Relationships

Hi again,
I don't know why but I felt the need to address one significant problem women with endo and pelvic pain have - relationship issues, but as I started to write I realized there is much I don't know about this aspect of the disease. So, I'll start, and you guys can send me your comments so that we can have a discussion about this and we'll all be better for it.
To start with, there are a couple of obvious issues for women with endo and their partners. The 800 lb gorilla is the sexual component, and how pain affects intimacy. We see a lot of couples with these problems, but since we're not "Dr. Ruth", we don't really delve into the emotional aspect very much (because hopefully these issues will be solved postoperatively). Yet I sense that these are very serious challenges that can either strengthen or ruin relationships. Some of the men are frustrated because they aren't as active as they'd like, yet at the same time they feel guilty when they do try intercourse and cause their wives/partners pain. Most of the women by the time we see them could care less about sex, all they want is their pain relieved, but underneath the immediate need for pain relief are the suppressed desires for a normal life and normal relations. Some couples can find other ways to share intimacy, replacing actual intercourse with other aspects of physical intimacy, or having deeper conversations to sustain the emotional intimacy. These are usually the ones that can get through these difficult times, sustaining each other when pain turns to depression and hopelessness. Other couples have difficulty and end up separating, probably for lots of different reasons - some sexual, some emotional, and some because they've lost their "normal life" that they used to have.
Another big issue is the husband/partner as caretaker thing. Some guys do this exceptionally well and are incredibly patient, doting, caring, and just great nurses. Other guys pull back into their shells when their wives/girlfriends are suffering, mainly because they don't know what to say or what to do. Here's a story for you - the first baby I ever delivered (back in 1988) was to a couple where the wife was pushing, screaming, and miserable, and her husband sat with his head on the back of the chair, looking at the wall. I thought he was such a jerk until I realized he was probably scared stiff and didnt' know how to help. I think there are quite a few guys like him - they want to do the right thing, but really don't know what to do. For men who are good caretakers, the issues change some when their wives have their surgery, then start to feel better. They have gotten so used to the "nurse" role, that it takes some adjusting to get things back to normal.
You can probably tell that I'm not a real expert in this particular area, but I think it deserves some discussion and consideration. I'm sure that all you ladies who are suffering and living with endo think about this all the time, and have a lot to contribute about your own insights and things you've learned over the years. I'd love to hear from you, because the more I know about what people are going through, the better I can counsel my patients and the more I can empathize with them.
Take care, and have a great week. I look forward to hearing from you!
Dr. Mos

Answers to you questions.....

I've received some questions from readers on various subjects, so I thought I'd answer them individually.
First, a number of questions about back and leg pain with endo. All of the nerves in the pelvis eventually run into the spine before connecting with the spinal cord. Endo tends to frequently involve the uterosacral ligaments, which as the name suggests, run from the uterus to the sacrum (the base of the spine that forms the back of the pelvic girdle). Pain from the uterus as well as endo on the uterosacrals can cause pain that is perceived in the low back, although touching the skin over the area where the pain is felt doesn't usually increase the pain. This is known as "referred pain", and it is caused when internal organs are painful, but the pain is felt where the somatic nerves (from the skin or muscles) from the same nerve root as the visceral nerves (from internal organs) from the source of pain. In other words, the lumbar nerves go to the uterus as well as the low back and buttock. When the uterus hurts, your brain can't localize all of the pain to the inside of the pelvis, so it is felt in the back where the other nerves from the same spinal segment come from. This is the same reason that appendicitis initially causes pain around the umbilicus (when only the appendix is irritated), then as the inflammation involves the abdominal wall, the pain localizes to the right lower quadrant. The nerves from the intestine are felt as generalized belly pain rather than an isolated discreet spot. Likewise, some pelvic areas don't send pain impulses that are perceived as coming from the pelvis, but they're felt in the back. The uterus can also generate pain referred to the legs, most commonly the anterior and medial thigh. Referred pain is usually a deep pain that aches and throbs, sometimes it can feel hot or burning, usually it doesn't increase by pushing or rubbing the place where it is felt.
Back pain in the context of pelvic pain can also be due to muscular issues. Pelvic pain can cause muscle spasm of the levator muscles, which can cause spasm of the piriformis and obturator muscles. These little bugger muscles are both on the inside and outside of the pelvis, and line the inside of the pelvic cavity. They externally rotate the hip, and when they are in spasm, they can alter the normal curvature of the lumbar spine by pulling down on the sacrum and flattening the lumbar curve. They can also cause the tailbone to hurt (coccodynia). Similarly, the hamstrings (muscles of the posterior thigh that flex the knee) originate on the iscial tuberosity, the bones we all sit on, the ones that get sore riding a bike. When people are inactive, many times the hamstrings will tighten up (try touching your toes with straight knees - if you can't, your hamstrings are tight). This also pulls down on the posterior pelvis and flattens the lumbar curve, causing back pain.
Then next subject is fatigue after surgery - this is incredibly common after any kind of surgery. One can think of postop fatigue as nature's way of making sure we rest enough to allow the body to heal itself. This is a simplistic explanation, but usually the fatigue resolves slowly as activity increases. One study looked at healthy students who were made to stay in bed for varying numbers of days. Their cardiovascular fitness was measured before and after their forced rest. It took an average of three days of activity for every day in bed to recover to their previous level of conditioning, and that was without any illness or surgery, so extrapolating that study to surgery, it would be normal to take a while after surgery to feel as energetic as beforehand. When the body is injured, whether by surgery, infection, or disease (like endo), our response consists of mobilizing white blood cells to swarm to the area that's injured. They release all sorts of factors that eventually help promote the healing process, but sometimes cause more inflammation than they should. These factors are things like histamine, leukotrienes, prostaglandins, and cytokines that act in an incredibly complex way to effect wound healing. Along the way, they can also cause fatigue, and more nerve stimulation that rarely can eventually lead to neurogenic pain. There is also a connection between inflammation and sleep disturbances, as well as a defined restorative effect of deep sleep enhancing immune functioning. Pain in and of itself can cause fatigue, and pain that results in lack of exercise also increases fatigue. To some extent as this postop inflammation resolves, the inflammatory mediators decrease, and fatigue lessens. However, in order to get back to preop or pre-disease levels of fitness, you have to work at conditioning by exercising daily, pushing yourself somewhat in order to recondition your muscles, heart, and lungs.
The last question was about estrogen and endometriosis. Yes, estrogen alone does stimulate endometriosis, but most birth control pills are progesterone dominant, which means that the progesterone in the pill is able to suppress endometrial cells more than the estrogen stimulates them. This is why most women have lighter menstrual flows while on the pill than when they're not taking it. To the extent that endometriosis can be suppressed (some superficial endo can be suppressed quite well, while the deep lesions really can't), the more progesterone dominant pills will be better. The best way to take OCPs with regards to endo is to take them continuously, so that you don't have a period. This is facilitated by slowly increasing the interval between periods - first putting 2 packs together, then 3, then 4, and so on, while skipping only 3-4 days between active pills rather than 7.
The last question was related to weight and endo. Most of our endo patients are thin, so although I'm not aware of a study of endo patients and weight, I'd have to weigh in (pun intended) to say that endo does not cause weight gain. Abdominal bloating around the menses is usually either gas-related, muscle laxity of the abdominal wall, or fluid retention, and isn't really fat deposition, so that doesn't count.
Well, I hope this helps your inquisitive minds. Please let me know if there are any other burning questions you have, and I'll do my best to give you the straight scoop. Also, if you think you have endo and want me to review your records to see if Dr. Redwine and I can help, please check our website for instructions on how to submit this information.
Thanks for reading, and have a great week.
Dr. Mos

