Episode 20: Gynecologic Causes of Pelvic Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00):

All right everyone. Welcome to Hernia Talk. Today is another hernia Talk Tuesday. Joining me. Thanks all of you guys for joining me. As you know, my name is Dr. Shirin Towfigh. I am a hernia specialist. You can find me at Hernia Doc on Twitter and Instagram. And for those of you joining me on Facebook Live, welcome at the end of this one hour, you will be able to access this video as well on my YouTube channel. And today’s guest is the very famous Dr. Thaïs Aliabadi. Dr. Aliabadi a good friend of mine. You can follow her on Instagram at Dr. Thaïs Aliabadi,. She is an obstetrician and gynecologist and also owner of the outpatient Hysterectomy Center of Los Angeles. And without further ado, I’d like to welcome you to Dr. Aliabadi. Hello.

Speaker 2 (00:53):

Hi, how are you?

Speaker 1 (00:54):

I’m good. So thank for

Speaker 2 (00:57):

Having me.

Speaker 1 (00:58):

Thank you. I know you’re very busy and you have a very exclusive clientele. Dr. Aliabadi, for those of you who you don’t know, is one of the most gifted gynecologists that I know, which is why she’s on this show laparoscopically. She’s just absolutely amazing. But she works really odd hours. Like she’ll say, Hey, I’m doing this operation, we’re going to start at five o’clock in the morning. Are you free? And I always say yes, but I don’t know. Is it just because you also deliver babies, so you’re okay with these hours? I don’t understand.

Speaker 2 (01:34):

I mean, delivering babies is definitely one of the most important reasons I delivered a baby this morning that was supposed to be delivered tonight. So my schedule is always up in the air, but I love operating with you and I enjoy it. And I appreciate you coming out of the house at 5:00 AM to operate with

Speaker 1 (01:54):

<laugh>. So as you know from my prior hernia talks, I do enjoy operating with people outside of my specialty, including urologists and gynecologists. Typically Dr. Aliabadi has been my go-to gynecologist because she actually has an interest in chronic pelvic pain. And a lot of the patients that see me may have hernias or groin pain relate to things other than hernias. So we’ll discuss that today. And then sometimes she sees patients with groin pain that are women and understands that women can have hernias, for example, as a cause of their pain. And she sends ’em to me and sometimes they have two problems. They have, let’s say endometriosis or fibroids and a hernia. So we operate together. I’m curious how you got involved in chronic public pain. Cause it’s really not a specialty that guidance colleges choose to tackle. It’s a very complicated and difficult and sometimes kind of frustrating topic for a gynecologist. How’d you get involved?

Speaker 2 (03:03):

So when I first started, I wasn’t as involved, but as a gynecologist, one of the most common complaints you hear is painful periods and 10% of women have endometriosis, and that’s 10% of the patients I see every single day that walk into my office. Endometriosis is the second most common cause of infertility after polycystic ovarian syndrome. So very quickly into my residency training, I realize that if there’s a condition that causes it’s a second cause of infertility on the planet and causes so much pain for women, I better learn it really well. And I did. And I think for endometriosis patients, the reality of it is they take a lot of time. So when I was seeing 40 patients a day was impossible for me to sit down and explain what endometriosis is, how it works, what we do for it, how do we treat it.

Speaker 2 (04:04):

And eventually as my volume went down when I started limiting the number of patients I was seeing in my office, it gave me more flexibility and more time. And I was able to sit with them and explain to them why we do what we do. Because I think the key to the treatment of endometriosis is patient education. You can sit with a patient who says, I have painful periods, and throw birth control at them. They will go home and their grandma says something, their aunt says something else, and they don’t take it. But when you take the time to go over how the disease process works and how these medications help alleviate the pain and protect their fertility, then the compliance goes up. But that takes a lot of time and effort on the side of the physician or the gynecologist treating that patient.

Speaker 1 (05:00):

Yeah, because people think, oh, well, I don’t need to be on birth control pills. It’ll make me fat or it’ll, I don’t, I’m not planning on getting pregnant, so I don’t understand why I’m being given birth control pills. But there’s a lot of different, it’s actually a hormonal therapy as opposed to the lay term, which is birth control. Right, right,

Speaker 2 (05:19):

Right. So endometriosis needs hormonal suppression. It’s a majority of the time we diagnose patients clinically and we only reserve surgical options for patients that do not respond to hormonal suppression. So using a combination of birth control is always the first step. So when you have a patient who complains of chronic pelvic pain and they’re young that’s the first treatment we consider.

Speaker 1 (05:55):

So as you know, I’ve promoting this hernia talk session a lot because I treat about just little over 50% of my patients are women and women’s hernias and women’s groin pain and chronic pelvic pain is a very difficult problem that very few doctors seek to tackle. So when I do have the opportunity to talk with a specialist like yourself, I really try to promote it. And we have a lot of questions. I hope we can get through some of them. Let’s just quickly go through the simple ones. So this patient says, I think I have endometriosis. Will my gynecologist be able to treat me or must I see a specialist?

Speaker 2 (06:37):

So that’s a very good question. Technically, when you see a gynecologist, your gynecologist should be able to treat diagnose, and treat endometriosis. The problem in this country and around the world is that it takes doctors nine to 11 years to diagnose endometriosis. Remember, the most common symptom is painful period. So I always tell my patients, I’m going to make a t-shirt that says painful periods are not normal. Because most patients, they have a mom who says, oh, I used to have painful periods, or the grandma says I had the same issue. So the most important thing to remember is that painful periods are not normal. If you have a painful period, you need to make sure that there’s no endometriosis. 10% of women on the planet have endometriosis. And so if you close your eyes and think of 10% of women, that’s a significant number of women that deal with this condition every day.

