ALOHA!
It's a beautiful snowy day here in Bend. This picture was taken this morning, and although I only had a couple inches of snow at my house, it's still so peaceful and serene to sit and watch the snow falls. It's almost like time stands still and nothing else matters much (except, of course, freeing the world from the tyranny of Endometriosis). I'm getting excited because my brother is coming out in a couple weeks for a ski vacation, and what kind of hostess would I be if I didn't keep him company on the slopes?
The other exciting thing these days is the research that's coming out about the origins of endo. As many of you know, there's a great debate over the mechanisms by which endo forms. The most common explanation is that endometrial cells flow backwards into the abdomen through the fallopian tubes each month during the menses and implant onto surfaces in the pelvis (known as Reflux menstruation, or Sampson's Theory). There are some big problems with this theory, not the least of which it means that endo can never be cured. It also can't explain why endo occurs outside of the peritoneal cavity (such as in the lung, brain, deep in the rectovaginal septum, and even in the prostate gland in men!), why it has been found in girls who haven't yet had a period, or why it follow reliable patterns of distribution regarding its locations in the pelvis. The famous and beautiful Dr. David Redwine has spent his life trying to disprove Sampson's theory in favor of the "celomic metaplasia" theory of formation of endo. Celome is a fancy ten dollar word for the inside of the abdomen, and the theory of metaplasia promotes the idea that certain sites in the abdomen are predisposed to change into endometriosis upon stimulation by certain substances such as hormones (estrogen) or other biologically active molecules. Whether these areas are susceptible because during embryogenesis (formation of organ systems during early gestation before birth) cells of the reproductive tract fall off along the path of migration (everything migrates somewhere in an embryo), or whether they are just naturally susceptible to hormonal stimulation is still unknown. This difference, however, doesn't have as significant an impact on clinical treatment issues as the broader question of metaplasia vs reflux menstruation, because if endometriosis forms every month by falling out of the tubes and into the pelvis, then no surgical treatment short of hysterectomy or tubal ligation will cure endo. On the flip side, if metaplasia is the way endo forms, then once the susceptible tissue has changed into endometriosis (which usually happens by the early 20s), removing it should produce a cure. In fact, when we reoperate on patients who have previously had excision of endo, there is almost never endo on the specific spots in the pelvis that had been previously excised.
So what's the exciting part of this? There's new research showing the earliest transformation of normal ovarian tissue into endometriosis. They actually have pictures showing areas of transition between normal and endometriosis, which substantiates the metaplasia theory. OK, so you're not as excited as I am, but for us humble folk trying to prove to the world that endo can be cured, this is about as exciting as a beautiful snowy day when you're expecting a ski day soon.
Remember, tell your friends ENDO CAN BE CURED! And if they have doctors that tell them, "sorry, there's nothing we can do, just live with your pain", tell them to run the other way and then contact us. It's now not just Dr. Redwine's mission in life, but mine too, to tell the world about what we do, and let them know there's hope for a pain-free life.
Take care, and have a great week.
Dr. Mos

Cocky or Confident?
David said to me last week after reading my blog, "sounds like you're getting a little cocky". I thought about that for a while, and re-read what I had written. I wasn't trying to be cocky or obnoxious or haughty, but to emphasize the point that not a whole lot of people do what we do, and that it is difficult surgery. When I was in the Navy, my last year and a half was spent at Pensacola where the Blue Angels are based. I took care of quite a few of their wives, and while some of the guys were very nice, ordinary guys, a couple were real arrogant, acting like they were some sort of hot shots, quite obnoxious in the way they made everybody feel like they were less important than them, the hot dog fighter pilots. At first I couldn't stand them, but then I realized that being a fighter pilot is a lot like being a surgeon. Both pilots and surgeons have to have a very strong confidence in their own abilities because what we do has life or death consequences. As a surgeon, I have a sacred trust and bond with each patient I operate on. Both of us has to believe and I have to know absolutely that no matter what happens in the operating room I will still be in control. I have to know that regardless of how abnormal the anatomy is, how bad the bleeding is, or what complications I get into, that I will not give up, I will not panic, I will not stop thinking and acting in the best interests of the patient. Because if I do, bad things will happen. This confidence starts small and builds just like it does with anything in life. The more difficult cases I do, the more I build the confidence that, yes, I can do anything I need to; I can remove endometriosis wherever it is. My favorite book when I was a baby was "The Little