Diaphragmatic Endometriosis

Diaphragmatic endo is an entity little known to most physicians. Many GYNs don't even know it exists, and most pulmonologists (lung specialists) aren't very familiar with endo. It is an incredibly rare manifestation of endo, with only 30 cases reported in the literature, most occuring on the right side. I actually think it's a little more common that this, as I've seen 2 cases since I've been here in Bend (9 months). Patients typically have pain in the right chest and shoulder around the time of their menses, and sometimes can cause pain with taking a deep breath. Rarely, it can cause what's know as a catamenial pneumothorax (a dropped lung around the menstrual flow). This can cause an increase in pain as well as difficulty breathing and air hunger, feeling like you can't breathe deeply enough. Because it's rare to have this dropped lung condition, as usual, endo of the diaphragm won't typically show up on any imaging studies, so once again, we're back to requiring a high index of suspicion to diagnose this entity. Laparoscopy with the scope through the belly button will allow visualization of the anterior part of the diaphragm, which can give you an indication of whether or not there's endo present, but by far most lesions hide out towards the back of the diaphragm behind the liver, which can't be seen with the usual scope position. We use a smaller 5mm scope through a port in the right upper quadrant (just below the ribs) in order to see the entire diaphragmatic surface in patients that complain of these symptoms. When diaphragmatic endo is present, because it's usually full thickness through the entire diaphragm, we have to remove it through an open incision beneath the ribs (like an open gallbladder incision.) This is because the liver can't really be retracted laparoscopically without risking tearing it, which will cause lots of bleeding (typically considered poor form in surgery...). That's also the reason that just lasering the lesions usually doesn't work (because they extend from the abdominal surface to the pleural (lung) surface).
The amazing thing about diaphragmatic endo is that just like bowel endo, the pain magically disappears even before the incisions are healed. It's truly amazing to see.
Well, that's about all there is to say about diaphragmatic endo. Short and sweet, but oh so necessary for those who have it.
Have a great week and Memorial day weekend, and say a prayer for the families of all the troops who have given their lives to defend our freedom. Take care,
Dr. Mos

Eileen left a comment last week asking me to write about adhesions.
This is an interesting subject, and there are some vigorous debates within the academic community about whether or not adhesions cause pain. Throughout the years it has become almost a running joke that the general surgeons don't think adhesions cause pain and gynecologists think they do cause pain. In reality, I think there are some adhesions that are dense, attached to something sensitive like an ovary, or definitely pull on structures like the bowel or abdominal wall that can definitely cause pain, and I've operated on these ladies and their pain resolves after cutting and/or removing the adhesion. There are some adhesions that are more filmy with less density to them that often run from small bowel to other structures, and these adhesions rarely cause pain.
Within the context of endo, I have read many, many operative reports from other GYNs who dictate "findings of adhesions in the culdesac". Most of the time this represents stage IV endo, and the adhesions aren't from prior surgery, they're from endo. The simplistic explanation is that endometriosis lesions are like glue, and they will cause other surfaces to stick together, ie bowel to uterus, bowel to ovary, rectum to cervix, and on and on. What really happens is that the lesion secretes metabolically active substances that cause pain and inflammation. The body's response to the inflammation is that of scarring and formation of fibrosis. Just as a scar on the skin contracts with time as it matures, so do scars and fibrosis in the pelvis, causing tension on adjacent structures. Sometimes the tension adds to the basic endo pain and causes (for example) worse than normal ovulation pain because as the ovary enlarges with the cyst that contains the egg, it can pull on whatever it's attached to (usually bowel or pelvic sidewall) and cause pain.
We don't know what the #1 gynecologic cause of adhesions is, because the only way to reliably find them is to operate, and who do we operate on? Women with pain. In one study, 75% of women with endo had adhesions, and 80% of women without endo had adhesions (essentially no difference). They can be caused from prior surgery (especially when there is post operative bleeding), infections like PID, appendicitis (especially if it ruptures), diverticulitis, cancer, or anything that causes inflammation in the abdomen. Some will say that excising endometriosis causes more adhesions than lasering endo, but I'm not aware of a good quality study comparing that. What I am aware of is the dozen or so women that we have operated on since I've been in Bend who have had surgery by Dr. Redwine in the past. These women on average have a few filmy adhesions mostly in the cul-de-sac (and most of these women have had bowel resections), and not too much else. It is remarkable how often we can see where the peritoneum and endometriosis was removed at the previous surgery and healed in perfectly with no adhesions, no endometriosis, nothin'! The patients who had bowel resections usually have some filmy adhesions around their anastamosis, but compared to patients with active endo that hasn't been excised, the number and quality of adhesions is usually less for both, especially the quality (meaning the adhesions are filmy instead of dense and fibrotic).
While there are still many unanswered questions about adhesions, it is the opinion of both myself and Dr. Redwine that simple filmy adhesions don't usually cause a lot of pain, that endo hides in dense adhesions. If doctors don't know what to look for, or don't have a lot of experience with stage IV endo, they may not realize that the pain in those patients is coming not from the adhesions but from the endo at the cause of the adhesions. For stage IV endo (obliterated cul-de-sac) and bowel disease, the only way to relieve pain and cure the endo is to excise it, remove it and the associated fibrosis. Many studies have looked at Lupron and other medical therapies for this most severe type of endo, and the meds failed miserably. Unfortunately, these are the patients who are most challenging surgically and require a surgeon who is familiar with the patterns of endometriosis, and has a lot of experience with this variety of the disease. These endo specialists are few and far between, but if you are a patient with this particular flavor of endo, I guarantee you that it will be worth your while to seek out one of the handful of us who do this kind of surgery every day.
To those of you who are in pain, I wish you the very best and hope you find relief. If I can do anything for you, please don't hesitate to let me know. Either leave a comment on the blog, or email me at info@endometriosissurgeon.com, and I'll do my best.
Take care, and have a great week enjoying the beautiful spring weather.
Dr. Mos

