In this episode, we break down what’s normal — and not — when it comes to menstrual cycles, heavy bleeding, and pelvic pain. We cover key warning signs, common causes like fibroids and when it’s time to seek care. Our experts also dive into endometriosis, including how it’s diagnosed, treated and its impact on fertility.
The Experts
- Director, Minimally Invasive and Robotic Gynecologic Surgery Division, Stony Brook Medicine
- Minimally Invasive and Robotic Gynecologic Surgery, Stony Brook Medicine
- Minimally Invasive and Robotic Gynecologic Surgery, Stony Brook Medicine
What You’ll Hear in This Episode
- 00:00 Opening and Introductions
- 1:20 What does a “normal” menstrual cycle look like?
- 1:56 Red flags for bleeding that is too heavy
- 2:24 At what point should patients seek care for their periods?
- 2:42 Common causes of heavy periods
- 4:24 Is the cause of heavy or irregular bleeding always identifiable?
- 5:08 Evaluation for endometrial cancer
- 6:03 What are fibroids, and how common are they?
- 6:38 Treatment options for fibroids
- 9:03 Holistic approach to treatment options for heavy bleeding
- 11:44 Surgical treatment options for heavy bleeding
- 14:23 Pelvic pain
- 16:00 What are some conditions that may cause pelvic pain outside of a menstrual cycle?
- 17:40 What is endometriosis?
- 21:00 Evaluating endometriosis
- 22:28 Medical and surgical treatment options for endometriosis
- 26:05 Endometriosis and fertility
- 26:44 If no endometriosis is seen at the time of surgery, what are next steps?
- 27:43 Case studies/success stories
- 28:22 The future of diagnosis and treatment options for endometriosis and pelvic pain
- 30:11 What is minimally-invasive gynecologic surgery (MIGS)?
- 31:07 What are some benefits of MIGS?
- 32:35 When should patients seek care from a MIGS specialist?
- 33:50 Closing Remarks
Full Podcast Transcript
00:00 Opening and Introductions
Description of Video Studio: News desk with Stony Brook Medicine logo on the front. A big screen is behind seated experts with the HEALTH Yeah! logo (red uppercase lettering with a microphone at the top of the “L”). Music plays as the announcer introduces the episode.
Announcer
Welcome to HEALTH Yeah! where experts from Stony Brook Medicine come together to discuss topics ranging from the complex inner workings of an infectious disease to tips and tricks for staying safe and healthy all year long.
Xun (Julie) Lian, MD, FACOG
Welcome to HEALTH Yeah! I’m Dr. Julie Lian, associate professor of gynecology at Stony Brook Medicine and division director of Minimally Invasive and Robotic Surgery. Today we’re talking about something millions of women experience, but are told far too often is normal, and that’s heavy bleeding and pelvic pain.
Heavy bleeding that disrupts your life shouldn’t be dismissed, and that goes for pelvic pain too. Whether it’s pain with your period, pain during sex or chronic pain that just doesn’t seem to go away, it deserves our attention.
In this episode, I’m joined by two of my colleagues, Dr. Sarah Kim and Dr. Caitlin Waters, surgeons from our minimally invasive gynecologic surgery team, also known as MiGs. We are OB-GYN physicians who specialize in diagnosing complex gynecologic conditions and offer advanced, patient-centered treatment.
Today, we’ll unpack what’s normal, what’s not and when it’s time to seek care. Most importantly, we’ll talk about how women can advocate for themselves and the treatment options available today. Let’s get into it.
1:20 What Does A “Normal” Menstrual Cycle Look Like?
Xun (Julie) Lian, MD, FACOG
So Dr. Kim, what does a normal menstrual cycle look like? How much bleeding is too much?
Sara Kim, MD, FACOG
Generally speaking, a menstrual cycle frequency is about anywhere from 21 to 35 days. It kind of varies by individuals and the bleeding could last anywhere from five to seven days.
Normally, if you really want to quantify, if you look at papers, they will say it’s about two to three tablespoons is considered normal. Anything greater than 80 milliliters is considered heavy. Personally, even for me, I find that kind of hard to quantify. So I usually tell my patients, if you’re bleeding through a super, super tampon or a pad more than one pad an hour, that’s considered too much.
1:56 Red Flags For Bleeding That Is Too Heavy
Xun (Julie) Lian, MD, FACOG
Okay. And what are some symptoms that would be red flags, or to suggest that the bleeding is too heavy?
