Episode 4: Rethinking endometriosis diagnosis and management

In this podcast episode, Vera Wellness gynaecologists Dr Peta Wright and Dr Thea Bowler explore the important nuances of endometriosis diagnosis and management.

From explaining the different types of endometriosis to challenging the idea that surgery is the only solution, Dr Peta and Dr Thea offer insights into what’s really happening in your body. 

They share how a more informed, whole-body approach can help you manage your symptoms and feel more in control of your health.

Whether you're newly diagnosed, have been dealing with endometriosis for years, or just want to learn more about your body – this episode is packed with insights to help you feel informed and empowered.

🎧 Tune in for this deep dive into…

🍃 What’s causing your pain: Not all pelvic pain is due to endometriosis. Find out how to identify if your symptoms could be rooted in something else – and what that means for your next steps.

🍃 A new perspective on diagnosis: Why the push for early diagnosis might not always serve you and how embracing a holistic, whole-body approach can lead to better, longer-lasting outcomes.

🍃 Understanding endometriosis types: Get clear on the different types of endometriosis – from superficial and deep infiltrating endo, to ovarian endometriomas and adhesive endometriosis. Learn what these mean for your symptoms and treatment options.

🍃 The truth about laparoscopy: Why this commonly recommended diagnostic surgery might not be the “gold standard” after all – and what you should consider instead.

🍃 Alternatives to surgery that work: Explore powerful non-surgical strategies like pain education, pelvic floor therapy, nervous system regulation, diet, and lifestyle changes that could help you reclaim your health and wellbeing.

**IMPORTANT NOTE**  If you’ve been diagnosed with endometriosis and are worried about fertility – book an appointment with a fertility specialist to discuss further fertility testing and options. Some women with endometriosis may experience more challenges trying to conceive, although the majority of women have no issues. Counseling early can help provide you with information specific to you, and provide you with all the options available for investigation and treatment if this is a concern for you.

Resources Mentioned:

• Healing Pelvic Pain by Dr Peta Wright

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Episode transcript:

Dr Thea Bowler: [00:00:00] 

Hi, this is Dr. Thea Bowler, and I'm incredibly excited for you to hear this episode of Women of the Well today, where Peta and I will be discussing diagnosis and surgery for endometriosis. This is a topic dear to my heart, as after becoming a specialist, I did a few years extra training in advanced laparoscopic surgery, primarily for endometriosis.

So I'm really looking forward to diving into the nuances of management with you here today. 

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Speakers: Dr Peta Wright & Dr Thea Bowler, Vera Wellness Gynaecologists

This is [00:01:20] Dr. Peta Wright. Welcome to another episode of Women of the Well. I'm Dr. Thea Bowler, gynaecologist at Vera Wellness. And today we want to talk to you about diagnosis of endometriosis. Yes. So we had one of our last episodes was on simple remedies for period pain. And I think what we hear from our patients and what we see in the media a lot is that if you do have bad pain, one of the things to do is to get it checked out because it might be endometriosis.

And while we totally agree that it's really important if you're having distressing pain that you do get help to manage it because having unmanageable distressing pain can definitely increase your chances of having or developing persistent or chronic pain. We want to be able to intervene and treat that pain early.

There's a lot in the [00:02:00] media and if you are someone who's, who is experiencing pain that you, you might be really worried about endometriosis and the messaging is that there needs to be early diagnosis of endometriosis. Absolutely. So what do you think about that, Thea? I think that the focus on endometriosis is detrimental for some women.

And we talked, in the last episode about the other reasons why periods can be painful. But I think that, you know, when we talk about early diagnosis of endometriosis, what we really should be focusing on is early validation. Treatment and management of persistent pain. And education. Exactly, and pain education.

I think whether it's persistent pelvic pain, or whether it's periods that are recurrently painful, we know that pain that goes on unchecked, can increase pain sensitization in the body, can worsen pelvic muscle tension, and can lead to worsening pain overall. So intervening [00:03:00] in a girl or a woman's pain is incredibly important.

