Endometriosis Unmasked A Conversation with Dr. Monika Juneja

Dr Gavin Nimon:
0:00

Endometriosis, what is it? It affects 1 in 10 women, can lead to chronic pain, can lead to infertility issues. Well today we're going to learn more about it with Dr. Monika Juneja, a gynaecologist from the Flinders Medical Centre who specialises in laparoscopic surgery and is going to tell us more about it today. Welcome to Aussie Med Ed. G'day and welcome to Aussie Med Ed, the Australian medical education podcast, designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field. I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Kaurna land. I'd like to remind you that this podcast players and is also available as a video version on YouTube. I'd also like to remind you that if you enjoy this podcast, please subscribe or leave a review or give us a thumbs up as I really appreciate the support and it helps the channel grow. I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the Elders both past, present and emerging. I'd like to remind you that all the information presented today is just one opinion and that there are numerous ways of treating all medical conditions. Therefore, you should always seek advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, Please speak to your GP or seek assistance from help organisations such as Lifeline in Australia. It's my pleasure now to introduce Dr. Monika Juneja, a gynaecologist with 25 years of experience in laparoscopic surgery. Specialising in minimally invasive surgery and teaching it to her peers at the Flinders Medical Centre. She's going to talk to us about endometriosis, in particular diagnosis and treatment. Welcome, Monika.

Dr Monika Juneja:
1:35

Thanks, Gavin, for having me here. It's my pleasure and privilege to be able to talk to this very common condition which affects so many women and girls across the world.

Dr Gavin Nimon:
1:46

I've read actually the incidences between one in seven to one in ten women. Is that correct?

Dr Monika Juneja:
1:50

Yes, that's correct. The diagnosis is difficult, so probably the true incidence could be close to one in seven. Women of reproductive age group, that's between puberty to before they hit menopause. Right. And

Dr Gavin Nimon:
2:04

after menopause, is it an issue after that or it's more

Dr Monika Juneja:
2:07

of a Generally not because the estrogen production goes down. So that causes endometriosis to become dormant and disappear unless it has led to a fair bit of scarring inside or some old endometrioma hidden in the ovary. But generally after menopause, it's not an issue.

Dr Gavin Nimon:
2:26

Okay. What actually is a condition? Is it like a benign tumor or does it behave in such a way? It

Dr Monika Juneja:
2:32

is it can present as like benign endometrioma, like a chocolate cyst in the ovaries, but more than that is just a generalized change in the lining of the peritoneum outside the uterus, in the abdomen, in the pelvis, and it can affect the ligaments behind the uterus. So it's a, quite often it's more of a diffuse change. Rather than just being localised to the ovaries. It's benign and it's difficult to diagnose. And it is present in various forms. Are there any

Dr Gavin Nimon:
3:06

particular blood markers or tests you can do for it or investigations to help diagnose the condition?

Dr Monika Juneja:
3:11

We don't have any biomarkers like we can't detect it with a cervical screen test or urine test or blood test. So the diagnosis is generally with laparoscopy. We are getting better at doing the ultrasound. Specialized ultrasounds can sometimes give an indication of the disease on more on the moderate to severe extent. So it's

Dr Gavin Nimon:
3:38

based on clinical symptoms and then investigations after that. That's right, yeah. And the cause of the condition? Is there any particular known cause for why this uterine lining study appears outside the uterus? Yeah,

Dr Monika Juneja:
3:51

there are various theories. So, it's you know, everything is possible here. So the commonest theory, which is taught in med school and it's still valid to some extent is retrograde menstruation but I guess retrograde menstruation will happen in majority of women but why that endometrium implants Outside the uterus, in some and not others, we don't know that. Then there is theory of genetic predisposition, like it's that's the latest where they say that these embryonic nests are already there, but in some women they change to endometriosis and they become a clinical problem. Then there is theory of like spread around lymphatic channels and blood vessels that's where we see it under the diaphragm at lungs and those, all those organs. And then there is theory of coelomic metoplasia that the endo that the Peritoneum suddenly decides to change its character. So basically everything and we're not sure of what actually causes

Dr Gavin Nimon:
4:58

it. So retrograde menstruation is when the uterine lining actually goes back up the fallopian tubes into the pelvis, does it?

