Making the Decision: Hysterectomy - Panel Discussion

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As a jersey girl, I love my sparkles <laugh>. Uh, she's the Director of Team Ministries, revival Church in Hampton, Connecticut. Thank you so much. Thank you. And I know this is a heart, this is a very hard topic, very hard. So let's start with you. Okay. Um, what brought you to your decision of having a hysterectomy?

So thank you so much for being here and for listening. Being in this room with you all is like a dream come true. To be in a room with people who get it and understand what I say when I say endometriosis. Endometriosis. And not to have a response of, huh. It's just like so amazing. So coming to this decision was very easy for me, to be honest. Um, I kind of wanted a hysterectomy, <laugh> all my life. <laugh>. I really, really did. I hated the idea of, you know, those monthly periods. And that really turned into everyday pain, even on and off periods. So I never really had a good relationship with my uterus. In fact, my first period started on April Fool's Day when I was in seventh grade. And I totally thought I was being hoodwinked. So <laugh>. So yeah, I never really had a good relationship with it.

Um, fast forward teen years, I did have like a laparotomy surgery. They removed my ovary. They told me I would never have kids. They lied three kids later. I was like, somebody owes me some money. <laugh>. But I love my children. They're the absolute highlight of my life, but they're miracle babies. I never expected them to be here. And so having three kids and being so, so young, I'm like, okay, what can we do? Can we take it out cuz I'm bleeding like a faucet? And when I say a faucet, I literally mean turn on the faucet. And that's how it was like bleeding sometimes. And so my doctors didn't wanna do it. They said, you're, you're young. Like, let's do ablation. Let's do, you know, uh, birth control. Let's try this pill, let's try this. And I'm like, no. And, and these are not specialists that I was dealing with, by the way, my doctors don't specialize in endometriosis. So, um, finally I begged, I literally begged and I used the term quality of life and not being able to go places. And like we heard earlier, this is what I'm missing. I'm constantly canceling plans. I am sad, I am anxious and I'm losing jobs. You know, things like that. So saying those things, he's finally like, yes, you can do it. And so it was, it was easy for me. It was scary cuz it's a major surgery. But when I thought about what life could be, I just made the decision.

Thank you for sharing. And, and for you, Cynthia,

Um, similarly, um, I knew very young that I never wanted to have children. Um, what I didn't know is, what was so interesting is my friends getting pregnant by accident and having abortions. And that just never happened for me. Little did I know, I probably never could have gotten pregnant <laugh>. Anyway, I have a different story cuz I didn't go through fertility. So I actually was on the pill and didn't know I had endometriosis till I was in my forties. I'm in, in my mid fifties now. Um, but at 40 I decided to go off the pill, um, and try some other types of birth control just because of the risks of being on birth, of being on the pill later in life. And I had been on since I was probably 18 years old. Um, when I went off within a few years, I was getting very sick during my periods, um, not feeling well at all.

Um, I didn't have the proper care and I didn't know I had endometriosis. Um, finally I had, um, a massive infection from bleeding internally that sent me to the hospital. And that's when I found out that I had endometriosis. I was 46, uh, maybe 44, 45, went on a round of Lupron to calm everything down. Um, which now I probably would not have done knowing a lot more information. Lupron. Um, and then I had a first surgery. I begged the surgeon to gimme a full hysterectomy and he would not. Um, we were talking earlier, there's a lot of patriarchal issues that are involved in the medical care, especially when the majority of the surgeons are men. A lot of them are. Um, I met with other surgeons as well, but I did not have an endometriosis surgeon. I didn't know about what, where to go or who to talk to.

And then finally I found Dr. Sukin and his group, which was like a miracle because he, you know, he basically was like, of course you should have had a hysterectomy. Like, and that of course was like, yeah, I should have, I know I should have <laugh>. Um, so actually just this past September I had a radical hysterectomy. Um, I'm 53 years old and I just started hormone replacement therapy, um, last month. And I'm feeling fantastic. Um, I have had no pain. I've had no migraines, I'd have no nausea. Um, kind of like migraines without migraines, you get all the symptoms. But the headache, I was having multiples of those day in and day out affecting my everyday life, affecting my work. Um, so for me it was very easy. I really just needed, wanted the hysterectomy. Um, it ended up being a lot more complicated cuz I also had stage four progressive, um, and ended up having to have a colon resection at the same time. So the surgery wasn't, um, what if I had had just had the hysterectomy, I think it would've been a much faster recovery. Um, but because of the colon resection, it really, um, took me a few months to really get to myself. Um, but I'm feeling terrific now, so, yeah.