If that pain is distressing. If the pain is distressing. I think that's far more important than the presence or absence of endometriosis. There are obviously subtypes of endometriosis, more severe subtypes, the deep infiltrating endometriosis. Could we talk quickly about the fact that only probably four out of ten women who present with bad period pain or pelvic pain are going to have endometriosis at a laparoscopy.

So that's six out of ten women who have bad. period pain or pelvic pain don't have endometriosis. That's right. And I think, you know, honing in on that subset of people who do have endo, we know that there are those subtypes. So there are deep infiltrating endo, there is endometriosis in the ovary, or endometriomas, and they probably account for 15 to 20 percent of endometriosis presentations.

The remaining 80 percent is [00:04:00] likely to be superficial. endometriosis, which is basically a thin layer of cells coating some of the surfaces in the pelvis. And I guess what we're learning is that that type of endo, A, is less likely to be causing pain and B, less likely to respond to surgical intervention.

And I think it's in those patients. That we see so frequently, repeated surgeries, because it probably was never the mild endo that was causing the pain in the first place. It was probably all the other things, the brain, the nervous system, the upregulated pelvic floor muscles, the inflammation, all of that.

All of those things. Look, I think a woman Being educated and understanding what's going on in her pelvis is incredibly important. Ultimately, the presence or absence of superficial endo I don't think is particularly relevant in someone's pain because what we certainly see in our patients is that if we're really proactively managing pelvic floor and gut health and the nervous system, pain [00:05:00] sensitization, stress in the environment.

All of those things that regardless of whether a patient has endo, their pain typically improves. And certainly in those patients, what we tend to find is that even if they do go on and have a surgery, they tend to come through that surgery so much better to recover better and to be much more likely to have lasting improvements in pain postoperatively.

Yeah, and we also know that if you did have superficial endometriosis from our episode on myth busting endo is that that is a kind of endo that is very likely to go away by itself. And in some studies up to 44 percent completely resolved with absolutely no treatment. That's right. So. So if you, can I ask you a question?

Yes. This investigator. So what would you say about the idea that laparoscopy is the gold standard for diagnosis? I mean if the goal is to diagnose every tiny piece of endometriosis lesion, then. Yes, that would be [00:06:00] true, but I think as you've been alluding to, that approach of doing laparoscopy for everyone with that aim to diagnose even the most tiny bits of endometriosis that may not have anything to do with the person's pain and may make things worse, isn't working.

And we know there was a big end, world endometriosis conference in the last few years where one of the big endometriosis researchers had said he actually thinks it's more of a copper standard. So not something that we should be doing for everybody with pain because of that probable irrelevance of that mild endometriosis.

And I think we have, from our previous podcast, we talked about the fact that even severity of endometriosis isn't correlated with extent with degree of pain. So someone can have dreadful pain and have no endometriosis. And if we're doing a laparoscopy to diagnose that, and they don't have any endo, then all of a sudden in this.

They're not validated because they don't have a lesion to see, you know, and if they do have a little bit of endo and we diagnose it [00:07:00] and then they don't really get better because there's other things going on then again that Doesn't seem to be an effective way of treating that person's pain. No, you're right.

I think we're ailing that person Yes, if all we're doing is a surgery and looking for endo and not addressing All the other potential causes of their pain. Yeah, and I think the thing is, some people do choose to have surgery for endometriosis, and that might be for fertility reasons, and it might be for pain.

And we do know that some people, you know, for some people who have severe, like, deep infiltrating disease or endometriomas, they might do better when it comes to surgery and pain. So it's good to know if you have deep infiltrating disease or ovarian disease, but we can actually diagnose both of those types of endometriosis with really good sensitivity, almost 94, 95 percent sensitivity with really good quality ultrasound or in the cases of women.

Who haven't been sexually active because normally the [00:08:00] kind of ultrasound that we would want to do is a transvaginal scan. So that's like the, I hate the word probe, like the vaginal wand I feel like that's a much better word. The vaginal wand, which is like an up close camera to your cervix, your uterus and your ovaries.