Dr Monika Juneja:
5:04

So the menstrual blood, it backflows through the tubes. Back in the abdominal cavity, but normally body should be able to deal with that. But in some women, obviously the endometrium is perhaps more sticky or there are some immunological factors and it just decides to grow inside. So

Dr Gavin Nimon:
5:26

with the normal menstrual periods, do you actually get blood loss and loss of the uterine lining into the pelvis as well, like you do with normal menstrual periods?

Dr Monika Juneja:
5:32

Yes, so these endometrial implants, they just swell up, they get inflamed, they release cytokines and interleukins and they cause fibrosis. That's why we see premenstrual buildup of symptoms and during periods, again, they have worse period pain than Someone who hasn't got endometriosis. Yeah, that must be

Dr Gavin Nimon:
5:55

awful. It's almost like someone injecting a cytotoxic agent into the peritoneum on a regular basis.

Dr Monika Juneja:
5:59

The severity of the symptoms doesn't always correlate with the extent of the disease. So, you know, at times you can see a big endometrioma and lots of endometriosis inside and a woman is not symptomatic and then you'll see a young girl with one or two spots of Patchy superficial endometriosis and her symptoms are completely out of proportion to what on laparoscopic inspection. Is

Dr Gavin Nimon:
6:25

there an increase in incidents with time as well or are they just identifying greater numbers?

Dr Monika Juneja:
6:30

Probably the actual incidence would be the same but there is more awareness. Girls are delaying starting their families. So the average age of having first baby has gone up now. So it's kind of, you know, generally around 30 or even 31. So, pregnancy somewhat protects to some extent from endometriosis, but we see it more as the age goes up. And there is more awareness. Girls talk a lot about their periods to their parents and their general practitioners. There are there, there are educational talks from health professionals. They have been to school. So, generally there is better access. GPs are more open to it. The. We try conservative measures and if someone is not responding to pill and anti inflammatories, they do make a referral to gynecologist. So I think we are detecting it more, but the actual incidence probably would be the same.

Dr Gavin Nimon:
7:36

So the pathology is purely endometrial lining outside

Dr Monika Juneja:
7:39

the uterus? So, it is benign lining but it can be in various It can be like just as if someone has sprayed pepper on a steak. So sometimes it can be just that diffuse change. Or it can be like plaques, which can be fibrous. They can be yellow, they can be white. Along with fibrosis and endometrial glands and stroma. Then it can be a nodular disease where it's quite lumpy. And it can be deeply infiltrative in organs. Like it can go in the bladder and it can involve the peritoneum of pouch of Douglas. And then it can also involve the rectal sigmoid, and also sigmoid colon. So that's quite hard to deal with because then you have to involve colorectal colleagues or urologists accordingly. So, it probably increases the risk of adenocarcinoma. I've seen that and that's generally in the rectovaginal septum. It's not, it's uncommon. But generally it's a benign disease. Are

Dr Gavin Nimon:
8:46

there any risk factors for endometriosis? Is there any particular genes that occur that actually make you at greater risk of developing it? Or are there any other particular factors that may make you at greater risk of having endometriosis?

Dr Monika Juneja:
8:57

No particular chromosomal or gene factors which we can conclusively say that this is it. If you have this gene, then yes, you will get it, but there is some clustering in some families. So if mother or sister have had it, then probably that would increase the odds of that girl having endometriosis. Early menarche, starting of periods at an earlier age. Nulliparity some environmental factors, probably, Too much of environmental toxins and estrogens, whether they increase the risk, they cause endocrine disruption and increase the odds of endometriosis but we're not sure. Right.

Dr Gavin Nimon:
10:20

Okay, so it sounds like it's a bit associated with estrogen release, just the same way the breast cancer is associated with estrogen release in the sense that having children reduce the amount of estrogen and reduce the risk of breast cancer. Is there an association also between endometriosis and breast cancer because of the same association with estrogen release as well?

Dr Monika Juneja:
10:39

No nulliparity can increase the risk of breast cancer. Estrogen window being open for too long increases the risk of Breast and endometrial cancer but I'm not aware of any studies where they've said that if someone has had endometriosis, they're more likely to have breast

Dr Gavin Nimon:
10:59

cancer. Okay, what about hormone replacement therapy in someone who's approaching menopause? Is endometriosis a contraindication to giving hormone replacement therapy in that scenario?