Well thank, thank goodness for that. Going through the process of coming to your own decision of wanting a hysterectomy, did you do a sort of pros and cons list? Whether you actually wrote it out, did you try to just in your head, sort out, okay, how does my life look with this organ that is not serving me? How does it look without whether are there possible implications that I'm not considering? How did you do your, your own, your internal check and also then your own research? Cuz we know with so much of endo and that it's all about self advocating.

So for me, um, kind of like I mentioned before, I missed so many things, like actual events. Like my husband has bought us concert tickets and I wasn't able to go, I've actually ended up at the casino leaving in a, in an ambulance due to pain. So it's like life, just the quality of life just was not there. And so my internal check just consisted of how much do I wanna live? Like, I'm literally so young and I'm not living like that. The mental strain of not being able to live or do what, I'm only 37 now, but like going through all of this in my twenties and thirties, um, doing what all, what all my peers are doing, right? They're living normal lives. They're going on vacation. I remember bleeding every day, going to Jamaica, tragic

<laugh>.

It's so tragic. So it's just like weighing the pros and cons in that sense. Like, how much do I wanna live? What I did deal with after and before is who am I now that I don't have a uterus? Is the uterus the only thing? And and it is no slight to however anybody identifies. I'm a woman and I wanna identify as a woman and I like being a woman, but am I a woman now that I don't have a uterus? Am I still going to be feminine? Um, like who am I like rediscovering that person? And you know, I am glad to say that while that was, while those were very hard thoughts, the rediscovery of who I am was just delightful. You know, like figuring out yourself over again and recreating what you want life to look like after hysterectomy.

I I love that you talked about that because there's so much attribution to an organ and we tie it to, as you said, if you identify as a woman our womanhood. And what has looked life looked like after that? Um, Cynthia, how, how would you like to elaborate?

Yeah, I think I went through that similar process when I had known I never wanted to have children. Um, so much of womanhood is attached to motherhood. Um,

Take your time.

Yeah, no, there's um, there's a lot. I mean, this is why I knew this was gonna be a, a tough talk. A a must have talk, but a tough one. Um,

But it was a decision that I, I didn't make the decision not to have kids. I just never wanted them. So having to make the decision for hysterectomy, that wasn't an, that wasn't an issue for me. Um, it wasn't an issue of womanhood, but I understand where it could be. Um, for me it was really just understanding what, what menopause meant and going through that stage of life as after, you know, when you finally get through. I have no idea why I'm crying <laugh>, it's a laugh. You know, I have to say that like I cry all the time after my hysterectomy. I have no idea why. But I do think that there was a lot of trauma involved in the decision making and where you come from. I could not be happier with my decision. Um, I only wish I did it earlier. That's truthfully the only regret that I have.

No, it's by the time you get to the decision of a hysterectomy. I think we've all been through so much and each of us has our own individual stories. And like you said, it's endometriosis affects the head, the heart, the body. It's so much more than a disease. It's, it just kind of all encompasses your spirit. It breaks your spirit in a lot of ways. And then to feel like you're not understood and then you add all these other layers of surgery and hormonal therapies. And I've even had friends and I know we're kind of just going all about this, this topic around, but it all goes back to these big decisions we have to make for ourselves. Yeah. For our quality of life. And I had a friend who said, well, you know, you have a surgery, you should be better now. Why do you keep getting sick?

Like, why are you deciding to keep getting sick? And I remember going, wow, she doesn't mean that she doesn't know what she's saying cuz she's not informed. But I was maybe two days out of having a three, three night stay at the hospital after a really long, extensive excision surgery with Dr. Sukin. And I just felt, wow, nobody gets it. I would never choose this for anybody. Certainly not myself. And I'm not choosing to be sick again. Yeah. So by the time you get to hysterectomy, it's almost like we're just so broken and we have to fight so hard to even get someone to say, okay, you, you really are ready for this. Your body really needs this. So the emotions all make so much sense.