And only specific places who've been trained in sensitive endometriosis scanning are good at picking these things up. So you need to make sure that if you are wanting to have a scan like that, you ask your GP or your gynecologist to refer you to someone who specializes in that kind of ultrasound.

If we talk about like the findings of that sort of ultrasound, what like, what things do you find are more likely to be associated with endo and what findings often are less likely to be associated. Yeah. So the most obvious one is endometriosis in the ovaries is really actually pretty simple to see on a very basic ultrasound actually.

And they look like big sort [00:09:00] of ground glass, you know, circles or cysts in the ovary. Quite, be quite obvious. And then deep deposits of endometriosis or when organs are stuck together, for example, uterus to bowel and things are obliterated and not moving, you know, deep rectal lesions that can be seen on ultrasound or MRI.

Sometimes ultrasounds make the report about ovaries that don't move. And I think you did a recent review on this for a, radiology radiological conference that you spoke at and because a lot of people get really worried or the report even says ovaries aren't immobile or not moving this could indicate endometriosis even in the setting of them not reporting any ovarian endometriosis and often when we see that and we have people who are really worried and we go and we do a laparoscopy so much of the time It's their normal and the ovaries are perfectly fine and there's not endometriosis.

And what were the stats on that when you looked at it? Yeah, I looked at some [00:10:00] reviews looking at the chance of endometriosis in a normal ovary that appeared to be less mobile on an ultrasound. If the ovaries were normal, the chance of endo was three to four percent. So really, really low. Unlikely. Meaning 96 to 97 percent of people who only have that finding won't have endometriosis.

I think the other finding that can commonly crop up that does worry patients quite a lot is tender ovaries. And I guess we would call these like subtle, potential subtle markers of endometriosis. But again, in my experience. For people who are reported to have tender ovaries, that's much more likely to be the vaginal probe actually pressing on pelvic muscles that are really sore, rather than an ovary itself.

Totally. Being a cause of pain. A thousand percent. Because the sonographer, that's the person who's doing the ultrasound, they're doing it through the pelvic floor, and if you have persistent pelvic pain or, continual bad periods, you're [00:11:00] going to have that degree of pelvic floor tension and dysfunction.

And you're putting that wand right through that pelvic floor. Number one, it's not like a, comfortable or like normal situation anyway. So it is a time where your muscles are going to be more likely to tense up and be more painful. And then add to that, that history of, persistent pain. And I a thousand percent agree that most of the time that's due to the pelvic floor muscles rather than the actual ovaries.

And there's actually no way for the stenographer who's doing the scan to tell if it's the ovaries that they're poking or the pelvic floor muscles. Muscles surrounding the probe. That's right. And then we will often see when we see the patients in clinic, you actually do a vaginal examination and feel those muscles.

And when you're isolating those individual muscles, then you can easily ascertain that they're the things that are painful rather than the ovary itself. So if you had pain and you had a really good ultrasound that had reported normal ovaries, um, no deep deposits of [00:12:00] endometriosis, uterus is mobile. , And, you know, otherwise fairly normal, what do you think about that?

And still this person has pain, do you think that they then need to go and have a laparoscopy? I certainly wouldn't be jumping in and doing a laparoscopy on those patients, knowing that, you know, an immobile or a tender ovary is very unlikely to represent endometriosis. I would certainly be focusing my treatment on, Managing the period pain with hormones or with medicines or supplements, managing the pelvic muscles, helping to downregulate the nervous system signaling, at least in the first instance, , and certainly, you know, I would say in the vast majority of our patients, that means they then don't need to go on and have a surgery.

But if they do, they're much better placed to do that. Yeah. So the message would be that if you have a fairly normal MRI or pelvic ultrasound, then you can be reassured that even if you did have endometriosis, that that endometriosis is likely to be superficial, which means it can come, it can go, it can resolve by [00:13:00] itself.