Interstitial Cystitis

Aloha!
Sorry I didn't write last week but we were in the OR until 10 pm one night and 8pm the other. Nobody ever said this kind of surgery was easy, but it sure is challenging.
I thought I'd write about interstitial cystitis today. IC as we call it, is the second leading cause of pelvic pain in women, behind (you guessed it) endo. Some studies show as high as 80% of women with chronic pelvic pain (CPP) had evidence of bladder involvement as a cause of pain, sometimes by itself and sometimes accompanying other pain generators such as endo or levator muscle spasm. IC causes pain in the central pelvis that can radiate out towards the groin or back to the sacrum. Some people feel it deeper, like at the top of the vagina. Typically the pain is worse with a full bladder, so these patients tend to void often, and they usually have some degree of urgency and frequency because the bladder wall doesn't like being stretched out. As you can imagine, intercourse can be miserable, although sometimes changing positions so the bladder is out of the way can make it tolerable.
One of the biggest problems with IC is that it can take years for patients to get a diagnosis. IC falls in the gap between gynecology and urology, with both specialties trying to pawn the patients off on the other. This is partially because of a lack of training about IC that hopefully is being rectified, and partially because many docs don't like taking care of chronic pain patients. It is true that patients with chronic pain can be difficult to care for, some requiring a lot of time and hand-holding and some with narcotic abuse issues, but I'll tell you what, there is nothing as satisfying as helping someone who's been in pain for a long time. Most patients don't want drugs, they want pain relief, and when you help them accomplish that, they are so grateful that for me anyway, that's all I need to keep me going. The other thing about pelvic pain is that it usually doesn't show up on ultrasounds, CT scans, or lab tests. Doctors that are good at diagnosing pelvic pain have to rely on listening to the patient and doing a focused, methodical exam, then use their powers of deductive reasoning and gut intuition to come up with an idea of what's causing the pain, and what to do about it. Doctors aren't used to making diagnoses this way these days, without confirmatory imaging studies, so it takes a special person with an interest in pelvic pain and compassion and empathy for the patients to be good at it.
Nobody is quite sure yet just what causes IC, but the leading idea is that of "neurogenic inflammation". What happens is that a painful stimulus that continues over time, (whether from endo or levator spasm or essentially anything in the pelvis) eventually can cause reverse transmission of nerve impulses from the spinal cord on down to the pelvis. When these stimuli reach the end of the nerve (for IC the bladder nerves) certain substances (like histamine, cytokines, and prostaglandins) are released from mast cells that cause swelling and nerve irritation. These inflammatory mediators that the mast cells release then cause more nerve irritation via other mediators that upregulate the pain fibers (nerve growth factor and substance P), eventually causing a vicious circle of pain. Another theory is that there are breaks in the mucousy lining of the bladder that protects the cells from all the irritants that the kidneys are excreting. These two theories are not mutually exclusive and likely the neurogenic inflammation causes the breaks in the lining (the technical term is the "gag layer" because it is composed of glycosamino glycan, or gag, which is a big huge sugar molecule).
It is logical based on the above theory of neurogenic inflammation why there is a significant overlap between those with endo and those with IC, but this doesn't explain why women without endo (or men, for that matter) get IC. Going back to the painful stimuli part of the theory, it is possible that any pain generator in the pelvis can induce the backwards nerve transmission and thereby neurogenic inflammation. It is a well-known fact that we are in an epidemic of abuse in this country. Whether by parents, partners, or strangers, nearly one third of all US women admit to having been abused at some point in their life. Women with IC have a higher percentage of abuse than those without - nearly half of IC patients admit to being the victim of abuse. The reason this is significant is that any abuse, but especially sexual abuse can cause a prolonged spasm of the levators, the muscles of the pelvic floor (the muscles used in Kegel exercises). Prolonged muscle spasm eventually causes increased firing of the pain sensing nerves in the muscles, which starts the vicious cycle. There is a lot of cross-innervation in the pelvis, which means that nerves to the bladder, pelvic floor, upper vagina, rectum, and any other pelvic site come from the same nerve root as it exits the spinal canal. They also interconnect like an LA freeway, joining and separating often on their way to the end-organ. This allows for 2 things to happen - the first is that a painful stimulus can start anywhere in the pelvis and cause the neurogenic inflammation in another pelvic location (this is also the proposed etiology for vulvar vestibulitis, but we won't get into that today). The second is that "neural cross-talk", or this sharing of nerve fibers between various organs in the pelvis, is probably why there are patients with IC, irritable bowel syndrome, and fibromyalgia all at the same time.
IC can be treated in a variety of ways, but none are "curative". Hydrodistention (blowing up the bladder with water under anesthesia) is both diagnostic and therapeutic. When either ulcers (only seen in 10-15% of pts) or glomerulations (small areas of bleeding from surface blood vessels) are seen after hydrodistention, then IC is present. Hydrodistention also is known to give some relief for a few months afterwards. Bladder instillations are my favorite treatment because they work quickly and pretty effectively. For people with significant pain, instilling lidocaine (a local anesthetic) and heparin (rebuilds the mucous lining) can give them immediate pain relief that can last for several days. Initially the instillations are 3 times a week, but with time the interval can be stretched out to a week or 2. Elmiron is a drug designed specifically for IC. It also rebuilds the lining like heparin does, but it takes 3-6 months to see a benefit, which is why I like to start with both oral Elmiron and bladder instillations. Tricyclic antidepressants work well to depress the pain fiber activation, essentially putting a damper on the hypersensitive pain nerves. Since chronic pain does cause depression, having a side effects of a little mood elevation and improved sleep doesn't hurt, either. Some people advocate antihistamines, specifically atarax, because it stabilizes the mast cells so they don't release their nasty inflammatory mediators, but I find that most people can't tolerate the sleepiness it causes.
I think there's a lot we don't yet know about pain, why some patients have minimal disease and a lot of pain, why some patients have a ton of disease and a little pain, and why some people develop new pain after their old pain was fixed. The good news is that a lot of research is being done to identify places in the inflammation cascade as well as the nervous system where interventions can be made. Right now we have some drugs that definitely can help women with IC and those with chronic pelvic pain (non-endo related), but I think that within the next 5-10 years some significant advances will be made. (for those of you that missed the previous articles on excision, that's the cure for endo). Just think, it was only 20 yrs ago or so when they called IC a "disease of hysterical women" and told them to see a shrink!
There is hope on the horizon, and if we're lucky it will come soon.
Take care and have a great week. Don't forget, send me your questions and ideas for next week's blog. My record review are free until further notice, and you get two for the price of one!
Dr. Mos

