Dr. Kaldas – Live Video 3


Hello. I’m Dr. Rami Kaldas of the Kaldas
Center. Welcome to our latest Facebook Live Q&A. As many of you know, March is
Endometriosis Awareness Month, so considering that, we will be discussing
endometriosis. Dndometriosis diagnosis and treatment are very important to us
here at the Kaldas Center and to our patients. If you have questions, please
comment on our Facebook live feed below. We will do our best to get all of the
questions answered. Before we begin, we need to remind you that we host these
Q&A sessions for informational purposes only. Be certain to consult your doctor
about all medical decisions that you may be considering. If you’d like to reach
out to us at the Kaldas Center, please call us at 920-886-2299 or online at KaldasCenter.com anytime So let’s get started. The
first question is submitted by Kristen and she asks: Is there any way to tell
the difference between endometriosis and bad period pain? That’s a fantastic
question, Kristen. Well, bad period pain is frequently a
symptom of endometriosis, but you’re right, there are multiple reasons
multiple causes of bad period pain. Probably endometriosis is one of the
ones that’s very high up on the list. Probably, in fact, the most common for
like killer periods. Killer periods are not normal. But some other things that
cause bad period pain, perhaps you know a stenotic cervix and it’s really hard to
get the menstrual flow out or perhaps you have a uterine malformation where
you’re bleeding into your body rather than having it come out or it
could be that you’re having perhaps to some kind of infection and
that can give you really nasty period pain. However, the bad period
pain caused by those things may not cause the symptoms of endometriosis or
it may but usually not. For example, endometriosis frequently is
accompanied by pain with intercourse and that is not necessarily the case for
people who are just having bad period pain from another reason. It could be
that with the endometriosis you have diarrhea during your period that may not
be the case if you’re having back pain caused by something else like an
exuberant production of prostaglandins causing unusual spasm of the uterine
muscle. So there is a way but I think it would be really hard for an individual
to tell the difference between the two but with a good clinical examination and
a good history, an endometriosis specialist most certainly can give you a pretty
good idea if it’s endometriosis or it’s something else.
Thank you, Kristen. “Can endometriosis grow after menopause?” is the next question
submitted by Lisa. Also, can all the chemicals in our food and plastics be
causing endometriosis? This is a cluded-in crowd and so, yes, endometriosis can grow
after menopause, especially if you’re on a hormone replacement therapy. So if
you’ve never had excisional therapy, it’s not going to grow probably unless you
have a very high fat content in your body and then you may have a relatively
high-circulating estrogen that continues to stimulate endometriotic implants but
it’s unusual. That said, you can have endometriosis implants that have caused
a lot of scarring and they have nerve fibers in them and even when the
endometriosis grows dormant, the pain doesn’t go away. It’s still
there because you have all kinds of nerve scarred into this old endometriosis
that has caused if your organs to stick together and so it can be a bad
situation still after menopause, but usually it doesn’t get worse but
it may not get a whole lot better. This is the challenge when you have
someone who has bad endometriosis and then they go through a surgery and they
have a hysterectomy and remove the ovaries and they make the person
menopausal, but they don’t get rid of the endometriosis. Well, you know what, the person may have a lot of pain still because it wasn’t
dealt with. It wasn’t excised, the adhesions were not taken care of and, on
top of that, the person may be miserable after surgical menopause,
because of menopausal symptoms, hot flashes, thinning
hair and moodiness and they want hormone replacement and they
can’t have it because it will stimulate the endometriosis that was left behind.