And very likely isn't the whole cause of your pain. That's right. Um, and if you then had an ultrasound that suggested that you had endometriosis in the ovary or a deep nodule, then you, um, would want to have a discussion with your gynecologist about the symptoms that you have. Um, because as we've talked about before, many women who do even have that deeper disease or more severe disease don't actually have symptoms.

And. Again, this is another, um, another recent study where they did ultrasound follow up of deep lesions endometriosis. And can you tell us about what they found in that study? Because I think it's so many women just really think endometriosis, if it's there, it just gets worse and worse. Absolutely. Yeah.

This is a study that was done in Sydney, I think during COVID where they couldn't operate on people. So they'd done a scan saying, yes, you've got deep endo, we're going to do a surgery. Actually, we can't do the surgery because COVID has happened. So instead they did [00:14:00] surveillance of the endo and I think they did a baseline scan and then a six month.

Maybe they did them every six months up until two years and what they found in that study Was really similar to the laparoscopic studies that looked at what endo did over time But that it was probably only about 25 29 percent that progressed over time with around 30 percent Improving or regressing and around 30 percent staying the same.

So really we know that the majority of endometriosis either doesn't get worse or gets better. And I think that can be really reassuring for people. Yeah. And maybe we need, and I think that we need to be spending our research dollars on looking at what's causing what's different about that subtype of women whose endometriosis gets worse, because It's not all of it all the same and you know, as we talked about 80 percent of women who even have endo have had that diagnosis, had that very superficial disease.

Could be there one month and not there in six months. Yeah. [00:15:00] And I think the other thing as you've alluded to with deep endo is a, it's not always symptomatic. Like we would see patients every week who have terrible, terrible endo and either don't. Want an operation or you know, I've had patients recently who we've done a surgery for something unrelated to pain you know to do a hysterectomy or to remove a patient's tubes for contraception and have seen Really really terrible embryo and they've never had a day of pain in their life So I think that's just an incredibly important piece of the puzzle but the other thing is, you know in a patient who does have Bad endo and pain still, even in those patients doing surgery alone is often unhelpful, often unhelpful, and still we need to have that really holistic approach that's addressing all the other things.

Yeah. And so we're going to do another episode about surgery, but I feel like we just might roll on in. Do you think? I think so. So I think that then, so say if you had the normal scan. As we talked about, we would [00:16:00] look at all of the other things, nervous system, and I think one of the things that I would do as an assessment and working out, you know, where someone's nervous system is at, are they in fight, flight, freeze? Have they got a lot of stress? Is there, uh, are there pain pathways dialed up so that amplification of the pain system? There are little questionnaires that we can do with people to figure out the degree of what we call central sensitization or pain system hypersensitivity, which is the word we use to describe that amplification of those pain signals in the brain.

And. I think for anybody who is considering surgery, who either, even, even if they have lesions on ultrasound seen and absolutely if they have a completely normal ultrasound, I would be recommending that if you're seeing a surgeon or a gynecologist to think about surgery that they do this surgery assessment with you. Because so it's just a set of like 25 questions looking at how [00:17:00] sensitive your nervous system is basically. And there was a study that came out early this year, I think that looked at, um, if you had a high, moderate to a high score on this survey, then surgery was actually likely to be unhelpful, might make no difference to your pain, you know, or actually cause worsening of pain. 

Yep. And I think the interesting thing is that there was an Australian study done looking at people presenting to gynecology clinics with period pain, and they found that 75 percent of those patients, or it might have even been 80%, but like the vast majority had really high sensitization scores.

That was actually at a endometriosis clinic that has set up to, you know, deal with endometriosis. And that's really like, it is multidisciplinary, but it is, has a surgical focus and almost 80 percent of those women, if they went on to have surgery, they wouldn't be, they wouldn't be benefited from that.
So I think, Can you explain, like, can you explain that why surgery? [00:18:00] On, I guess, a peripheral problem, why that doesn't help with centralised pain? Yes, so if you've got, um, surgery to remove something in the pelvis, which may be something that has started off potentially causing pain, but still, I would say, the evidence that all endometriosis Is the signaling, um, thing I don't think is there, but if we're doing an operation on the peripheral part of our body, so our pelvis, but the way that we perceive pain is actually in our nervous system, our central nervous system in our brain, clearly just removing a lesion in the pelvis or doing something in the pelvis isn't going to an amplification of our pain signaling in our brain.