Dr Monika Juneja:
11:09

So if someone has had severe endometriosis and they've gone through Menopause, in the early menopause hormonal replacement therapy can aggravate the endometriosis. symptoms but it's not contraindicated. And if they still have uterus, then we have to obviously give them combined HRT but cautiously, but it's not a contraindication. Okay. What

Dr Gavin Nimon:
11:36

about the younger person with someone on the oral contraceptive pill? Does endometriosis affect what dose or what type of pill you actually give in that scenario?

Dr Monika Juneja:
11:43

contraceptive pill where it can help with mild to minimal disease and we can do a regime of continuous OCP suppression where girls can skip the sugar pills and just take the active pills together. So that way they can avoid periods and the related discomfort. So it's called a pseudopregnancy regime. So you're just producing an environment inside where they're not having a period. So that can help. It's a medical management of endometriosis and that can be successful I'll say 30 40 percent of girls, yes.

Dr Gavin Nimon:
12:23

Okay, how else would someone present with endometriosis? What other symptoms present to you? and make you aware that endometriosis may be a cause of a condition that's occurring.

Dr Monika Juneja:
12:33

So it can present with having terrible periods as you have said. It can also present as a girl saying that my periods were not so bad and now in the last few years they have worsened. I used to be able to cope with my periods and now they're really affecting my life. I get uncomfortable several days actually before my period is starting and the pain radiates to back, knees and it affects me, it affects my mood. Also, they can have painful intercourse, deep dyspareunia. They can have trouble on holding urine. They can have bladder sensitization. In severe cases of endometriosis Especially with involvement of pouch of Douglas, they can have painful defecation and if they have endometriotic implants which are close to the bowel or intraluminal, then they can also have cyclical rectal bleeding. It can affect the mood and low energy levels and not coping with general work, missing school, fainting There is 30 percent overlap probably with Irritable Bowel Syndrome. So, they can say that , they get quite distended and uncomfortable and bloating. We see that a lot as well. And the diagnosis is harder and natural periods also are not pleasant. So, our job is to work out whether it is just painful periods or actually Whether it's something pathological going on with that person. Right.

Dr Gavin Nimon:
14:11

So, you obviously got these symptoms that makes you think that it may be endometriosis. Yes. What's the next step? How do we go down the path of diagnosis and then also staging the condition as well? What staging

Dr Monika Juneja:
14:21

options do you have? If I can add to your previous question, we'll also find endometriosis in about 30 to 40 percent of couples who are coming to us with infertility. So there, the women may not have symptoms, but there could be a component of asymptomatic endometriosis or Just, period pain which she has just taken as normal. We also see non menstrual pain in severe cases. So, in terms of diagnosis careful history taking. Looking at what has been tried. And then getting a pelvic ultrasound. So pelvic ultrasound can be completely normal, but That woman can still have extensive endometriosis, but that's just to make sure that the anatomy is normal. There is no big endometrioma in the ovary, or there's no fibroid or adenomyosis, and adenomyosis is like a cousin of Endometriosis, where the endometrium is inside the myometrium in the muscle fibers of the uterus. And it is a diffuse change. And so once we have done this, then we'll also make sure that at the same time. We are checking the cervix, add on the routine cervical screening test and discuss with them about what stage of life they are, whether they want to start. Family, or if they are very young, then, you know, we have to also address their contraceptive needs. If there are any psychological factors, lifestyle factors whether they have regular cycles or whether there's a component of polycystic ovaries there. And then generally for diagnosis we have to do a laparoscopy which is under general anesthesia. It's a hospital procedure. Laparoscopy is extremely common, but one in 750 cases anywhere in the world. Any surgeon doing laparoscopy, there can be complications, so I'll present to them that this is what I think we need to get a diagnosis and these days generally, we don't really subject them to 2 anesthetics if possible so do a laparoscopy and treat endometriosis as seen suitable at the same time. Along with that, generally, I'll add hysteroscopy as well, which is the assessment of the cavity of the uterus and for prevention of endometriosis and prevent its recurrence as well as to deal with periods after. Quite often, we propose, most gynecologists will propose, Putting in a Mirena, which is a progesterone IUD. So that will help in dealing with the periods post surgery. Because we can't cure endometriosis. So, you know, you have done one laparoscopy, and then if you do nothing about it, and if the girl still continues to go on naturally without any hormonal suppression of periods, then it will recur in 30 percent of cases. In somewhere between three to five years. Severe cases, it can actually recur very soon. And then, you know, you're back to square one with pain and dealing with it. And repeated surgeries get challenging. So endometriosis is always in tricky locations and it is not in convenient locations. I always tell the girls that, you know, it's not like cherry picking that I go and just pick it up and So it can be in quite vascular locations. It can be in the ovarian fossa. It can be on the peritoneum overlying the ureter. It can be, close to the rectum and sigmoid in the pararectal region. So, we don't want to go there again and again if possible. And so, if they are not quite ready to start family, then probably at the same time, we consider the option of putting in a mirena. If they say that, yeah, no, maybe, you know, I'll have endometriosis surgery done. And then, you know, maybe in a year or two, I'll start family. So in that case, we can skip the long acting progesterone IUD and consider other short acting measures. But I'll normally not do a MRI. In every case, but if there is suspicion of deeply infiltrated endometriosis, then I'll get an MRI just to see the extent and Also to make arrangements and liaise with my colorectal colleagues In case we have to excise endometriosis from the wall. So that case we need their help. Yeah A few