So excisional therapy is important. Part two of the question, Lisa, is really
interesting because you bet. The chemicals in our food and the plastics,
there’s a lot of estrogen analogs in those plastics,
lining of the plastic bottles that we drink out of, when we put
Tupperware into the microwave and that is causing those
estrogen analogs to come off of the plastic into our food and that results
in worsening of endometriosis. It’s toxic. It’s the one of the reasons we have such an epidemic
of breast cancer these days, because breast cancer so frequently is estrogen
dependent, too. Well so is endometriosis. So thanks for that question Lisa. It’s an
excellent question. What is endometriosis exactly? Well we
need to cover that for sure because I’m thinking that everyone knows
what this is but we need to explain and so endometriosis, in fact, is a systemic
syndrome. We think it’s an auto immune dysfunction and what happens is that,
even though a 100% of women have menstruation backwards through the
fallopian tubes, only about 10 to 15% does the immune system
not clear it out. Then it takes up residence in outside the uterus and it
causes all kinds of inflammation and scarring and it causes all kind of grief
in the forms of killer periods, severe pain with intercourse, and
diarrhea with with your periods and it can cause you all kinds of bowel
symptoms, or it may not cause any of those. It may just cause you not to be
able to get pregnant, because pregnancy abilities is 50%
reduced when you have endometriosis. So the next question is I had never heard
of endometriosis before last year. Is it a new disease? Why is it being diagnosed
more? Great question, Lisa. No it’s been around since time immemorial, but we
already talked about the estrogen analogs on the inside of our plastic
bottles and Tupperware and all that and, in fact, in Europe they are not allowed
to line the plastic bottles with that stuff. I don’t think we’ve made progress
on legislation here. However the reason you’re hearing about it more is because
the endometriosis association, the International Endometriosis Association,
which is headquartered in Milwaukee, is doing such a great job of letting people
know about this disease. A lot of times endometriosis is like a cancer that
doesn’t spread and it just really starts growing on things inside the pelvis,
inside the abdomen and beyond, but but it doesn’t spread like a cancer and
but it can it can be very much like that and the kind of pain it can cause and
the symptoms it can cause and the surgical challenge that it presents
and that’s why so few people know how to get rid of it. So the next question comes
from Billy Joe. Can it grow in other organs such as the gall bladder, stomach
pancreas or liver? Oh you bet, Billy Joe. It sure can. In fact, I’ve had just
amazing patients throughout the 26 years of doing this and discovering endometriosis in the thorax, next to the heart and the lungs. I’ve discovered it in the nose
and the person would have bloody noses every time they had a period. That was just one.
It’s been found in the brain. It’s been found on every organ in the abdominal
cavity and it seems to be particularly drawn to where the blood supply is and
so it’s on the diaphragm frequently, it’s on the appendix and definitely on the
bowel and then once it’s gone to those areas of increased blood supply and
because that’s the most hospitable place for it because it’s
like a parasite situation. It’s not supposed to be out in the middle of your
belly, but rather that tissue is only supposed to be in the uterus. Then more
blood vessels grow to it and you get a very angry situation inside causing all
kinds of unpleasantness for you, presenting in different ways, Billy Joe.
So yeah, it can grow on many different organs. What happens if it’s growing
elsewhere? How do we discover it? Oh geez, the only way to really
diagnose endometriosis is by surgery, laparoscopic surgery is preferable and
you look everywhere for it. That’s what you’re supposed to do. You’re supposed to
look everywhere for it and then if it’s there, then you can you can treat it, you
can excise it which is really the only effective treatment. You can use
medications like Lupron therapy or progesterone therapies and so on or the
contraceptive pill, but these will only suppress endometriosis cysts. They do not
cure it, mind you, even after taking it out, there’s about a 50% lifetime
recurrence rate on the endometriosis so it can cause you a lot of grief.