Speaker 2 (07:38):

When diagnosed early, you can treat these patients and you can stop the infertility process that comes with it. But the key is to diagnose these patients early and put ’em on hormonal suppression. Now if you go to a gynecologist or to your primary care or family doctor and you complain of pelvic pain or period pain and they send you home with pain medications or they tell you you’re going to be okay those are the patients that I would say need to get a second opinion, get as many opinions until you get an answer. No one should walk around with pain between Dr. Towfigh, myself and a team of urologists that we work with. We have never not been able to treat patients with chronic pelvic pain. We might not make their pain a hundred percent better, but we know how to significantly improve the quality of their life.

Speaker 1 (08:38):

Yeah, I totally agree. I learned so much from you. I didn’t know that that severe painful periods is not within the norm. I just assumed that if you pass out from pain, then you just, that it runs your family. I’ve heard, oh, it runs in the family like your aunt the same way or something like that. Also, she had difficult pregnancy. It all kind of goes together.

Speaker 2 (09:02):

So when it’s true, when you have family history of endometriosis, you’re four times more likely to also have endometriosis. So if you have a family member or a mom or an aunt or a sister that passes out with their period, then you should be extra careful as far as diagnosing it. Like I said, it’s a clinical diagnosis, but I always tell my patients, if you come to the physician office and you complain of painful periods, that’s the first red flag for me. If you end up in the emergency room, that’s a second like red flag, no one should end up in the emergency room or at the hospital. Hospital or doctor’s office with a painful period. That’s just not normal. So these are red flags to watch out for. I have patients who walk into my office with prescription for with narcotic prescriptions from Percocet to Vicodin, and they think it’s okay to take it. That’s not normal. If you need narcotics to control your period pain, then you need to be evaluated.

Speaker 1 (10:11):

Very good point. I kind of lost my train of thought. Oh, so the term, I have two questions. One is what causes endometriosis? And then the second is I love your co. I would like to to know your comment about chronic pelvic pain. I feel because I see a lot of people that have been labeled chronic pelvic pain for their whole life, and it was just like a hernia that’s very treatable and fixable I feel for women. Now, there is a chronic pelvic pain in men, but it’s very uncommonly used term. And women, they just say, oh, well you’re just going to have to live with this for the rest of your life. You have chronic pelvic pain, it’s an actual diagnosis, you can bill for it. It’s got a code for it, and it seems to be so easy to just label it. And now that you have a label, you can walk away from it and just be inadequately treated. What’s your thought on that? I think that’s a, just even the name chronic pelvic pain is a disservice.

Speaker 2 (11:13):

It is to women. I agree with you. Like I said, there’s always a reason for the pain. And if you look close enough and you spend enough time and you listen, the key is to listen to your patient. Yes, most of the time you can figure out what the cause of the problem is. Going back to endometriosis in a simple way, if you think about it from the day we get our period, which is about 12 and a half to the, they were menopausal, which is about 51 and a half. Our ovaries are trying to get us pregnant every month. So they secrete a hormone and the lining inside the uterus gets stimulated with this estrogen that’s released by the ovaries as the lining thickens and gets ready for pregnancy. If we don’t get pregnant, that lining breaks down and comes out in a form of period. So this happens month after month, year after year. 10% of women have the lining inside the uterus, outside of the uterus, around the tubes and ovaries. Some women have,

Speaker 1 (12:13):

There’s an opening. The tubes are actually, it’s an opening. The tubes are actually an opening into the abdominal cavity.

Speaker 2 (12:19):

Exactly. So with these cells being outside of the uterus once a month, when the ovary is stimulating the lining of the uterus, the cells on the outside also think they’re in the uterus. So they get stimulated. And when we don’t get pregnant and the uterine lining breaks down, these cells also think they’re in the uterus. So they start bleeding, but they’re actually bleeding outside of the uterus and inside the pelvic cavity, that blood is an irritant. You’re we’re not supposed to have blood in our pelvis. So patients blood in their pelvis, they end up having a lot of pain. That bleeding causes a local inflammation, and that inflammatory process adds to the bloating and to the pain. So this is like a vicious cycle that happens month after month, year after year. And because doctors ignore it, patients ignore it. This chronic inflammation can do permanent damage to our tubes.

Speaker 2 (13:15):

It can cause local scarring. But most importantly, if there’s one thing you all remember from me today is that this chronic inflammation will affect the quality and the quantity of eggs inside the ovaries. So a lot of times with endometriosis patients, when you do an egg count at age 30, which is considered young, they have nothing left. So that’s why it’s so important to diagnose these patients. There are studies that show endometriosis can start as early as age eight. Average age of diagnosis is 32. So you see how for how many years this gets hit in patients, well,

Speaker 1 (13:57):

There’s a question on Facebook Live that asks, does hysterectomy help endometriosis go away?

Speaker 2 (14:04):

Very good question. And I sometimes argue about this with other physicians. So if for patients who have endometriosis in the wall of the uterus, so the uterus has a muscular wall, sometimes the endometriosis implants infiltrate the wall of the uterus, though that’s called adenomyosis. For patients who have adenomyosis. When you do a hysterectomy, you can significantly improve their pain. However, for patients who have endometriosis, which means they have these little implants around the tubes, ovaries doing a hysterectomy is not going to make them feel better. So you have to be very careful when you do a hysterectomy, as long as the ovaries are secreting estrogen, that estrogen will stimulate these little implants that are all over the pelvis, those you cannot remove at the time of a hysterectomy. So if you leave those behind and the ovaries are still functioning and every month secreting estrogen, those implants still cause pain, still cause bleeding, and the patients will not feel better after hysterectomy.