Dr Gavin Nimon:
19:28

questions come to mind in what you're saying there. The first one is the Pelvic Ultrasound. Is that a transvaginal Pelvic Ultrasound that's required or is it done just through the abdominal

Dr Monika Juneja:
19:37

wall? Yeah. So, transvaginal is far superior to diagnose endometriosis or adenexal pathology but if they've never been sexually active, then we obviously say, okay, transabdominal. Which is fine, , but, you know, if you're heading towards laparoscopy, I don't worry too much about transvaginal. Someone is very shy and very young. I won't push for a transvaginal in that case, but generally speaking, it's transvaginal. The endometriosis specific ultrasound actually goes a step forward. So they need little bit of bowel prep also, and only specialized centers can do that. The routine ultrasound. Is not endometriosis specific. So in the specialized ultrasound they can measure the thickness or change in appearance of the uterus sacral ligaments, the mobility of the ovaries the adherence of colon to the back of the uterus. It's not 100 percent specific but it has certainly helped us and recently I did a case so they were spot on and that girl had endometriosis in the utero-sacral ligaments so that was impressive so Right,

Dr Gavin Nimon:
21:03

so it's getting better

Dr Monika Juneja:
21:03

the investigation. It is getting

Dr Gavin Nimon:
21:05

better, yeah. When you do a formal excision is that actually done as an ablation using diathermy or other devices or you actually excise the actual deposit?

Dr Monika Juneja:
21:14

So, it can be either ablation or excision. Ablation is really suitable only when it is a superficial disease. Generally speaking, if it is anything nodular or significant if we ablate it, the thermal spread will happen to the underlying structure. So that's not advisable. So in that case, I'll say more often it is excision. But if it is, in a tricky location, like I had one spot recently on. external iliac vessel, very close to it. So, and it was superficial, so I just retracted it and diathermied it. But it is a combination. So in one particular case, you know, there could be a very superficial spot where you may just ablate it, and then if it is significant, then generally we excise it and every surgeon has their preferred. Modality how they want to do it. So, bipolar cautery is very common to do the ablation. And for excision, we can go traditional with monopolar cautery, or else we can use ultrasound based energy sources. So like harmonic scalpel or thunder beat. Laser used to be a thing in the past. I've never used laser, so I think that was more in 80s. So, also at the time of surgery, we have to take care that, you know, we are checking the tubes and swing the camera around and check the appendix, upper abdomen, adhesions. And also with surgery, if we've done a significant excision of endometriosis, we don't want the ovaries to go and stick to those raw areas. So Quite often in severe cases I'll do ovariopexy where I can tie the ovaries to the round ligament with an absorbable suture and put an adhesion barrier on the raw areas so that at least the ovaries, they don't go and stick to and become a cause of pain down the