Engine That Could". The little train would chug up the mountain and chant "I think I can, I think I can...." until he finally got to the top. Most of the time confidence comes slowly but steadily. Sometimes you back up a few steps when several complications lump together (as they usually do) and you think "what the heck am I doing? Should I be doing this?". Once in a while you figure out something you're doing that's different, but most of the time there's no reason for what happened, and you move on, a little more slowly and carefully for a while until things get back to even keel. Rarely, confidence comes in a big leap, usually after prevailing over a seemingly unconquerable challenge. I remember most of my "giant steps" in confidence, whether in surgery, sports, or relationships. This past two weeks we've done 3 very difficult bowel cases, and I personally did my first laparoscopic bowel resection. I've gotten to be able to see the things that David does, not only the endo lesions, but the anatomy: the small blood vessels hiding beneath the surface, the contours of different structures and their significance. All of a sudden it's all coming together, and what seemed difficult a few months ago is now a whole lot easier (there's still a few more levels to go before it will all be easy, and some surgeries will never be easy, but they will all become possible). I remember the day I learned to trust the edges of my skis. I was at Stevens Pass, WA, on top of this short but really steep outcropping (I think I was 13 or so). I stood there scared to come down because of the steepness, but then I thought about what I knew about how skis worked, and what I had learned in my lessons about weight forward and all that. And all at once I thought "I can do this" and took off down the hill. After about 3 or 4 turns I was down off the steep, and with that one experience I knew that I could ski down anything (maybe not really fast or pretty, but I could make it down). That's how I feel now about my surgical abilities - I may not be as good or as fast as I uptimately will be, but I'm to the point that I can get through anything I face, and I know that (mostly) without a doubt.
Now, having confidence doesn't give you a license to act like you're better than anybody else - actually, it's just the opposite. My confidence in my abilities
hopefully will allow me to act with humility, valuing the relationship I can develop with my patients that allows us to achieve our common goal. What makes me continue this quest to be the best endometriosis surgeon possible isn't the notariety, money or respect. It is the experiences like I had last week, where a scared, traumatized young woman came to us after 3 failed surgeries for endo. She had a difficult lesion that others said couldn't be resected. We took care of her, excising her disease, and when she said good-bye she nearly cried from relief that her 10 year search for resolution of her pain was over, and from joy that she was finally pain free. There is no way to describe the satisfaction, joy, elation, and yes, a little pride, involved in an experience like that. It's like knowing that I'm doing exactly what I was put on earth to do. That's a pretty good feeling.
Take care, and have a great week.

Hello again.
I had the exciting privilege of meeting the one and only Nancy Peterson last week. Nancy is the nurse who started the whole "endometriosis treatment program" here in Bend many years ago. She had endo herself, and because of that, she had a passion for the patients, a special understanding of what they're going through, and I think she stimulated Dr Redwine to continue his quest for conquering the evil disease. Nancy still has a passion for curing endometriosis, and answers quite a few emails every day from women who don't know where to turn. I applaud her efforts to educate and encourage those who are in pain and looking for a better way than is often offered them. Speaking of a better way, we operated on a lady last week who had been to "experts" in several locations around the country in search of someone to rid her of her rectal nodule. One told her it "couldn't be done" because it was in the wrong location, one tried but gave up because "it was too low", and others put her on Lupron (which didn't do anything). We went to war against the forces of evil invading her body, and, at the end of the day (literally), we prevailed, with the villainous nodule in the pathologist's bucket. (do I sound too much like George Bush? I apologize...) It was the largest nodule I've removed, and was quite an exciting surgery. I finally have experienced firsthand the difficulty of this type of surgery, because David makes it look so darn easy, and it's not. Endometriosis is not a disease for the faint of heart, neither for the patient nor physician, but it is incredibly rewarding when you can tell an anxious, fearful patient (fearful because so many others have failed at excising her disease) that she will no longer have the one pain that has ruled her life for the last 10 - 15 years. I think I'm making great strides toward where I need to be in order to continue this work after Dr. Redwine retires. It's exciting and exhausting at the same time, but the joy from taking care of people who need you easily overwhelms the difficulty. March is Endometriosis month, and I encourage you to tell your friends with painful periods, painful sex, or painful bowel movements to get treated, and not give up. I will be doing free record reviews, so if anyone would like me to review their files, contact Kate or Deena in our office.
Take care, and have a great week.
Dr. Mos