Speaker 1 (15:11):

So it’ll treat future problems, but it may not treat current problems if they’re outstanding.

Speaker 2 (15:17):


Speaker 1 (15:18):

And that’s why you need hormonal therapy. In addition, still

Speaker 2 (15:22):

So and correct endometriosis implants, these little tiny implants grow with estrogen. So as long as women are in the reproductive age, from age 12 until about 51 and a half every single month, the ovaries are secreting estrogen and these little implants are growing. So the only way to suppress these implants is using by using hormonal suppression, which we talked about a little bit. If you have no idea what’s going on, even if you start a patient on a very low dose birth control pill, that will make a difference. It’s been my experience. So if you want to treat endometriosis patients with birth control, you want to pick a birth control that’s very low in estrogen. You don’t want to give these patients a lot of estrogen because then you’ll help those implants grow. And if you give them combination birth control pill, which has estrogen and progesterone and their symptoms don’t get better after a few months, then you have to take that estrogen away and consider going to progesterone only treatment and the marina IUD or the Kyleena IUD, the Depo-Provera.

Speaker 2 (16:27):

And if that fails, then you need to become even more aggressive and go to an anti-estrogen treatment. Right now we have a new pill called Orilissa, it’s a GnRH antagonist. It’s a daily pill that endometriosis patients can take. And there are two dosages of it, the hundred 51 a day and the 200 milligrams twice a day for patients who also have painful sex because of endometriosis, we tend to go to the higher dose of 200 milligrams twice a day. But for other patients, you can put ’em on this 150 milligram one a day for up to two years, and this medication will strangulate the endometriosis implants. It’s very easy. It’s a pill. They take it once a day, and usually I tell them by a month to two months, their symptoms should be resolved. So if after a month or two months they don’t see any resolution, then we have to go to an even more aggressive treatment. So it’s a step-wise approach. You start with the least aggressive and you keep adding up.

Speaker 1 (17:30):

I learned so much from you every time, and I love how you explain it. Do you have tons of people making comments right now, including someone whose life you may have saved? She actually, I want to read this comment. This is amazing. My niece needs to see this. Will it be available later, please? Which it will be. It’s available on Facebook and on YouTube later on. This lady’s niece is currently using narcotics and walks around with a hot water bottle. She’s been told by her gynecologist, there’s nothing that can be done. So thank you once again. And what an outstanding contribution you make.

Speaker 2 (18:04):

It’s a sad story. Sometimes I really sit and cry with my patients in the office. I feel I’m grateful when I catch ’em at a very young age. But when I see 30 some year olds with no, yes, she’s

Speaker 1 (18:17):

32. This lady,

Speaker 2 (18:18):

Yeah, me too. About the age when they get diagnosed, and I’ll tell you why their pain gets, they have so much scarring that the chronic pelvic pain is so bad that they start jumping from doctor to doctor, doctor to doctor until someone finally diagnoses them, or that’s the age that they try to get pregnant and they can’t get pregnant. So they end up seeing a fertility doctor, and even then sometimes they don’t get diagnosed and they end up doing IVF.

Speaker 1 (18:50):

So one of the reasons why we’re discussing endometriosis so early on in this session is that patients with endometriosis can have pelvic pain and specifically even groin pain on one side similar to an inguinal hernia. And so they either come to me or to you, and the question is, what is their problem? We had to figure out is this endometriosis, is this some type of other gynecologic problem or is it an abdominal wall, like an Anglo hernia? How do you start the process of working up endometriosis? Endometriosis, or even maybe it could be ovarian problem. How do you know just so history exam,

Speaker 2 (19:34):

Ultrasound of Yes, in my office I think history is the most important part of the entire process. Like I said, endometriosis is a clinical diagnosis. You don’t need to see anything on ultrasound to diagnose it. You don’t need surgery to diagnose it, you don’t need to do a pelvic exam. Sometimes, almost 99% of the time when patients walk in, my medical assistant does a full complete intake on them. And what, before I walk in, I always look at the chief complaint and in parentheses, she has the diagnosis for me. So <crosstalk> with me so much that they can even pick up endometriosis patients. And almost 100% of the time I can say they’re absolutely right. So if you take a good history, you can pick up these patients one out of 10, it’s huge. So these patients are coming through these GYN offices every single day.

Speaker 2 (20:30):

And once I do a full history it comes to the physical exam, endometriosis, patients usually complain of painful sex, especially with deep penetration because endometriosis implants sit in the round ligaments and in the posterior. So when you do a pelvic exam, when you press on those specific areas, they literally jump off the table. So that’s a very common finding in endometriosis patients, especially the ones that complain of painful sex. For me I do an ultrasound. I consider myself a very good ultrasonographer, done it for 20 years. And if I see a chocolate cyst is what we call it, which is endometriosis inside the ovary, it has a classic presentation on ultrasound. And that would, that’s for me, it confirms my diagnosis, but you don’t need to have any physical findings and you don’t need to have any ultrasound findings in order to diagnose endometriosis. Now sometimes if they’re complaining of pelvic pain, the ultrasound pays a huge plays a huge role because maybe their history is not consistent with endometriosis, but maybe they could have a hernia.

Speaker 2 (21:53):

Maybe they have a fibroid on pelvic ultrasound, maybe they have a large ovarian cyst that has nothing to do with endometriosis. So doing a pelvic ultrasound for me in the office is a must. I cannot diagnose patients without doing an ultrasound which sometimes makes it tough because not all gynecologists are comfortable doing pelvic ultrasounds and they send these patients out and when you take a history and then they send a patient out two weeks later for an ultrasound and you get the report, you don’t remember really what happened in that room with that specific patient. So the follow ups become very tricky. So I think for me, it’s easy because I can just work them up. By the time they leave my office, they have the diagnosis, they’ve been treated, and they know exactly why they’re doing what they’re doing.