Fatigue and Endo

Hi there yet again,
It's a beautiful day here in Bend Overagain (that's what my friend Brad calls Bend), plus, I just figured out how to stream jazz over the internet into my little speakers on my desk. Cool.
Well, in my quest for new and interesting things to write about, I was asked to enlighten you all about endo and fatigue. Now this is a difficult topic, because there is not much in the literature about these 2 entities. One paper was written by some people at NIH and Mary Lou Ballweg, the founder of the Endo Assn. They sent out a survey to over 3000 women with endo, and asked about their pain, and any other diagnoses they'd been given. As you can imagine, these types of papers are not the most reliable, because they're based completely on the responses of individuals, which are truthful most of the time, but sometimes there can be some bias interjected. Regardless, this paper does give us some idea of the prevalence of various other diseases in women with endo compared to the general population. "Chronic fatigue syndrome" was much more common in women with endo than in the general population, but was still a very small percentage (4.6% vs 0.03%). Chronic fatigue syndrome is a nebulous diagnosis in the way that fibromyalgia is, where there are symptoms present but no known cause for them, and the authors did not comment on why the incidence was so much higher in women with endo. Just looking at fatigue in general, chronic pain can induce fatigue, depression, and anxiety. This may happen because of how pain limits activity, and with decreased physical cardiovascular activity, there usually follows a sense of tiredness.
It may be due to chemical mediators of inflammation that are produced by the endo and get absorbed systemically and act on the brain to cause fatigue. Or, it may be due to changes in the part of the brain where pain and emotions are processed. Chronic pain has been shown to cause atrophy in certain areas of the brain (thalamus and dorso-lateral prefrontal cortex). This increases the emotional component of pain, and decreases one's emotional reasoning powers. There is much that is yet unknown about the way the brain processes pain, but suffice it to say that it is very complicated, with interactions between chemical mediators, receptors for natural chemicals like seratonin and dopamine, opioids, and various other modulators of nerve cell function. I'm fascinated by why some women (not too many, thankfully) continue to have pain after their endo is excised. We all know that endo is only one of many sources of pelvic pain, but it is the only one with a defined cure. There is research into why there is such an overlap between patients with Interstitial Cystitis (IC), Irritable Bowel syndrome (IBS), and Vulvodynia (inflammation of the vaginal opening). The current thoughts are that there is cross-innervation of all the pelvic organs, and when one is inflamed, it causes inflammation in the other organs via nerve mediation (neurogenic inflammation). Why are some women lucky enough to have their pain resolve after their endo is excised, but a few have the persistent "chronic pelvic pain" syndrome with this cross-innervation and cross-inflammation? Probably it goes back to what makes us individual - our genes.
I don't want to make you discouraged by this - by far the majority of women with endometriosis have a dramatic reduction of pain after excisional surgery, but there are a few (ironically with typically very little endo) that don't, and those are the puzzling ones I was referring to above.
I am confident that the research into nerve and brain function specific to pain processing will continue, and continue with the focus on pelvic pain, so that a few years from now we'll look back and laugh at how uninformed we were back in 2007, like looking back at the days before penicillin. I want to encourage all of you to persist in finding solutions to your pain. Everyone has a slightly different journey, but my hope is that you can find a way to live happy, productive, pain-free (or at least pain-controlled) lives. I heard someone say that the key to being happy at work is to feel like you have a purpose, and that you're pursuing that. I know that my purpose in life is to help women with pain, (and incontinence), and in so doing to swim upstream against the current of Lupron, Lasers, and ineffective management of endo.
I wish you all well, and again, I will be happy to review any of your records to see what we can do for you here in Bend. Let me know what topics you're interested in reading about.
Have a great week.
Dr. Mos

Hi there,
I got a request to talk about excision, why what we do is different than other docs, and why it's different than using a laser or other ablative techniques. I will do that. Yesterday my nurse Deena told me to look at some chat rooms about endo and as I read them, it really blew my mind how many women are not getting appropriate treatment that will bring them relief. I'll comment on that later as well.
To begin with, endometriosis is a disease that forms when cells in the pelvis that have the genetic propensity to turn into cells of the reproductive tract are stimulated by hormones. The stimulation by estrogen makes normal peritoneal cells turn into cells that resemble the endometrial lining of the uterus. As the stimulation continues, the disease continues to grow but only in the original locations where it started. This means that endo can grow deeper, but not have lateral spread as a rule. When the cells are metabolically active, they make inflammatory mediators that cause fibrosis (scarring), adhesions (different type of scarring), and pain. As a woman ages, the endo gets deeper and can cause scarring around other organs like the ureters, bowel, nerves, and just about anything else that is nearby. Suppressing estrogen levels, either by birth control, lupron, or aromatase inhibitors, can lessen the metabolic activity of the endo and thereby lessen the pain, but the disease continues in the body and will reactivate itself after the suppressive medicine is stopped. The amount that the endo is suppressed is variable from patient to patient, and this is why some women have no pain on medical therapy, and others have essentially no relief whatsoever. Looking at surgical treatments, some docs just look in the belly and say "yep, that looks like endo", take out the scope, close the incisions and prescribe lupron. This is not surgical management of anything, and it is WRONG. The most common surgery for endo consists of burning the surface of the lesions with either a laser (light energy) or cautery (plain old electrons). If the disease is superficial, then these treatments can work, but more often than not, it works for a while, and then the "roots", or the deeper part of the lesion that didn't get killed by the electricity start becoming active again, and the pain returns. This doesn't mean that the endo comes back, (because it was never gone), but the pain comes back. The other problem with simple burning is that when endo is overlying the ureters or the big blood vessels that feed the legs, or is on the bowel, it doesn't get treated at all for fear of injuring the underlying important structure.
What Dr. Redwine and I (and 3 or 4 other docs in the US) do is to carefully dissect the entire lesion of endo, whether it's superficial or deep. When the lesions are superficial, then removing them is easy, like taking the skin off of a chicken breast without nicking the meat. When the lesions are deep, then it's a lot more difficult and takes a lot of time and skill. We use plain old-fashioned cautery to do this dissection, because Dr. Redwine feels that this technique allows us to get a better feel for where the bottom of the lesion is. Excision can be done with a laser, but it can be harder to identify the base of the lesion so you don't cut through it leaving some endo in place. Whatever tools are used really doesn't matter, but what does matter is that all of the endo is removed with the least amount of bleeding and injury to the surrounding tissues and organs. Once endometriosis is removed, it doesn't come back. The only way it comes back is when it wasn't all removed to begin with. We have removed endo the size of chicken eggs in the rectovaginal septum that other "specialists" in endo said couldn't be removed because it was too low. We have removed endo that has encased the ureter, actually removing a part of the ureter, then sewing it back together again. Wherever endo is, we have removed it, and 99% of the time it can be done through the laparoscope (so the patient has little band-aid incisions and heals up faster). The quality of an endometriosis surgeon should be judged by these 3 things: How often do they remove 100% of the endometriosis; what is their complication rate, and how often do they open up the patient ( make a big incision). If you ask your doctor about these issues and they get defensive, run the other way. If they say they never have any complications, run the other way because that is impossible (either that or they never do any surgery). Any doc worth anything should be able to have a friendly, informative conversation about exactly what they are planning on doing, what their experience is with that procedure, alternatives to the procedure, and what complications can happen. This is called "informed consent", the dialogue that happens between the surgeon and the patient, not the form you sign, like a permission slip in kindergarten. If they say they're too busy to talk to you preop, then they'll be too busy to take care of you postop.
Some pelvic pain is indeed caused by the uterus and won't go away by removing the endo. In these cases , there are 2 options. One is to remove the uterus, if the patient is done using it (done with childbearing). The other option is something called a "presacral neurectomy". We do these very commonly in younger women who have a lot of uterine pain - midline cramping during the period, pain that radiates into the anterior thighs and back during menses. The "PSN", as we call it, works 75% of the time, and takes about 2 minutes to do at the time of a laparoscopy for endo with very little risk.
I don't know of any studies that have looked specifically at pain relief after excision alone vs excision with hysterectomy, but this brings up an important point. When a gynecologist evaluates a patient with pelvic pain, the goal should be to identify all possible sources of the pain. Some women have pain from endo with a perfectly normal uterus. Some will have a tender uterus with or without endo. Some will have a tender bladder, or interstitial cystitis. Some have tenderness of their levator muscles, the muscles of the pelvic floor that are most famous by being contracted with "Kegel exercises." All too often there is a "one size fits all" answer that consists of "hysterectomy" or "oophorectomy" (take out an ovary), because that's the only surgery some docs think will help. Sad, but true. Certainly there are plenty of great GYNs that understand pain, and understand how to diagnose what's actually causing the pain, but unfortunately listening to patients and making a diagnosis based on what they tell you and what the exam is like is becoming a lost art. It's faster to order a Cat scan or an ultrasound, but those tests won't help ferret out the multiple causes of pelvic pain. The short answer is that if your pain is from endo, then remove the endo. If your pain is likely to be from the uterus, then either do a PSN or, if you're done having kids, then have a hyst. If your pain is from the bladder, then you need to be checked for interstitial cystitis. Anything that is likely to be causing pain needs to be addressed in order to have the best chance of relieving the pain.
Well, I think this is an epic, long-winded blog, but I wanted to give some facts for those of you trying to figure out what's true and what's not. Remember, let me know what you want to know about, and I'll do my best. Also, I'm doing FREE record reviews, so check with our website for instructions on how to submit your records to get a free personalized recommendation made just for you. (Do I sound like Bob Barker???? sorry...)
Until next week,
Dr. Mos, signing off.

