Transcription:
Endometriosis Awareness

Melanie Cole (Host): Thanks for tuning into Back To Health, the podcast that brings you up-to-the-minute information on the latest trends and breakthroughs in health, wellness, and medical care. Today's special episode is part of our Women's Health Wednesday series, which features in-depth conversations with Weill Cornell Medicine's top physicians on issues surrounding women's health throughout the life course. Listen hear for the information and insights that will help you make the most informed and best healthcare choices for you.

I'm Melanie Cole, and we're discussing on this Women's Health Wednesday National Endometriosis Awareness Month. Joining me in this panel today is Dr. Ja Hyun Shin, she's the Director of Minimally Invasive Gynecologic Surgery at New York Presbyterian Hospital Weill Cornell Medicine; and Dr. Kristen Pepin, she's an assistant attending obstetrician gynecologist at New York Presbyterian Hospital Weill Cornell Medical Center and an Assistant Professor of Minimally Invasive Gynecologic Surgery at Weill Cornell Medicine.

Doctors, I'm so glad to have you with us today. And Dr. Pepin, I'd like to start with you. Can you give us a little rundown, what is endometriosis? How common is this?

Dr Kristen Pepin: Sure. So this is a really great question. And sometimes it's a little bit difficult for people to actually understand, but how we actually define endometriosis is having endometrial glands or the type of tissue that normally lines the uterus occur outside of the uterus. So instead of being in the area where it normally would build up and shed for a period, it can be outside of the uterus, including on the pleural cavity, on the intestines, the appendix, things like that. And that can cause inflammation, it can cause pain with periods, pain with sex. And sometimes symptoms are relatively minimal and sometimes they really can be quite debilitating.

Melanie Cole (Host): So interesting. And it's really very common for ladies. Now, Dr. Shin, who is at risk? Is this something that affects younger women, older women? Is it hereditary? Tell us a little bit about who's at risk.

Dr Ja Hyun Shin: Women at risk for endometriosis are usually of the reproductive age, typically in any time when they begin their menstruation, what we call a menarche, to menopause. These are the women who are going to be primarily impacted by the symptoms of endometriosis.

Several things expose you to an increased risk of endometriosis. This includes having immediate family members like your mother or sister can put you at higher risk for developing the condition yourself. There is a hereditary component to it. And then basically, other states that expose you to a prolonged estrogen state. So women who have never given birth, who have started their periods at an earlier age or going through menopause at a later age, longer period durations and shorter cycles. These can all increase your risk for endometriosis.

Dr Kristen Pepin: And I would also add, as I think you asked with the first question, that endometriosis is quite common. In some studies, it affects up to 10% of reproductive age women. Other studies actually quoted it being a little bit lower, maybe somewhere closer to 5% to 7%, but regardless is a disease that affects many, many women.

Melanie Cole (Host): Well, it certainly does. I personally know quite a few, including my sister. So let me ask you this, Dr. Pepin, what symptoms would even send somebody to their gynecologist? What are the first signs? And generally, I mean, Dr. Shin was discussing age and when these typically present themselves, but what is it that we're looking for as women? I mean, we get all kinds of the same symptoms for many different things.

Dr Kristen Pepin: So one thing that can make endometriosis a little bit challenging to diagnose is that the first symptom that most people have is pain with their periods. And what is a little bit difficult about it is that sometimes people's initial complaints of pain with periods gets dismissed because most people have some discomfort with their periods. However, people with endometriosis tend to have really severe pain that they get with their periods and, over time, that pain may happen even in between periods, even during the middle of the cycle when they're ovulating. Not in everybody, but it is pretty common for me to hear from endometriosis patients that the symptoms started really quite soon after they started their first periods, that even when they were in middle school or high school, sometimes they would have to miss school or miss their after-school activities or sports every time that they got their period, because the pain that they had was so severe. And that really is not considered to be a typical amount of pain.

Other symptoms that people can get include pain with sex and pain with bowel movements. Sometimes people have pain related to endometriosis cysts. It's called endometriomas. If those cysts grow to be large, they can put pressure in the pelvis, which can be uncomfortable. And then sometimes the first symptom that somebody has from endometriosis is actually that they have difficulty getting pregnant. It's not the most common reason why endometriosis is diagnosed, but that can be a symptom as well.

Melanie Cole (Host): That was an excellent comprehensive list, Dr. Pepin. So Dr. Shin, I think women's biggest questions are what can be done about it? She mentioned that one of the first signs might be having trouble getting pregnant. I'd like you to speak about some of the treatments for endometriosis and whether or not this is something that can affect a woman's ability to get pregnant at some point in her life and some of the treatments that you're doing at Weill Cornell Medicine.

Dr Ja Hyun Shin: So as Dr. Pepin pointed out, one of the leading symptoms is pain with periods and infertility as well as urinary and gastrointestinal problems. So one of the reasons why it might be difficult to get to the right provider and get to the right treatment is because sometimes it's not very clear. It's not just painful periods, they also have painful episodes with urination and irritable bowel syndrome symptoms.

So it's important that when they do seek a provider, and it's usually the OB-GYN who is the initial provider that many of these women will seek, that they have access to also multidisciplinary care with other providers. And I think that's one of the things that makes our endometriosis and pelvic programs so unique, that we work very closely with not just OB-GYN but other surgeons, including colorectal surgeons for more complicated disease that might impact the bowel. We also work closely with pain management, fertility specialists, as well as physical medicine and rehabilitation specialists that focus on pelvic floor dysfunction. So all of this is necessary to target these symptoms in women with endometriosis, who again, rarely have just one type of pain.