Speaker 1 (22:42):

So true. So history is very important with endometriosis, you don’t have to have any positive findings on ultrasound, but ultrasound can help you either rule in a pretty bad endometriosis or rule in other causes of the chronic pelvic pain or groin pain, let’s say. And w, and we already discussed the non-surgical treatments, which is basically what do you call it hormonal therapy. At what point do you use Lupron? Is that the anti-estrogen you were talking about?

Speaker 2 (23:17):

Yes. Prior to the Orilissa pill, I used to do a lot of luprons. For severe cases, you have to be careful giving a patient endometriosis, patient’s Lupron. And I’ll tell you why. We talked about 32 being average age right of diagnosis. So by 32, a lot of these endometriosis patients have a very low egg reserve and an egg count. Sometimes when you give them Lupron for six months, you push ’em into permanent menopause. So you have to be extremely careful. I never give Lupron to anyone until I know that they have a normal egg count. If they don’t have a normal egg count, I send them to a fertility specialist, I freeze their eggs and then I give them Lupron. But right now, with Orilissa, the pill that I was telling you, which is a GNA GnRH antagonist, it makes it very easy. It’s a pill.

Speaker 2 (24:10):

They take one once a day and if they decide they don’t like it, they’re nauseous with it, they have mood changes with it, they have hot flashes with it, which just the risk is very small. It’s about one to one and a half percent, then they can stop it and within 48 hours it’s completely out of their system. When I give a Lupron shot, I cannot reverse it. So if they get depressed, if they start having hot flashes or if they have other side effects of it, there’s nothing I can do. So I personally prefer using or Alissa for these patients, and I’ve had very, very good results. So I Lupron usually I haven’t used it in a very long time because patients can’t tolerate this. The side effects of it,

Speaker 1 (24:49):

Going back to the surgical treatment, one of the patient’s reports here, when I had endometriosis, my gynecologist would do a laparoscopic procedure to burn the lesions outside of the uterus. This would help me for years. Is this still used today as a common therapy? And also a second similar question is can you just cut out the implants?

Speaker 2 (25:09):

Very good question. So we used to ablate endometriosis implants, but now we know that ablation doesn’t sometimes help the patients. For patients who end up having surgery or laparoscopic surgery, you’ve seen me do it before, we basically resect the areas of endometriosis and send it to the lab. So resection helps these patients, but again, remember surgery can help for maybe six months to two years. The easiest way I can describe it is imagine you have a patient with colon cancer, you go in and remove her tumor. You don’t ever tell her, go home, you’re going to be okay. If you do that six months to two years, she’s going to come back with cancer everywhere. Endometriosis is not cancer, but it acts the same way. So you can resect all you want, but there are areas that are microscopic that we can’t see at the time of surgery and we leave those behind. And if you don’t do hormonal suppression after surgery, your patients will bounce back six months to two years. I have patients that come to me from Bay Area or other parts of the country and they tell me they’ve had seven laparoscopic surgeries and one year they do their surgery and they go home. So that’s not normal. There’s no reason for any endometriosis patients to have recurrent surgeries like this.

Speaker 1 (26:32):

So we recently had a patient together that we operate on she had adenomyosis. You explained to me that that’s endometriosis, but it’s the, it’s leaked into or implanted into the wall of the uterus as opposed to floating around. Does that sound right?

Speaker 2 (26:50):

It absolutely does. And it’s the

Speaker 1 (26:52):

Treatment for that.

Speaker 2 (26:54):

So adenomyosis has in the hand of an experienced ultrasonographer, you can pick up adenomyosis. These patients usually complain of heavy and painful period adenomyosis. The symptoms usually start later in life. So past 40, the patients complain of heavy and painful period. When you do an ultrasound, there is a specific finding in the wall of the uterus, but if I do an ultrasound and I’m not convinced if the patient has adenomyosis or is it purely endometriosis? And remember sometimes they go hand in hand. You can have adeno and endo. So when I see a patient with endo, I look for adeno. And when I see a patient with adeno, I look for, but again most of the time for patients who want to have children obviously hysterectomy is not an answer. But for older patients or for patients who do not desire fertility, then a hysterectomy will fix the prolonged heavy and painful periods that come with adenomyosis.

Speaker 1 (28:02):

And then is his, other than hysterectomy, are there any options for adenomyosis?

Speaker 2 (28:08):

I have good luck with using marina IUD or progesterone only IUDs. These are IUDs that secrete progesterone locally. And a lot of patients the IUDs reduce the amount of blood and also it helps them with their pain.

Speaker 1 (28:27):

Okay. So as we’ve said before, Dr. Aliabadi and I, do you operate together? We had one question which is related to this kind of combination issue. And the question is this. It says, I have huge fibroids. I also have hernias unclear if my pain is from the fibroids or the hernia, or sometimes we’ve seen people where they have a hernia and then I also get from the history, let’s say they have really bad uterine bleeding in their anemic. So is it safe to have both of these operate on surgically addressed at the same time?

Speaker 2 (29:06):

Do you want to answer this or do you want me to

Speaker 1 (29:09):

<laugh>? Well, I’ll tell you from, so from a general surgical standpoint, it’s uncommon for general surgeons to get involved with a gynecologist. A lot in most hospitals, we don’t even operate in the same floor or in the same division. So to kind of leave your home to go to another, going from the east wing of the west wing, so to speak. So that is a problem sometimes. And there’s also a concern that a hysterectomy is not a clean operation because it does get into the vagina if it’s a total hysterectomy and the VA vagina has bacterial flora, there’s a concern from a hernia surgeon standpoint that entry into the vagina as part of the hysterectomy will then cross-contaminate and contaminate, let’s say a hernia repair, especially if you’re putting Mesh in place and you can get a Mesh infection. I think those have all been very theoretical. And most of the time people who have that I’ve operated on with Dr. Aliabadi who have fibroids, don’t need a total hysterectomy. It’s a super cervical hysterectomy where you’re technically not in the vagina and don’t get exposed to the vaginal flora. I mean, I need you to explain this to me, but does that sound right? We do it all the time and we’ve had no problems. And the patients love it because I actually use your scars. I’ve adapted my technique to use your scars. So you start and I finish these operations.

