We talk with Dr. Julie Lamb about Endometriosis and Adenomyosis. Dr. Lamb is a board-certified reproductive endocrinologist practicing at Pacific Northwest Fertility in Seattle and Bellevue and serves as clinical faculty at the University of Washington.
In this episode, we cover:
Endometriosis
Adenomyosis
General
This podcast is produced by www.CreatingaFamily.org. We are a national non-profit with the mission to strengthen and inspire adoptive, foster & kinship parents and the professionals who support them. Creating a Family brings you the following trauma-informed, expert-based content:
Please leave us a rating or review RateThisPodcast.com/creatingafamily
Please leave us a rating or review RateThisPodcast.com/creatingafamily
We talk with Dr. Julie Lamb about Endometriosis and Adenomyosis. Dr. Lamb is a board-certified reproductive endocrinologist practicing at Pacific Northwest Fertility in Seattle and Bellevue and serves as clinical faculty at the University of Washington.
In this episode, we cover:
Endometriosis
Adenomyosis
General
This podcast is produced by www.CreatingaFamily.org. We are a national non-profit with the mission to strengthen and inspire adoptive, foster & kinship parents and the professionals who support them. Creating a Family brings you the following trauma-informed, expert-based content:
Please leave us a rating or review RateThisPodcast.com/creatingafamily
Please leave us a rating or review RateThisPodcast.com/creatingafamily
Please pardon the errors, this is an automatic transcription.
0:00
Welcome, everyone to Creating a Family talk about infertility. I'm Dawn Davenport. I am the host of this show as well as the director of the nonprofit creating a family.org. Today we're going to be talking about endometriosis and adenomyosis. We will be talking with Dr. Julie Lamb. She is a board certified reproductive endocrinologist practicing at Pacific Northwest Fertility in Seattle and Bellevue. She also serves as clinical faculty at the University of Washington. Welcome Dr. Lamb.
0:32
Thank you for having me. Dawn.
0:34
All right, we're gonna start we're going to be talking about both endometriosis and endometriosis. But we're going to start with endometriosis. Let's start at the very beginning not to be overly simplistic. But what is endometriosis?
0:47
Well, endometriosis is when the lining of the uterus grows outside of the uterus. So every month a woman grows the lining for an egg or an embryo to implant in and then sheds it, and that's normal. But when the lining grows in other places, say the ovary or inside the wall of the uterus, or just anywhere outside of the uterus, we call that endometriosis.
1:11
All right, so let's let's identify the symptoms before we get too much further. So what how would a would a woman obviously know she has endometriosis? Or does she have to or there have to be symptoms? And if there are symptoms, what are they?
1:26
So not everyone has symptoms of endometriosis? I think the most common presenting symptom is what we call dysmenorrhea or pain with our period. It's really you know, we all feel menstrual cycle cramps differently. And it's hard for women to gauge what's normal compared to another woman. But when they have severe pain with menstrual cycles, it's very common that that's a sign of endometriosis. The other way it often presents and where I often meet the patient is with infertility. And it's very common to present with difficulty conceiving when you have endometriosis.
2:03
Okay, we're going to talk about that further on. Okay, excellent. So what are the causes of endometriosis? I mean, why do some women have it? And some women don't? And how does the lining get outside of the uterus to begin with?
2:15
Yeah, so there's a lot of things we don't know about endometriosis, that the implants that implant other places, It's unknown if they just the cells generate there and grow or if the cells past maybe retrograde back through the tube and implant in the abdomen, or in the pelvis area. And then they grow. And every you know, every month that you grow your lining, these little implants grow, and every month you shed your lining those little implants shed, and that can cause pain, and it can cause infertility.
2:46
So the lining of the uterus, that the cells that have implanted outside the uterus behave with the hormones the same way that the cells inside the uterus behave.
2:57
Right? Exactly, they are a little bit different kinds of cells, if you look at them under the microscope, there's some good characteristics that are different, but they behave very similarly to the cells that grow inside the uterus that make the lining tick every month.
3:13
And they're they're responding to the same hormonal bath that they that the cells inside the uterus, right? So it is possible that they how so they could they could migrate through the fallopian tubes into the that makes? I don't know if it makes sense, but that I understand, how else could they get there.
3:31
There's a couple other hypotheses that are mainly surround like just cells that kind of turn into that endometrial kind of implant. So some kind of pluripotent or cell that can change and then grow in other places. The most common theory is that retrograde through the tube. But there's, you know, just like everything in medicine, there's a lot we don't understand, it's maybe an inflammatory autoimmune process. So there's a lot of things that affect that, that we don't know,
3:59
interesting. Do are people who have endometriosis. Do they often present with other autoimmune disorders as well?