Sara Kim, MD, FACOG
So most symptoms are what we consider like signs of anemia, that your actual blood level is a little bit too low. So if you’re fatigued, (have) dizziness, shortness of breath, I think those are really (the) red flags.
But even if they don’t have those red flags, if the bleeding is bothersome, I usually say, hey, come in for an evaluation, for us to kind of assess what’s going on.
Xun (Julie) Lian, MD, FACOG
Okay.
2:24 At What Point Should Patients Seek Care for Their Periods?
Xun (Julie) Lian, MD, FACOG
And Dr. Waters, at what point should patients seek care?
Caitlin Waters, MD, FACOG
If patients are experiencing frequent periods, prolonged periods or heavy periods, they should come in and seek care. But also, one that’s often forgotten is if patients are also skipping periods regularly. It would also be a good idea to come in as well.
2:42 Common Causes of Heavy Periods
Xun (Julie) Lian, MD, FACOG
Okay, and what are some common causes of heavy periods?
Caitlin Waters, MD, FACOG
So some benign causes of heavy periods can be fibroids, endometrial polyps (and) adenomyosis. Patients can also have a regular bleeding from PCOS. Sometimes you can have genetic conditions that can cause periods to be heavier, and then a non-benign condition would be a cancer of the uterus. So that’s something we take pretty seriously.
Xun (Julie) Lian, MD, FACOG
So a lot of things to think about (for) our patients. And how do women find out if they have any of these mentioned conditions?
Sara Kim, MD, FACOG
I would say, come look for us, because first and foremost, history and (a) physical exam is very important. So (we) ask patients what their symptoms are like, how long they’ve been having those symptoms. And then we would do a physical examination where we could, if someone has a big fibroid uterus, we could actually field out an exam. And then our best friend is actually an ultrasound. So that would give us a little closer examination to look at the actual uterus to see if there’s fibroids, polyps, things that Dr. Waters kind of talked about, and we’re able to kind of assess for other structural causes like adenomyosis as well.
Xun (Julie) Lian, MD, FACOG
What I find sometimes interesting is that with the sort of advent, let’s say, of social media, I think a lot of our patients are seeing what’s normal and what’s not normal because sometimes they don’t really talk about it with their family members or their friends, or sometimes they do, and then that’s when they realize, oh, what I’m experiencing isn’t normal. And other times, patients we see, I talk to them, and they have, you know, really heavy bleeding to the point where they are passing out. And they never said anything, because they thought that was their normal. So I think, you know, certainly, if you’re ever concerned, I think patients should definitely bring up their symptoms to their doctors.
Sara Kim, MD, FACOG
I agree.
4:24 Is The Cause of Heavy or Irregular Bleeding Always Identifiable?
Xun (Julie) Lian, MD, FACOG
So Dr. Waters, is a cause of heavy or irregular bleeding always identified?
Caitlin Waters, MD, FACOG
That is such an important question. And the answer is, unfortunately, no, we don’t always identify why a patient might be having heavy or regular bleeding. That being said, we still take the symptoms very seriously, and patients should be counseled on all of the medical, procedural and surgical options that we have available.
My hope is that as more research is put into women’s health, the percentage of times we don’t know the answer to the bleeding will decrease with time.
Sara Kim, MD, FACOG
I think the positive is that even if we don’t necessarily know the cause of the bleeding, there are still options that we could use to help our patients.
Xun (Julie) Lian, MD, FACOG
Right, and again, taking them seriously and offering them the options that we have at our disposal.
5:08 Evaluation For Endometrial Cancer
Xun (Julie) Lian, MD, FACOG
And how can we evaluate for possible endometrial cancer?
Sara Kim, MD, FACOG
So oftentimes, patients may come, as you know, have irregular bleeding. So is that something that’s going to be a red flag for something? So we usually say, hey, one of the things that we do as part of the workup is to rule out cancer, because endometrial cancers can present with irregular periods. In the reproductive age female, it could be regular bleeding, irregular menstrual cycles. In a postmenopausal female, it could be just postmenopausal bleeding in general.
So we rule endometrial cancer out by actually doing a biopsy in the office. We basically put a little pipel, which is like a little straw inside your uterus, attain some cells, and we send that off for pathology.
Xun (Julie) Lian, MD, FACOG
Right. So I think besides assessing for some structural or nonstructural causes, we also make sure that you know something more serious, like pre-cancer, the cancer of the uterus, isn’t the cause of the heavy or irregular bleeding as well.