Speaker 2 (30:46):

I mean we’ve had a great, never had a complication and our patients have been very happy. I can’t think of going under the knife twice. Once for a hernia and once for fibroids, just like you said, we use the same scars. I do almost all my hysterectomies super cervical. Unless you’re worried about cancer or a sarcoma, there’s no reason to remove the cervix. Cervix, especially when you do a hysterectomy in younger patients it, it functions as a support system for the upper part of the vagina and it holds the organs in place. And for patients who have a total hysterectomy, if they’ve had a suspicion of cancer, if they have an abnormal pap smear or for different reasons, then they’re more at risk of having a vaginal prolapse yours down the line. So with the cervical laparoscopic approach I’m able to just do a hysterectomy. I usually start, first I remove the uterus through the umbilicus. We pull it out without spilling any of the cells inside the abdomen. We have specialty bags that we put the uterus in and bring it to the surface out of an incision that’s maybe about an inch. And after I’m done, usually Dr. Towfigh comes in and fixes the patient’s hernia and we’ve had great success with it and our patients are very happy.

Speaker 1 (32:12):

So someone is commenting that the cervix should come out for endometriosis. It what’s the state, why is that a statement

Speaker 2 (32:22):

For endometriosis if you do a hysterectomy? It depends. I mean, if it’s an advanced stage then you don’t want to leave any cells behind. But if it’s a perimenopausal woman and I’m doing a super cervical hysterectomy, then usually we’re leaving the ovaries behind. So it’s true. I think it has to do with the stage with severity of their disease, whether they have fibroids if they don’t have it. And I have a lot of patients because of, there were some studies that talked about orgasms after total hysterectomy versus a super cervical hysterectomy. So a lot of counseling go into it before we decide to remove it or not.

Speaker 1 (33:04):

Okay. We’ve another patient whose cervix was removed with a total hysterectomy for stage four endometriosis. Does that sound appropriate?

Speaker 2 (33:13):

Yes, absolutely.

Speaker 1 (33:15):

Okay. I have some random questions. Hopefully these are simple. Why is my groin pain worse during my period?

Speaker 2 (33:25):

I mean, these

Speaker 1 (33:26):

Are not migraine

Speaker 2 (33:27):

Pains. It could be part of just the general PMS symptoms. Patients tend to feel achy during their periods. They get back ache, some patients get leg pain or young patients who complain of it could be headache breast tender and as lower abdominal pain, hip pain, leg pain. So all of those are common as long as usually these symptoms are also, if they’re PMs related, they’re also associated with other symptoms. It could be nausea, it could be all these other symptoms, hot flashes. But if it’s purely pain and nothing else, then it needs to be investigated.

Speaker 1 (34:04):

So we looked at our data which we’re presenting at the American Hernia Society. It got accepted for, its one of its main sessions where we looked at sex differences in presentation for inguinal hernia. And the symptoms that women present are very different, male versus female if they have an inguinal hernia, but specifically, and interestingly, one in four, almost one in three patients that are women say that their pain is worse during their, their hernia pain. So they have baseline hernia pain throughout, activity related whatever, and then their pain is worse during their period. And unfortunately that triggers a whole endometriosis pathway because they say they’re pain, they have more pain during their period. What is not understood is they still have pain in between their periods which is not as consistent with endometriosis. Is that correct or can you still get a lot of pain during your in between periods with endometriosis

Speaker 2 (35:02):

Advanced? So the way it works, usually when the symptoms are mild, it starts with only painful periods. It might start a couple of days before the period and ends by the time the period’s done. Eventually, as this disease progresses, it starts maybe five days before and it lasts five days after, then it starts a week before and it lasts a little bit longer. The reason chronic pelvic pain diagnosis is so common in endometriosis patients is because of that scarring that I was talking about. I mean, we’ve operated on patients that when you put a camera in, their ovaries are stuck to the pelvic side wall, you can’t even see their organs. It takes about five minutes just to orient ourselves to where the anatomy is, where’s the bowel? Where’s the tube? Where’s the ovary? Where did the left ovary go? And we have to lyse a lot of adhesions and release these. But then again, if you don’t continue with hormonal suppression, those adhesions will be right back.

Speaker 1 (36:01):

So I was told that the hormonal surge during menses makes all pain worse. That’s kind of what I explained to my patients. The reason why you may notice it more during your period is because of it’s the hormonal effect underlying your pain. There’s some comment about round ligament, just to be clear, you can get round ligament endometriosis, not very common at least in the patient that I see but it definitely is in the differential diagnosis of cyclical groin pain, which would be pain along the round ligament, which eventually ends up in the groin or in the inguinal canal. And then if that has endometriosis cells with it, then each time you get your endometriosis flares, you’re actually getting hernia type pain and groin pain, well you said earlier is great. It’s all about the history. So if they say they get groin pain every month as opposed to every time they cough or get up and about and exercise, then that’s really endometriosis versus a hernia.

Speaker 2 (37:13):

And I think I just want to make sure, one of the most common places for endometriosis is in the utero sacral ligaments of the uterus. So that’s commonly where we see it and usually in zero cul-de-sac around the ovaries. So every patient’s different, but a lot of times when the patient says, I have pain on the left floor or quadrant, that’s exactly where we either find adhesions or we find a grouping of endometriosis implants.