Yeah. No, but I do wanna acknowledge also the privilege, right? That I carry. Um, especially being able to afford to be able to go to a doctor like Dr. Sk and spend a week in the hospital and go for public floor therapy and do all of these things. Um, I'm lucky I have a supportive family. All of these things that a lot of women are not, do not have that are struggling with the same thing. So I definitely wanna recognize that for sure.

Yeah. I wanna, um, just piggyback off of that. A supportive family or some sort of support system is very important to your success in your health, you know, in your body. I think having someone there or a team of doctors or you know, who no matter who it is, just having somebody personally there who's gonna support you and you know, still validate you and affirm you is really important through this entire process.

Yeah. And I was, I was going to ask, did you have anyone in your lives individually, um, who, when you were deciding, okay, I'm gonna go through with this that you spoke to that you really felt like you had someone else to bounce things off of?

Absolutely. My husband, he'll be at the blossom ball tomorrow. If you're coming, you'll get to meet him. Amazing, amazing man. He does get on my nerves like the rest of them. But he, um, he's been very supportive. In fact, when I had my first surgery and the doctor told me that I would probably never have children, he was standing there, you know, he was my boyfriend at the time, and he was standing there and he affirmed to me all the time, you're fertile, you're fertile. And I'm, I never really wanted kids like her. It wasn't a thing on the top of my head, but I'm like, this guy is crazy, but whatever, you know? Um, but having him there to just say, you know, whatever it is that you decide to do with your body, I'm here to support you. That was so pivotal, um, to have his understanding even through all the symptoms that come with endometriosis, um, just not feeling well all the time. It, it was just very important. So he was definitely my soundboard.

Yeah. I think, um, when you get into your fifties, you really don't, excuse my French, give a shit with other people. Think <laugh>. So I actually, um, made the decision on my own. But of course all of the people who love me were supportive because they wanted to see me be happy. Yeah. Um, I was in the middle of graduate school when I really wasn't feeling well and it's two years, um, like sort of in the middle of Covid. So I knew I had to push myself through, um, like the doctor was saying before, Dr. Sukin looked at me and he said, how have you been living like this? Like, I just didn't think about it. I just did it. But to the doctor before, you know, everyone wanted to see me out of pain, um, and discomfort. Um, and yeah, so it was very easy decision

For someone who might be sitting here today and kind of grappling with, do I, don't, I do, I don't, I, what would you recommend to them? And of course we know that this is a very personal choice, but through your experience.

So I do wanna be very careful. I really, really do. Um, if you have symptoms like I've had and you are not committed to bearing a child naturally on your own, I respectfully say rip it out,

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Just completely rip it out. Um, and you know, it's so unfortunate because there are some women who really, really desire that bond of motherhood. Um, and sometimes you do have to make the decision that, you know, this is not going to be for me. And I know you're like, it's easy for you to say you have three kids. And I just, I don't wanna be insensitive to that. You know, I'm very sensitive and empathetic with you. Um, but if you are not living a life, you have to put yourself first, right? So if your quality of life is low, put yourself first. If there's no other way to medically get it better so that then you can have children put yourself first and then, you know, adopt, get a surrogate, do those other things. And I know, like I said, I'm not being insensitive. I really don't desire to be that way. But if you are not here and if you are not well, you're no good to anybody, including your future children. So respectfully rip it out.

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Um, I would just say go internal. Like understand, especially if you do wanna have kids, why you wanna have children be truthful to yourself, um, and think about what it means for you, what it would mean for you on the other side. So like, the list of negatives, what does that mean for you? You know? And again, just to your point, think it's internal, it's an inter it's the only decision that you can make for yourself. Yeah. Whether you're married or not. Um, whether you have a partner or not, this is your decision. This has to be your decision. And I would say, um, try not to feel the pressures of society. Yeah. And also all of the people around you that are sort of like, oh, but just have the baby. Then you can have it. Do this, do that. You know yourself, you know your body. Be true to yourself. That would be my only suggestion. And it's a hard, hard thing to figure out truthfully. But, um, take yourself away for a weekend, go somewhere quiet and just like really think through where you wanna be in your life.

How did you even find the education about a hysterectomy? When was the light bulb that you were like, this could be my option here?

