Episode 142: Surgical Options for Female Pelvic Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

All right, everyone. Welcome. This is Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A on Tuesdays. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thanks to all of you who join me. Joining me live currently on Zoom and on as a Facebook Live, as you know, can follow me on Instagram and Twitter as well at Hernia doc. And at the end of the show, this and all prior episodes are available to all of you on YouTube, and pretty soon I will announce my podcast version as well. But I’m very happy to introduce to you a good friend of mine, Dr. Larry Orbuch. Dr. Orbuch is a gynecologist, but his specialty is in endometriosis treatment and he sees a lot of women with chronic pelvic pain and understands hernias. So it’s like a great, going to be a great discussion today. So you can follow him on Instagram at Dr. Larry Orbuch. And please give a warm welcome to Larry. Hi, how are you?

Speaker 2 (00:01:16):

Hi there. Thank you for having me. Yes, it’s a pleasure to be here with you.

Speaker 1 (00:01:20):

Thank you. So I know I first learned about you from my colleagues in New York because you used to practice in New York. That’s correct. And then you moved to my side of the world in Los Angeles. Maybe you can explain what you were doing in New York and how you got into being a specialist in your field.

Speaker 2 (00:01:39):

Sure. So I’ve been in practice now for over 20 years, or close 24 years. I was in practice in New York until about seven years ago when I moved my practice out here. And my focus has been on endometriosis and chronic pelvic pain and the treatment thereof, both surgically with minimally invasive surgery as well as treating all the coexisting symptoms and pain generators that most people who have endometriosis usually suffer. From what I found in my early years of practices that it was kind of a void. There was a void in the availability of good care in this area and the paucity of people available to provide it.

Speaker 1 (00:02:47):

And you learn that in residency. Was there someone in your residency that kind of showed you that there was this kind of void in, or was it once you were in practice you decided

Speaker 2 (00:02:58):

There’s this population

Speaker 1 (00:03:00):

That’s not being treated necessarily optimally? Yeah,

Speaker 2 (00:03:03):

I noticed that it was something that was not given a lot of focus during residency and the level of awareness among practicing physicians not forget about residents and people in postgraduate training. And when I started to really analyze it, I realized how minimal the amount of education that you get in medical school and even in residency in obstetrics and gynecology where that is what your area of study is. And it was not really given the amount of focus and attention that it should have. And I found also that the approach that many practicing OBGYNs had was very outdated. They were still quoting the, not even literature, but the theories about endometriosis that had been postulated over a century ago.

Speaker 1 (00:04:18):

What were those theories

Speaker 2 (00:04:20):


Speaker 1 (00:04:21):

That are no longer,

Speaker 2 (00:04:23):

Yeah, so the famous one was called Samson’s Theory, which was postulated right by a general surgeon named Dr. Samson back in the 1920s who incidentally found these implants or growths in patients when he was operating on them, not necessarily for that, for other things. And he biopsied them and looked at these specimens under a microscope and it looked like endometrial glands and stroma or the connective tissue under the glandular epithelium. And so he just assumed for, based on the level of knowledge in the 1920s, that if it’s looks like endometrium, it’s end the abdominal cavity, it must be coming from the endometrium. Hence, his most logical conclusion was that there was what was called retrograde menstruation, that there was flow of endometrial tissue out from the inside of the uterus via the tubes into the abdominal cavity. And that’s how it was getting there.

Speaker 1 (00:05:29):

Is that incorrect?

Speaker 2 (00:05:31):

It it’s so it’s kind of half true. Okay, because that’s

Speaker 1 (00:05:36):

What I was taught too.

Speaker 2 (00:05:37):

Yeah. So I believe in the 1950s they did some studies where they did real time like fluoroscopic imaging of women during their period. And they found that pretty much most if not all women have some degree of retrograde flow period. Because as the uterus contracts when you’re having your period, the bulk of the flow comes out through the canal into the cervix and into the vagina. However, there is some degree of retrograde flow out through the tubes,

Speaker 1 (00:06:16):

Out through the fallopian tubes which communicate with inside the belly around the intestine. Exactly,

Speaker 2 (00:06:21):

Exactly. So that’s a direct communication into the abdominal cavity.

Speaker 1 (00:06:25):

So they did a fluoroscopic study which showed, in fact, that happens in a lot of patients and they don’t get endometriosis.

Speaker 2 (00:06:33):

Exactly. So whatever was flowing out generally gets reabsorbed by your body and doesn’t really do much.

Speaker 1 (00:06:44):

It’s blood.

Speaker 2 (00:06:45):

Yeah, it’s mostly blood. It’s

Speaker 1 (00:06:46):

Like any bleeding inside.