4:08
Um, that's a good question. Statistically, I'm not sure that that's been researched. But anecdotally, in patients, it's not uncommon to have it be associated with other inflammatory type conditions or autoimmune conditions. Interesting. But, you know, women are the people that are affected by those things, too. So all of those are more common in the female population.
4:29
Right? Is there a genetic link to endometriosis? If your mother or grandmother or sister have it? Are you more likely to have it?
4:36
Certainly, that's the case. And actually I asked patients when I'm doing their initial intake when they're trying to conceive about a family history of endometriosis. So if they've had surgery, sometimes a patient will know if their mother had endometriosis, or even just a family history of painful periods.
4:56
Right that maybe all they know is that my mother also or mom Mother also struggled to conceive that so yes, right painful periods.
5:03
Right? I think we see that less because, you know, when our mothers were trying to conceive it was a generation ago and people were having their kids in their early 20s. And now that we're waiting till longer, I think endometriosis probably has longer to cause infertility and caught those painful periods for 15 extra years seeing an increase in fertility risk.
5:27
Well, yeah, and it also, it makes sense to think that if if you were conceiving it 21 When your fertility is particularly high, the impact of endometriosis, and making it subpar, you're just you're coming down for such a large high such a large and your bar is originally fairly high, as opposed to when you're 35. And your fertility is the bar the initial starting point is a little lower than Yeah, that makes perfectly good sense. Right, right. You know, a question that we often get is, if I have endometriosis, am I more prone or more at greater risk for cancers, cancer of the uterus cancer or the cervix, or other forms of cancer?
6:10
That's a good question. There are several forms of cancer that are associated with endometriosis and an increased risk but the risk is very small. Certainly we don't want women being an ambulatory and do like there's a lot of other things that increase the risk much more than endometriosis. The risk of cancer from endometriosis is very small, but there is some association with some types of cancer and endometriosis.
6:35
Would it be cancer of either the uterus or the cervix?
6:39
Um, it's not usually the cervix, it's usually an endometrioid. Like endometrial type of cell that's unregulated growing outside the pelvis.
6:48
Alright, growing in the pelvis outside the outside the uterus, right for some of the endometrial more of like an
6:53
ovarian cancer. Interesting. Okay,
6:56
so how do we diagnose endometriosis other than the symptom of pain, but certainly we can do more than just associate pain. And then is there a way to more definitively diagnose? Dimitri?
7:09
I think this Dawn is one of the most overwhelming things for my patients is that they want to know why they're not getting pregnant. And Dimitrios This is difficult to diagnose. It's actually a surgical diagnosis. So it's done by laparoscopic surgery where you biopsy some of the tissue that's thought to be endometriosis. And that's really the gold standard for diagnosis right now. I'm really hoping there's a lot of development going on looking for some kind of blood tests that could diagnose it, but we're just not there yet.
7:41
And is that an abdominal biopsy or a kind of intro vaginal? How is the how, what's the procedure? Usually, the
7:50
lesions are in the pelvis, so inside the abdomen, occasionally, someone will have a vaginal or a cervical lesion that you could see with a speculum vaginally, but that's more uncommon. So if a woman really would like a diagnosis, or if they're having severe pain will sometimes recommend that they have a laparoscopy to clarify the diagnosis and to treat that pain. So the biopsies done the kind of through the belly button, it's a surgery where they stick a scope through your belly button and look around
8:23
is a definitive diagnose diagnosis necessary before treatment for endometriosis. And that begs the next question, which is going to come up which is how do we treat it? But first of all, if you said you the way you said it was If a woman wants a diagnosis, so is a definitive diagnosis necessary?
8:41
Yes, that's a great question. And it's usually not that treatment is the same whether you have endometriosis or not, I often tell my patients so if a woman is young, and her tubes are open, even if we suspect endometriosis, we often try and attempt have simpler treatments like intrauterine insemination. IUI, if the tubes are open, we try to get them to work by some of the simple interventions. If the tubes are blocked, no matter what's blocking them, then we move to we start with IVF whether it's endometriosis, or a history of infection, the next step would be IVF. And same with treat early treatment failures. So if the inseminations aren't working and your tubes are open, then the concern is even though they're open, they might not be working, and then we move to those more invasive, more successful treatment options.
9:32
So that's treatment for the symptom of infertility. But what about treatment for endometriosis itself?