However, 50% of time it doesn’t ever come back and in the meantime, after you take
it out, it’s a lot easier to get pregnant with about 80% of people after treatment
of endometriosis who have not been able to get pregnant for at least a year
becoming pregnant 80% of time over the
following year once it is properly excised. So remember if you’d like to
reach out to the, Kaldas Center, you can contact us online at KaldasCenter.com or by calling 920-886-2299 and we can answer your questions in
in person. The next question comes from Danielle: Does endometriosis cause
infertility? Most certainly it does. So we’ve already talked about reducing
fertility by about 50% and you might say, but wait, it’s not blocking my tubes. Well
it’s still causing a lot of inflammatory process inside the cavity that abdomen
and pelvis and therefore when you think about it, you have those big immune cells
that going to town in there then because of all this inflammation
caused by endometriosis and the egg and the sperm, which are each single cells,
have a harder time getting together because the immune system is like
gobbling in them up and so it’s a difficult situation for getting pregnant
when you have endometriosis and I would say that that is the presentation for
half the patients with endometriosis who come to the Kaldas Center. They’ve been
trying to get pregnant for over a year, over three years, over ten years and
they have not been diagnosed and they have not been treated. They may have seen
four or five docs in those ten years. But then it just takes knowing what you’re
looking for on history and clinical exam to give and get a good idea that this is
what’s going on and then you can treat it and normalize fertility rates
essentially. My sister has surgery for endometriosis.
I have endo as well. Do I have to have surgery to remove it? Great question,
Megan. You don’t necessarily have to have surgery to remove it. If you are
asymptomatic. You’re not having bad bowel symptoms of diarrhea.
You’re not having bad bowel cramps. You’re not having that
being with intercourse. You’re not having killer periods. You just take a
ibuprofen or two to get through it just fine. You’re not having
very heavy periods that can be endometriosis of the wall of the uterus.
Then you don’t have to take care of it. That said, if you don’t do
something to stop its progression, like being on a continuous contraceptive pill
or the progesterone IUD that will prevent you from having periods most of
the time, then it can progress to the point where it does become symptomatic
and then you’ll need something done about it. On other hand, people want
to know. Do I have it or don’t I? And I want to preserve my fertility. Then I
would say, if we think you have it, it’s a good idea to to do surgical
therapy in a lot of cases because we don’t want those tubes damaged, we don’t
want that lining of the pelvis all scarred up from this endometriosis
that may make it harder, well we know it makes it harder, to become pregnant later
on. I would say it depends on the situation and it depends on your short
and long term goals whether it would be a good idea to remove it or not, Megan.
As you know, it’s about a 7 to 10 fold increased risk of having
endometriosis if your first degree relative, your mom or your sister has it.
So right then there you’ve got a pretty good chance of having it before ever
seeing any doctors at all, Megan. The next question submitted: I have endometriosis. I had surgery and had my ovary and tube removed.
Also had removed some bowel because it was stuck together. I had my first
surgery in 2003. My periods are back an very heavy and lots of pain. What’s my
next option to resolve this? This is a challenging story and it’s
something that we see over and over and over. So it depends on if you want to
become pregnant or not. You obviously have the other tube and ovary and
I wish, if you were quite young, they hadn’t taken out your tube and ovary,
but what happens is, it’s difficult surgery to have the system
endometriosis removed from an ovary and then frequently a doctor will be
afraid that it’s cancer, when it’s just an endometrioma with only about one in
250 risk of cancer, and then they take out the whole kit and caboodle. So if you’re done
having children and you’re having horrible pain, you may consider
excisional therapy of the endometriosis, as well as a hysterectomy to try to
prevent it most effectively from coming back. That does not mean you have to have
the other ovary removed and be in menopause. Obviously, if you want
to become pregnant again, then it can be excised the endometriosis and,
whatever endometrioma you have in the remaining ovary, so you can still get
pregnant either the natural way or through assisted reproductive
technologies, like injectable medications or oral medications with
inseminations or even in vitro, but you will still be able to get pregnant somehow
most that time and so the other option is, if it’s largely central pelvic pain,
you can have the nerve plexus going to the central pelvis
removed and that has been shown by several studies to improve pain by 75%
with your periods. However, it may start coming back
after about a year. So it’s mostly to buy time for someone who wants to keep their
uterus and that is totally reasonable to do. By a qualified surgeon.
That’s not something you want to do well I should say a caveat.