Speaker 2 (00:06:48):

So just to take a sidetrack and I’ll get into more details about what we have found and what’s been theorized also is that perhaps women with endometriosis do have a harder time of clearing that. So if they have endometriosis and they get that added flow out of the tubes, they may not be able to process it in the manner in which is necessary in order to eliminate. But the actual etiology and the pathophysiology of how these implants arrive where they are is more so one of a combination of things. One, the most prominent component of it is that during embryonic development, when embryo develops in the uterus,

Speaker 1 (00:07:48):

When you’re a baby

Speaker 2 (00:07:50):

And you’re developing little baby, or even before you’re a baby or a baby, an embryo, there are three cell lines that differentiate into all the parts of you and the endoderm, epiderm and mesodermal. The mesoderm, some of the structures that it creates are the whole urogenital tract, meaning uterus, tubes, ovaries, ureters, bladder, kidneys, and lots of other structures in the pelvis and lower abdomen. During that process, the cells migrate to different places and then differentiate into to these different structures. So for some reason, some of these cells are kind of go haywire or programmed differently and they can end up being dropped off or stuck in places that they shouldn’t be. Oh. And that’s how you end up with these implants in strange places. And we know this all fits into the whole puzzle of the greater picture of, because we see a lot of, a lot of endometriosis, not a lot, but there’s a fair amount of endometriosis patients that have other structural developmental anomalies that we see of which kind of goes in into the realm of the urologist and general surgeon’s domain where there are deviations in how the whole urinary tract forms and they can end up with got it.

Speaker 2 (00:09:23):

With either one kidney or two kidneys on one side or double ureters or so. Usually when there’s something odd in the history and they have, we usually work them up to make sure that there’s not something else that we’re missing. There’s also developmental issues with the uterus where there’s a high incidence of uterine tum where the uterus, when it develops, it doesn’t fully develop and you end up with this central kind of, it’s kind of connective, tissuey, cartilaginous tissue and in the midline at the top of the uterus, which can result in people having difficulty getting pregnant because the funders, so the top of the upper wall leaders is probably the most prime real estate for implantation of a pregnancy. And if you have a septum there, it’s not well vascularized vascularized so very, it makes it difficult for a fertilized embryo to implant. So we usually look for those things as well because those things like a septum can be repaired at the same time as we deal with the endometriosis surgically. Got

Speaker 1 (00:10:49):

It. Got it. I see. So some people, I heard about it, I’ve never seen myself where they say, oh, there’s endometriosis in their eye, endometriosis in their lung. Right. I think those were part of a developmental, yeah, those cells just happen to hang out there inappropriately.

Speaker 2 (00:11:06):

Yeah. So for the longest time until several years ago, the only surface or organ that endometriosis had not been identified in was the spleen. And then, but more recently there have been case reports of splenic endometriosis as well. I’ve seen patients with nasopharyngeal endometriosis, lung endometriosis, diaphragmatic end endometriosis. You can have the brain thyroid, I mean you name it, it’s been reported. So there’s definitely nuts. There’s definitely an embryonic developmental factor. There’s also, there’s questions as to how they get triggered there. Well, there definitely is a hormonal component to it where usually with the onset of puberty, that’s when things get worse because with the ovarian function revving up and having more circulating estrogens that stimulates these implants just like it stimulates the endometrium, the lining inside the uterus. And then there also have been environmental factors that have been associated with it, like dioxins, which are the byproduct of bleaching and other chemical toxins and radiation and different environmental exposures have been found to be triggers.

Speaker 2 (00:12:23):

And also in lab animal studies and rats, they found that with super physiologic dose exposure, they can trigger these implants. There was even a study, which I think we discussed when we spoke last done in Italy, where they did autopsies on female fetuses that were miscarried and they found the incidents of finding endometriosis infra abdominally was pretty much similar to what the rate of endometriosis is among the adult population, which was, it was like 9.4% versus about 10% is what we find in the population at large. Wow. So there’s, there’s probably some multifactorial sort of a pathway that it takes. One component may be more prominent than another in particular individual because they big genetic component to it as well. And people who have a one first degree, at least one first degree relative with endometriosis, that puts them at a seven to 10 times greater risk of having endometriosis. So mother, aunt, sister, grandmother, either maternal or pot. Yeah.

Speaker 1 (00:13:40):

But I feel like older generation people were not being diagnosed with end.

Speaker 2 (00:13:43):

No, they weren’t. Were basically being labeled as just generalized pain, chronic pain. And they usually would end up, the typical story that I hear when I speak to patients when they tell me about their family, like mothers, grandmothers. Yeah. But the classic is, oh yeah, my mother grandmother had problems and she had a hysterectomy when she was 30. Oh, big red flag. Did she have fibroids? No, she just had really painful periods. Oh my lord. And whatever. And the old school, and unfortunately not so old school because people I still see,

Speaker 1 (00:14:21):

So I saw

Speaker 2 (00:14:22):

Now that have had hysterectomies as treatment for endometriosis, which it’s not.

Speaker 1 (00:14:29):

Can you explain why hysterectomy is not a treatment for, of

Speaker 2 (00:14:32):

Course, endometriosis. So endometriosis is when you have these implants outside the uterus. Yes. So if you have endometriosis, the only way to treat that is to excise those implants

Speaker 1 (00:14:42):

Which are outside the uterus.

Speaker 2 (00:14:44):

Adenomyosis is a component of endometriosis that involves the uterus, and that’s when you have invasion of these,

Speaker 1 (00:14:51):

That’s endometrial, that’s endometriosis in the wall of the uterus.