9:39
Oh, that's a good question. Yes, so endometriosis itself is treated by suppressing the menstrual cycle. So I often tell my fertility patients like the best way we can suppress your endometriosis is to get you pregnant. The hormones of pregnancy really suppress the endometriosis and then breastfeeding time does as well. But then most kids I'm in medical treatments that we give to patients to treat endometriosis also prevent pregnancy. Like putting you on the pill. Yeah, like being on the birth control pill suppresses endometriosis from growing it keeps that lining thin in the uterus and outside the uterus. There's other treatments for more severe and then we treat osis such as higher dose progesterone or Lupron which really suppresses ovulation and therefore suppresses endometriosis. But all of those keep a patient from conceiving. And so most of my patients aren't very interested in that option, right?
10:35
Yeah, that may have been what they had been doing before. But now they're coming off because they are have any of those treatments because they want to conceive? Exactly. So when should the lesions the endometrial lesions be removed surgically? Or should they ever?
10:55
That's a good question, and it's evolved over the years and different surgeons think differently. Different specialists think a little bit differently. The current guidelines are mainly surrounding treatment of pain, not treatment of infertility. So if a patient's has a lot of pain with our cycles, and they're trying to conceive will offer surgical management of endometriosis, which includes diagnosis, but also treatment of it. But as far as we know, are the big studies that look at that don't see an improvement in success rates from fertility treatment, through surgical treatment of endometriosis prior to treatment. So oftentimes, the fastest way to pregnancy is to pursue pregnancy over surgical management,
11:41
if that makes sense. What about is from the let's say the patient, and I realize these are not the patients coming to infertility clinics, but a patient who is wanting to deal with the pain, but as surgical excision of the endometriosis lesions, will that diminish pain,
12:01
it significantly improves pain scales, yes, oftentimes, they'll try medical management first with a birth control and then move to other more significant medical or management before they'll offer surgery. But some of these women present really late and have excruciating pain and surgical management is required to just like allow them to continue to try on their own. So we see that often. The other indication sometimes for surgical management is big sis of endometriosis on the ovaries, and we call that endometrioma us and that concern with that one, it's a later stage of endometriosis if we can see it by ultrasound growing on one of the ovaries, but it's also associated with increased pain increase for infertility and will often sometimes consider talk about taking those out depending on the size and depending on the pain scale and what their kind of fertility goals are an age weighs into that as well as ovarian reserve. Anytime you operate on the ovary the concern is that some of those follicles or some of those future eggs are removed as well. So we don't want to cause someone to have lower egg supply by treating the endometriosis when someone's thinking about conceiving
13:20
when they when you have endometrium is the endometrial tissue growing lesions growing on the ovaries. Does that have a greater impact on fertility? That than say if it was growing somewhere in the abdominal cavity or on the outside of the uterus?
13:41
We assume that it does, but certainly it's a higher stage. So once we see it on the ovary, it's a higher stage of fertility or of endometriosis. And so that's associated when we can't see it and we suspect it those early stages it's still unclear if that's associated with a higher chance of infertility. Eventually it is as it progresses. But there's plenty of women that don't know they have endometriosis that conceive naturally and don't have difficulty.
14:12
We here because there was Lena Dunham had a hysterectomy as a as just a treat. The symptoms of endometriosis are that's anyway how I am how how the press reported it. So afterwards, that was a number of years ago, but afterwards there was we got a lot of questions about people wondering if that now this is obviously not somebody who is considering pregnancy. But what is the current thinking on treating endometriosis through a hysterectomy?
14:43
That's a good question. That's a very personal decision. I think as medical management improves, it's really individualized between the patient and the surgeon. There's a lot that we can do medically either with an IUD that's progestin dominant or medical management through pills or Lupron and once those things are failing, it's not wrong after fertility, you know, after fertility is not desired to treat surgically more permanently, and that's often done still, but I think it's not quite as common as it used to be even 20 years ago.
15:21
Yeah, they would agree. And if you remove the uterus, they're still have these these endometrial cells that are outside and they because by definition, if you've had endometriosis, those endometrial cells are existing outside the uterus. So what happens in would they not continue to grow and spread or because if the uterus is removed, they may exist, but there's no more coming? How does that work?
15:47
Yeah, that's a great question. So the thing that makes the endometrial implants grow as the ovary the ovary makes hormone that can make those implants grow. So one, they could be treated at the time of surgery and surgically removed, which doesn't 100% Eliminate them but significantly reduces you're talking about the lesions, not the lesions. Yeah. And that significantly improves pain outcomes. Occasionally as a woman approaches perimenopause or menopause. The ovaries will also be removed with a hysterectomy with the removal of the uterus. And when the ovaries are removed, that implants lose that hormone stimulus that makes them grow and continue to cause pain.
16:29
Okay, but removing the ovaries is quite moving the uterus is a less impactful surgery for women pre menopause, right? Yeah. So
16:40
you go through that before menopause and some patients with severe endometriosis do need that and they'll choose to have their ovaries removed.