There are less than a 100 surgeons that are recommended
across the whole country to treat endometriosis effectively with
excisional therapy, according to the Endometriosis Association and be
careful, because you’ll end up with unnecessary organ removal and
inadequate, as you know, surgical treatment even if you have a
hysterectomy, unless you vet your doctors really well. The next question
is my from Rachel. I am battled terrible period pain for most of my adult life.
I’ve never been diagnosed with endometriosis. Besides the pain, what
symptoms should I be aware of? T auto immune dysfunction, Rachel. So
you have 7 fold increased risk of having thyroid dysfunction, like low
thyroid. You have 5 fold increased risk of rheumatoid arthritis and so if your
thyroid is off or you’re having chronic fatigue or you’re having your diarrhea
frequently with your periods or before your period or after your period, or
you’re having pain with intercourse or you’re having just bad
upset stomach frequently, then I would say that endometriosis must be in the
differential diagnosis. It is not unusual, let’s say you go to a doctor
and they say, I had a patient just brand-new patient, one of my new patients,
they came in and said doctor I was to see another doctor.
No offense, most of your doctors are very well-intentioned but they just
haven’t committed themselves to understanding this disease. So this gal
said I have horrible period pain. I went off the pill a year and a half ago. My
one child is five years old and we haven’t gotten pregnant, but most
importantly, I just want to feel better because I’m on the bathroom floor for
two days having my period. I can’t leave the house and the doctor said that’s
normal because you’re in your late 30s now and that’s normal for the late 30s.
Then wrote a prescription for double dose ibuprofen. No! She had endometriosis
it was obvious on examination. If you just know how to
examine the person, then you can tell 90% at a time if they have it or not with
pretty high degree of certainty and then avoid unnecessary surgical interventions.
But you do have people you can’t feel it on it’s too high to feel up in the
pelvis or in the abdomen and then you wouldn’t be able to feel it, but on the
basis of symptoms and nothing else working to relieve the pain, it’s
appropriate to figure it out and then excise the endometriosis. Thank you,
Rachel. Remember if you want to reach us, you can reach us at KaldasCenter.com
or calling 920-886-2299 and we will be able to tell you quite honestly
whether we can talk with you on the phone, whether you need to be
visiting with us or not, but we hear so many painful stories and tragic stories
of hopelessness that arise on the endometriosis front and on the pain
front associated with this unfortunate disease and fertility front associated
with this that, if in doubt, please call us. We’ll let you know if we
you need to be coming in or not. We’re straight shooters here and so
we don’t like it if you wait 10 years instead of you know just
coming in sooner rather than later. That’s 10 years of life that could have
been a happier situation for you. Ashley writes, is there a time frame
following laparoscopic surgery in which success rates are highest for conceiving?
After the first year of excisional therapy for endometriosis, 80% chance
and one year that you’ll be pregnant. Don’t be disappointed if it doesn’t
happen the first month. Don’t be disappointed if it doesn’t happen the
second month. Obviously you need to know the other factors. Is there a male factor? Are you sure the tubes are open or how are we doing with egg
quality? What is the anti-mullerian hormone level? In general,
if it’s only endometriosis, all other things being normal, 80% pregnant
within one year. Of the other 20%, half of them will be pregnant by the end of the
second year after surgical therapy. So you’ve got a 90% success rate
within two years. More can be done than just that if you don’t want to
wait two years to find out if you’re gonna get pregnant after treatment for
endometriosis, Ashley. Are all the doctors at your clinic specialists for
endometriosis? They are, Tanner, and so obviously, I’m an old
man now and and so I’ve been doing this for 22 years since my residency and then
in residency I was for four years treating endometriosis with really
pioneers in the treatment of endometriosis out of Stanford and so
that is obviously variable. Every doctor comes
with their own experience and their own history. However at the Kaldas
Center, once someone joins us, we really make an effort to get them up to speed
so we are sure and we have no pride here so if one of us need things they have a
really dreadful case, then they say to the you know more senior associate, hey
it would be a good idea to join me on this case because we need to take care
of the patient for maximal benefit. So there’s no fear that you will
get you know inadequate excisional therapy because it’s all about
the team effort to make the right choices and for the patient and have the