Speaker 2 (00:14:55):

So it invades into the wall of the uterus. The uterus is made out of smooth muscle, and it basically interlaces itself in between the muscle fibers. And that can cause pretty much most of the similar, same and similar symptoms as endometriosis, but generally more heavy bleeding possibly. But it’s not something, if that is the major component of what’s going on or the excision of the endometriosis doesn’t do the trick and you have diffuse adenomyosis, then the only treatment for that is hysterectomy. But note that I said diffuse because generally if it’s minimal or focal, it may not be really adding a lot to the symptomology. So if you

Speaker 1 (00:15:47):

Have endometriosis limited to the pelvis or around the uterus area, are those people that have it because they’re having men retrograde menstruation and it’s implanting? Yeah,

Speaker 2 (00:16:03):

No, usually if you have adenomyosis, there’s endometriosis too. I mean, I would say if I was a gambling man, I would put even odds that if you have adenomyosis, there’s endometriosis in the public. Because I, I’ve seen patients who, they’ve had an MRI and they’ve, they’ve been told that have, they have adenomyosis and their doctor goes in and does a hysterectomy with blinders on, doesn’t look anywhere else outside of the immediate area of the vis with the uterus is so they miss the forest for the trees. So they take the uterus out and then sure enough patient is still symptomatic, they may not be as symptomatic or they may be just as symptomatic. Then the only way to treat that is to go back in and remove the endometriosis.

Speaker 1 (00:16:50):

So taking adenomyosis out of the picture, if you only have endometriosis outside the uterus, is a hysterectomy ever a treatment for endometriosis?

Speaker 2 (00:17:01):

No. If the uterus is not involved, then there’s really god no real justification for,

Speaker 1 (00:17:08):

I know so many patients that are either recommended or have had hysterectomy for endometriosis.

Speaker 2 (00:17:13):

Right. So it’s, it’s not

Speaker 1 (00:17:16):


Speaker 2 (00:17:16):

It’s doing the wrong surgery for the wrong condition,

Speaker 1 (00:17:24):

But endometriosis is hormonally activated, right?

Speaker 2 (00:17:28):

Yeah. But it generally tends to be more hormonally influenced, obviously in someone who’s premenopausal. However, it can continue to be just as, or almost as symptomatic symptom causing even peri and post-menopausal, you

Speaker 1 (00:17:55):

Can have endometriosis.

Speaker 2 (00:17:58):

Yeah, it doesn’t go away. It’s still there. And the unfortunate thing is if you have long standing endo that that’s been going on for decades and then it’s a progressive condition, there’s always a potential of becoming deep infiltrating lesions. And that can result in heavy scarring and adhesions and nerve entrapment and nerve impingement where the lingering pain may be from that and not from active plump juicy

Speaker 1 (00:18:38):

Lesion from this negative side effect of the damage that’s done by the endometrial.

Speaker 2 (00:18:45):

So that’s why it’s another misconception when people are told by the doctors that just wait until you go through menopause and everything will be fine. Pardon me? I mean, can’t tell you how many patients I’ve seen who they’ve done that with. And now that implant that they had on their ureter was now completely invade the ureter and they’re obstructed and their kidney is now dead on that side.

Speaker 1 (00:19:15):

Oh my god.

Speaker 2 (00:19:16):

Or they’ve had an infiltrating nodule in their rectum and now it’s partially obstructing the rectum and you have to do a rectal resection with a colostomy and it’s, it’s not something that you know can wish away. I’m not saying that those extreme cases are what happens with great frequency, what happens often enough, and even without those extreme situations, you still have the quality of life issues. So if you are miserable and in pain and can’t function, the fact that you’re postmenopausal, so you’re not having a period anymore or you’re irregular, but you’re still having as much if claim as you did before.

Speaker 1 (00:20:11):

So this what you are teaching right now and I’m learning is not necessarily taught during residency?

Speaker 2 (00:20:18):

No, no. I mean, I think part of the problem is as medicine evolves, people tend to become more and more specialized in different areas

Speaker 2 (00:20:38):

And general practitioners are kind of swimming in a shower pool. So they know a lot of, they know a little about a lot of things, which then ends up leading to people pursuing these niche areas where you can really focus on these issues. I think the other issue in G Y N training is that the, it’s kind of a double-edged sword with the advent of a lot of these subspecialties in, even within our specialty, a lot of surgical exposure and experience that we used to get when we were residents is taken away and it is done by the specialty fellows. And rather than that’s true the general residents. And that’s why they’ve been talking about now for years about creating different, two different tracts in training of the general

Speaker 1 (00:21:41):

For gynecology,

Speaker 2 (00:21:43):

Like doing the obstetrician who does minor general G Y n, and then the gynecologist who basically specializes in gynecology and all the surgical issues, gynecology. So that I think that’s somewhere coming down the road. But

Speaker 1 (00:22:09):

Does taking out the ovaries treat endometriosis in any way?

Speaker 2 (00:22:12):

So it doesn’t treat it, I mean it will diminish the hormonal stimulation by decreasing your hormonal because you basically put into an induced menopausal state. So I don’t routinely recommend if you have normal ovaries and you’re having endometriosis surgery, especially if you’re far away from menopause. That’s the downside to taking the ovaries out is far greater than any potential future issue that it can do can add to vis-a-vis endometriosis.

Speaker 1 (00:23:00):

It’s so interesting. So general surgery, we’re in a similar bind, which is there’s so much to learn in the five years of training and most special, most general surgery residents now that graduate end up doing one to three years of extra training to

Speaker 2 (00:23:19):


Speaker 1 (00:23:20):

More or do better or be more specialized, just too much to learn. But there’s actually something called rural surgery, which you know have to be able to deal with a lot, very wide range of surgical problems. You’re like, you don’t have specialists nearby and her hernias are very much specialty that all generals surgeon or it’s a topic that all general surgeons should be able to do. It’s considered the most common outpatient surgery done by a general surgeon is gallbladder or hernia surgery. But now we are also specialized because I could be sitting in your space now and telling you all the stuff that I learned in a residency that are completely wrong, that I’m no longer doing as a hernia specialist. And people to this day, the majority of ’em are still doing it incorrectly and they don’t even know.