16:50
What is the current best method for removing the surgical method for removing the endometrial lesions used to be laser than your electrical pulse? Are there others? What is they are just good old fashioned scaffolding is
17:05
right. There's a lot of different modalities. Not only do they do it laparoscopically, which is through a scope through your belly button. But they also often do it robotically depending on the severity of the endometriosis and the surgical preference the surgeons preference, but yeah, there's a lot of different ways to ablate they burn off with lasers co2 laser that cauterize it really popular right now to do completely excisional surgery and that's had, we're waiting, I guess for more data on that. But patients that have that type of surgery where it's completely excised seem to do or at least my patients seem to do really well with pain after an excisional surgery.
17:47
How does excisional differ from the other surgeries? You're just mentioning? Yeah, so
17:51
instead of burning or cauterizing, the cells they're completely removed by taking out some of the inside of the pelvic wall as well. Okay,
18:01
gotcha. You're moving all similar to not that we're confusing this with cancer, but similar to where you're removing the tissue and the surrounding tissue that is causing the problem. Right. I want to talk to you about one of the partners of creating a family that helps this show exist. Cooper, surgical fertility and genomic solutions are global leaders in IVF and reproductive genetics, Cooper genomics offers PGT, a PTT M, peak TTSR And er peak, which is an endometrial receptivity testing for those pursuing IVF. Er pig tests offers accurate and reliable detection of the receptivity status of the woman's endometrium and helps to inform her physician of the most suitable time for embryo transfer to increase the likelihood of achieving a pregnancy. Thank you Cooper genomics. Alright, so the so if the if the endometrial lesions are on the volute fallopian tubes, do you have other than up what can you do then is there any way to preserve fertility when you're in that situation where you're trying to deal with them on the fallopian tubes themselves.
19:18
So the fallopian tubes have such a important role and fertility they have to kind of go over to the ovary pickup the egg and very carefully move it down all the way to the uterus and fertilization and Claire's in the tube and when the tube is open, but not mobile, it has a higher risk of ectopic pregnancy. So whether tube is open or not, doesn't necessarily tell us if you have endometriosis or not plenty of my patients that have pretty severe endometriosis have open tubes, but it's more difficult to tell if they're working when they're open.
19:55
And is that because the fallopian tube needs to be able to move near the ovary to be able to and I know this is not correct, but suck up the egg,
20:05
a little slippery, our fingers just kind of pick it up off the ovary. And if there's endometriosis on them, they have a harder time, you know, capturing that egg
20:16
and even moving over to get to the in the physician to get it,
20:19
right. Or maybe the you know, the tube is mobile, but the ovaries stuck to the back of the uterus with an endometrial. And so we see that as well, too. Especially ultrasound. So you know, I can kind of suspect someone has endometriosis. When I can't move, they're over a year. I can't move there too, but it's kind of stuck.
20:39
And how can you tell? Is that through vaginal exam or no?
20:42
Through the vaginal ultrasound? Oh,
20:45
gotcha. Okay,
20:45
all right, that are a bimanual exam. Okay. But that's certainly not diagnostic. It's still a surgical diagnosis, but it helps us to have a better, you know, if we have a suspicion, there's some things we sometimes do differently.
21:00
So now let's talk to just exclusively about how endometriosis affects fertility. How many? What percentage of and this is maybe an unfair question, but what percentage of patients with endometriosis also have infertility? Because as you mentioned, plenty of women with endometriosis are able to conceive naturally.
21:22
That's a good question. Don, I don't know if I can give you an exact number. I think you know, we diagnose it more in the infertile population. Sure. Yeah. And by the time I see a patient, that's 35, and they're having difficulty getting pregnant. So it's not necessarily age related and fertility. Almost half of those patients will have endometriosis when they look surgically and they know that from prior studies and a different era where they, you know, used to diagnose it laparoscopically. And every patient that was infertile, would get a surgery to better understand their infertility and try to treat it. That's no longer done. But that data is what comes from that. And you know, the people that don't necessarily know they have endometriosis are getting pregnant naturally and aren't
22:09
right. So you would never see them. Right. And the point you made that is so interesting is that we, if younger women may still have endometriosis, but they're able to conceive because their fertility is at such a high base. And then, yeah, so that's such an interesting thing. And so it's big, but because we're waiting so much later now that it's in a major osis can be interfering more,
22:37
right, it has more time, more months of growing on inhibited to kind of impact and caught, like the pathogenesis or like the growth of endometriosis. And its effects get worse with age, every menstrual cycle can, you know, cause it to progress? And so when you're having children at 35, or 40, it's a lot more difficult to conceive in the setting of endometriosis than if you're 21. Yeah, although anyone can have difficulty once they have endometriosis. But it's more common that increasing age
23:13
does struggle. So does the presence of endometriosis affect the success of infertility treatment? And so let's break that down into the sort of effect the success of IUI intrauterine insemination. Sorry about that?