So, I think that because we know that information, I think that it's actually, I would actually say that it's, we hear all of the time about women's pain not being taken seriously and not being validated, and the sort of thought then is that if we're not operating on [00:19:00] women and giving them operations, we're not taking them seriously enough, and I think that that is really outdated, old fashioned, not modern.

Pain science. And we've seen in, in specialties like orthopedics. So that's like bones and stuff like that. They've stopped doing a lot of surgeries where studies started to show that the surgeries weren't helping and they could possibly be making things worse. And I actually think that continuing or going on and doing more and more and more surgeries on women, where we actually have the evidence now to show that it isn't improving the situation is the misogynistic negligent pace.

Absolutely. And I think, like we always say in our discussions, like, if someone's needing to have surgery after surgery after surgery, it tends to imply that the original surgery or any of the surgeries hasn't actually helped. That's right. And I think that ties in perfectly to what we're saying, which is that the surgery might be missing the point.

Correct. Completely [00:20:00] missing the point. And like, even when we look at some of the data about the average number of surgeries for women who've been diagnosed with endometriosis. Is like, uh, four, four up to 25 in a, in an audit. Yeah. And I think if you're doing something 25 times, I think we have to say it's not working.

It's ineffectual. Yes. And it's negligent and potentially even worsening abusive. Yes. To continue to operate on women and Absolutely. And say that they need these surgeries and, yes many women might may find it have an improvement initially because there's placebo effect with with any treatment that we give and that placebo effect is actually Increased the bigger the treatment that we give and we know that in some of the endo removing studies It's as large as 30%.

Yes, but we know that that Reduction in pain isn't sustainable over the long term. No, that's right and have surgery. Yes So if we're thinking about surgery for endometriosis [00:21:00] Who do you think it's beneficial for? So I think if you have done that, uh, so I think if you had a normal pelvic ultrasound, I don't think you should have surgery.

I think you should do all the other things. If you've had a pelvic ultrasound, which suggests deep endometriosis or ovarian endometriosis, you should have surgery. And you don't have pain system hypersensitivity, you are probably someone who's gonna do better with surgery. It's not that if you do have that hyper sensitization that you shouldn't have surgery, but maybe you need to work on the nervous system and the pain system hypersensitivity and the pelvic floor muscle function first, so that your outcome is likely to be better if you need it at all. Women who are wanting to conceive naturally, we do know that, that if they have evidence of endometriosis, there, um, can be a higher natural fertility rate. If you've got big, like lots of endometriosis in your ovaries, like [00:22:00] big endometriomas, and you're considering, um, IVF or, or wanting to conceive and you have pain, they would be also someone I would think about surgery.

But again, that's a gray area because you don't want to go in and remove ovarian tissue that can then reduce someone's ovarian reserve or reduce the number of eggs. So again, it's got to be a really nuanced discussion. I guess the only time in which, and these are rare cases, I suppose, that, that they happen is if someone has a lesion that's like obstructing a ureter, the tubes that go from the kidneys to the bladder or, you know, a big bowel lesion that's causing a lot of symptoms. They might be cases where you might be more inclined to do surgery, but I think that if you don't have any symptoms even if you have severe disease on ultrasound, I think it's totally fine, reasonable to watch and wait and surveil with another ultrasound and, if you definitely have [00:23:00] that, that hypersensitivity with your pain system, then I think definitely working on that first. What do you, what do you say?

No, I totally agree. I think really avoiding surgery or addressing the nervous system prior to surgery is incredibly important for most of our patients with pain because, you Almost everybody does have a degree of central sensitization.

I think most of the studies show that. You know, if you have pelvic pain and evidence of deep infiltrating endo on an ultrasound, then you're more likely to experience a reduction in pain after surgery. And that would be probably, in more recent studies around 80 percent of people report an improvement in pain.