Speaker 2 (00:24:19):

And it’s the same thing in the realm of endometriosis. The proper surgery is to do excision surgery. We actually exide and cut out and remove the disease. The wrong way to do it is the easy way, which is what most people do who are not experienced surgeons, is to do ablation or you burn it. So you’re basically zapping these lesions and on the recurrence slash persistence rate with ablation is over 35%, whereas the recurrence rate with excision is in the single digits depending on what’s the study you look at, it’s between I believe three to nine point something percent. So to do proper excision requires a lot of dissection and knowledge of anatomy and it’s also time consuming. And most people do not have adequate skills or experience do that. So they do what used to be acceptable, which is ablation and essentially leave the patient either no better off or sometimes even worse off than they were be formed.

Speaker 1 (00:25:41):

So in the topic of female pelvic pain, we kind of titled this as a surgical approaches to female pelvic pain because endometriosis is very much a surgical surgically approach disease. There are hormonal ways I think of monitoring it or managing it, but what percentage of patients that have endometriosis need surgery?

Speaker 2 (00:26:04):

So it really is a matter of the individual clinical scenario. If you have a high suspicion, because let me say this, go backwards a little bit. It’s a presumptive diagnosis until you actually do a laparoscopy and look inside, oh, there are telltale signs and symptoms that will make you suspicious of its existence, but there’s no imaging study that will diagnose it. There’s no blood tested, there’s no medical way of diagnosing it unfortunately. But when you ask all the right questions and you get all the answers that all the arrows point toward endometriosis, that’s kind of where you get to the scenario of calling the patient. I think we have endometriosis and we can treat a lot of your coexisting symptoms that are triggered by the endometriosis, but ultimately the only way to really address it is to directly treated by doing laparoscopic surgery and excising and removing the lesions and also dealing with any other issues that are going on like adhesions, scar tissue.

Speaker 2 (00:27:32):

We incidentally a lot of times find things like hernias that can be additive to their pain. The appendix is oftentimes involved as well. And if you leave that behind and there’s appendix, you’re never going to get, eliminate all their symptoms. So really, and then kind of jumping to another side of the coin, which is the realm of fertility in pregnancy, pretty significant statistics are pretty significant in that over 50% of women who have unexplained infertility, meaning they have the million dollar workup, yeah, I V F cycles, et cetera and so forth, half or more of them have undiagnosed endometriosis. So we recommend the recommendation by the American Society of Reproductive Medicine in the American College of OB gyn. In those scenarios, when everything is normal, normal, negative, the next step is a diagnostic. Even if they’re not symptomatic because you’ve ruled out every other cause.

Speaker 2 (00:28:44):

So that then there has to be something organic going on or anatomical that that’s resulting in their inability to conceive. And the interesting thing about endometriosis, unlike a lot of other conditions where you know pretty much expect people to have certain symptoms in order to have the condition or a certain degree of symptoms with endometriosis, you can have people who are minimally symptomatic and then when you operate and then they have significant amount of disease and you can have the reverse where they have significant amount of symptoms and very pinpoint minimal disease. But for that person, that’s what it takes to trigger all these issues, symptoms and in the realm of pregnancy infertility. So no, I see that it doesn’t follow a set pattern. And quite frankly, I find that even people who are refer to me by reproductive endocrinologist and they say, well, my doctor sent me to see you.

Speaker 2 (00:29:58):

She thinks maybe I have endometriosis, but I don’t have any symptoms. Invariably, when you sit down and you take a thorough history, there’s always symptoms. The problem is it is what I call the new normal. These people have been dealing with these symptoms for so many years and it’s slowing onset and insidious, and they think that being miserable and curled up in a ball with a heating pad for 24 or 36 hours every month when their period starts, they think that’s normal. And they’ve been told that’s normal. Yeah, they’ve been told that by their pediatrician, then their mother’s got OB G Y N, and then by the school nurse when they’re in high school and in college or whatever. True. And this is how it’s easy to understand how the delayed diagnosis is over 10 years, over 10 years. And

Speaker 1 (00:30:52):

This is what I’m dealing with, occult ankle hernias. So in women hernias are always smaller than men to begin with, and the really small ones often are really symptomatic. They have pelvic floor spasm and painful sex, and they have groin pain radiates to their vagina around their back. It’s worse with their menses. It’s always activity related. And they go to most doctors and they’re like, either you don’t have a hernia or that’s too small to cause pain. And yet for that person you fix the hernia and it gets better. And it’s hard to get other surgeons to believe that a small little piece of fat in an inguinal canal can cause so much pain and disable some people.

Speaker 2 (00:31:39):

And this kind of goes back to what we were talking about before is is level of experience and exposure you and I see, but the

Speaker 1 (00:31:47):

Symptoms are correct. Yeah.