So let’s dive a little bit deeper into one of the more common causes of heavy bleeding, which are fibroids.
6:03 What Are Fibroids And How Common Are They?
Xun (Julie) Lian, MD, FACOG
So Dr. Kim, what are fibroids and how common are they?
Sara Kim, MD, FACOG
So fibroids are benign. There’s smooth muscle growth on the uterus. It’s very common, actually. So I think a lot of women find it surprising when they learn that they have fibroids. But about 60 to 75 percent of reproductive age females actually have fibroids. Sometimes, it’s incidentally found when we’re doing an ultrasound for some other reason during pregnancy sometimes. But during the workup for heavy bleeding, oftentimes, fibroids could also be found.
6:38 Treatment Options for Fibroids
Xun (Julie) Lian, MD, FACOG
Right. Are all fibroids treated the same? And what factors might influence which treatment options are available to a patient?
Sara Kim, MD, FACOG
I think the biggest thing that goes into what options and how to treat fibroids are usually patient symptoms. So one of the things that patients (have said) was like, Hey, I have this, you know, one centimeter fibroid that they found incidentally. Do I have to do something with it?
I always say, if you have no symptoms from it, then not necessarily. And then the next step is, you know, the size and location also kind of dictates what kind of treatment options are available. So depending on how big it is, whether we could actually remove it with small incisions, minimally invasive. We also could sometimes remove fibroids like vaginally. Again, so the location and size matters as well as symptoms.
And not everything is always surgical. So we could also have medical management options as well. So again, based on their symptoms is what we offer patients, and kind of have a discussion about the options.
Xun (Julie) Lian, MD, FACOG
Great. Dr. Waters, what are some of the medical options that are available to treat fibroids and heavy bleeding?
Caitlin Waters, MD, FACOG
So starting with over-the-counter options, NSAIDS (ibuprofen) can actually decrease not just the pain associated with bleeding from fibroids, but also the amount of bleeding, which is something that patients also often find surprising.
In terms of nonhormonal, but prescription medications, one of the ones we use a lot would be tranexamic acid, which is a pill that you can take five days a month when you’re bleeding from your period, but you can only take it five days a month, so it’s a bit limited.
Then we get into our hormonal options, which do make up the bulk of the medical management treatment options. For fibroids, there are hormonal options that have both progesterone and estrogen, like the classic birth control pill. But for patients who are not candidates for estrogen, which is a fair number of our patients, there are also a lot of progesterone-only options that we can use to safely stop the bleeding.
Sara Kim, MD, FACOG
Okay, and I still want to put a plug for like Mirena IUDs.
Caitlin Waters, MD, FACOG
It’s another great point.
Sara Kim, MD, FACOG
That depending again, size and location, if you have a fibroid in the cavity, you may not be a candidate for an IUD, but if it’s more in the the wall the uterus, what we call intramural fibroids, and you still have heavy bleeding, that is something that we could use as an option to help with the bleeding,
Xun (Julie) Lian, MD, FACOG
Right. And each option comes with the associated benefits and risks as well. And so I think having that detailed discussion with your doctor, but depending on what your workup, your physical exam, your ultrasound shows, will then ultimately help tailor your treatment.
Caitlin Waters, MD, FACOG
Absolutely.
9:03 Holistic approach to treatment options for heavy bleeding
Xun (Julie) Lian, MD, FACOG
What about a holistic approach to treatment of heavy bleeding? Let’s say, you know, someone is a little concerned about what they’ve read and heard online about hormonal options.
Caitlin Waters, MD, FACOG
So that’s a question we’re getting more and more often from our patients. I think an important point to make is that because the menstrual cycle is driven by fluctuations in hormone levels, which bring on a period, that’s often the way in which we can treat bleeding. So the hormonal medications are particularly effective because they’re really addressing the cause of menstruation or the cause of the irregular bleeding.
I would say, I’ve had a lot of patients come to see me hesitant about the use of hormones, and then they end up being willing to give that medication a try, and they end up being able to avoid invasive surgery with the use of the medication.
So of course, there’s risks with any medication, but ultimately, it’s a good discussion for a patient to have in depth with their doctor. As for the question about some of the alternative or complementary modalities that you can use to treat bleeding. In this day with social media, patients are asking us more about those other methods. Unfortunately, there is a lot of misinformation on social media, and so we have to be really careful about parsing out what information is useful and correct and what information is potentially harmful. So if you’re wondering about a particular supplement, I would say, please discuss it with your doctor.