Um, so as I said before, my doctors do not specialize in endometriosis, but upfront they did tell me,

You know, you've had these procedures, they'll last about eight years. This is exactly what they said. Um, eventually down the line, maybe you'll want a hysterectomy. So that's kind of like how they offered it to me. I was just asking a lot sooner than they wanted me to. But yeah, I I didn't know anybody with a hysterectomy until now after having it. It's like I'm meeting people, but there was no, you know, when I was diagnosed Google wasn't a thing. We were talking about that earlier, me and Leah. So I I didn't have that research knowledge.

Yeah. World of social Media has Right. Created all the communities. And I think in the endo, even the, the sisterhood hashtags that I found, like there's, there's a great support system that didn't exist, like you said, over a decade ago, or even less than a decade ago, Cynthia, for you?

Um, well, when I went to through my first doctor and had the surgery, um, they removed my tubes. So it was considered a partial hysterectomy. But understanding that I could have had a full hysterectomy at that time, but they wouldn't give me one, um, because I was 46. And, um, the doctors are very scared of being sued if I had changed my mind, but I already didn't have my tube. So I have no idea what happened. But he woke when I woke up out of the surgery and he looked at me, he's like, I was able to save your, your ovaries. I was like, like <laugh>. I didn't want those ovaries. But, uh, thanks. Is that what I'm supposed to say? <laugh>? Um, the reality is, is that, that from that moment, that's all I ever wanted. So after that surgery, until I had my last big flare up and um, you know, was very sick, um, that's when I finally was able to have the hysterectomy.

But yeah, I, if I had even known earlier and understood a little bit more, um, and knew more about the disease and had doctors around me that knew about the disease. Um, my gynecologist I'd been with, with for 25 years and she was like, oh, when I have patients with endometriosis, I just put them on the pill and they feel so much better. I've never had a patient like you. I was like, okay, well that's not serving me well. So it was really a blessing to find Dr. Sukin and the team there and be affirmed.

Right. And I think that's a another thing too, is we talk about advocating for yourself. And I I love how so eloquently and directly as someone said, if you don't like your haircut, is that, and yeah. Right? You don't like your haircut. <laugh>, you find a new stylist. Same thing with the doctors. If you go to a doctor, and I've gone to doctors and they'll say, uh, before I also found doctor sections group, um, say, well, you know, I don't really, I don't really know what endometriosis is. And I was on my fertility journey and, and I was told like, well, why are you infertile? You're so young. I'm like, oh God, this is, this is, I'm not being understood at all. Here am I. And you just find someone who understands. Um, and just to give a depiction, and again, this is, this is personal, this is individualized, but gimme a snapshot, cueva of your life before your hysterectomy. What was your daily life like when you had your uterus?

With my uterus, I, um, what life <laugh>? Like, that's, that's my initial thought. Like what life? But I was very debilitated with pain. And like I said before, it moved outside of that week of a cycle. It was every single day when I had my surgery, they had found that it spread to my intestine and my bladder. So, um, I was dealing with more pain than what the ultrasounds were able to see. Um, I was constantly taking Motrin, and mind you, I, my kids are very close together, so, um, right now they're 11, 12 and 14. So like, I had three babies under three <laugh>, like at the same time. So I'm taking Motrin, I'm always tired, always having a headache, all like, it just wasn't good. It just, I didn't feel good. So life just, I don't wanna say it wasn't worth living because I had plenty to live for. Um, it just wasn't a good quality life.

Um, I was one of those patients originally that didn't really feel a lot of pain until I had something major going on, like a significant flare up or, um, bleeding, which caused me to go to the hospital the first time. Um, and then the second time I just, um, I just didn't feel well. That was really what it came down to. I just knew I wasn't feeling well put on a lot of weight very quickly. That was one sig signal my blood pressure had spiked, which was another, um, after my surgery and my hysterectomy. And I know Dr. Sutchin said there's really probably not a correlation, but my blood pressure has been perfect ever since. I'm on no medication for blood pressure anymore. Um, so I think my body was just in this height of inflammation, sickness, but again, I was, it was covid at during that time, during the second flare up. Um, and then I was in grad school, so it's like you just gotta finish. Right? So I had to finish my work, um, and, and get that degree so I could move on. But like to be feeling well now is just, um, I guess I kind of forgot how to, how to feel good. <laugh>.