Speaker 2 (00:31:50):

You and I see the whole spectrum and we, I, I’ve seen my share of, incidentally, I go in, they have endo, but they have this little inguinal hernia with a lot of omentum tucked into it. Or people are like, no, there’s no way you can have a hernia and never pregnant, but they have a diastasis with a loop bowel or omentum. Yes, you, I’m sitting there, I feel like I’m a magician pulling the rabbit out of the hat. I’m like, and you think it’s just a little and you just keep going? And I’m like, yeah, I can’t believe she wasn’t even more symptomatic.

Speaker 1 (00:32:32):

But even the small, because I’ve been in operating rooms with gynecologists similar to yourself that they may have a hernia and then you got to look in there for endometriosis or vice versa. They’re going in there for endometriosis, they want me to be in there for the hernia. And you’ll see one spot. But you know what, that one spot, maybe the spot that’s causing all the symptoms, you don’t have to have stage four endometriosis where everything has stuck to each other. Yeah,

Speaker 2 (00:33:01):


Speaker 1 (00:33:02):

So interesting. And I’ve seen stage four endometriosis where the gynecologist would make the comment of, wow, I’m surprised she’s not more symptomatic.

Speaker 2 (00:33:13):

And my personal theory, which there are many in this area that agree as well. Yeah, I think there’s an autoimmune component to this and how the individual’s immune system and how the individual patient, how their immune system handles things that are inflammatory. Inflammatory things that are foreign or things that are in places that they ought not to be. And that varies. And I’ve seen similar kind of things where I’ve gone in, the patient is not really super symptomatic, but it’s more so because of fertility and you find it’s everywhere and you’re like, you sit there scratching your head, you’re like, I can’t believe that she wasn’t way more symptomatic than she’s Yeah.

Speaker 1 (00:34:16):

When you talk about the medical treatment, because I’ve seen doctors go in and see what you just said, endometriosis everywhere on the bowel, on the peritoneum between the uterus and the blood. So then they come out and they say, oh, we’re just going to stop. We’re not going to do surgery. We’re going to start or LSA or Marna, I U D or some type of

Speaker 2 (00:34:39):

Hormonal. So the medication

Speaker 1 (00:34:41):

And then maybe come back later. Yeah. Is that valid?

Speaker 2 (00:34:45):

No. So that’s really not a valid approach because if you look at medications like the birth control pill, the progesterone I U d, Alisa and G N R H agonists, the only thing that they are F D A approved for is to decrease pain during your period dysmenorrhea. That’s the only it, it’s not indicated or cited as being helpful for anything else. It does not treat it, it does not halt the progression of it. It doesn’t melt it away. Some people are unlike the pill and the I U D, these medications like ISSA and Lupron, the RH agonist puts you into a chemically induced menopause, which comes with all the wonderful side effects of menopause and some of which are reversible when they stop the medication. And some of them are irreversible. And I’ve seen young patients and who are in their late teens and twenties who were put on these medications for years, and they aren’t even approved for use more than a half a year or a year depending on the dose.

Speaker 2 (00:36:21):

So logically you ask yourself, why would you want to go on a medicine that you can only use for six months or a year? Where are you going to end up after that six months or a year right back where you started from. So you’re basically, to call it a bandaid would be a compliment. Not even that because, and my personal experience is I have never, or almost never encountered a patient who has been treated with those medicines who reports having benefited from, they usually were more negatively impacted by all the side effects. They hit the side effects and they were by than they were by any decrease in the pain during their period. So the, they’re equally as effective as the pill or the I U D. However, the pulmonary I U D are reversible, you stop taking it, its effects will disappear. But the bottom line is in people who are not severely symptomatic and they’re very reticent about having surgery.

Speaker 2 (00:37:30):

You know, never push anyone into doing having surgery, but you just educate them. And what I generally do is someone who’s not ready to have surgery, who doesn’t want surgery, I’ll treat all the other issues. I’ll treat their painful periods, I’ll put them on a pill, I’ll put in a progesterone, I U D I, I’ll send them. They have tight pelvic floor muscles. I’ll cement their pelvic floor physical therapy, I’ll treat their GI symptoms. A high incidence of a lot of inflammatory conditions of the GI tract, like small intestinal bacterial overgrowth or sibo, leaky gut syndrome, which leads to food sensitivities and food intolerances. There’s also a high incidence of an inflammatory condition of the bladder called interstitial cystitis, which gives people kind of these UTI I symptoms so that a lot of these patients tell me, oh yeah, I have UTIs all the time.

Speaker 2 (00:38:21):

And then when you start really investigating it, it’s not, it’s just this inflammation on the blinder, which triggers pain, which causes symptoms that are akin to UTIs. And it also mimics a lot of the endometriosis symptoms. And that’s why in the literature they refer to interstitial cystitis or IC as the evil twin of endometriosis because there’s a lot of overlap. So you need to treat all these coexisting pain generators and issues which will make someone feel better. So if you can in the interim, improve their symptoms by 20 or 30 or even 50%, that’s fantastic. And that’s something that I do, whether or not somebody’s planning on surgery in the immediate future, because you want to start helping people dig their way out of the misery of all the chronic pain that they’ve been having. And by addressing all these things, you start give them positive feedback and seeing that, oh, I can feel better and this is working. And it just changes their entire state of mind. You give them hope and optimism that if I stick with this, I’ll get out of the woods.