Dr Gavin Nimon:
23:22

track. Brilliant. Very clever. What about the, I can imagine with these tight spaces, the robotic surgery might have a place. Does that have a role in this sort of area?, Dr Monika Juneja: yes, robotic You don't need it for every case. And the vision will be much better. It will be less tiring for the surgeon. I haven't taken it on because it wasn't there. When I first started doing it, and now I'm comfortable with what I'm doing, but a few of my colleagues in Gold Coast and Brisbane who are using robot they have commented that actually they have found that robotics really helped them with Severe endo disease more so, rather than doing robotic hysterectomy, they said it was much easier more productive to use a robot for endometriosis case. You can't really stage it prior to a laparoscopy unless on ultrasound you are seeing. Two big endometriomas. We call it as kissing ovaries. You can get indication of the ovaries are stuck to each other. They're big, they're stuck to back of the uterus and on ultrasound they can say it's fixed retroversion. Uterus is not moving and it's really pathologically retroverted, which is it's pointing backwards. And There you know before you go in that, okay, this is a stage four case of endometriosis. So there is a American Fertility Society classification which goes from minimal to mild to moderate to severe. Even in stage four, there is variation and practically I don't find it very useful. What I find handy is taking pictures and taking a close shot, before I've done anything and After pictures and then drawing a diagram and just noting it down in the case notes and also noting the number of the lesions. So, practically that is more. Useful for us and also whether the ovaries were involved or not and if on the ovary they have got endometriosis whether therefore that was just some spots on the surface or whether there was an endometrioma and if there is a chocolate cyst or endometrioma in the ovary how big that was and if we have excised that then how much of normal ovarian tissue is remaining. So that is more of a practical approach. Location based and visual. Excellent. What about the patients having problems with fertility and they've got endometriosis? What's the options for treatment in this scenario?

Dr Monika Juneja:
26:25

So it will depend on symptoms and say if a woman is Close to 40. She hasn't got any symptoms of endometriosis. And ovarian reserve is on the lower side. She may have endometriosis, we don't know. She has got regular cycles, so we don't think it's an ovulatory infertility due to not producing eggs in a timely manner. So in those sort of cases, we can go straight for IVF. Provided the ultrasound is normal. Whereas if a woman is younger we have got time and if she has got any symptoms or maybe no symptoms, then we have got time to do laparoscopy and assess. So, even in mild to minimal cases one of the studies it did show that the chances of conceiving naturally actually doubled where you have just treated the mild disease as well. So the outcome improves with treatment of endometriosis laparoscopically prior. So if I've diagnosed someone with significant endometriosis, I'll always tell the girls that consider starting family earlier, you know, don't wait till 35. So,, prioritize Conceiving first. So the best thoughts of conception will be when we have just cleared endometriosis. It hasn't had a chance to grow back. So that's the best time actually to conceive. Now if someone is 20, obviously they are not ready. But at times girls will change their plans and say at 28, 29, if I've cleared endometriosis and I'll go back to them and say well this is what it is you know it's better to prioritize having baby first so then they take the message on board and if they say no not quite ready yet but maybe you know in few months or next year after I get married so in that time you know we can suppress the cycles with other progesterone tablets and things and then they can start trying. So even if Every bit of endometriosis is cleared up it's not a surety that everyone will conceive naturally.

Dr Gavin Nimon:
28:49

So is the infertility issue related obviously then to the endometrial deposits as opposed to I assumed it might just be the scarring causing adhesions that caused infertility, but it's actually even the endometrial deposits can cause infertility issues as well, is it?

Dr Monika Juneja:
29:03

So we're not sure how exactly endometriosis affects the Fertility, what the mechanism is. So there are various theories and what is happening in a particular person is anybody's guess. So it can be due to release of inflammatory chemical cytokines, interleukins, which can cause oocyte release, the transport of egg through the tube, the motility of the tubes could be affected it could be on fertilization, it could be on implantation it can be a very inflammatory environment in the pelvis it can be due to fibrosis and dyspareunia. In severe cases, it can also be due to the egg quality. That the ovarian reserve is low. The quality of the eggs is not good. That could be affecting their odds of conceiving. So, the per cycle fecundity. For conception, which is, so if a normal couple you know, the conception is say 15 to 20 percent per cycle, in endometriosis it will go down to somewhere between 2 to 10%. And this is based on a very old study that doesn't take into account the staging, but statistically that has been put forward by them.

Dr Gavin Nimon:
30:29

It's amazing if you are doing a laparoscopic surgery to ablate or to remove the endometrial tissue. Yes. And the person's thinking about a family and they're in, say they're an order age group. Is there a role for harvesting eggs exit at the same time? Would that be considered or is that something that's a separate group that would do that through a second laparoscopy?