Xun (Julie) Lian, MD, FACOG
Right. So I do think that while we have medications and treatments that can definitely help a lot with fibroids and bleeding. If someone does want to consider other options, complementary and supplemental options, then definitely speak to your doctor about the safety of those methods.
Sara Kim, MD, FACOG
I oftentimes get questions about if there’s any dietary changes that they could make or (if) exercise could shrink fibroids. I always tell patients there’s no clear evidence, but I’m a big proponent of exercising and healthy lifestyle choices. So is it? Why not? It’ll make you feel better overall. So I think that’s also something to consider that those changes are okay, depending on again, talk to your physician about it, if you’re if it’s more for overall healthier life choices.
Xun (Julie) Lian, MD, FACOG
Right. And I think there is some emerging research into certain things like vitamin D levels and other, let’s say, green tea extracts, that could potentially affect fibroid growth. Certainly those are new data. I wouldn’t necessarily recommend someone drink a lot of green tea to try to shrink their fibroids. But again, I do think there’s growing research and looking into other methods to help.
11:44 Surgical Treatment Options For Heavy Bleeding
Xun (Julie) Lian, MD, FACOG
So what about some surgical options?
Sara Kim, MD, FACOG
I’ll first talk about some of the minor surgical options that we have. One of the things is embolization. So you could have uterine artery embolization or uterine fibroid embolization, that is basically decreasing the blood flow. So we would send a referral to interventional radiologists. So as gynecologists, we don’t necessarily do the embolization, but interventional radiologists will see you as a consult, and we’ll kind of discuss the procedure, which, again, is decreasing the blood flow to the fibroids. So then, over time, the fibroids will shrink and die.
Another thing that is relatively new, but we do actually offer as Stony Brook is called a sonata ablation. So that is using radio frequency waves and to basically char the fibroid. It’s kind of burning the fibroid, and preventing it from getting any bigger — shrinking it. It has been shown to be very successful. Again, we do offer that at Stony Brook Hospital, and a lot of patients have found it very favorable because the downtime from the ablation is actually very minimal, and they usually don’t wake up with any type of abdominal incision. It’s all done vaginally.
And then if you have kind of, like I said, a location of the fibroid that’s intercavitary, again, a vaginal approach, where you could introduce a hysteroscope, which is basically a camera inside the uterus, and then use a shaver to resect and shave down the fibroids.
So those are kind of the minor options, minor procedural options that we have,
Xun (Julie) Lian, MD, FACOG
Right and then these are all things that we offer at Stony Brook. And Dr. Waters, any other procedures that patients can think about?
Caitlin Waters, MD, FACOG
So once we’ve tried medical management or the procedural management options, then we move on to sort of some of the larger surgical management options, and those are typically myomectomy or hysterectomy.
Myomectomy, meaning we remove the fibroids. Hysterectomy, meaning we remove the uterus. And I think a really important point to make is that when we do a hysterectomy to remove fibroids in a premenopausal patient, a patient who has not yet gone through menopause, we don’t need to remove the ovaries, and so patients will not necessarily be put into menopause from a hysterectomy. I think that’s a common point of confusion, and so it’s nice to have the opportunity to clarify that.
In terms of treatment options, myomectomy versus hysterectomy, that’s (a) discussion that patients have with their surgeon to figure out what surgical management option is the best. Regardless of whether a patient’s undergoing a myomectomy or hysterectomy, we always opt for a minimally invasive approach where possible, meaning we would opt to use small incisions if feasible, instead of a larger incision.
Xun (Julie) Lian, MD, FACOG
Dr. Waters, can you tell me about a recent success story?
Caitlin Waters, MD, FACOG
Speaking generally, I see quite a few patients like this patient, but younger patients will come in and tell me that a previous doctor recommended an open hysterectomy. Then we review the imaging, I talk to the patient about what they’re interested in and we find that we can do a myomectomy — and not just a myomectomy, but a minimally invasive approach. Typically, we opt for a robotic-assisted laparoscopic myomectomy, and patients tend to do very well with that. They’re really pleased to hear about these expanded options, and it’s usually very successful.
Xun (Julie) Lian, MD, FACOG
Right. So again, definitely a discussion to have with your doctor, and then possible referral to a minimally invasive GYN surgeon if needed.
14:23 Pelvic Pain
Xun (Julie) Lian, MD, FACOG
So I’ll switch gears a little bit and talk about another big topic that we see a lot as gynecologists in the office, and that’s pelvic pain. And a lot of times patients talk about or complain about their pelvic pain, and can be then their doctor tells them it’s normal, it’s part of their menstrual cycle. So how do we know when pain isn’t normal?