Speaker 1 (00:39:40):

It’s so much overlap. This is fascinating because the people that I see, the women with chronic pelvic pain for years, that case, like you said, right? And then some of them, because their pain is worse during their menses, they’re already told, oh, it’s endometriosis, but they still have pain in between. And it is often activity related, which is not endometriosis.

Speaker 2 (00:40:04):

And that’s a very good point you raised because there are cyclic types of symptoms and then there are as cyclic or psycho independent symptoms. And that’s another one of these general misconceptions that many physicians have. Yes. You think, oh, if you’re having pain outside of your period, it can’t be endometriosis. Or if you don’t have pain during your period, that’s particularly bad, but your pain is outside of your period, then that can’t be endometriosis either. There’s no checklist of things that are diagnostic endometriosis. Really, it’s more nuanced than that. And the important thing is to get a thorough history and then to look logically. I mean, when something doesn’t make sense, you got to take two steps back. I see. For example, a patient who’s 20 years old and has been miserable since they were 11 years old when they went to, they have painful periods, pain outside their periods, back pain, bloating and GI issues and bladder issues and anxiety and depression and sleep disorder, blah, blah, blah. You go on and on and you’re like, wait a minute, what disease does this person have? And you ask them, do you have any medical problems? They’re like, no million workup. They’ve seen the gastroenterologist, they’ve had a colonoscopy, an upper endoscopy.

Speaker 1 (00:41:36):

Endoscopy, colonoscopy twice.

Speaker 2 (00:41:38):

Yeah, motility studies, barium swallow. Yeah, they’ve tested them for celiac and for Crohn’s in, yeah, they have nothing as diagnostic. They label them as i b s, irritable bowel syndrome, and they give them some Ben or some other and they pat ’em on the head and send them on their merry way. Right. Ibs? IBS is not a diagnosis, it’s a description. Why are they having irritable bowel syndrome? Unless you determine that. Sorry, what? You know, don’t have a diagnosed. So true. And

Speaker 1 (00:42:13):


Speaker 2 (00:42:14):

You have to look at the bigger picture. You’re like, why is this person having all these unrelated symptoms?

Speaker 1 (00:42:19):

It’s so true because for inguinal hernias, the small ones especially, you can get bloating. And so they get the full workout. Why am I bloated? I feel like almost any pelvic kind of pain thing can cause bloating and it gives you pelvic floor spasm. So they have frequent urination burning with urination. Intercourse is painful. So they’re labeled with inter interstitial cystitis because of that component of it or some type of pelvic, just pelvic floor spasm without a reason for it. And all they need to do is get their hernia fixed.

Speaker 2 (00:42:54):

And with the pelvic floor dysfunction, the tight pelvic floor muscles, people minimize that. But you think about it logically, the pelvic floor is sort of like a hammock of muscles that kind of interlace and they support everything in above it and through that, I mean this, but I’m just, for our audience, yes, I love it. Through that pelvic floor run some very vital structures, the urethra, the vagina, and the rectum. If they’re trapped in that, the muscle sheath, if you’re in there and the muscle tone is really tight or hypertonic, it’s squeezing all those things. So that’s why I have patients who complain of feeling like this weird pressure and spasm when they urinate extreme spasm and tightness during intercourse. Yes. Because pain with bowel movements, I have patients who report feeling like someone’s strangling their rectum. Yes. Or they’re passing glass, broken glass through their rectum,

Speaker 1 (00:43:57):

Or they feel like they have to go, but they can’t. They don’t. Right.

Speaker 2 (00:44:02):

So if even if you treat and you do the surgery, remove the endometriosis, you don’t treat that pelvic floor dysfunction. Yes. You don’t treat that SIBO. You don’t treat that interstitial cystitis. If you miss that hernia, if you miss that abnormal appendix, you are never going to get to the best place possible.

Speaker 1 (00:44:21):


Speaker 2 (00:44:22):

That’s why you have to.

Speaker 1 (00:44:23):

Can you talk to me about the appendix when you go in there for pelvic pain, right? So unknown reason for chronic pelvic pain. You go in there to take a look. Let’s say you see a little bit of endometriosis. What do you do with the appendix? Is it still something

Speaker 2 (00:44:37):

That is generally? Generally I remove them. Oh, you do? I published a paper a couple years ago and then big international laparoscopic journal of what my experience has been. And over 18% of these appendices were abnormal with endometriosis in them, but there were another 25% that had other abnormalities. I picked up some carcinoid tumors, some primary cancers of the appendix, chronic appendicitis, acute appendicitis, something called fibrous obliteration where the pathologist looks, they section up the appendix on the entire lumen as we know there’s a oh god cavity. And inside appendic completely gone. It’s just scar tissue. Wow. And so do you

Speaker 1 (00:45:29):

Have a general surgeon do that or do you do the

Speaker 2 (00:45:31):

Appendectomy? Usually I have a general surgeon in there because especially in patients who have other bowel issues where they could be potential needs, the bowel resection or hernia repair. I mean, I can do the append appendectomy myself, but they’re there anyway. And sure they’re usually addressing other things as well. And that’s another thing that I think is underestimated is being prepared. So true. It’s better to be over prepared than to be caught in a situation where you are over your head. So if you think there’s going to be a bowel involvement, if you think there’s going to be issues with the bladder or the ureter that are out of your domain of expertise,

Speaker 2 (00:46:18):

Then have first of all, get a proper workup. Because a lot of times you’ll pick up things which will definitely tell you there’s, there’s a nodule of endometriosis invading the bladder. You’re going to be resecting that part of the bladder with the endometriosis. So there’s a lesion into the ureter or there’s a rectal nodule or a sigmoid nodule. I mean, you really want to do the best thing for the patient and avoid having to go back in because you get in there and you’re like, oh my God, she needs a bowel resection, but I don’t have a general surgeon. So it’s sort of a multi-specialty approach because there are so many things that can be involved that are in the domain of other specialists.