If they have deep on a scan. But yes, like you say, really trying to avoid it in people who are asymptomatic in people who have a normal ultrasound and in people who have evidence of, um, central sensitization. And I think the other thing is that people in this space will say, well, the thing that's [00:24:00] driving the central sensitization, so that's that amplification of pain is the lesion.

I actually don't think that we have good evidence that that's actually the case because if we think about it, lots of people have the lesion and they don't have any pain, let alone amplification of their pain system and chronic pain. And when we think about, you know, for example, when we think about what the things that cause nervous system dysregulation.

Which is where we move into that fight or flight or freeze and we have increases of cortisol and adrenaline and especially when we think about that in terms of developmentally like, um, developmental stress, developmental trauma, things that, um, shift our nervous system to be more likely to be in that fight or flight or freeze zone.

We know that that can happen, and that may actually be the thing that predisposes us to have that heightened sensitivity to pain because our nervous system is in [00:25:00] a survival or danger mode, and when our nervous system or our brain is thinking, Everything's dangerous and it's on the lookout like it's super sensitive to be able to pick up any cues from the environment that might be dangerous because, um, we have maybe been in a situation as a young person or a child where we weren't safe or our brain interpreted that there was danger.

We might've been an attachment problem. It might've been, um, you know, even simple things like mom having postnatal depression, a disruption to attachment. Divorce. Anything that disrupts that feeling of safety in a young person's body can make our brains more, uh, alert to danger. And when we're more alert to like looking, scanning the environment for danger, obviously at a subconscious level.

We are much more likely to interpret any potential painful sensation as dangerous. And then that sensation is likely to be more [00:26:00] painful. And then our body reacts with, um, you know, tightening of the pelvic floor muscles and more fear and more pain. So I actually think the way that I see it is that that amplification probably happens before.

And then the stimulus is probably for women who have periods. The inflammatory event period, which is a without endometriosis, exactly, which is a unique phenomenon that it is a Repeated dynamic inflammatory potentially uncomfortable process in the body. Yeah, that is not pathological Like that is not a problem But when the nervous system is dialed up like that, it's read as being incredibly dangerous and there's not many Things that go on in the body that do give exposure to that repeated pain.

Which is why periods can do it, I think. Yep. And we know that, uh, from lots of studies now that, that early developmental trauma predisposes or increases the risk that you [00:27:00] might have persistent pelvic pain or really bad period pain. Yep. So I feel like, cause I know when we go on like when you go on social media, which I know we talk about is a, can be a real minefield because of course it's a place where women who traditionally not felt validated, um, go to seek support, which is really good.

And it's so good that there's awareness and discussion and support for people who feel alone and are suffering, but there is also, there's also, you know, a lot of anger there, and I know that there are groups of people who say, well, the thing that's causing that amplification of pain is the lesion and we must go after that.

But I think we've established that the evidence doesn't support that. No. And especially if you think about it, like we're doing more surgeries than ever, like more and more people are having laparoscopies. And there's more awareness than ever. That's right. Of endometriosis. That's right. And more and more people have pain.

What can you briefly talk about, like, I guess, historically and culturally, why [00:28:00] surgery has been the mainstay of treatment? Yeah, I think that, so from a Western medical perspective, surgery has been the thing, well, there hasn't been very many studies on women's bodies and what's normal. And when a woman comes and says, well, I've got pain in my pelvis, and we have a Western approach, which is, surgery or medicine, the aim is just to go and look in the pelvis.

And when we look in the pelvis and we see that some people have these lesions that we can identify and call it a name, call it endometriosis, call it a disease, and then say, Oh, well, that must be what's causing the pain. Even though we know that if I took a hundred random people who had no symptoms and put a, did a laparoscopy, Almost 50 percent of them would have endometriosis.