Sara Kim, MD, FACOG
So again, come look for us. A history and physical exam is crucial because it helps differentiate the different causes of pelvic pain and how to address them. If it is gynecologic-related, one of the first things we ask is, ‘Hey, is it always related to your menstrual cycle? Is it cyclical? Is it related to something else?’ We also ask, ‘What other symptoms do you have? Do you have pain with intercourse? Do you also have pain with urination? Do you have pain with bowel movements?’
Then we start thinking about other systems that may potentially be involved. If it’s cyclical, we lean more toward gynecology, since patients in our population have menstrual cycles every month. If it’s non-cyclical, then we start thinking, ‘Okay, maybe it’s more bladder-related, not really us,’ and maybe the uterus and pelvis are more bystanders.
So one of the things we do, again, is a thorough history and physical exam, which really gives us more answers. Then we refer patients for an ultrasound to see if there are any anatomic causes of the pain they’re having.
16:00 What Are Some Conditions That May Cause Pelvic Pain Outside of a Menstrual Cycle?
Xun (Julie) Lian, MD, FACOG
So I think one of the key things is to take your patient’s complaints seriously. And I think again, pain to the point where someone may be missing work or school or events of their life and it’s affecting their quality of life, should always be taken seriously, and that’s not normal.
So sometimes pain, as Dr. Kim said, isn’t associated with your menses. What are some possible conditions that may cause pain outside of periods?
Caitlin Waters, MD, FACOG
One of the most common causes of pelvic pain that is not cyclic would be something called high-tone pelvic floor dysfunction, and we treat this a lot in our Chronic Pelvic Pain Clinic here at Stony Brook. But this is essentially when the muscles of the pelvic floor are persistently tight and they don’t relax normally. Patients can experience pain with intercourse, pain at the time of the speculum exam at their gynecology visit or chronic pain unrelated to those conditions, and it’s really important to have an exam done by a qualified provider who’s familiar with the exam and the assessment one.
I want to make a plug that if any patient is experiencing any type of sexual dysfunction, that they should talk to their doctor about it. I think a lot of times patients can be nervous, but if you’re having pain, especially with intercourse, we are here to support you through that and talk about options. And then if we do find high-tone pelvic floor dysfunction, the treatment is primarily pelvic floor physical therapy, which can be very effective and has minimal risk. And if patients don’t respond to that, sometimes we consider trigger point injections to help as well.
Xun (Julie) Lian, MD, FACOG
Right. So I think similar to bleeding, again, these are topics that some people might find embarrassing, but you know, certainly, if it’s affecting their quality of life, (it’s) something very important to talk about with your gynecologist. And then hopefully they can counsel you on the options or refer you to someone like our team to help you with your with their symptoms.
Caitlin Waters, MD, FACOG
Yeah.
17:40 What Is Endometriosis?
Xun (Julie) Lian, MD, FACOG
So let’s dive little bit deeper into another hot topic, which is endometriosis. That’s a condition that causes, or a main cause of painful periods. So, Dr. Kim, what is endometriosis? And why do you think it’s such a hot topic these days?
Sara Kim, MD, FACOG
So endometriosis — one of the ways that I explain it to patients — is kind of like retrograde menstruation. Meaning that, technically, during a normal menstrual cycle, blood is supposed to flow out of the uterus. But what starts happening is that you’re almost menstruating into your pelvis, whether it’s into your ovaries or into the peritoneum, which is the tissue surrounding your pelvis.
This creates a chronic inflammatory condition inside the pelvis, so it becomes almost like a hostile environment. Every time you have a period, it creates a lot of inflammation and pain. It irritates all the nerves and tissue around it. Over time, some patients start developing non-cyclic pain because there is now so much scar tissue and inflammation throughout the pelvis, even outside of the menstrual cycle. The tissue becomes chronically inflamed, so they may start feeling pain more and more outside of their menstrual cycles, along with pain during intercourse.
Those are all things that start to inflame the overall pelvic floor, and that is what endometriosis is.
The reason why it’s such a hot topic is, one, it’s a very common cause of pelvic pain. But two, it takes time to diagnose. The average time to diagnose endometriosis is about seven to 10 years. Part of the reason is that most women do experience some menstrual cramping, so oftentimes it gets ignored as, ‘Hey, this is just part of your menstrual cycle. Just take some NSAIDs or birth control pills, and it will go away.’