Infertility was mentioned. Certainly endometriosis can cause infertility even up to 40% of women who display these symptoms. And for this reason, it's important to not only speak with your OB-GYN, but also consult with a fertility specialist if there is difficulty getting pregnant. Endometriosis can certainly affect the ability to become pregnant by a number of ways, including damage to the sperm, as well as oocyte function, decreased ovarian reserve. There can be implantation issues with an embryo and there can be distortions of the tube that is caused by the surrounding inflammation and scarring from endometriosis.

There are several treatments for fertility that's impacted for endometriosis, especially for advanced stage disease. IVF has shown to lead to good outcomes. But overall treatments include medical management and then a stepwise progression to surgical therapies. And most of the medical managements that we offer have to do with decreasing the estrogenic state for these women because, as we know, endometriosis is an estrogen-driven inflammatory condition.

So all these medications, really there's not one medication that's better than the other, work to decrease the estrogen production in the environment of these lesions, and that can lead to a decrease in inflammation and pain in these women. And then if the medications don't work or if a patient might want to go straight to surgery to have definitive diagnosis for endometriosis, surgical treatments include excisional surgeries where we biopsy anything suspicious for endometriosis, send it to the lab and, as Dr. Pepin mentioned, being able to visualize glands and stroma of the endometrial lining. And depending on the severity of disease and all the different treatments a patient may have received, ultimately it may lead to hysterectomy. It certainly does not have to go that route, but there are conservative as well as more aggressive treatment options.

Dr Kristen Pepin: Absolutely. And I would just add, one thing that sometimes is surprising to patients is that it actually can be difficult to make a diagnosis of endometriosis officially. And that's because the only real way to do that is with surgery, to actually go in, see endometriosis lesions in the pelvis, remove them and then have them looked at underneath the microscope to tell us for certain that it does show both glands and stroma, the pieces of that endometriosis that need to be seen underneath the microscope. And so it is not uncommon that it is recommended for somebody to try medical therapy with a presumed diagnosis of endometriosis before the true formal diagnosis is made, just because the way that that diagnosis needs to be made is actually quite invasive with surgery.

Melanie Cole (Host): That's so interesting. So doctors, I'd like to give you each a final thought here, a chance to tell the listeners what you'd like them to know about endometriosis and this multidisciplinary approach. So, Dr. Shin, I'd like to start with you. Are there any homeopathic natural ways to treat endometriosis? Is there anything that you recommend women try before they would consider surgery or even as an adjuvant therapy, things that they can try?

Dr Ja Hyun Shin: There are several different treatment options. We discussed the medications that can lead to a hypoestrogenic state, as well as the surgical therapies. It's difficult to hear, but there is no cure for endometriosis. And so what we have is trying the different treatments available to help alleviate the pain symptoms.

We hope, for example, after excisional surgery that a patient's symptoms will be completely resolved. And for some women they are, but for others, there's a significant improvement. And for others, pain may persist. So for these reasons, it's usually not just one treatment and complimentary therapies can certainly help to alleviate pain for these women. These include pelvic floor physical therapy, that can be very helpful for painful, spastic muscular vaginal pain, as well as symptoms from having a dysfunctional pelvic floor.

Dr. Bonder, who's a medical director here for physical medicine and rehabilitation, works very closely with our endometriosis patients to help guide and treat some of these symptoms and also refer to pelvic floor therapists. We work closely with the integrative health center here at Weill Cornell, where providers may advise body movement as well as behavioral therapies to provide a kind of more holistic approach to their care. Acupuncture has been shown to be helpful to decrease pain symptoms associated with endometriosis. And of course, we always support, you know, maintaining good nutrition and an exercise regimen to be healthy overall.

Melanie Cole (Host): And Dr. Pepin, last word to you, kind of reiterate and summarize for us everything that we've discussed today. It's a lot to take in for many women that are suffering from this type of pain. Please kind of reiterate for us any of the lifestyle, complementary treatments, new medications, anything that you would like to tie this up and let women know that there is help out there for endometriosis.

Dr Kristen Pepin: Absolutely. So I think one kind of take-home point that I try to emphasize to my patients when I see them in the office, is that a lot of times there's actually more than one pathologic process that's going on in the pelvis at a time. And that is just unfortunately, very, very common in women with endometriosis.

So like Dr. Shin had mentioned, sometimes patients have issues with their bladder or their bowels. Sometimes that's related to the endometriosis, but there can be other conditions going on, such as painful bladder syndrome, irritable bowel syndrome or pelvic floor dysfunction. And so sometimes if patients don't feel like a hundred percent better when they have medical treatment or even surgical treatment of their endometriosis, it may be that we need to work on some of these other areas like their pelvic floor, their bladder, et cetera, in order to get them to really have the most optimal pain control. So that is one thing that I'm always sort of looking at with my patients. If they have endometriosis, sure, that's great, we can treat that with medicines and surgery. But the patients will not feel better unless we address any other issues that are going on in the pelvis as well. So that's one thing for patients to really be aware of as well.

Melanie Cole (Host): Thank you both so much. Really great information and so important for us to hear. Thank you so much for joining us and sharing your expertise on endometriosis.

And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

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