So again, is all endometriosis a disease? I don't think so. But historically we would look in, find these little lesions and then say, well, this is a disease. And then women, [00:29:00] because I think the, the most seriously you can be taken is to have, you know, to be, because we get such little support to help deal with any of this, there is no acknowledgement of the link between mind, body, spirit, all of that seen as very woo.

And women historically were. You know, persecuted for, for dealing in anything that wasn't like concrete. Here is the lesion that we're looking at under a microscope or with a surgery. Women have internalized the idea that if you talk about like mind, body, spirit, medicine, we are disregarding or not validating it.

And so because culture. Really only recognizes and gives you help if we can say there's this lesion like think about our training When we trained and we did laparoscopy and it was naked. There was no endometriosis There would be no further. Sorry. That's all we can do. Yeah, that's all you might need to go see a gastroenterologist That's [00:30:00] how we were trained or the woman felt like it was in her head, and she was crazy, and there was no support, and there was no acknowledgement of mind body spirit medicine. Yes, and no other alternatives exactly. And so of course women really, the only way they've traditionally been validated is through surgery.

And so of course, that is kind of, if you believe the media approach that all pain must be due to endometriosis, everybody needs surgery for diagnosis or else it's neglectful. Then you'll want to have a surgery because you want to be validated, but you should be validated for your experience regardless of that before you remotely think about having surgery.

Absolutely. And I think it's like that whole pendulum swing thing, isn't it? That like, you know, historically women's pain was dismissed, you know, women was. Just, you know, it's in your head. Tuck it up. It's pain is part of being a woman, and the pendulum's almost swung to the other extreme, which is that, well, if you have pain, we've got to look for endo and treat endo at all costs [00:31:00] and there's nothing else considered.

And it's always pathological. That's right. And there's got to be. Somewhere in the middle that actually considers the whole woman, the whole person, her environment and the other things going on in her body that can contribute to pain. And research is increasingly showing that those other things, so physiotherapy, nervous system regulation.

Um, feeling safe even to have a period or to talk about it, those are things that actually make a big difference when it comes to pain. And you know, we've talked about it before, but that ongoing fear and immobilization and avoiding things that is, has much higher correlation with ongoing pain and an endometriosis lesion.

Um, so, so yeah, and I think I would also say that there are women who have horrendous endometriosis, really much more rarer. who have horrendous endometriosis that they, that does require multiple surgeries and things. But I think [00:32:00] often we maybe needed to be more mindful of the first surgery and all of the other things that we can do to help, um, that person's quality of life.

And maybe all of the research about endometriosis maybe needs to be In that subset of women who have the deep infiltrating disease, which is really like 5 percent and the, and the ovarian disease, which is like 15 to 20 percent of women. And then the people who have the superficial stuff, I think that's more likely, I think wear and tear of normal periods.

Totally, totally. And there are pathologized. Yes. And there are those two studies being done overseas at the moment about whether surgery for that type of endo, for superficial endo actually helps or does it harm? Yeah, exactly. Exactly. We've really waffled on from the beginning. We were talking about diagnosis and then surgery and now we've just moved into pain.

Yes, we did. But I would really say that if you are considering having surgery, that number one, even if you've [00:33:00] seen a surgeon who's just a fantastic surgeon, fabulous, but make sure around the edges you're seeing somebody who has examined your nervous system. system has looked for pain system.

Hypersensitivity has talked to you about your pelvic floor, has talked to you about diet and how your environment can affect you and how addressing those things will help to improve your outcome. Cause I don't know about you, but I used to do. All of the things and do surgery and then I was like, everyone gets better.

That's good. And then I realized, um, but maybe if I just talked about what's happening, talked about pain and nervous system, education, physiotherapy, which is so underrated, and we've got a podcast episode coming out about talking about early life adversity, helping to heal trauma and helping to decrease inflammation with periods, then I would find, and I find this now because now I hardly, hardly any of my.

Patients will go on to have surgery because we do a trial of that for three or four [00:34:00] months and most of them come back and they're way, um, way better. I reckon less than 5 percent of people have gone on to have surgery and we're talking about the people who, I'm probably talking about the people who've had a normal ultrasound.

