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Melanie Cole (Host): SLUCare’s general obstetricians and gynecologists care for women at every stage of life. From premenstrual syndrome to menopause, abnormal test results, or something just doesn’t seem right, our specialists will give you the treatment you deserve. My guest today is Dr. Patrick Yeung. He’s the Director of the Center for Endometriosis at SLUCare. Welcome to the show, Dr. Yeung. Tell us, what is endometriosis?

Dr. Patrick Yeung (Guest): Well, thank you very much, Melanie, for the chance to be on this program and for the opportunity. Endometriosis, I tell patients, is where the cells which line the uterus and are shed during a period are found outside the uterus implanted in the pelvis.

Melanie: So what would a woman feel? Would she feel anything? Give us some symptoms, because people always want to know if they’ll feel anything in enough time to go see a doctor.

Dr. Yeung: All right. Well, I always say the problem is this disease is under-diagnosed and under-treated. It’s thought to be in a one in 10 women and can take up to 12 years to diagnose, especially in younger patients. It causes two main things—pain, and can affect fertility. It can cause chronic pelvic pain; it can cause painful periods, pain with intercourse, pain passing stool. And like the pain with periods, I always say there’s pain, and there’s pain. If we’re talking about painful periods that are not like your friends’ periods, cause you to have to miss school or work, you’re curled up in a ball, doubled over during the period, you have to take narcotics just to get through the pain or you take hormones—hormonal suppression like birth control pills for the pain—and do not feel better, those are all red flags, and those are things that should be checked out.

Melanie: Are there some risk factors which may predispose a woman to endometriosis?

Dr. Yeung: That’s a great question. There is sort of a classic theory as to how we get endometriosis in the first place, which is called the backflow or retrograde menstruation theory, meaning that a woman, when she has her period, she bleeds backwards through the tubes and those cells implant. But that is actually not a very good theory. The answer would be it’s probably multi-factorial. Different things probably do lead to what causes endometriosis and predisposing somebody to endometriosis. Modern-day theories include stem cell theories or immune system issues, and a lot of patients do have overlapping immune system issues with other conditions. Hereditary is probably part of it, so having a mother or a sister with endometriosis may give you some added increased risk. But most women have it without any kind of hereditary component either.

Melanie: So if women are experiencing this intense pain and it’s different than, as you say, their normal period pain and they come to see you, how is it diagnosed? What do you do?

Dr. Yeung: Well, if we’re talking about pain in general, there are other things that can cause pain. I always start, when I talk to patients, that female-related cause of pain is only one among other causes of pain and so, there needs to be some sort of comprehensive evaluation to look at other things that can also cause pain—bowel issues, bladder issues, musculoskeletal, for example. And sometimes, patients overtime can get sensitized to pain or centralization. The classic example is an infected leg, they cut off the leg, the brain still feels pain from the leg which is not there. So, pain is more than just anatomical, and pain is often multi-factorial or from more than one thing. A comprehensive evaluation is important. A good exam is important, sometimes, for more advanced disease. We can pick up things on exam, on a public exam. An ultrasound can also help us look for masses or evidence of deep or advanced endometriosis. Then we talk about options, and now we go through everything with everybody. I always say to patients, “My approach is we report, you decide, Fox News.” We talk about basic categories of how to treat pain thought to be from endometriosis, including hormones and suppression but also surgery. Surgery is really the only way to really know if somebody, if a woman has endometriosis or not. You have to see it—even better, biopsy so.

Melanie: What’s involved in the surgery and in this diagnosis? If you have to go in and look around and see what’s involved, what can a woman expect?

Dr. Yeung: Surgery is surgery, but we try to do it minimally invasive, so we do it by laparoscopy, which is keyhole surgery. It’s a hole in the bellybutton for the camera, tube down low within the bikini line, and that’s it. It’s minimally invasive. The patient can go home usually the same day, at most the next day. They’re back to work in a week or two. We try to do what’s called “see and treat” laparoscopy. We go look for it, but also take care of it at the same time. It’s very rare that we cannot take care of it at the same time. We try to get patients back to work quickly. Most people, when they treat endometriosis, they “burn it,” for lack of a better word. They try to destroy the implant with energy. But the problem with that approach is if it’s widespread, it can be hard to try to uniformly destroy all the implants. They can go deeper, so you might just be charring the tip of the iceberg and not get down to the bottom with lesion. And it might be on or near a vital organ. And most people would not nor should they be burning near those organs. So, our approach is to cut it out. We cut around it, we cut under it, make sure we get under the root, so to speak, down the normal healthy tissue. I use a noncontact CO2 Laser as my cutting tool of choice, which allows me to cut it out even on or near vital organs, and then whatever we cut out will be sent out to pathology for a tissue diagnosis. So our approach is different than most. We cut it out, and we think that it’s more complete, safer, and you get that tissue confirmation.