Dr Monika Juneja:
30:48

So harvesting the egg is we can't do it at the same time. Right. So basically they have to. see the fertility specialist. I have to refer them on to an IVF clinic. It's a separate process. So you have to give a lot of hormones, gonadotropins to stimulate the ovaries. And then the ovaries have to produce the eggs and then the egg retrieval is ultrasound guided under sedation and then those eggs have to be stored. So we normally cannot just cut the ovary and save it for use at a later date. There's an orthopaedic based question. I get that asked a lot by patients. Oh, can you just save my eggs at the same time that you are doing the surgery? So it is a common question. Right, so I'm not alone then. No, you're not alone there.

Dr Gavin Nimon:
31:46

Okay. It's a question off the top of my head as we're speaking. What is multidisciplinary approach for endometriosis? Obviously it sounds like it's basically gynecologist treatment, and you mentioned the colorectal teams when it's involving the rectum and other areas. Are there any other teams that you have involved in the treatment? I mean, is there a specialist nurse that is involved in intermediate treatment as well? Or is there other teams that are involved like there are for other conditions we have around medicine?

Dr Monika Juneja:
32:11

So, in terms of specialties I involve urologists, fortunately not very often. If there is hydronephrosis or a suspicion of bladder involvement, then Yes, we involve the urologist, but quite common involving a gastroenterologist especially if they have got bowel symptoms or Upper abdominal discomfort or unresolved pain. So we have cleared endometriosis and they still have bloating and GI disturbance, then I'll get a gastroenterology colleague to have a look into other factors. Also a psychologist. Quite often, you know, you have treated the endometriosis, but about 20 percent can still have persistent pain. So psychologist for support and coping mechanisms physiotherapist, so pelvic floor physio for vaginismus and pelvic floor dysfunction where they can have overactive pelvic floor muscles. So that can cause dyspareunia and ongoing pain. Pain specialist, where you have done surgery, you have suppressed the cycles, but they've still got pain, so they're involving the chronic pain team is quite common. And having a good support from the GP is of course very important. So someone who is sympathetic and can be the anchor point to coordinate the care as well.

Dr Gavin Nimon:
33:41

Brilliant. There's a huge team involved. There's a lot more than I expected and it's great to hear it. It's a it's an amazing condition and I'm still so surprised I don't know more about it. Obviously I'm an orthopaedic surgeon, so I understand that, but it should be more in the media and I think it is coming out more in the media. Where do you think the advances are in the future? Where do you think things are heading for this condition? Can you see light at the end of the tunnel or is it still far away at this stage?

Dr Monika Juneja:
34:07

I think we'll have better imaging modalities. So the ultrasound diagnosis will continue to improve. There is funding now for MRI, so it is rebatable if we are suspecting severe endometriosis. Also I think with time we'll see a better Non invasive biomarker, hopefully, which will reduce the need for operative laparoscopy, which is obviously invasive. Also, new oral medications, so I think there are phase 3 trials and we are close to having a GNRH antagonist which is available orally in combination with estrogen and progesterone. That might improve the outcome and it can also hopefully reduce the size of fibroids. And think for prevention of pain newer IUD where a non steroidal can be added to the progesterone in the IUD itself to help with chronic pain. The IUDs which have got a different hormone and combination of medications to, Help to deal with the problem long term. And perhaps better pain control measures. This stage, that's what I can think of. That's

Dr Gavin Nimon:
35:33

brilliant. There's a lot of better things on the horizon there, which is good news for the future. So, there's actually light at the tunnel, . One in seven or one in ten is a huge number and it's a really important topic to hear about it. I'm really pleased you're able to come along and give us some more information about this topic. So I'd like to thank you very much for your time. And we'll see you next time. Really appreciate the advice and the information you've given us today. Thank you very much,

Dr Monika Juneja:
35:55

Monika. Thanks a lot for having me here. It was my pleasure to be here.

Dr Gavin Nimon:
36:00

Excellent. Thank you very much. Thank you very much for listening to our podcast today. I'd like to remind you that the information provided is just general advice and may vary depending on the region in which you are practicing or being treated. If you have any concerns or questions about what we've discussed, you should seek advice from your general practitioner. I'd like to thank you very much for listening to our podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.