Well aloha once again,
Last week I took a vacation and went back to my old stomping grounds in Hawaii. (don't tell anybody or they'll think I'm slacking!) It was great to see my house there, and my old friends. The highlight of the trip was seeing all the whales! It was truly whale season, and we must have seen 100 whales, more than I've ever seen. We were fishing one day on a boat, and this huge humpback breached right in front of the boat, then rested at the surface just off the bow for several minutes before diving back into the deep. That was cool.
So what's new in the realm of Endo???
Well, there was a new paper published this month that identified genes in the peritoneum of women with endometriosis that are not active in women without endometriosis. These genes are thought to promote the development of endometriosis lesions via the same pathways that were used during embryogenesis (the formation of organ systems in the first 10 weeks after conception). The genes were found in highest concentration within endometriosis lesions, then slightly less in normal appearing peritoneal cells of women with endometriosis, and almost none in the peritoneal cells of women without endometriosis. These same genes are important in the formation of a normal uterus and normal endometrial tissue. Their conclusion was the same as Dr. Redwine has spent his life trying to prove: that endometriosis forms by a metaplastic (change) process where normal peritoneal cells (cells lining the abdominal cavity) change tissue types such that they become cells that resemble the endometrium (endometriosis). This means that it is NOT formed by retrograde menstruation (Sampson's theory) and does NOT continue to repopulate the pelvis and regrow after excision, therefore it is NOT futile to remove endometriosis instead of giving Lupron. Gee, sounds familiar, eh????
When I was in Hawaii last week I told my old neighbors about what I was doing here in Bend, and about what endometriosis surgery was like. I told him that endo was like a weed that had really deep roots that wrapped around all the important structures in the pelvis like the ureters, bowel, blood vessels, etc. He said, "why not use Roundup?" I just laughed, because the analogy of Roundup to Lupron was so obvious. The endo weeds are resistant to Lupron roundup, so we have to be able to get in there and dig it out. I think it's a great analogy, so I thought I'd share it with you all.
So, I'm still taking suggestions for topics to write on. Let me know what you're interested in, if I'm answering your questions, if you think I should take a different tack, or whatever. I'm like the genie in the bottle - your wish is my command.
A Hui Ho (Hawaiian for "Until next time"),
Dr. Mos

