physical therapist.

Host: That's fantastic. Well, thank you so much, Dr. Park, for taking time out of your busy day and for sharing all of your knowledge with our audience today.

Dr. Beau Park: Thank you so much for having me.

Host: To book an appointment with Dr. Park, call MarinHealth OB-GYN, a UCSF Health Clinic, at 415-461-7800. That's 415-461-7800. Learn more about MarinHealth@mymarinhealth.org. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm your host, Dr. Rania Habib, wishing you well. Thank you for listening to The Healing Podcast brought to you by MarinHealth.