Speaker 1 (00:47:08):

Yeah, it really is. I have a question about endometriomas. I had a lady who went to a cancer hospital for her and they treat it like a tumor. They took out all this huge, it was in her abdominal wall. So it took out not only the endometrioma, but also a huge round like defect of abdominal wall left or with a huge cavity. Endometrial is not cancer. You don’t need to remove it with positive margins. In fact, you don’t need to have any margins. Is that right? Or

Speaker 2 (00:47:45):

You don’t. But if you leave Rives residual disease behind, it’s going keep doing its thing. So I’ve had cases where with abdominal wall masses that [inaudible] even from direct extension from the ovary or a lesion from C-sections, or even just a lesion that was in the lining inside the abdominal cavity that invaded into the abdominal wall. And I’ve had bad cases where it’s basically grown into muscle in the abdominal wall, do a major resection. It’s very, it’s unpredictable. It’s far almost unpredictable than malignancies or cancer. And it really, from the standpoint of eliminating the potential for future, for continued or future symptom and future issues, dealing with it as definitively as possible is ideal to be able to avoid having the patient have to have subsequent surgery.

Speaker 1 (00:49:09):

And if you have endometrioma, which is like a, call it chocolate cyst or a ball

Speaker 2 (00:49:13):

Of, yeah. So classically, end endometrioma is a cyst in the ovary with where endometriosis is now kind of burrowed its way in and created this walled off collection inside the ovary. Got it. So those you have to remove by basically opening the ovary, shelling out the entire cyst wall with all that material that’s inside it. If you just drain it and burn it, it’s just going to seal back up and re-accumulate. So that’s another thing that has to be done properly. Just like excision of implants, proper excision of the entire cyst itself along with its content is the appropriate surgery

Speaker 1 (00:49:59):

Size cyst and its contents. And then if the liquid spills, it’s not like it’s going to implant again, you can just wash it off.

Speaker 2 (00:50:07):

So generally what we try to do is dissect it out intact if possible, and put in a specimen retrieval bag into the abdominal cavity, put the cyst inside the bag, then put in a suction device into the cyst wall, suck out all the material so it deflates, and then you’re containing everything. You’ve got the fluid out, you’ve got the cyst inside this bag, which you then cinch closed, and you pull it out because one of

Speaker 1 (00:50:40):

Where your scar is.

Speaker 2 (00:50:41):

So that’s how people end up with implant endometriosis. The incision. Yes. So you want to keep that away. You don’t want to be tracking things endo through the abdominal wall.

Speaker 1 (00:50:54):

Got it. There’s a question about how do you handle endometriosis involving the nerves? So

Speaker 2 (00:51:01):

That’s a good question. So depending on where these lesions are located, can’t, two ways that it can impact nerve, either by direct involvement or invasion or by the neural communication from nerve fibers that transmit pain. The unfortunate thing with endometriosis implants is they emit different substances. They emit a lot of inflammatory mediators like cytokines and interleukins and things like that. But in addition, they also release nerve growth factor and vascular growth factor to help itself grow even more. Wow. So what you find if you at an implant over time, it will develop more nerve fiber connections, which then communicate via the peripheral nerves, the central nervous system. And that’s a big part of the pain. As much as the direct type of visceral pain that the endo can cause itself is the upregulation of the whole central nervous system. When you have chronic pain, which by definition is pain that lasts more than three months, you’re now in that chronic pain domain.

Speaker 2 (00:52:21):

So these pain signals are just continuous. And I know that the way that the central nervous system is hardwired, it’s not linear it, your pain in your pelvis doesn’t, there’s not one nerve that goes to your spinal cord, up to your brain communicates, and then there’s a signal back. It jumps to via different fibers. It jumps to different levels in the spinal cord. And then in neurologic terms, it’s called crosstalk. And this is what you see with chronic pain. So as these signals are going back and forth, they start communicating with other nerves locally and also in distant places. And that’s why it starts out as pinpoint right-sided pelvic pain becomes bilateral, meaning both sides radiating to your back, radiating down your leg, neck pain, shoulder pain, abdominal pain,

Speaker 1 (00:53:17):

This whole

Speaker 2 (00:53:17):

Syndrome, migraines. It just takes on a life of its own. So with involvement then it would entail, if I’ve had nodules that have put pressure on nerves, I’ve had implants or nodules that have grown into nerves. So that’s a much more involved dissection. You really need to isolate what’s being triggered. There are nerve are procedures, neurectomies where they sever certain sensory nerves to lessen symptoms. It has varying degrees of success. But really it’s one of those things where it’s, you really have to, it’s an individualized diagnosis. And sure there are diagnostic tests you can do like uhs, which is an MRI that that. Right. So it really, it’s key to have proper workup

Speaker 1 (00:54:28):

For groin hernias. a lot of people have nerve pain. So it’s usually ileal nerve, sometimes general nerve branch, not because the nerve is injured, but because the nerve is somehow being touched, pinched.