Endo of the bowel

Hi there once again.
Well, I had a request to do a little review of endometriosis of the bowel. Bowel endo is actually more common than one might think, with over 25% of our patients here in Bend having intestinal endometriosis. That number is most likely higher than the general population, as our patients typically have more severe disease than what the average gynecologist sees. Most doctors aren't familiar with the treatment for bowel endo, so these patients tend to float around from doctor to doctor looking for someone who can help them. Unfortunately, usually nobody has until they get to us.
The most common site of intestinal endometriosis is the sigmoid colon, the portion just above the rectum that lies on the left side just beneath the left hip bone. Following that, the rectum (behind the vagina and cervix) is next, then the last part of the small bowel, appendix, and cecum (beginning of the large intestine). Some patients have bowel disease in more than one location, and it is often associated with ovarian endometriomas (also called "chocolate cysts"). (as we said in Med school, "there goes another food group....")
If the lesion is of sufficient depth, endo of the sigmoid and rectum will cause pain with bowel movements (sigmoid - left lower quadrant pain, rectum - midline pain right where the lesion is). Most of the time these will hurt all month but can get worse during the menses, and rarely (if the lining or mucosa is involved) they can cause rectal bleeding during menses. Some women have diarrhea, constipation, or both in an alternating fashion, but these symptoms alone do not necessarily indicate bowel involvement as they can be seen in those with pelvic (non-bowel) endo as well. Endometriosis of the appendix, cecum, and ileum tend not to cause pain, but in rare cases if the lesion is large enough obstructive symptoms (nausea, vomiting, intermittent crampy pain) can occur.
Why can't some cases of bowel endo get diagnosed? Doctors of old had very few "tests" to do (x-rays, lab studies), so they had to rely on their ability to ask the right questions, listen to what the patient was telling them, and gather the data they needed by their 5 senses. Nowadays, since the advent of CT scans, MRIs, Nuclear medicine scans and the like, plus the atmosphere of "defensive medicine", most docs have lost at least some of the old-fashioned ability to make a diagnosis with their brain, eyes, ears, and their own 2 hands. Imaging studies are notoriously poor at finding endometriosis (with the exception of endometriomas), so in order to diagnose it, one must have a strong suspicion from the history and the physical exam. Rectal nodules can usually be felt on exam and are exquisitely tender, reproducing the defecatory pain, but nodules of the sigmoid colon or higher oftentimes cannot be palpated. Disease is then confirmed by surgery where the surgeon sees the lesions, then by biopsy where the pathologist verifies the lesion to actually be endo and not an imposter. If the surgeon doesn't routinely look at or think about the bowel as many GYNs do (or don't), even at surgery lesions on the bowel can be missed. For those docs who don't trust their own suspicions as much as they trust a CT scan, bowel endo will be missed because it usually doesn't show up on ultrasound, CT, MRI, or most other imaging study. Once in a while if the lesion is large and the radiologist knows what to look for these lesions can be seen, but not commonly. Colonoscopy and flexible sigmoidoscopy (a "mini-colonoscopy" where only the rectum and sigmoid are inspected) typically do not reveal endometriosis either, so unless one is both familiar with and suspicious of bowel endo, it likely will go undiagnosed.
What can be done for bowel endo? The good news is that most patients who undergo surgery to remove the lesion have excellent, long-lasting pain relief. The bad news is that these lesions (even when they are diagnosed) are typically not removed by gynecologists because most don't operate on the bowel. Some patients are referred to general surgeons for treatment, but most are placed on Lupron for suppression, even though it has never been proven to work for this type of lesion. When Dr. Redwine and I remove bowel lesions, most of the time the lesion can be removed by either a partial thickness or full thickness resection of a disc-shaped area, then the hole is sutured closed in layers. This is almost always done laparoscopically, and most patients go home within 24 hours of surgery. Sometimes if the lesion is very large or more circumferential, a segmental resection must be done. This involves removing a whole segment of bowel, sometimes up to a foot in length, then reattaching it using a stapling device. Because of the larger dissection involved and the longer operating time, these types of procedures will usually require a 3-4 day stay in the hospital to allow for normal bowel function to return, marked by the passage of gas (flatus is the $10 medical term). The irony is that these patients very often have immediate pain relief, and when they wake up from anesthesia they can tell that that deep, burning, agonizing pain they've been living with for years is gone. Their postop pain is usually nothing compared to what they've been dealing with preop, and it has been my experience that these ladies are the happiest patients of all. In fact, for both Dr. Redwine and myself, seeing these women pain free for the first time in years is our reward for the physical challenge of a long, demanding surgery. Long-term results of these surgeries are excellent with about 80% cured at 5 years, and fertility rates above 40% (not perfect, but much better than preop).
Our experience thus far has been to operate on almost 800 cases of bowel endometriosis, and to be honest, it is my favorite type of patient to take care of. The surgery is challenging, fun, and satisfying because these women do so well, both in terms of their immediate postop course and their long-term pain relief.
I hope this helps those of you who see a little of yourselves in the above descriptions, and I wish you the best in dealing with your disease. Remember, I'm doing free record reviews through the end of March, so if you think this might be you but you're not sure, don't hesitate to contact us. I'm really not typically into self-promotion, but in this case, I have to because not very many other docs in this country do this well, and I have to say, David's the best. And I'm getting there. Let me know what other topics you're interested in.
Take care, and have a great week.
Dr. Mos

Hi there and Happy March!
I saw Bob Woodruff on TV last night, (he's the anchorman who nearly had his head blown off in Iraq last year), and he was in amazing shape. I couldn't believe how well he had recovered, especially when I saw a picture of him without part of his skull. I just wanted to take a minute and give out a big Oo Rah to all of the phenomenal military surgeons, nurses, corpsmen, and the entire group that is keeping our fighting soldiers and sailors alive and well over there. Most people may not know this, but most of the major advances in trauma care and surgical intensive care medicine have come from the battlefields. So, I'm proud to come from a military background (my dad was a cook in the Navy in WWII), and proud to have served in the Navy, and to have trained at Bethesda Naval Hospital. Stateside and peacetime military medicine may have some flaws, but if I was in Bob Woodruff's shoes with a major head injury, there's nobody in the world I'd rather see than the Navy or Army docs and crews.
Now to endometriosis.....
I'm having fun doing all these bowel cases. It's really true that endometriosis follows repetetive patterns, hanging out in nearly the same spots in most people. Once you get the hang of looking for important structures like ureters (the tubes that bring the urine from the kidneys down to the bladder), and you learn how to separate them from the fibrous web of scar tissue woven by the endometriosis-driven silk worms (just kidding - no worms, just scar tissue), and you figure out how to do all this without injuring the large vessels carrying blood to and from your legs that live just beneath all the endometriosis/fibrosis/scarred in junk, then the only thing left to do is to take the endo off the bowel wall, sew it up, and be done. That's a little like saying, "just give the space shuttle a little tune-up". Easier said than done. But, with practice and a great teacher (Dr. Redwine), it truly is getting easier.
The hard part is convincing the scientific establishment that endometriosis can be cured by removing it from the body. They all want to cover it up by giving Lupron, and now aromatase inhibitors. All that does is suppresses the activity of the endometriosis cells for a while, and lessens their ability to produce all those little biologically active molecules that cause pain, then when your menopause (induced by the Lupron) gets better, your pain gets worse again. I really think they don't want to admit that if endometriosis can be cured by surgical excision, then we need better surgeons than we have in general gynecology, and that 4 years of residency for learning all of obstetrics, office gynecology, surgical gynecology, and primary care (thrust on our specialty about 10 years ago for dubvious reasons) is just Not Long Enough to train excellent surgeons. I can truly understand the frustration of many of our patients who have been told "there's nothing we can do for you" by doctor after doctor.
Well, time to get off my soap box.
If you have issues related to endo, pelvic pain, incontinence, or women's health in general that you would like me to address, please let us know.
Take care, and have a great week.
Dr. Mos