Speaker 1 (37:41):

What is your opinion on pelvic floor therapy after orlissa? This was a very specific question submitted last week.

Speaker 2 (37:48):

So I think I’ve had a lot of success with my patients. I think when it comes to endometriosis patients, it’s a multidisciplinary approach to it. A lot of my endometriosis patients I refer for pelvic floor therapy. It makes a huge difference. But again, it’s a combination of the treatment with an anti-estrogen birth control or IUD pelvic floor therapy. You have to make sure you rule out all the other causes of chronic pelvic pain. The one other thing I want to quickly touch on, endometriosis, patients with chronic pain that have gone to doc from doctor bounce from doctor to doctor, doctor to doctor for many, many years, and they struggle with pain at home. A lot of them have depression and there’s not a single human on this planet who can have pain once a month for a week and not get depressed. I’ve never seen such a human, so I know I would be depressed. So I think when I say multidisciplinary, I always, it’s almost these patients almost have P T S D post-traumatic stress disorder. So that needs to be dealt with also. So that anxiety, that depression needs to be dealt with. And of course pelvic floor therapy is definitely part of the treatment for these patients.

Speaker 1 (39:07):

That’s a good point. And going back to what you said earlier, which was you really need to spend a lot of time with these patients in the office. It’s not a quick like, oh yeah, boom, done. Well check. And I feel it’s very difficult in a high volume practice to be able to take care of patients that have chronic pain, chronic pelvic pain, et cetera. We have another question, live question. What are the options for treating fibroids other than his, well, first of all, do fibroids cause pelvic pain or growing pain? And then what are the treatments to treat fibroids other than hysterectomy?

Speaker 2 (39:47):

Okay, so it’s a very good question. Fibroids can definitely cause pain when it comes to fibroids. Fibroids are very common. If you pull hundred people off the street and do an ultrasound on every single one of them, half of them might have fibroids. So it’s a very common finding on ultrasound, but when it comes to fibroids, size makes a difference and the location of it makes a huge difference. You can have a tiny little fibroid in the cavity of the uterus, which can be problematic. It can cause infertility and it can cause patients to bleed so much that they become anemic. But you can have a 10 centimeter fibroid outside of the uterus that doesn’t affect the bleeding and may might not even cause any pain. So the location of the fibroid is very important. I saw a woman yesterday in my office that had a fibroid uterus as big as a 15 week size pregnancy.

Speaker 2 (40:43):

So that’s a pretty large uterus. This woman has had pain for many years. She has problems urinating. She has to get up at night because there’s so much pressure on her bladder. So we operate on fibroids for different reasons. If it’s inside the lining of the cavity and it’s the patient’s bleeding or they’re trying to get pregnant, it needs to be removed. Those we usually go transvaginally through the cervix. It’s very easy. We call it hysteroscopic myomectomy, and we resect the fibroid. It has no downtime. We go through the vagina, into the cervix, into the uterine cavity. We resect the fibroids, send it to pathology. The patient wakes up, goes home, and they’re back to normal the next day. So that those are for the ones that are inside the cavity, for the ones that come close to the cavity or they’re in the wall of the uterus or outside of the uterus, then depending on whether the patient wants to get pregnant, how big they are, the location of it, if they’ve had prior surgery we can have the option of laparoscopic myomectomy or a mini lap, a myomectomy. The difference is with laparoscopic myomectomy, we use little cameras, we put it in, we release the fibroids and then make a one and a half centimeter incision, put those fibroids in a bag, bring them to the surface of the skin and remove them from the abdomen for,

Speaker 1 (42:06):

I love it when you do those. They’re just like my favorite operations.

Speaker 1 (42:11):

I love it. For those of you that don’t know, there’s this technique, obviously I was not taught this in residency. It’s something that gynecologists like you have learned to do, but they take out this enormous fibroid through an incision that it’s like a little hernia incision and it’s like cores out. I call it like an apple core. It’s the coolest thing ever. I kind of would love to put a camera inside the belly to see what’s happening to this fibroid as you are coring it out through this little hole. Yeah, it’s the coolest thing ever. I could watch it all day.

Speaker 2 (42:49):

So we used to morcellate these fibroids. So we had these power morcellators, we would put ’em in and they would just suction the fibroid out of the abdomen. But in the process a lot of tissue would get spilled all over the abdominal cavity. So one in 300 women could have a sarcoma, which is a cancer form of the fibroid. It’s very rare, but it happens. So if you do enough surgeries, you’re going to catch these patients with sarcomas. So the FDA banned the power morcellators, and since then which I prefer anyways once I release my specimen, no matter how big the uterus is, it could be the size of a watermelon. Then we have this special bags that look almost like Ziplocs. We push ’em through the incision into the abdominal cavity, put the specimen in it, bring the back all the way out the incision, and then little by little we remove the uterus. Sometimes the specimen is it takes longer than just doing the hysterectomy.

Speaker 1 (43:54):

So in other words, so hysterectomy is an obvious way of removing all the fibroids, but you can surgically remove parts just like individual fibroids if you want to. What about this? Is it laser or you burn it or you devascularize the fibroid? What is that all about? You

Speaker 2 (44:15):

Can do uterine artery embolization to treat fibroids but remember when you do that can’t, these fibroids are solid tumors. So if you’re dealing with a very large uterus that’s taking a lot of space a bleeding, it will help with the bleeding. It’s usually a painful process to recover. So it’s not as easy as it sounds. And in my experience, patients with large fibro uterus are not happy once they’re done with it. However, I reserve ablation for my patients who have smaller ureter, uterine or they have underlying conditions that are like they’re diabetic, they have heart disease, they have conditions that they would not get clearance for surgery. So that’s a great option for those patients.