Yeah.

Yeah.

Um, both, both of your stories are so impactful and to, to see almost the before and after of what life has been like and it seems like it's been restored for you or a life that you really didn't know before. Mm-hmm. <affirmative>, um, in terms of health. Yes. So thank you for being with us today. Um, we appreciate your time and your honesty and candidness.

Thank you.

Thank you.

We can open up the floor for, for questions. Oh, oh.

Um, thank you for sharing your stories. I know it's hard to talk about even, you know, if, if you did know what you wanted. Um, my experience at doctors has actually been the opposite. Um, I was 40 last year and before I was diagnosed with endometriosis, I found doctors would say, what do you need your female parts for? You know, basically you've missed your window to have kids. You could never have 'em now. Anyway, a lot of insensitivity and of course that almost made me want them more <laugh>. Uh, but a concern of mine, like if I have a hysterectomy, other than taking away the ability to have children naturally. Um, how have you dealt with menopause symptoms? Because like, that's a big scare for me. I've heard surgical menopause. It's terrible, it's awful. Don't do it, avoid it. So like, what was that like for you? So

I'll, I'll let Cynthia answer that because I still have an ovary and so right now I'm, I'm kind of normal

So, right. So I had a radical hysterectomy. Take it all please. Um, you know, um, when I went to see Dr. Sk for my follow up like two months after, he said like, how are you feeling? But I think cuz I had the colon resection, I really wasn't feeling great for a while. Um, but then when I started to feel sort of back to myself, I could better understand what symptoms were from recovery, what symptoms were maybe from, from menopause. Um, I did get a blood test, um, right away. So we knew I had no estrogen at all left. Um, and the only real symptoms that, and I was very afraid of the symptoms as well. Um, not as afraid of keeping everything in though. Um, and the symptoms can be properly managed with the proper healthcare. So, um, I felt a lot of hot flashes that was like definitely the number one for me, um, were my hot flashes. Um,

Other than that, I guess I didn't know what I was feeling until I just started hormone replacement therapy now, um, with a doctor who's part of the Menopause Society of America because that's, you know, what I was important for me. Um, and it's been working out great. Most of the symptoms have subsided since and I am like, what one of the doctors said I'm taking estrogen and uh, progesterone. So it's the combination cuz my biggest fear really is reactivating the endo, right? So I've been through all of this, it's like the last thing I wanna ever do is have endo again, which I know is a possibility, but, um, the reality is I'm only three like from September to now. So I was like, hopefully not for a long time, but, um, I'm feeling good now, but I wouldn't, um, I wouldn't make it, I don't know what the difference is between going naturally and going surgically except that it's on set very quickly. Um, I feel great. I wouldn't let the fear get in your way. Um, but definitely talk to your doctors about that and what what, what the treatments are on the other side for sure.

Hi, <laugh>. Hi. Um, thank you very much for sharing all of that very personal information and how you came to your decision. As somebody who's on the precipice of making this decision and kind of, you know, shopping around and doing their homework now you hear a lot of different things about, you know, keeping your ovaries, keep one ovaries, keep your cervix, take your cervix, like, you know, for all different reasons. And so I'm just curious if you could share anything in terms of like your thought process or how you made the decision to keep certain additional parts or not keep them.

So my doctor told me that if he took out everything I would go into immediate menopause. And at the, the time I, my mom was menopausal age, I don't know quite her whole story, but I was like, I know there was a switch <laugh> and I'm not ready for that switch, you know, um, with that hormonal imbalance and you know, just kind of feeling all those changes in your body. And so it is a tough decision because obviously we're dealing with endometriosis, it's like a beast, but I just knew I did not want to take additional medication. So I take medicine for high blood pressure, high cholesterol. I'm on very low doses, but I'm also a type one diabetic. You know, I have this skin condition on my back called scle edema, not to be confused with scleroderma. So like I'm treating all these other things and another therapy drug is not what I wanted for my life at the time.