23:28
Yeah, so I y is when we put the sperm inside the uterus, so it still requires the tube to pick up the egg and bring that a down to the uterus and to implant it doesn't bypass the tubes. So yes, there is probably a lower success rate or that's what we, you know, counsel patients is we know your tubes are open, but we don't know they're working. If a patient's had a prior successful pregnancy, that's good evidence that those tubes are working. But without that, you know, we try to make them work, but the success rates are likely are lower, certainly when they have a surgical diagnosis of endometriosis.
24:08
All right, now let's talk about how endometriosis affects the success of in vitro fertilization IVF.
24:15
So IVF allows us to bypass some of the problems that endometriosis causes, we can take the eggs directly out of the ovary, and we eliminate the need for that tube to pick up the egg and bring it to the uterus because we take it out of the ovary with a little needle so fertilizing it outside the body and putting it into the uterus, bypasses those common problem transport problems that endometriosis causes. It doesn't necessarily treat that kind of unfriendly or unfavorable environment that endometriosis causes. So whether it's endometriosis growing on the ovary and affecting the quality of the egg or endometriosis, is growing in the wall of the uterus, which we call ad, no meiosis, it doesn't treat those things. So usually most endometriosis patients get pregnant just like we would expect they would with IVF, we don't see a huge difference in success rate, maybe less than 10%. Some patients with really severe disease continue to struggle despite and treatment with IVF. Because of those kind of unfriendly poor egg quality or just kind of, we call it like cytokines like a more unfriendly environment for the egg or for the embryo in the uterus. And there's ways around that. But there are significant like treatment with medical menopause or treatment with high doses of Lupron prior to embryo transfer. So we prefer to not have to be as aggressive and just give patients the highest success rate from the beginning and save those kind of more aggressive treatments for patients that aren't successful with those first embryo transfer.
26:00
It makes sense to me when you're talking about endometrial lesions on the ovary that could affect either the amount of eggs that are produced through IVF, or the quality, I hadn't realized that they could impact the quality. That makes sense. But what are the other and we're going to talk about AdMob ad, no meiosis, and just a minute we're gonna have that will be our second section here. But so it makes sense that if the uterus itself was compromised, because of the amount of lesions that that would decrease, if not the success of the actual conception, but certainly being able to carry a baby, that would make sense. But what are some of the other things that you said a hostile or unfriendly? You were kind? Or he said, unfriendly? I would say hostile environment. What are the ways that the lesions other that the endometriosis lesions could reduce the success of even implantation or successful carrying the pregnancy?
27:01
Right? That's a good question. So that endometriosis can cause fluid to build up in the tube. So if a tube is blocked, it can cause like old menstrual fluid and just like fluid to be stuck in there instead of drain out so that if that's the case, and we can see it by ultrasound that can kind of backflow into the uterine cavity. And when we put an embryo and can cause like, just like a cytokine, or an inflammatory response that causes difficulty with implantation. And if that's the case, then we have the tube surgically removed, or the pathway from the tube disconnected from the uterus. The other ways it can cause problems is ad no meiosis or endometrial implants that are inside the wall of the uterus. They can be diffused, they can cause the uterus to be baggy and have difficulty carrying a pregnancy. It can potentially increase the risk of miscarriage because they can form almost like fibroid like structures that can cause difficulty with implantation or difficulty carrying the pregnancy. And all of those we see, it's just very difficult to if you can't see them by ultrasound, it's difficult.
28:14
Yeah. But there's nothing in specific that the lesions are what the inflammed this the general inflammatory response to these patients? I mean, we do have, I don't know that I'm not sure where the science is right now on there, but there is certainly and there's been research on the fact of just general inflammation throughout the body, and it's specific in the reproductive tract area can impact fertility and like can endometrial lining cause just that General? Inflammation?