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

Happy New Year!
It's been a while since I last wrote, but I haven't forgotten about you all.
In case you're wondering, I had a great Christmas break, the highlights of which were my brother-in-law and his family coming to visit, and taking my dog cross country skiing. Here's a picture of Birdie.
OK, I should be writing about my quest to become the worlds second best endometriosis surgeon (which I will), but my dog's so cute, I couldn't resist.
So, what of the surgery epic? Things are going well. I've been doing more and more cases, and I'm getting faster, which is good because it means less anesthesia time for the patients. I'm still challenged somewhat by the really difficult cases, where everything is stuck to everything, the anatomy is totally skewed, and it's just plain hard. But, some of the tough cases we do are as difficult as any surgery can be, so it stands to reason that those surgeries won't be easy for anyone. My goal is to do as many surgeries as I can with Dr Redwine before he retires so he can coach me through the difficult ones.
One of the things I would like to do is to visit some of the local endometriosis association chapters and give some community talks, so women with endometriosis know what options are available to them. Many women have multiple surgeries by OB/GYNs who don't know how to recognize the subtler forms of endometriosis, and don't know how or have the surgical skills to treat it appropriately, so they have surgeries which don't result in any significant pain relief. I feel compelled to spread the word that endometriosis can be cured, and that most pelvic pain can be improved quite a bit, but unfortunately the number of physicians who can and will help these women no matter what it takes are few and far between. It's so sad to see patients coming to us after 3,4, 6 previous operations that haven't worked. At least they're finally at the place where doctors will both care about them and care for them appropriately. So, if any of you know contacts with community support groups for women with endometriosis or pelvic pain, please forward their contact info to me. I would be greatly indebted to you, and the women who are suffering without hope will be as well. The most important thing people need when they're going through difficult times is hope, and it's just scary how many patients come to us after being told "there's nothing anybody can do for you". No hope, no possiblities, no compassion.
Well, I'm off to change the world, or at least help a few women along the way. Pay it forward, that's my goal. Peace to you in this new year.

Good Morning everybody,
Today when I woke up it was 9 degrees here in beautiful Central Oregon, and the sunrise on the mountains was spectacular! My mom calls it "strawberry ice cream" on the mts. We are truly blessed here in the Northwest to have such a beautiful place to live and play.
I've been doing quite a few endometriosis surgeries lately and I'm getting faster and more confident. Dr. Redwine is an excellent teacher, and is patient with me as I take a while to dissect the dense scar tissue underneath the endometriosis lesions which lies directly over all the important structures of the pelvic sidewall (the ureter, big blood vessels going to the legs, nerves, the federal reserve bank). Surgery for endometriosis can be tedious, as the surgeon has to be careful to remove all the scarring (fibrosis) from the endometriosis, but leave the ureters, intestines, and blood vessels intact. Most gynecologic surgeons never operate in these areas, and don't know the anatomy of these spaces very well. We've been into the retroperitoneum on every case, and into the spaces behind the vagina, lateral to the rectum, (basically everywhere most surgeons aren't) routinely since I've been here. I finally feel like the rust is coming off after not operating for a while during my move, and I'm back into the swing of things. The cases I used to do well are now incredibly simple, and the cases I used to struggle with I can do now with a little style. If surgery can be compared to baseball, when I was in Hawaii I was a good player in the minor leagues, as are most doctors. Very few play in the major leagues, and David is like Roger Clemons, the star pitcher of the World Series champs. Now I'm getting used to stiffer competition, and am playing (operating) better because of it.
It is always gratifying to see patients happier, in less pain, and more functional after surgery, and I will never tire of being able to help them with their endometriosis pain or their urinary leakage. Life is too short to be miserable, and as doctors we have an ethical mandate not to throw up our hands when difficult problems come at us. We went through years of training so we would be strong, tough, and smart, and to banish the phrase "I'm not comfortable with that...". Here in Bend we see more patients than I care to think about being treated with useless medications and told "there's nothing anyone can do about your pain". We will not quit on anyone, either in the OR or in the office, we will go the last mile to figure out what needs to be done to improve someone's quality of life, to cure their endometriosis, to ease their pain. OK, I sound like I'm on a soap box, but it gets frustrating seeing patients who've been blown off by the people they trusted to help them. I'm incredibly glad I'm here, learning from the best endometriosis surgeon in the world, a guy that doesn't know the meaning of the word "quit".
Have a great week.

Hello again.
I know, I've been negligent and have skipped the blog for a couple weeks. I have a great excuse - the dog ate my homework.....
Seriously, though, a lot has happened in the past few weeks. The most significant event was that we submitted our first paper for publication (well, not Dr. Redwine's first, but our first together). The paper is about the response of endometriosis to either surgical excision (what we do) or to Lupron. The bottom line is that Lupron does not cure endometriosis, and over 60% of those who go on it will have their pain recur within a year. Women who undergo surgical excision, on the other hand, have an 80% chance of NOT having endometriosis 5 years after their surgery. It's a pretty significant difference, and it flies in the face of what the drug reps and many doctors have been telling people (you). One of our missions here in Bend is to stamp out endometriosis any way we can, and since it would be impossible for us to operate on every woman with endo, the next best thing is to educate the world about the best ways to treat it. It's a big job, but somebody's got to do it....
The next most exciting thing involved going to Las Vegas for the AAGL annual meeting (that's the gathering for gynecological laparoscopists from all over the world). David taught several courses, and there was live surgery beamed in from various exotic places (France, Germany, Brazil, Atlanta..). It soon became obvious to me that I was one lucky girl, because Dr. Redwine is a far better surgeon than most of the surgeons being teleported in for viewing. The meeting was informative, and I met quite a few prominent endo surgeons from around the world, so now when I read their papers I can put a name with a face.
The Central Oregon Women's expo took place the weekend I arrived home from Vegas, and Deena and I spent the weekend talking to women about their bad bladders. We had more business than I would have guessed, and spread the word that incontinence can be cured (almost as heretical as curing endometriosis. Go figure). I met quite a few very nice people, did some "networking", as they say, and won an exercise ball, so now I have no excuses for not doing my situps (now called "core exercises").
This week my thoughts are ping-ponging between our next paper and the menu for Thanksgiving dinner. I need a good sweet potato recipe; everything else I've got down pretty well. The other exciting thing that happened last week was a patient told me she actually read my blog! She said it made us more human, and she felt like she knew me. Comments like that make the whole thing worthwhile. I think it will take a while before I learn all of what David can teach me, but I think the surgical aspects will come faster than all the knowledge he has stuffed into his brain. I'm doing more and more, and the main issue is the speed factor. It takes me longer than David to do things, but every case gets a little faster, so there's hope for me. I'm still having fun, and I definitely feel like I'm in the right place. Thanks for reading. More later....