Speaker 1 (45:02):

Okay, cool. I have a question about imaging. So the question is, I had an abdominal ultrasound and it doesn’t show anything, but I still have a groin swelling. What can it be? And I just want to clarify. When people get ultrasounds, Dr. Aliabadi in her office primarily does transvaginal ultrasounds that only shows things you can see through the vagina. So the vaginal cough, the uterus, ovaries, but you’re not going to be able to see a hernia on a transvaginal ultrasound. And then an abdominal ultrasound’s going to look at the abdomen. So gallbladder, pancreas, liver, kidneys, and often doesn’t even look at the hernias. And then the best way to actually look for a hernia is a hernia ultrasound. And the reason why this is important is a hernia ultrasound is a dynamic ultrasound. If done correctly, the patient will have to push in and out stand move around, and it is focused on the actual groin anatomy and the angle anatomy.

Speaker 1 (46:10):

And when the thing in the United States, at least most ultrasounds that are ordered for a radiologist is not done by a radiologist, it’s done by a tech. And the techs follow a protocol. So the abdominal ultrasound has a specific protocol. Transvaginal ultrasound has a specific protocol. Hernia ultrasound has a specific protocol, and they typically don’t overlap. And so if you don’t order the right test, you may not be getting your right answers. If you’re lucky and you go like Dr. Aliabadi where she does a transvaginal ultrasound she can talk to you. The beauty of it is you the patient, you examine the patient and then you do the right ultrasound to, for example, look for endometriosis or ovarian cyst or whatever. You come to me, I’m going to be thinking more hernia. I can do a hernia ultrasound and focus on it. But just because you had an abdominal ultrasound doesn’t mean every single thing in your body has been looked at because that’s not the protocol. It doesn’t, not the way that these are written up as.

Speaker 2 (47:21):

And one thing I’ve learned from you, Shirin, is that when, well, I’ve learned a lot from you, but one thing I’ve learned from you is when you get an MRI report back and it says no hernia it’s always good to get a second opinion. And my second opinion is always Dr. Towfigh and I can say, what percentage would you say that I sent to you? And they have negative MRI reads, and when they come to you there’s a positive finding.

Speaker 1 (47:51):

So with you, because you’ve seen the patient and you have a hunch, so you ask me to look over the prior imaging almost a hundred percent of the time, you’re right, all comers, you looked at everyone that’s come to me with a negative MRI or negative CT scan. And the CT scan, almost 90% are incorrect. And the MRI, almost 75% are incorrectly read. So it was either misread as no hernia or it was the word hernia wasn’t even there. Like yes, hernia, no hernia, they didn’t even look for it. So those are horrible numbers and we, we’ve published two papers on that so far and hopefully we’ll do more to try and educate radiologists about what hernias look like and then how important it’s to claim them when you see them on imaging.

Speaker 2 (48:41):

Well, what happened to me last year with my breast MRI? So you see why I do second opinions on everything?

Speaker 1 (48:49):

Yeah, yeah, no, absolutely. But I enjoy that when you, I enjoy solving puzzles, <laugh>, when I get a phone call from you, I always answer it and I enjoy it. One question here is what do you look for in hernia physical exam? Do you want to answer that or do you want me to answer that?

Speaker 2 (49:08):

I think you should answer that. Okay.

Speaker 1 (49:11):

So a good hernia exam, it should be done standing up. The patient should expose the groin area. So everything from the belly button down to below the groin crease, and I follow landmarks, so everyone’s a little bit different, but you should find the pubic tubercle, which is a bone in the middle of the lower pubic part. And your anterior superior iliac spine are what we call the ASIS, which is the two bones that jet out from your pelvis on the sides. And if you connect those two lines, that’s your angle canal. I then follow that line between the pelvic bone and the pubic bone. And along that I feel for fullness, tenderness, bulging in men, it’s usually a bulging, you don’t have to be that special with your exam. In women, it’s often just tenderness. In fact, again, in this paper that we’re presenting at the American Hernia Society I think our number was something like 90 something percent of women who have what we call occult al hernias or hernias present with pain but not a bulge. Whereas the reverse is true for men. They often present with a bulge with no pain. So it’s a complete different presentation, but the key is to do it standing so that gravity helps and then the can follow inguinal canal and just see if you feel fullness or if the patient says, oh yeah, that’s where my pain is. And it’s al always above the growing crease.

Speaker 1 (50:49):

Oh, so interesting. So here’s a comment. I’m so confused with this information on endometriosis, it goes against so much that I learned from some of the top endometrial excision specialists. What’s your comment about that?

Speaker 2 (51:05):

Which part of it was false?

Speaker 1 (51:08):

No. So this person has learned a lot from top endometriosis excision specialists. So she’s very confused. A lot of what you’re saying goes against what

Speaker 2 (51:19):

Suppression? You mean about hormonal suppression or

Speaker 1 (51:22):

Maybe I’m not

Speaker 2 (51:24):

Understand the question. So excision helps significant to significantly reduce the patient’s pain. However, surgery alone does not treat endometriosis. Combination of excision of endometriosis implants and hormonal suppression is a great option for patients.