28:42
Yeah, I don't think that certainly in the implants, they cause they can cause inflammation. And I tend to, you know, think about it, that if they're outside the uterus, or even if they're on the ovary, once we have healthy embryos, they shouldn't impact it, they're kind of far enough away in the periphery of the pelvis, that they shouldn't make a huge impact. We do often with frozen embryo transfers, treat with Lupron for a variety of reasons. But one of the reasons is for treatment of endometriosis and kind of that bad juju or the bad environment that it could create somewhere you know, I don't think necessarily that people with endometriosis have poor endometrial linings, they're usually just fine. It's just that it's growing outside. Right and the majority of patients we don't see problems with implantation. But that being said, there's definitely a subgroup that struggles and that's probably something that we have a hard time diagnosing or understanding that affects the lining in those
29:43
please follow or subscribe to creating a family dot orgs podcast wherever you listen to podcasts. We have almost 15 years of archived shows and once you subscribe, you can also scroll through our archives for even more topics related to endometriosis. As, as well as other fertility challenges women face. Alright, now let's talk more specifically about endometriosis. You've mentioned that it is endometrial lesions growing inside the wall and microcracking inside the wall of the uterus cracked on. Okay, is it in the muscle itself?
30:21
Yeah, it's in the muscle itself. So the wall of the uterus has three layers, the outer layer, which is kind of the skin layer called the serosa, the inner muscular layer, which should look really smooth and is the majority of the uterus and that's where the fibroids can grow. And then the lining of the uterus, which is the endometrium, but when those endometrial cells, the lining grow inside the muscle of the uterus, it also is a surgical diagnosis. But sometimes we can suspect it or be concerned about it by either physical exam, history of really painful periods, or heavy bleeding, or we can see clusters of cells by ultrasound that we think might be most consistent with that no meiosis.
31:06
How does endometriosis differ from fibroids?
31:09
So fibroids are a smooth muscle or a muscular ball of cells that's benign, not cancerous, but they're more similar to the cells of the myometrium. And the endometrioma. Us or the ad, no myomas or endometriosis inside the wall is more similar to the lining uterus
31:29
cells. Okay, and when you're looking from from an ultrasound standpoint, can you tell Can you make a distinction just by a by imaging in that way as to whether or not do they look different? Through imaging?
31:46
Yes, yes. And no, you can't make a diagnosis other than surgical. And certainly we're not going to take somebody's whole uterus out if we expect him to add no meiosis. But occasionally, you can see an adenoma versus a fibroid and suspect one or the other. The fibroids tend to be more encapsulated and have very clear borders. And ad No, meiosis tends to be less homogenous consistency, and just kind of more vacuolated. And, you know, harder to see borders.
32:19
Okay, so what are the symptoms of ethno meiosis as that might be different? Or would they be different from endometriosis?
32:30
They can be similar. They can be it can also be asymptomatic, or it can present with heavy periods, you know, when someone tells me that they have very painful, long, heavy periods, that's always in the back of my mind. And I'll take a look, you know, we always look by ultrasound. But even if we don't see anything by ultrasound, it doesn't rule adenomyosis out.
32:56
There are women who have endometriosis also very likely to have individual lesions in other places in their abdomen,
33:04
right. Yes, exactly. But I think the majority likely would have endometrial lesions and other places.
33:11
So in some ways, it's just another place for the lesions to be growing. Right. Gotcha. Okay. And so I guess the answer would be if there's Is there a genetic link to it? The answer is yes. Because there was a strong genetic link to endometriosis.
33:26
Yes, exactly. Yeah, yes. I think there's less known because it's such a big surgery to take out someone's uterus versus just wait the implants. So we know less about how it runs in families. But yes, it's certainly genetic sisters tend to have it you know, endometriosis, or add no meiosis, Mother family history of painful periods, long periods, abnormal uterine bleeding, all of that can be related to add no meiosis.
33:55
So the symptoms are how is it? How is at no meiosis diagnose? Will? You've mentioned longer periods is that differ from enter in when the lesions are growing out in other places and not in the in the uterine wall? Do you see extra long periods? Certainly, we know you see extra painful periods, but as extra is additional length, also a sign of endometriosis, regardless of where it's present.
34:23
I don't think cycle length is a sign of endometriosis. Just that painful period. And the painful period can also be a sign of ad no meiosis.
34:32
So but with AD no meiosis, then the length of the period of longer periods is a sign.
34:37
Yes, it can be a clue. Okay, cool.
34:40
Good point.
34:42
The way I think about it, or the way I talked to patients about it is if the uterus is bigger and bulkier, you have like more surface area to grow that endometrium and it's just harder for a kid to contract and to slow down the bleeding. So when it's bulky like that, you see heavier periods more painful. periods and longer periods.
35:02
Okay. So and then you also mentioned that you can through imaging, sonograms and others you can get, if not a definitive diagnosis, at least a good idea whether an ethno meiosis exists, is that correct? Yes. Okay. So that's another way. Although I guess it isn't a definitive diagnosis there either. If you have to wait a biopsy be what is required.