Good Morning!
Winter is on it's way to Central Oregon, as the temp this morning was 16 degrees. Now all we need is some snow in the mountains to start the ski season.
This past week has been an exciting one in our office. We've been refining some of our educational information and will soon be modifying our website so it can better inform potential patients regarding incontinence and pelvic prolapse. There is so much information on this topic, it's hard to know what to include and what would just be contributions to your "cesspool of useless information", so to speak. The trick is how to organize it, and to explain things in ways everyone can understand. Don't worry, it's coming and will soon be better than it is now.
I'm starting to build up my surgical numbers, and last week we repaired a large cystocele (bladder fallen down), and did a laparoscopic sacrocolpopexy. This is a procedure where the top of the vagina is resupported via a piece of mesh sutured to the sacrum (the base of the spine). This procedure has been done for years through a big incision, but over the past few years a few centers have started to perform them through the laparoscope, which allows for a much faster recovery. To my knowledge, we are the only center in Oregon doing these laparoscopic procedures.
I want to let you all know that we will be at the Central Oregon Womens Expo at the fairgrounds in Redmond Nov 11 and 12th. For those of you who live in this area, I'd love to meet you and discuss any issues you may want to talk about regarding womens health, or anything else on your mind. It will be exciting to meet a lot of people (hopefully) and try to address their health concerns.
Take care, and have a great week.
Dr. Mos

Hi there again.
Thanks to those of you who are reading this, and who have written comments. If there's anything you would like me to address, please let me know.
Today Deena, our nurse, brought her 3 legged dog to the office after her bath. It reminded me of Tommy, my cat, and his adventures before we left Hawaii. I was worried that an outside cat who doesn't have front claws and lost his top fang teeth wouldn't fare well here in Bend with the cougars, foxes, wolves, and whatever else is out there lurking. I took him to Mililani (the middle of Oahu) to give him to a family I'd gotten to know there who really wanted a cat. Three days after I left him there, the family called and said Tommy was missing for the last day and a half. A friend of mine and I went up there and spent 3 hours looking for Tommy and calling him, and just as we were ready to give up, I heard him, but I couldn't tell where his howling meow was coming from. Finally, I looked down and realized he was in the storm drain! After rescuing from his wild travails, I couldn't leave him there, so he came to Bend with me. The only thing that wasn't right about taking him back was that the family that wanted him had a little 5 yr old toehead who loved Tommy. So, we went to the pound and found a little 3 month old kitty that looked just like Tommy, and took him up to Kaeden, the little boy. Now, all is well in the feline world, and Tommy's happy being a mostly indoor cat (he doesn't like the cold weather).
I'm currently working on a series of educational talks geared both for women in the community and for physicians. I think there's a great need for better understanding of incontinence and prolapse in both groups, specifically regarding modern treatment options that don't require big huge surgeries. Most primary care docs don't bother asking their patients if they're incontinent because they don't want to deal with it if they are. The other reason is that with only 10 minutes to spend with each patient, they feel it's more important to deal with their high blood pressure and diabetes than with their incontinence, which is understandable to some extent. This is why I'm trying to educate the patients themselves so they can self refer to doctors who like treating these types of problems, and then tell their friends thereby spreading the word that they don't have to suffer in silence. We're going to the Central Oregon Womens Expo at the Redmond Fairgrounds the second weekend in November. Kate and Deena and I will be there to talk with women about incontinence, prolapse, and endometriosis, to try to spread the word that there are some great new procedures that work great with minimal surgery.
Which reminds me, I have to work on my handouts....
See you next week,
Cindy

Here we are again - it's hard to believe it's been a whole week since I last wrote. Two wonderful things happened in the past week - someone actually posted a comment so I know at least 1 person is reading this (thanks!), and more importantly, I did my first case here in Bend. Dr Redwine talked me through my first laparoscopic lymph node dissection. For those of you, probably most, who don't know what this is, it's a procedure only recently adopted by most oncologists for staging cancers of the uterus. You may be thinking, 'well what the heck does this have to do with endometriosis? I don't have cancer.....', and there is an answer to that question. The laparoscopic lymph node dissection is actually the perfect case to learn the deep retroperitoneal pelvic anatomy. This is the part of the pelvis where 99% of general gynecologist never go. It is also where we go quite frequently in the pursuit of invasive endometriosis, and in those cases the anatomy isn't always normal or easy to navigate through, so this was actually a great learning case. More importantly, Dr. Redwine was pleased and impressed with the way we operated together. Plus, I'm showing him a few new tricks that were invented in the 21st century....

The other fun thing I did in the past week was go to Seattle to watch a laparoscopic sacrocolpopexy. This is a procedure done laparoscopically in only a handful of locations around the country, but regardless of the approach (open or laparoscopic) it is the best way to resupport the top of the vagina after it falls down. I've been doing sacrocolpopexies open for many years, and now we will be doing them through the scope, which allows the patient to recover a lot faster than if she has a big incision, as the incision is the part that hurts the most and limits activity the most. A mesh is sutured to the upper vagina, then sutured to the sacrum (the bone at the base of the spine). This procedure gives stronger support and a longer vagina than do most vaginal approaches to apical descent. It also allows better sexual function after the repair, so for most women in their 50s and 60s, it is the ideal surgery for repairing that stubborn nasty prolapse. Sometimes I wake in my sleep and hear vaginas around the world calling "help I've fallen and I can't giddy up....."
But seriously, I'm really excited about how my 2 passions, endometriosis surgery and pelvic prolapse surgery are dovetailing. The joy of helping women return to their normal lives comes from both types of surgery, and the surgical challenges, understanding the anatomy, and doing everything with the most minimally invasive techniques are nothing new to me. Nonetheless, being here and getting to operate with Dr. Redwine is exciting and fulfilling and challenging all at once, and I love it.
Well, I'm off to the hospital for more fun and excitement.
See ya next week, and a hui ho.....

Well, today was a very exciting day, as I got my new toy - a brand new Urodynamics machine. We had 2 pts for the nurses to learn on, and for me to get used to the new machine. It was nice to find out that although this machine is 7 years newer than my old machine, it works very similarly, but better. We can now accurately test for all different types of incontinence, and even detect occult incontinence in women with more severe prolapse, which is a condition where they would leak if it were not for the severe kinking of the urethra which happens when the bladder is falling out. We can also check the strength of the urethra itself, which can indicate just exactly which type of sling should be done, or if a sling is even necessary. Sometimes, especially in the context of a failed prior procedure, a low urethral strength can indicate that a very simple procedure of injecting a bulking agent around the urethra can help resolve the incontinence with essentially no surgery or recovery! Sometimes, though, we find out that the prior procedure has failed, and we gain information from the urodynamics that helps guide the choice of the correct procedure for the patient. Basically, when it comes to incontinence and prolapse, one size does not fit all, so we need all the information we can get to design the right procedure for each individual. The urodynamics also test the emptying phase of the bladder, to ensure that after surgery the patient will still be able to empty her bladder. Believe me, being able to empty your bladder may be something most people never think about, but when you have to go and can't pee, it's MISERABLE!!!!!!
So, off I go to conquer the world of incontinence and put the Depends people out of business....