And I think it's really important, like we can say to those people, you know, you've had a normal ultrasound. You might have a little bit of superficial endometriosis there, but really what we're learning, as we've said before, is that that's potentially not contributing to pain and potentially not going to benefit from surgery, and therefore we can feel really safe that there's nothing harmful or dangerous going on in your pelvis, and that addressing all of the other factors first, um, is probably going to be the quickest and least invasive path to, um, healing.

Hmm. Hmm. Exactly. And who would you recommend an MRI to? I think, um, MRIs have their place and we actually should say like MRI compared to ultrasound is they're pretty, um, similar, pretty similar in sensitivity and specificity. I [00:35:00] think an ultrasound has the added benefit of being a dynamic imaging procedure.

So you can actually see when you move the uterus, does the bowel move with it? Like, is it actually all, you stuck together, but there are certainly people for whom an MRI is beneficial. You said before, if people aren't sexually active, so we don't want to do an invasive vaginal procedure, then we would do an MRI preferentially.

And that's if we're really considering that there might be significant endo there. Um, and then the other people that it's beneficial for, I think is to really delineate. Um, the extent of deep infiltrating endos, so often we'll do an ultrasound that says, yes, you know, um, the bowel and uterus are adherent and stuck together and the ovaries might be involved.

And then we know that if there is ovarian endometriomas or that the bowel appears to be tethered to the back of the uterus, that the chance of actually having endometriosis that involves the wall of the rectum or the bowel is much higher. And obviously if we're doing endometriosis surgery. [00:36:00] Um, for endo that does involve the bowel, then that can be more extensive, often will involve a colorectal surgeon.

So I guess the MRI can be beneficial there in terms of surgical planning, but an ultrasound is always an incredibly great place to start. Absolutely. Okay. So if you've had pain that isn't improving with the things that we've talked about and all of the education and that you've made space for your period if you can, and you've seen your GP and you've had a normal ultrasound, then I guess if you're still not reassured and you're still experiencing pain, then I would recommend seeing a gynecologist who understands.

You can also read more about this in my book, which is called Healing Pelvic Pain and any questions or comments or worries, please, contact us on our Instagram. And yeah, the main thing is I don't think we need a laparoscopy for diagnosis anymore. We have really good imaging. Superficial endometriosis is not likely to be particularly relevant and it's [00:37:00] always a holistic picture when we're considering treatment.

Yeah, there are people for whom, people with endometriosis for whom surgery is beneficial, but it's not the majority. Yep. And they're the people who are likely to have a deep lesion or an endometrioma on ultrasound. And that's what we know from our studies. So it's important that we're thinking about all of those things to improve your chances of getting better, because we don't, you don't want to be in a position where you're having surgery after surgery.

That's right. That's right. And I think that's the other thing to mention is that if you do have surgery and you still have pain, having another surgery is not necessarily going to be beneficial, but rather actually seeing someone who helps you to address. Other factors in the pain story. One more thing I would say, yes, of course, skill of surgeon is very relevant, um, and excision of endometriosis is thought to be the best in terms of removing disease and making sure that procedures are done safely.

But I also think again, so an online thing that people often worried [00:38:00] about is if they've had ablation versus excision. And what can you say about those studies? I think that there are a lot of studies, um, showing ablation and excision to be And ablation is when you burn the endometrium. And, but also in cases where there's ablation or burning the lesion, they're probably likely to be more superficial, like mild lesions, because you can't really just ablate or burn a deep lesion.

No, that's right. So By definition, those patients are going to have milder endometriosis and probably milder symptoms. A lot of the studies show them to be equal, but there are some studies that show excision is slightly superior in terms of postoperative. And most surgeons now who you go to see will be doing.

That's right. Everybody now is trained in excision. Yeah, exactly. So I think we've covered everything in a hodge podge of ways. So thank you so much for listening and we look forward to seeing you next time. 

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This podcast is for information and educational purposes only and is not intended as a substitute for medical advice, diagnosis, or treatment.