35:27
I haven't seen biopsies done. Occasionally we'll take out something that's interfering with it endometrial cavity, like where your baby's gonna grow, and it will come back at no meiosis. Or if somebody takes out a uterus, the pathology will come back at no meiosis, but in general, the treatments the same, and we know kind of how to treat it. And we don't need a definitive diagnosis, even though you know, it'd be nice to have one. I think patients desire to know why they're having painful periods or not conceiving, but a biopsy of the uterine wall. Sounds a little bit invasive and complicated, and it doesn't usually get performed. All right, you endometrial biopsy, so of the lining, but that wouldn't give you a diagnosis of adenoma is
36:17
right, because this doesn't exist there. Right. So the does the presence of endometriosis affect the success of infertility treatment? We've spoken about to level a start with IUI, but it impact the success of intrauterine insemination.
36:37
So I think that because they run so closely together, it's unlikely to have AD no meiosis without also having endometriosis. And we think of ad No, meiosis is a pretty significant case of endometriosis. So probably by the time it's causing infertility or tool disease, or it could also impacts intrauterine inseminations because it doesn't really bypass those tubes to put the sperm inside the uterus. Is it impossible to get pregnant without no meiosis? No, it probably happens all the time. And we just patients don't know they have it. And when you're pregnant, you get nificant suppression of the cells and sometimes the return the fertility you know, I always wonder if these patients with endometriosis, they're pregnant and breastfeeding for almost two years. By the end of it, they might just get put in might suppress the endometriosis long enough that they could get pregnant naturally. So there's a lot we don't know about how it affects current fertility and future fertility.
37:42
You know, we certainly know that fibroids are more common in black women. And I realize fibroids are totally different from endometriosis. But in general, do you see a distinction by race or ethnicity in the presence of endometriosis? Whether it's endometriosis or endometriosis?
38:02
I see it affecting all women. So certainly there might be ethnicity differences, but nothing that I'm super aware of or concerned about. It affects Caucasian women. It affects black women, it affects Asian women, Southeast Asian women. Everyone can be affected by endometriosis.
38:20
Just the nature of being female. The common denominator there unfortunately, right.
38:27
Very unfair. It's another gender inequity that we have this in the music business issue.
38:33
Yeah, well, that's because we have a we have a we have a uterus I guess that is the that's the ultimate there. I also want to tell you about another partner of creating a family and that is Reproductive Medicine Associates in New York. They have been a longtime supporter of this show as well as creating a family in general. They are a full service Fertility Center specializing in in vitro fertilization, egg donation, egg and embryo freezing LGBTQ plus family building, reproductive surgeries and male reproductive medicine. They have a highly individualized patient care through 13 reproductive endocrinologist and fertility specialists as well as a urologist and a full support team. You've talked about Lupron as being used as a treatment. It Lupron is confusing drug in some ways. For me anyway, can you explain Lupron and how it how does it work in our bodies.
39:35
So Lupron works at the level of your pituitary in your brain and it changes the ability of the pituitary to make factors that stimulate the ovary. So essentially, when you use a long acting Lupron, it shuts down the ovarian function. So when you're not making estrogen and progesterone, you're not feeding those endometrial cells that are growing outside the lining, and it causes is kind of a surgical menopause it's or a medical menopause. So you're not removing the ovaries, you're just quoting their function.
40:07
And how long does the treatment if you are going to if you if the birth control pill does not work, and so you're moving to something higher, which I assume you would start with the pill. And if that doesn't work, then you're going to try other things which would include Lupron, if that's the case, how long was that treatment last? And what are some of the side effects.
40:27
So the side effects are the similar to anytime you remove estrogen, you can get hot flashes and moodiness and difficulty sleeping. And there's a lot of things that it can impact. And it can even cause severe depression. So it's nobody's favorite. No one feels better. Other than that, pain sometimes goes away. So it can have really big impacts on the pain. Occasionally, if somebody's having very severe menopausal symptoms, we'll do what we call add back therapy, but give them a little bit of progesterone or a little bit of hormone back to keep those symptoms at bay.
41:06
All right, and then assuming and not always, as is the case, but assuming that they want to get pregnant, then how long you would take the Lupron. But at some point, you have to be off of it for a long enough period to reestablish a normal cycle, I would assume so it and yet that is in delaying your attempts to get pregnant. So there, you've got to weigh that as well. So how long do you need to be off the Lupron?