Um, it wasn't really much of a decision for me. Um, I made that decision with the doctor based on what he saw, um, in my body and what was going on and my age. And I think that that's the one of the decisions you would definitely need to speak to your doctor about and really understand for you what leaving something in means. Um, for me, um, I was probably already cl going to go into the menopause, um, phase soon anyway. Um, although there was no indication of that because again, I was on the pill for so long, um, cuz I went back on the pill and really didn't go off the pill until like a week before surgery. Um, so I would just, I would highly suggest just speaking to your doctor more closely about what would be important for you and what it means for you to take it all out. Yeah, yeah. It's, I'm sorry, we can't really give you the answer. Yeah. <laugh>,

This is what happens.

People

Tell you different things, so you just have to

Yeah, yeah. Really

Think about it. Yeah.

Let, make comments. May I make some comments? Absolutely. So I want to clarify, uh, like taking everything out versus partial hysterectomy versus keeping the ovaries or the cervix. And it's very, it's not, it's, it's confusing what patients think is, is different than what the doctors have in their mind. Mm-hmm. <affirmative>. But before that, there's, I have to assure you, there's different tendency in America that as we are divided red and blue, the doctors are like that too. I mean, we, in Texas, I, or certain areas of the kind, they're doing hysterectomies on 22, 23 year old ladies before in the assumption that they have, I dunno, males, I have a, I have seen them many times, not once, not to, I have one patient that came from Texas. She had 20 laparoscopies and 10 of them has been done robotically by one doctor. Oh my gosh.

And the last surgery was hysterectomy. Wow. And you know, I, I don't wanna go on the, the bottom line is this, so it depends how much the uterus from the doctor's point of you we're talking. It depends how much the uteruses is involved with the problem. Uh, with the endometriosis, it's very difficult for us to tell. You need to say, I rarely as a man, especially I have been, I, they talk women taught me <laugh>. I, I hesitate to spit out the word h I don't, I want to hear what they're gonna say, but I wanna really get the picture very straight to the patient first. If it's, if the uterus is involved with the disease, it, it can be all two ways. One is the uterus itself has ende uses inside, that's adenomyosis. Unfortunately, if it's, unless it's a focal adenomyosis, it's very difficult to save that uterus.

Uh, that's for sure. In that case, the uterus, the hysterectomy is easy to spell out. The second indication for hysterectomy, for an image, when it is somewhat stage four or frozen pelvis, in other words, URIs has got so much fibrosis, it's connected to the muscles, nerves all around. Even though you clean everything out, still there will be disease inside. I, in my practice, I still tell the patient, look, I could save your uterus, but you have to understand, don't point finger at me if you need another surgery because this is, this is situation is so far ahead in a better scenario, in every hysterectomy, I like to save the ovaries, unless the patient wants their ovaries out, I'll, I'll take them out or write that menopause or there's history of ovarian cancer. You know, these are all com communication that cooks along the way so the ovaries doesn't need to come out.

So the patient doesn't need to go to chemical menopause. Chemical menopause is different than surgical menopause. Surgical menopause. When you have hysterectomy, that's surgical menopause. You menopause mean that you stop having period. So your uteruses is out, you stop having, but your ovaries will continue to push your estrogen to the system. So you're gonna have the moon phases as the, as you proceed and your natural time clock for menopause will kick in. When it comes, it's as Dr or said is age 52 in general. So ovaries may not come out. The tubes have to come out because tubes are, you know, the conduit for endometriosis as long as there's so, so there's also something called subtotal hysterectomy. So we call it subtotal, meaning that partial hysterectomy, which which women generally thinks when you say partial hysterectomy do over is stays. And the whole uterus go when doctor says partial hysterectomy, it means the cervix stays subtotal history.

We need to make this very clear in our website. So cervix stays the body to corpus, the body of the uterus comes out. That's subtotal. The, the advantages of it or is, I'm gonna tell the advantages, but the bottom line, if the cervix is not involved with endo or minimally involved, if you clean the endo enough around, we could keep the cervix that holds the architecture of the vagina. So the vaginal architecture, the ligaments and the nerves, blood supply. And I think it's good for, uh, you know, intimacy for many reasons. Men always, men do feel if the cervix is gone. So there's the cervix has a role in synchronization of, I think of sexual, uh, relationship. Um, so when the cervix is removed, obviously unless the doctor repairs it very well, there's a chance of pre uterine prolapse, world prolapse. The architecture changes. So we like, I like to keep the cervix, I like to give that option to have the cervix not to be removed.