While those are actually treatment options for endometriosis, if patients truly do have endometriosis, the pain can be very debilitating and affect their quality of life. But it often gets dismissed, and more pills may just be thrown the patient’s way. Patients may then think, ‘Okay, well, if it’s that common, maybe this is normal. Everyone else has pelvic pain or menstrual cramping. This is just part of being a woman.’ So they may ignore it for a long time, until they finally talk to a provider and start describing symptoms like missing school or work.
At that point, we realize this may be more than mild menstrual cramping. This could be something more extensive, like endometriosis.
21:00 Evaluating Endometriosis
Xun (Julie) Lian, MD, FACOG
Right. I think, you know, you mentioned the delay in diagnosis — seven to 10 years. It doesn’t take seven to 10 years to diagnose it. I just think, unfortunately, women go through multiple doctors and different specialties trying to figure out why they’re having pain.
And then, as you said, sometimes — and frequently — it does involve other systems besides just GYN. Patients can have associated bladder dysfunction, GI dysfunction and involvement of other systems as well.
So endometriosis, similar to fibroids, is something that definitely needs more research looking into what’s causing it. We still don’t really know the exact cause of endometriosis or all the best treatment options. So, yes, it definitely deserves more research.
Sara Kim, MD, FACOG
I think part of the delay is also the fact that the true way to really diagnose endometriosis is surgically done. So that may be another reason why there might be a little bit of a delay, right?
Xun (Julie) Lian, MD, FACOG
So if someone comes to you and with pelvic pain, painful periods, and you’re suspicious of endometriosis, what’s the workup like?
Caitlin Waters, MD, FACOG
A (medical) history is going to be really important here. And if someone says they have pain with their periods, the discussion about possible endometriosis should really come up at that first visit — that this is a possible cause of their pain. So a very thorough history, a physical exam and then ultrasound are really a cornerstone for us in terms of evaluating endometriosis.
Here in the GYN department at Stony Brook, we have dedicated ultrasound to evaluate specifically for endometriosis, in particular, something called a sliding sign. So we do a little more advanced ultrasound here for endometriosis. Sometimes an MRI may also be helpful, particularly when you’re trying to evaluate for endometriosis affecting the bowel or bladder, which can be more difficult to pick up on ultrasound.
In terms of definitively diagnosing endometriosis, as Dr. Kim mentioned, surgery is the definitive method — you can directly see endometriosis lesions, and sometimes they can be confirmed on pathology. However, we can also sometimes identify endometriosis from imaging alone, so we don’t always necessarily need surgery for diagnosis.
More importantly, because surgery has risks, and because we know endometriosis is primarily managed medically, a lot of times if a patient responds well to medical treatment for endometriosis, that in itself is a strong indicator that they likely have it. So response to presumed treatment, even without surgery, can give us a lot of information.
22:28 Medical and surgical treatment options for endometriosis
Xun (Julie) Lian, MD, FACOG
Right. What are some of the medical treatments then?
Sara Kim, MD, FACOG
Yeah, so some of the medical treatments options are like hormonal intervention, because endometriosis is hormonally driven, so birth control pills is usually our first go to because the side effect profile is a bit less a lot of patients have could tolerate it, and you could whether it’s estrogen containing birth control pills or progestin only birth control pills, those are also options. We also have a little bit more dedicated endometriosis medicines like elagolix or Lupin so there are more acting on the best way to say it is kind of putting the body into medical menopause, so temporarily, kind of shutting off your ovaries, because, again, endometriosis is hormonally driven, making sure that you’re not menstruating. So then the idea being that if you shut off your ovaries and you’re in menopause, the endometriosis pain should subside
Xun (Julie) Lian, MD, FACOG
Right. I mean, these are, you know, the different options. And to someone hearing that, ‘Oh, putting me into a medical menopause’ just sounds very, you know, scary and very severe. Again, these are options that we discuss with patients. It doesn’t mean that, we highly recommend one versus the other, but it’s, again, shared decision-making that we review with our patients.
Besides medications — you mentioned surgery — so what is the role of surgery then for endometriosis?
Caitlin Waters, MD, FACOG
So surgery for endometriosis can be effective in a number of situations. One, if a patient has, let’s say, a very large cyst on their ovary or very significant findings on imaging, it can be effective. It can also be helpful for patients who are struggling with infertility. Sometimes the fertility specialist will refer those patients to us to see if there is any visible endometriosis that we can remove. And then sometimes, when patients are further along and are done with childbearing, they may request a hysterectomy.