Speaker 1 (51:47):

And I think the same is true for me. I give talks on hernias and there are a lot of people that claim that the hernias that I’m treating in women is just fake and it’s not causing their pain. So the way that I fight back with that is I then publish my data and I say, look, I have let’s say 200 patients and they all had these symptoms, no significant bulge, but symptoms and a history consistent with the hernia. You fix the hernia and 80, I think 87% of them are cured with either Amelia or within two weeks. So I find it with data, but this person’s right, I see so many people that have been to other surgeons that are endometriosis specialists and they all get the surgery and I’ll read the OP report. It’s a complicated, all these areas with endometriosis stage four. And then I ask ’em if they’ve been on hormonal three treatment, they’re like, no. And they’ve had, like you said, 3, 4, 5 operations. They keep going back to the same surgeons. And I’m like, really? I mean you still have your ovaries and there’s your uterus is even still in a lot of these people, so how are you going to prevent it? And it’s treated like a chronic disease that is not being suppressed in between. It’s the surgical, I think this person is right. Not everyone practices hormonal suppression in addition. Why is that? Is it controversial?

Speaker 2 (53:24):

I don’t know. I honestly don’t have an answer to that, but it’s very rare for me not to be able to treat someone’s pain. It is possible that if they have a mild condition, you resect the endometriosis, they’ll do well with it for a few years. But majority of these patients, unless you suppress them with hormonal suppression, they will bounce right back with pain. Yeah, with months or years. Yeah.

Speaker 1 (53:52):

Okay. Two more questions because we’re almost out of time. We didn’t really discuss adhesions as a cause of pelvic pain. You did mention it. So can they cause pelvic pain and are there techniques to prevent adhesions?

Speaker 2 (54:05):

Do you want to answer that As a general surgeon?

Speaker 1 (54:08):

So as general surgeons, we don’t believe that adhesions really cause pelvic or any abdominal pain. Almost every operation we do causes some sort of adhesions and we just don’t see abdominal pain due to adhesions. However, strategically placed adhesions may cause internal hernias that for sure can cause pain. But a lot of the pelvic adhesions that gynecologists treat as general surgeons, we don’t feel that they’re causing the pelvic pain. But I know your answer is going to be different.

Speaker 2 (54:46):

My answer is different because surgically patients, especially with advanced disease, when you release their adhesions postoperatively, they feel so much better. I mean, you’ve scoped with me, we’ve, we’ve done cases together where in the pelvis everything stuck. And I think we did a bowel resection on a lovely patient last year an advanced endometriosis patient that had seen nine doctors in my area and she was never diagnosed by the time we scoped her, we had to resect part of her bowel because of pain. So adhesions because of endometriosis can cause complications. That patient had diarrhea. She almost had bowel obstruction symptoms. Remember her?

Speaker 1 (55:34):

Yes, no, I totally remember her. She was cured and her pain was very consistent with known endometriosis on her ileocecal junction. That was never surgically addressed. And I think the attempts were made to harm suppress that and it didn’t work. And she was getting obstructed, actually. She had obstruction, intermediate obstruction symptoms from that. Yeah, that

Speaker 2 (55:58):

Was interesting. In certain patients, I mean, it needs to be worked up and it needs to be evaluated.

Speaker 1 (56:05):

Yeah. I have a acute question that was submitted through Instagram. This lady had her gallbladder removed and now she’s pregnant. Are there any precautions that she should take?

Speaker 2 (56:17):

No. During her, it should be good to go. I’m glad her gallbladder is out, so she’s not going to have a gallstone attack during pregnancy, which is very common. We have patients who end up having pancreatitis in pregnancy, very tough to control when patients are pregnant. So she should be good.

Speaker 1 (56:34):

Yeah, I just did it operate on a patient to count her gallbladder. She had known gallstones but was fine. So I said, you know, as long as you don’t have symptoms, go ahead and have your pregnancy. And then she did her fertility and all the hormones for the fertility before the embryo was transferred just sparked huge pain. So I took out her gallbladder and now she’s having the embryo transferred. Good sparked. She definitely needed that surgery. More questions here it says, my adhesion seemed to have returned after femoral hernia repair. I had stage four endometriosis, many laparoscopies, everything was stuck together. Then I had a hysterectomy and hormonal suppression.

Speaker 1 (57:15):

They seem to be back after femoral hernia surgery. Let me just make a comment about that. So there are different ways of doing femoral hernia surgery and some of them are quite painful and should not be performed. The gold standards, laparoscopic surgery. So if you have pelvic pain after a femoral hernia surgery, you should make sure it’s not due to like a meshoma or some type of bawling up of Mesh, constant recreating the pelvic pain as opposed to endometriosis. In fact there’s one patient that made a very good comment, which is someone who’s had endometriosis and hernia surgery and she said her, she’s had, she had endometriosis pain 30 years ago and now she has hernia pain and they’re, to her, they feel exactly the same. So if you’re having chronic pain after hernia, femoral hernia surgery, it seems like your pelvic pain from endometriosis pain, you should still look into making sure it’s not related to your femoral hernia surgery. That would be my 2 cents.

Speaker 1 (58:35):

All right. So that is the end. I would like to say that we had a lot of engagement, lots of great questions. I of course learn everything. Learned something new every time that I see you. So thank you Dr. Aliabadi for joining me. I look forward to operating with you again. Yeah I would like to say that Dr. Aliabadi is not only gifted laparoscopic surgeon, but one of her significant traits is she does outpatient laparoscopic hysterectomies. And we, I’ve operated with her many times in doing the same. And so I would like you to join her and see her new website. It’s called outpatient hysterectomy.com as part of the outpatient laparoscopic Hysterectomy Surgery Center of Los Angeles. So thank you, Dr. Aliabadi. We will say goodbye now, as you all know. Thank you. Thank you for having me. Thank you so much. I will post this and the YouTube version of this on all my social media sites, on Facebook, Twitter Instagram, LinkedIn, and of course YouTube if you want to share with your loved ones. So thank you everyone. We will see you next week at another Hernia talk. And again, thank you very much for Dr. Thaïs Aliabadi, and her time. Bye-bye.