But then you have to do your routine pap smears and everything as if you never had hysterectomy. But that the good part is you never have, you don't have periods and you don't have the pain of uterine pain that's associated with irregular heavy bleeding and also endometriosis, you know, but hysterectomy is not a treatment of endometriosis, it's partially a treatment of endometriosis where the origin of blood bleeding. So endometriosis is a disease where the endometrium like tissue is outside uterus. So you have to clean the old mess around the uterus for hysterectomy to be helpful. This is all one-to-one decision. You know, you can't have this discussion in 15 minutes and this, this discussion is ten one hour at least. And you have to make sure the patient is getting it too. You know, not everybody is like you here, people walk into the office with no idea about these. So good luck, you know, how far can you go? Yeah. You guys have seen moments. So many doctors had so many operations, you know, better than me. Many of the things I have to adapt to. Why have you asked the questions? And I have to answer accordingly. Yes, ma'am.

Um, in your patients that also have this is trying

To make sense. Well first of all, we are seeing Aden mos younger and younger ladies. I have 23, 24 years old. Coup quite a few of them. So they have an i u d, we do suppress their menstruation additionally with i u d with something else. So we are very strict on their ov ovation activity. So if they don't really bleed monthly, the end, that cellular activity does not keep going. So both adenomyosis and endometriosis, estrogen dependent diseases. So if you estrogen is the fuel jet fuel, okay? So you gotta cost cut ovarian estrogen out of their system. Ovarian estrogen. So birth con, a medical student asked me a question just recently that was a great student. The question because we tend to simplify these things very easily and don't even talk Daniel, you are giving birth control pills and it has, uh, estrogen in it.

She's right. But the estrogen we given birth control pills is synthetic estrogen along with there's a progesterone and estrogen. So it doesn't have the same effect. It really is PR in a way protective. So it's good. So we see ayos, so aosis have three com four type of AEOs. I can say one is diffuse aosis, one is focal aosis. It could be like fibroids or like one is a myoma, it's more fibroid like. And there's an externals, which is the ayos endometriosis grows from outside to the inside of UUs. This happens with very advanced endometriosis cases. So the focal myosis and ayo, I can treat with eyes closed. I mean simple. I I don't take it very, the diffuse ayos, you know, not every diffused animal is also very painful or they, they may not need treatment, but if it's she's bleeding heavily and all the measures are not taken care of it, you can get away with his subtotal hysterectomy.

In other words, the corpus comes out, cervi stays. It's a mini, mini, mini, very minimal hysterectomy with Aries in place, I think, uh, it has a, in in Scandinavia all 90% of the benign hysterectomies are done in this way. The cervix are preserved somehow over there. It's a cultural practice. We have different of, I mean I I have maybe a little bit more European perspective in my mind too. More flexible also being in New York. Also different, I have to say practicing in New York is different than other places. We do see different attitudes. Doctors' attitudes reflect their environment also. Mm-hmm. <affirmative>, was that [inaudible] Okay. Yes ma'am.

Is it normal to bleed while you're on birth control

Suppression? No, you shouldn't. You should. Well if you're bleeding, either you are missing the, somebody's missing the timing of the birth control pill or a day or so or there's something else going on. It's normal. You can, I just got two calls about this this morning. So we doubled it for one or two days it should correct. And if it's still continuing, if sonogram has to be done that there's no polyp or improper growth within the uterus. Thank you. Anymore questions? We're almost coming to the end. Yes ma'am?

Um, when it comes to like recommending or potentially describing directing, um, your conversation on like the outside, you were talking about architecture.

Oh yeah. You mean sex? Yeah,

Life after like how your

Pressure changes. Well it's not only sex, let's get more to, there is also questions with respect to bladder issues like prolapse, yes. Going to bathroom at night, uh, stress incontinence or issues with rector cell. Enter a cell, you know, for patient. Usually I, you don't see these pelvic prolapses in patient who have c-sections or having nobody if there's no childbirth in the past, you don't see a childbirth really does do the trick for prolapse. You know, unfortunately <laugh>, it depends on the big babies. Um, uh, and uh, other than that, I've, I've seen rarely on patients who never had children some degree of prolapse. But in every hysterectomy where if cervix has to be removed, I personally have a way of being suspended. We strengthened the ligaments. So, uh, architecturally it's preserved. What else? So, um, if it's, yeah, hysterectomy is in good hands. A lot of doc, you know, regular ob gys are trained to do it. It's not. But hysterectomy for advanced endometriosis is very difficult. So you, you really have to tie the arteries in very widely. Like it's like cancer surgery, advanced endometriosis. Yes. Yes ma'am. In the back

C-section.