But there are limitations of surgery as well. For example, if we were to perform a hysterectomy but leave the ovaries, that would not be definitive treatment for endometriosis because, as Dr. Kim mentioned, it is chronic, inflammatory, and hormonally driven. So if the ovaries remain, patients can still have cyclical pain even without a uterus. And that can be a difficult concept for patients to wrap their minds around, because typically surgery is thought of as something that completely fixes a problem — and endometriosis is different.
Something to consider, especially for fertility patients, is that sometimes we see a small cyst on the ovary. But if we perform surgery to remove that cyst, it can have negative effects on fertility if ovarian tissue is compromised. So it really requires a close back-and-forth discussion with the surgeon and the fertility specialist about whether surgery for endometriosis would be potentially helpful or harmful.
The last thing to mention is that each subsequent surgery performed for endometriosis, unfortunately, tends to result in fewer and fewer improvements in pain. So we try to reserve surgery for situations where it will provide the most benefit. This is not a condition where we recommend repeated surgeries, because the benefit decreases with each subsequent procedure.
Xun (Julie) Lian, MD, FACOG
More risks with each substantive surgery.
Sara Kim, MD, FACOG
And that’s why sometimes when patients come in for pelvic pain, they say, ‘Oh, I want my uterus out because I have pain.’ I always kind of circle back and say, ‘Okay, there are multiple reasons for the pain, and it may not necessarily be that taking the uterus out will cure your overall pain.’
26:05 Endometriosis and Fertility
Xun (Julie) Lian, MD, FACOG
Right. And you highlighted another facet of endometriosis, that being impaired or difficulty with fertility.
I think a lot of patients are referred to us from their fertility specialist because they have had trouble getting pregnant, or have failed different IVF cycles. And so, even if they are not symptomatic from, let’s say, painful periods, they may have so-called silent endometriosis, where the main outcome is impaired fertility.
Caitlin Waters, MD, FACOG
Right. That being said, patients with endometriosis can still get pregnant. So, as you know, we always encourage our patients, if they are not planning to become pregnant right now and are not interested in pregnancy, to please use birth control.
26:44 If No Endometriosis Is Seen At The Time of Surgery, What Are Next Steps?
Xun (Julie) Lian, MD, FACOG
Yes, yes. If surgery is done looking for endometriosis, and let’s say no endometriosis is seen, what are the next steps?
Caitlin Waters, MD, FACOG
So if no endometriosis is seen at the time of surgery, which happens, for us first and foremost, I think a lot of reassurance needs to be given to the patient that their pain is certainly real, even if endometriosis isn’t seen intraoperatively.
27:43 Case Studies/Success Stories
Caitlin Waters, MD, FACOG
And more importantly, that we’re going to continue to take their pain seriously and treat it. So even if there’s no endometriosis, we still have great treatment options for cyclical pelvic pain, you know, related to a patient’s period. And I think that’s something we often discuss with patients before surgery, to say, hey, there’s always the possibility we don’t see anything, we will be here to support you regardless.
Xun (Julie) Lian, MD, FACOG
I mean, another plug for seeing a minimally invasive GYN fellowship trained surgeon is that endometriosis has different appearances, and so, you know, you should see someone who is well-versed in the different appearances of endometriosis is the best way to remove those lesions.
28:22 The future of diagnosis and treatment options for endometriosis and pelvic pain
Xun (Julie) Lian, MD, FACOG
So Dr. Kim, what would you like to see happen in the world of endometriosis moving forward?
Sara Kim, MD, FACOG
Overall, I would like to see more research and funding go into endometriosis and, more generally, pelvic pain in females. Again, because it has become more normalized, I don’t necessarily see a lot of research opportunities or clinical trials to try different medications.
With that, I would also like to see more treatment options — newer treatment options for patients. We’ve seen the GnRH (Gonadotropin-Releasing Hormone) agonists and antagonists, like the injections that can put you into medical menopause; those are relatively newer, as are the oral options. But we haven’t really seen much come after that, and it’s been many years since those medications came out. So I would like to see additional treatment options.
I would also like to see other ways to diagnose endometriosis, or additional diagnostic markers. As we said, imaging — ultrasound and MRI — can be helpful. But the gold standard is still surgery for a definitive diagnosis. If there were something less invasive, such as a blood test to assess for endometriosis, I think that would be very helpful.