most effective treatment. But your question does bring up a good point
because I brought up earlier today already that there are a fewer than
100 doctors that are recommended to treat this disease across the entire
nation. Well, this is a thing, when we all go through residency, we have
different experiences. I figured you know there are thousands of doctors in
the state of Wisconsin who are OBGYNs who are very competent and proficient
and they do excellent deliveries and that’s all wonderful and good but you’ve
got just a couple in the entire state who are recommended to deal with
this disease. Even though we all get the same residency by name, the experience in
that residency and what we did after that is very different, Tanner, and that’s
why it’s important to find a proper endometriosis
treatment center who has a full grasp of the disease and also very importantly
who’s interested in in taking care of the disease because a
lot of people, just don’t know how and they don’t want to because it is
difficult and it is challenging and perhaps sometimes is easier to just you
know delivered a baby, it’s a beautiful miracle, but it’s a lot easier sometimes
than doing this kind of surgery. The next question is from Taylor, she asked:
Can endometriosis be seen on a history hysterosalpingogram? No, not really
Taylor. The only thing that can be seen on
hysterosalpingogram is sometimes you’ll get easy entrapization, meaning
the dye goes into the muscle of the uterus. That implies that there are
little microscopic tracks from the lining of the the cavity of the uterus
into the muscle and that implies that the person has something called
adenomyosis, which is a fancy word for simply saying endometriosis of the
muscle of the uterus, and boy, that’s an unpleasant thing to have because you
when you have your period you bleed into the muscle of the uterus and then in
your uterus is like one angry big bruise of a muscle and it’s angry and it’s
cramping and it’s not gonna let you ignore it and then you end up with that
old blood that collects in the muscle of the uterus then coming out as this brown
mucoid sometimes malodorous stuff before or after your period. So that’s
adenomyosis and that one you can see on HSG sometimes, but you have a hard
time finding that endometriosis on ultrasound. The only two kinds of
endometriosis that can be seen on ultrasound though are adenomyosis
with high resolution, and you have a great sonographer and a doc who knows
what they’re looking at. Most of the outside ultrasounds I review, when I get
the pictures, I don’t trust reports anymore. I’ve been burned too many times
and they they call it normal when it’s anything but normal and it’s all proven
born out if I end up taking the patient for surgery and
addressing the situation or on uterine specimen. Very high detection rate if you
just if you know what you’re looking for. And obviously endometritis cysts in the
ovaries can be seen and most of the time you can tell exactly what they are with
a high degree of certainty. Not 100%, but a high degree of certainty, by looking at
the ultrasound, knowing what you’re looking at, it just takes someone who
knows how to recognize the pattern, someone who deals with this disease all
the time. So thank you. How much higher are the chances of it
coming back after ablation than excision? Stephanie, my gosh Stephanie, ablation,
unless it’s like a really tiny lesion, doesn’t do any good. Ablation is like the
tip of the iceberg and so what happens is doctors are frequently scared to
actually cut it out because we’re going to grow worried, they’re gonna injure
your bowel, they’re gonna injure your ureter, injure your bladder, you know, but the
thing is, if you have endometriosis growing through the bowel and you have
symptoms, then you know what, maybe a wedge resection of the bowel is
appropriate and you should have someone who knows how to do that and that will get rid of your
symptoms. Nothing else will or someone who’s gifted in laser laparoscopy who
can shave it off if it’s just on the surface. I would say that ablation
simply is not very good treatment and that’s why the Lupron
representatives when they they come and ask you how do you treat
endometriosis, they want the doctor to say, Well I blade and I burn, they say,
Well you know what the studies show. Lupron will increase benefit after
you take that for six months after surgery. They don’t want to hear, well I
take it out because then Lupron doesn’t have any benefit because you don’t need
it. You removed it and so it’s not even
an issue of when it comes back, it’s just that was never removed. So what
are the best treatment options after surgery for endometriosis? Brenda, let me
tell you what they are. It depends on what you want to do. If you want to
become pregnant, then you’ve treated, you try to have someone become
pregnant on their own knowing exactly when ovulation happens on the basis of
their cycle links and you let them know when they should be having intercourse.