Speaker 2 (00:54:44):

And it’s being

Speaker 1 (00:54:45):

By the herniation

Speaker 2 (00:54:46):

And it’s being, it’s continuous,

Speaker 1 (00:54:50):

But people focus on the nerves. They go to the doctor, I got nerve pain. You do have nerve

Speaker 2 (00:54:54):


Speaker 1 (00:54:56):

Go down the whole nerve pathway

Speaker 2 (00:54:58):

And you have to be careful because when you start severing nerves and nerve yes trunks, you can have unwanted sequela from that where yes, nerves that you don’t want to be affected are affected, which can lead to other issues. So it’s not something to be taken lightly.

Speaker 1 (00:55:19):

Yeah. We’ve discussed that in the past with some of our pain doctors. Something called complex regional pain syndrome and can spark more nerve pain by touching and cutting those nerves. So sometimes I do neurectomies as needed for chronic pain purposes, especially if the nerves been damaged from, let’s say a prior hernia repair. But there’s absolutely no reason to cut nerves that are healthy.

Speaker 2 (00:55:42):

Absolutely not.

Speaker 1 (00:55:44):

So do you still practice in New York or you’re completely in

Speaker 2 (00:55:48):

Los Angeles still? Well, COVID kind of neutralized that for a while. I may do that periodically. I still have a lot of patients on the East coast, but with many of them have come out here. So to be determined.

Speaker 1 (00:56:07):

Okay, good. It’s good to travel, it’s fun. Yeah. And then I assume you see patients from out of state. Do they contact you at a time? And what do you offer for

Speaker 2 (00:56:17):

That? Yes. I see a lot of patients from out of state, from the other side of the country, international patients. The one of the benefits of the internet is that people have access to resources to guide them to the right clinician, which I think is really important because I think in the bad old days, people just believed whatever their local physician told them and took it as gospel. I think now people are becoming far more informed and educated. And there are many professional societies and other referral networks with very reputable and reliable people that can guide you regionally and beyond to people who are the thought leaders and the best possible clinicians to tend to these issues.

Speaker 1 (00:57:17):

Absolutely. And I guess you do telehealth in the states of

Speaker 2 (00:57:23):

Material? Yeah, yeah,

Speaker 1 (00:57:25):

Yeah. Lyse, I offer online consultation where they can still contact me if they’re out of another state to at least initiate some type of guidance. They’re not my patient necessarily, but at least I can guide them through.

Speaker 2 (00:57:44):

I offer the same sort of services as well.

Speaker 1 (00:57:46):

Yeah, it helps a lot because not everyone can travel, especially if it may not be

Speaker 2 (00:57:52):


Speaker 1 (00:57:53):

Something they need to travel for.

Speaker 2 (00:57:54):

And it’s useful to people in those situations to have a good sense of is there a high suspicion that what it could be. And then they’ll make their way, whatever, however possible, to seek care.

Speaker 1 (00:58:12):

And if someone travels to see you and they need surgery, how long did he have them stay in town?

Speaker 2 (00:58:18):

So if they’re having surgery, I generally ask that they stay local for at least 48 hours, mostly somewhat, just so I can keep an eye on them and they can see me before they leave. And also, as you know, with laparoscopic surgery with the carbon dioxide, the c o two that we use for inflating the abdomen, usually not too comfortable if there’s any residual c o two in their abdomen going on a pressurized airplane. But yeah, that’s pretty much it. As long as they’re feeling up to it 48 hours later, they can.

Speaker 1 (00:58:54):

Yeah. Yeah, actually. Good. Were there any questions I should have asked that I didn’t ask?

Speaker 2 (00:59:01):

I don’t think so. I think we covered a lot

Speaker 1 (00:59:04):

Of, I’m just fascinating.

Speaker 2 (00:59:05):

Quite a lot of ground.

Speaker 1 (00:59:06):

I learned so much. This has been a great hour. I learned, I, I guess I still kind of remembered endometriosis the way that I was taught, but all these newer kind of innovative evidence-based stuff, I didn’t know about it.

Speaker 2 (00:59:26):

Yeah. I you, I think it’s really imperative of people to seek out what the conventional thinking is now on treating things, you know, can’t, can’t keep your head in the sand and expect to be delivering the best care possible.

Speaker 1 (00:59:51):

Yeah, this is true. This is true. And so it’s kind of fascinating how many people still do that. I don’t know. Okay, my friends, that’s it. That was the end of Hernia Talk Live. I had a fantastic time with Dr. Orach. I hope you all did too. This was so enlightening. I know that I’m going to take better care of my patients now that I know more about endometriosis and other reasons for female pelvic painter. I thought I knew a lot, but I can always learn some more. So thank you, Larry, for your time. I do appreciate it.

Speaker 2 (01:00:26):

My pleasure.

Speaker 1 (01:00:27):

A long day. And for those of you that were watching, do go to my YouTube channel at Hernia doc and subscribe so you can continue to watch all of these. And I will soon post about my new podcast. So you can do Hernia Talk Live as a POS podcast. You can be driving and listening to it. And I’m really excited that we’re doing that now. So thanks Larry, and thanks for everyone else who’s watching. Thank you.

Speaker 2 (01:00:50):

Thank you. Have a great evening.

Speaker 1 (01:00:53):

Bye. Appreciate it. Bye now.

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