Xun (Julie) Lian, MD, FACOG
Right. I think there’s a lot — there’s growing research coming out that endometriosis may be more immune-mediated, or immune system–mediated. And it’s definitely affecting not just the gynecologic organs like the uterus and ovaries, but also the bowel and bladder.
So I think, yes, there is definitely more attention being paid to this condition, which affects about 10 percent of women worldwide. But I do think, just like with other areas of women’s health, a lot more research funding needs to go into it.
Sara Kim, MD, FACOG
Yep.
30:11 What Is Minimally-Invasive Gynecologic Surgery (MIGS)?
Xun (Julie) Lian, MD, FACOG
So we talked some about heavy bleeding and pelvic pain and endometriosis and fibroids. We mentioned that we are minimally invasive gynecologic surgeons. What is minimally invasive gynecologic surgery?
Caitlin Waters, MD, FACOG
So providers who specialize in MIGS typically have additional years of fellowship training — usually two to three years dedicated to conditions such as endometriosis, chronic pelvic pain and fibroids. And there are sort of two components to this.
The first component is surgical expertise. We know that high-volume surgeons tend to have fewer complications and better patient outcomes, so we are really trying to ensure that patients receive the best care possible through this additional surgical training.
The other piece is medical management. Especially for conditions like endometriosis, some of the medications Dr. Kim mentioned are a bit more complex — they can only be used for a certain duration of time — so we also specialize in managing these medical therapies.
So when a patient has these issues and sees a provider, they can be given all of the options: medical, procedural and surgical.
31:07 What Are Some Benefits of MIGS?
Xun (Julie) Lian, MD, FACOG
Right. And what are the some benefits of minimally invasive surgery?
Sara Kim, MD, FACOG
I would say, one aspect is cosmetic — you don’t wake up with a big incision. Often, you may wake up with four or five small incisions, about five millimeters, which I always tell patients is about the size of my pinky nail. Recovery is often much faster, and pain is less. Studies have shown that pain after minimally invasive surgery is less than with an open approach, which involves a larger abdominal incision. Studies have also shown less blood loss and fewer infectious complications.
So overall, the benefits of minimally invasive surgery outweigh the open approach. However, I always tell patients there is a time and place for the open approach. I think that’s why it’s important to go to the right surgeon who can offer all of those options and is able to manage complex surgical cases — whether open or minimally invasive — and who has the skill set to offer minimally invasive surgery as a potential option.
32:35 When Should Patients Seek Care From a MIGS Specialist?
Xun (Julie) Lian, MD, FACOG
Right. I would say, in our world, most surgeries are able to be done minimally invasively, either through laparoscopy or robotically assisted laparoscopy. And so, again, going to a fellowship-trained surgeon, I think, is very important. So then, as Dr. Waters and Dr. Kim said that doctor should be able to offer you both medical and surgical options for treatment of your condition.
And then when should patients seek care from a MIGS specialist?
Caitlin Waters, MD, FACOG
So we work with some really fantastic community OB-GYNs in the area who know when to refer patients to us — large fibroids, endometriosis, patients who need medical or surgical management, and chronic pelvic pain. We obviously see a lot of referrals for that particular group of patients.
But sometimes, I would say to a patient who maybe isn’t in this area: if you feel that the provider you’re working with isn’t offering you all the options, please don’t hesitate to self-refer to a MIGS provider, because we’re happy to see you and discuss all the options with you.
And really, I think ultimately the takeaway is: if you’re concerned about any of this or you want a second opinion — even among MIGS providers — we would encourage you to do so. The more information you have, the better decision you’re able to make.
Xun (Julie) Lian, MD, FACOG
Right. I think subsequently, we’ll see patients that were self referred or that, you know, their friends told them about their mixed surgeon, and you know, they’ll say, my doctor told me I can only have this large incision, and frequently that’s not the case. So as we said, it’s really important to advocate for yourself, know what’s available in your community and don’t be afraid to speak up for yourself.
33:50 Closing Remarks
Xun (Julie) Lian, MD, FACOG
If you’re listening today and something you heard resonates with you, trust that instinct. Heavy bleeding or pelvic pain that disrupts your life is never normal. Those symptoms are worth paying attention to and worth discussing with your doctor. Our MiG specialists are here to offer you the full spectrum of medical and surgical management options. Come chat with us.
Thank you to our guests for sharing their expertise and thank you for listening to HEALTH Yeah! Please like and follow us for more great health information from Stony Brook Medicine.
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