and or doing fertility cycles controlled ovarian stimulation with you know with
inseminations or not, or if you don’t want to
become pregnant, then the best treatment option is to simply prevent periods. That
will prevent it from coming back. It will really slow the progression and the way
you prevent periods are either hormonal therapy, the continuous pill, continuous
progesterone therapy, either orally or with a patch or with Morena IUD. You get a lot
of spotting if you do that although and that might not go away
about 31% of time even after nine months, or you can be pregnant to prevent
periods or you be breastfeeding to prevent periods and so you
can do any of that if you’re not necessarily trying to get pregnant.
Can you talk about the importance of pelvic floor physical therapy? And that’s
Natasha asking the question. Yes Natasha that is important because what
happens is once you have all this inflammation going on in the pelvis and
all that pain associated with intercourse or anything going in the
vagina and all that pain with bowel movements when you have endometriosis,
your pelvic muscles think they’re just no good down there and you have about 30
pelvic muscles and they go into spasm. Just because you have a qualified
surgeon. Let’s say you find a great surgeon, they know how to take it out,
they take it out they show your path report there’s 10, 20, 30 excisional
legions. Endometriosis is gone, but you know
what, your body doesn’t work that way, it needs to be retrained because it’s still
thinking, oh my gosh I have pain, I have pain, I’m gonna cramp up. So with
pelvic floor physical therapy you can retrain those muscles that they’re not
going to be assaulted anymore because the endometriosis is
gone and they can and you can make slow and steady progress with pelvic floor
physical therapy to to get those muscles to relax and resolve that last bit of
pain. It’s not going to be a quick process. It’s not going to be an easy
process. However it usually will succeed with commitment
and with just a slow incremental process. Two steps forward, one step back to retrain
those muscles with biofeedback and such Oh my gosh.
We are overtime. I can’t believe how quickly that went. One more
question. Ashley asks: Is it more common with having multiple caesareans?
Awesome question, Ashley! Endometriosis, per se, outside the uterus
outside uterus, is not more common but boy is it more common in the wall of the
uterus. Almost uniformly I see lots of
adenomyosis and endometriosis the muscle of the
uterus above the cesarean section scar and sometimes it just grows and grows
grows in the front of the uterus there that the entire front wall of the uterus
is 2 or 3 times as thick as the back wall of the uterus, when they should be
symmetric because in the healing process some of that endometriosis has grown
into that uterine scar and migrated and grown into the entire front wall of the
uterus. In a way, endometriosis is more common if you’ve had a Costco-section. However
not the kindness outside the uterus, the kind in the wall of
the uterus. Thank you, Ashley. I cannot believe it. That time went by so fast and
I’ve just been talking, talking, talking. Well I wish that all of you could be
sitting with me right here and we can just keep talking about this you know
for the next few hours because that’s what I do every day. Thus is what I do for fun
and so remember, if we didn’t get to your question we’ll follow up with a
message and if you have any additional questions,
we’d love to have them because we’re all about improving the quality of life for
people who suffer from this disease and helping them achieve their goals to have
a family to get rid of the pain, to whatever your goal is. You just don’t
need to suffer and you don’t need to lose hope. This is a totally manageable
disease but it needs to be managed both short term for the lesions that
endometriosis exhibits but also long term and the psychological component of
it. All of that needs to be looked at as a whole, because a person is not a part.
They’re the sum of the parts and physical, psychological, emotional mental
all of it, and endometriosis feeds into all of that. So that’s the way we
approach it at the Kaldas Center. Thank you very much for joining us.
We will get together again soon. Keep an eye on Facebook for next question and
answer session. You guys have a good night.

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