Very good question C-section. If it's done. So lately we are seeing more and more c-section related endometriosis because the, somehow there's a tendency ob gys are taught not to close the peritoneum like general surgeons did in Vietnam war surgery. They think, oh, you don't need, that's not right. So some layers are missed uterus. If the uterus leaks blood after C-section, do you find the uterus immensely adhere to the abdominal wall? So my first question, if somebody's coming to me with pelvic pain after C-section, how was your recovery in the hospital? They usually say, I stayed 10 days. You know, I had antibiotics, I had IVs, I couldn't, you know, you know exactly that URIs is stuck to the abdominal wall. So yeah, go ahead.

I gave birth in in the us Thank you. I gave birth in the US uh, in 2009 and 2012. And I'm from Europe. So I went to Europe back in 2015 and my OB G there diagnosed that the cause of my endometriosis was a C-section.

He's right. Any other question? Yes ma'am.

Uh, forgive any ignorance and if this has already been answered, but I just to clarify, so if you have the hysterectomy, but keep the ovaries, how does and the, and the estrogen is, is ovarian estrogen that's still being released. How does that help the endometriosis?

It doesn't help the endometriosis. It doesn't? Okay. Because your surgeon is, if he cared about your ovaries, he took care. All the endometriosis is removed from the pelvis. So as long as there's no endometriosis, your ovaries is continues to do their job, that estrogen is not gonna bother endometriosis. That's not there anymore. No, but from

Progressing further, like I've had surgery, you clean me out pretty darn good. But if I were to consider having an, you know, I'm starting to get symptoms again already because I'm, it's all, you know, it's not a cure and it progresses.

No, no, no. Don't say you take cure. Look, this cure business really gets me ladies. Okay, let me tell you something. Endometriosis is highly treatable. Let's start from that. Alright. People who have, it depends why you have the endometriosis surgery. If you had the endometriosis surgery for, to get pregnant and you have three kids and your endo is cleaned with, with a good surgery. I think it is, in my opinion, it it is for that person. The endometriosis cured and she's living her j her life without even thinking. There's enemy uses. So enemy js cured for people who forget about their endometriosis, have continued to have normal life. And let me tell you, they are not in this room today. I'm in this room. They are not in this room. They are sailing away. They have gone going on in your, in their lives. I trust my experience.

Endometriosis is, cure is a cancer word, heavily associated with cancer, five year survival. But I think we should be very careful if you have endometrial surgery, well done. Everything is cleared and patient is very educated. She continues have a pain-free life. Normal functions are re you know, resumed that is almost cur. I mean I could say she's cured. I mean she's not complaining. So, but if she's complaining, it's surgery is botched, improperly done. She still has pain. And, and many times it's incomplete surgeries. We see this. And unfortunately those people never know that there is, I'm not saying everything I do, I cure. I'm not saying I'm curing endometriosis, but I am pursuing a perfection in a way that, uh, it's almost highly, highly so highly treatable in many women. I hate to say uses. There is no cure. Endometriosis, come on. That's not, that's not true when it comes to Sergio. What is there is not cure for pain. There is also not cure for genetic thing that's inborn with these patient endometriosis, a disease of disturbed stem cell of the endometrium. So you're born with genetically there with there. You can't change, there's no cure for that right now. But overall, the damage of endometriosis could be is highly treatable. Highly treatable is almost, if you're maintaining in life, it's almost equal to cure. If you don't complain about it and con your life is changed, in my opinion.

And Dr. Ska, I'm just gonna agree with you. I've, I've been paying free for almost four years and I have the same situation. So I think we

Have to, they're telling me I'm getting too exit. I have to cut. It's time to cut. But did I, did I make my point? So yes. Do someone agree with me, please.

Thank you so much for Thank you again ladies. It was incredible.