Melanie: Dr. Yeung, then what’s the follow-up? Will a woman experience pain for a little while after? What’s the recovery like?

Dr. Yeung: The recovery varies. For sure, I’ve had the experience that someone would wake up and say, “I feel better,” right away. That’s amazing. Some women, it takes a little bit longer. And then, of course, there’s the recovery period from surgery. I usually tell patients to kind of wait three to six months to really see how things settle out and to see, really, what the benefit or not is of the surgery. But it can take some time. I’ve had some patients, say, at six months, each period is still getting better. I give it about that timeframe to see how things settle out. But I never promise no pain, and I never promise it can’t come back, although the recurrence, after a good excision surgery, should be quite low. And we do expect at least some improvement of pain and better quality of life if we find and treat endometriosis. But my goal and my commitment is to try to cut out whatever looks suspicious for endo and to achieve this goal of what I call a complete or optimal excision of all visible disease. We believe that is the best way to help pain, quality of life, and fertility.

Melanie: Then is there any hormonal therapy after the fact? A woman, then she just keeps an eye on it and keeps visiting you? What goes on afterwards?

Dr. Yeung: That’s a great question. Well, I always see patients or ask a patient to come back and see me in six months. Most people would recommend hormonal suppression after surgery, and I always tell patients that is what the usual recommendation is. I don’t specifically recommend hormonal suppression after an optimal excision surgery, at least for the sake of preventing progression or recurrence. And in our studies that we’ve published and other studies, it’s not borne out that hormones actually prevent progression or recurrence. It might help a patient feel better if the periods are still painful and they want to stop the periods, or for whatever other reason, they could take it and it’s up to them. But in our study, in teenagers where all the patients got optimal excision surgery, we did not specifically recommend hormones after surgery for the sake of preventing progression or recurrence. We follow them for up to five years—on average two years—looked back at almost half of patients, and the rate of finding endometriosis again was zero. And we published that. Again, we did not specifically recommend hormones after surgery. On the other hand, when you look at the ablation studies or the studies where they burn the endometriosis, the rate of recurrence is up to 50 percent in that same two-year average follow-up timeframe. When they’ve added hormones after surgery, the rate of recurrence is about the same. So I and others believe that what is done at surgeries is the most important, and hormones after surgery, well, they may be helpful for symptoms or pain if the symptoms still occur after surgery. They do little to actually kind of “mop up” whatever endo is left or prevent recurrence.

Melanie: That’s great information. Dr. Yeung, in just the last minute, tell the listeners why they should come and see you at the Center For Endometriosis at SLUCare.

Dr. Yeung: Well, thank you very much. It’s an opportunity to kind of get the word out. We advocate trying to get checked early. And as a surgeon, I’d rather get the disease early before it’s advanced. If you’d heard of Padma Lakshmi, she’s an Indian supermodel and a host of Top Chef. She was diagnosed with endometriosis until later in life, and she was advanced at that point. Her fertility was impaired. She had it cut out. She got pregnant, and she feels better, but she would say if she could have been diagnosed a decade earlier, she could have had her fertility better preserved and avoided a lot of pain. So she has begun a campaign to get the word out. She’s created a poster called “Killer Cramps are NOT Normal,” telling young women if your cramps are not normal and you know it, you should get checked out. But at the Center of Endometriosis, which I direct, we try to give personalized excellent care. The majority of what I do is to treat endometriosis, so I always say people are kind of good at what they do on a regular basis, and we do almost exclusively—I do almost exclusively—treatment for endometriosis. We also offer a multi-disciplinary approach, so we have different surgeons that we can collaborate with in the OR to deal with advanced cases or deep cases of endometriosis, and we also work in a team to help different aspects of pain. Because again, pain is not just endometriosis. We try to do our best to take care of the patient and to offer that kind of care at SLUCare.

Melanie: Thank you so much, Dr. Patrick Yeung, the Director of the Center of Endometriosis at SLUCare. You’re listening to For Your Health with the physicians of Saint Louis University, SLUCare Physician Group. SLUCare is the academic medical practice of Saint Louis University School of Medicine. For more information, you can go to slucare.edu. This is Melanie Cole. Thanks so much for listening.