41:32
Everyone's different and it depends what the treatment plan is. So if somebody's doing a transfer, so putting an embryo back in the uterus, and they have severe endometriosis, sometimes we'll treat with Lupron to suppress that endometriosis. I never really aggressive way before we put the embryo back, but I'm not counting on that ovaries function returning immediately. I am giving estrogen to make that lining thick. And so we're not you know, stimulating the ovary in any way. When you quiet the ovary with lupine. Sometimes it does have a delay in return a function. And so sometimes we see challenges like stimulating the ovary or ovulating after Lupron. And everyone's different depending on their egg supply, depending on their sensitivity to the hormone how quickly they regain ovulation after Lupron that makes
42:27
it so you're in a kind of a bind, because it's assuming you have a woman who's in her mid 30s. It figuring out her competing interest. One would be that she would wants to get pregnant, assuming she's coming to you that she wants to get pregnant. But she also wants to be relieved of the pain and wants to be to treat some of the other symptoms of the endometriosis. Does it make sense to and you may have said this, to go through an egg retrieval cycle before trying to act and then treat the endometriosis in the interim, would that be something you could do?
43:03
Yes, yeah, we often will do that and wait until we have good healthy embryos and we're done stimulating the ovary and then quiet the endometriosis down. And sometimes we do this just with a small amount of Lupron which is like a luteal Lupron type of frozen embryo transfer where they just get it for a few weeks, like a micro dose. And that's generally what most people benefit from in a frozen embryo transfer. But a few of my patients with very severe endometriosis benefit from that longer, more aggressive treatment where we completely shut down the ovary for a couple of months.
43:43
But that's incompatible with pregnancy, you could not then do the transfer, you couldn't.
43:48
Well, we do the transfer, we just replace the hormone. So we give you estrogen to grow the lining, and then we give you progesterone. And so we're doing that anyway in these embryo transfers. So we don't require the embryos to or the ovary to function again. So a patient who's wanting to try it on our own or is doing IUI wise, we usually don't start with Lupron because of the effects on fertility.
44:13
And from what you're saying those effects, it's possible that those effects could be long lasting,
44:20
is they're not long lasting, but sometimes longer than we anticipate. A patient has very low egg supply, they can make your ovaries kind of sleepy, or it could result in getting fewer eggs from an IVF stimulation cycle immediately after, but for the most part, you know, it function returns that within you know, a couple months a month to a couple months.
44:43
Okay? And can endometriosis or endometriosis? Which sounds like it says subversion of invented matrices. Can it be treated through diet or lifestyle changes? Is that effective?
44:58
That's a great question. That's something that we need more research on. You know, we don't spend a lot of time or money in the US looking at how nutrition and how our environment affects our fertility and affects the states. And I think we're seeing more curiosity, some of it patient driven, which is great. I have anecdotally seen success and patients pain scales, not necessarily fertility ability to conceive, but by adopting kind of an anti inflammatory diet, so avoiding things that are associated with inflammation. And that seems to help with pain in some patients. But there's a lot we don't know. Like is are there chemicals in our environment that are affecting estrogens that are increasing risk of industry? osis is BPA in our water bottles, like affecting people? Is it causing it? We don't think so. But it certainly isn't helping it. So just looking for kind of environmental toxins that you can remove and eating a clean diet of unprocessed foods and lots of fruits and vegetables is kind of what we recommend. But there might be more to it that still needs to be investigated.
46:12
Yeah, it's frustrating that there's less investigation. I guess if it was a direct correlation, we might see it but it is frustrating. Is the incident of endometriosis increasing? Or is it been remaining the same?
46:29
We don't know. It's hypothesize that maybe increasing some of its we're diagnosing it more because it's causing infertility more commonly because women are waiting an extra decade in one generation, we went from having babies in our 20s to having babies in our late 30s. And so we're seeing it affect fertility more commonly, and therefore get more commonly diagnosed. You know, when a woman has a painful period for many years, they told them that's normal, I still see physicians tell patients that that's normal. And it's not normal and used to be worked up that needs to be treated. And because of that mentality, we're listening to women finally and talking to them about their periods, we're diagnosing it more. So it's hard to tell, is there something in environment that's also increasing at the same time?
47:21
Perhaps, if women with a higher BMI? Are they more likely to present with endometriosis than women who have a BMI within the normal range?
47:31
So the fat cells in our body do make some estrogen so anytime you have extra estrogen, whether it's from hormone treatment of high estrogen or if your body mass is making extra estrogen, all of those things increase the risk of endometriosis. Okay, so it is more appropriate. Yeah, I think it is more common within increasing BMI or body weight. And since
47:57
the BMI of the average BMI in the in the US has increased, we are certainly Yeah, that we would certainly be seeing more of that. Okay. All right. Well, thank you so much, Dr. Julie lamb for talking with us today about endometriosis and adenomyosis. That's been it's been very enlightening. Thank you. I really appreciate
Transcribed by https://otter.ai