March 3, 2024

Endometriosis Unmasked A Conversation with Dr. Monika Juneja

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Embark on a journey through the hidden struggles of endometriosis as Dr Gavin Nimon (Orthopaedic Surgeon and Host) interviews Dr. Monika Juneja about the mysteries of this pervasive condition. Discover how symptoms belie severity, why a laparoscopy can be a game-changer, and the innovative treatments on the horizon. Dr. Juneja, illuminates the path from pain to understanding for the countless women battling this elusive foe, offering a promise of clarity and hope in an often-misunderstood realm of women's health.

Through candid discussions on Aussie Med Ed, we uncover the intricacies of diagnosis, the critical role of multidisciplinary care, and the promise of advancing technologies that beckon a future where invasive procedures may become a thing of the past. As Dr. Juneja shares her frontline insights on integrating gynecologists with a squad of specialists—from general practitioners to pain experts—we chart the course of conquering endometriosis together. Tune in for a comprehensive exploration of a condition that doesn't just affect individuals, but reverberates through communities, fostering a collective surge towards betterment and relief.

Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.

Aussie Med Ed is sponsored by Avant Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.

Chapters

00:00 - Understanding Endometriosis

12:49 - Understanding Endometriosis Diagnosis and Treatment

31:27 - Advances in Endometriosis Treatment

Transcript

WEBVTT

00:00:00.179 --> 00:00:01.459
Endometriosis, what is it?

00:00:01.459 --> 00:00:06.746
It affects 1 in 10 women, can lead to chronic pain, can lead to infertility issues.

00:00:07.166 --> 00:00:09.099
Well today we're going to learn more about it with Dr.

00:00:09.099 --> 00:00:15.989
Monika Juneja, a gynaecologist from the Flinders Medical Centre who specialises in laparoscopic surgery and is going to tell us more about it today.

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Welcome to Aussie Med Ed.

00:00:19.989 --> 00:00:27.679
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.

00:00:28.278 --> 00:00:32.618
I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Kaurna land.

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I'd like to remind you that this podcast players and is also available as a video version on YouTube.

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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.

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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.

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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.

00:01:05.728 --> 00:01:09.088
Therefore, you should always seek advice from your health professionals in the area in which you live.

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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.

00:01:18.314 --> 00:01:19.655
It's my pleasure now to introduce Dr.

00:01:19.655 --> 00:01:24.254
Monika Juneja, a gynaecologist with 25 years of experience in laparoscopic surgery.

00:01:24.605 --> 00:01:29.334
Specialising in minimally invasive surgery and teaching it to her peers at the Flinders Medical Centre.

00:01:29.894 --> 00:01:34.344
She's going to talk to us about endometriosis, in particular diagnosis and treatment.

00:01:34.474 --> 00:01:35.275
Welcome, Monika.

00:01:35.825 --> 00:01:37.454
Thanks, Gavin, for having me here.

00:01:37.474 --> 00:01:46.525
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.

00:01:46.635 --> 00:01:49.885
I've read actually the incidences between one in seven to one in ten women.

00:01:49.894 --> 00:01:50.745
Is that correct?

00:01:50.795 --> 00:01:52.165
Yes, that's correct.

00:01:52.224 --> 00:01:58.245
The diagnosis is difficult, so probably the true incidence could be close to one in seven.

00:01:58.480 --> 00:02:03.760
Women of reproductive age group, that's between puberty to before they hit menopause.

00:02:04.114 --> 00:02:04.375
Right.

00:02:04.385 --> 00:02:04.415
And

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

00:02:07.204 --> 00:02:11.044
of a Generally not because the estrogen production goes down.

00:02:11.044 --> 00:02:22.435
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.

00:02:22.914 --> 00:02:25.604
But generally after menopause, it's not an issue.

00:02:26.155 --> 00:02:26.435
Okay.

00:02:26.435 --> 00:02:27.794
What actually is a condition?

00:02:28.384 --> 00:02:31.375
Is it like a benign tumor or does it behave in such a way?

00:02:31.435 --> 00:02:31.965
It

00:02:32.284 --> 00:02:50.814
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.

00:02:51.145 --> 00:02:55.115
So it's a, quite often it's more of a diffuse change.

00:02:55.889 --> 00:02:58.870
Rather than just being localised to the ovaries.

00:02:58.930 --> 00:03:02.400
It's benign and it's difficult to diagnose.

00:03:02.689 --> 00:03:04.729
And it is present in various forms.

00:03:05.949 --> 00:03:06.349
Are there any

00:03:06.349 --> 00:03:10.770
particular blood markers or tests you can do for it or investigations to help diagnose the condition?

00:03:11.719 --> 00:03:21.030
We don't have any biomarkers like we can't detect it with a cervical screen test or urine test or blood test.

00:03:21.030 --> 00:03:24.629
So the diagnosis is generally with laparoscopy.

00:03:24.629 --> 00:03:28.800
We are getting better at doing the ultrasound.

00:03:28.800 --> 00:03:37.669
Specialized ultrasounds can sometimes give an indication of the disease on more on the moderate to severe extent.

00:03:38.289 --> 00:03:38.569
So it's

00:03:38.569 --> 00:03:42.750
based on clinical symptoms and then investigations after that.

00:03:43.020 --> 00:03:44.060
That's right, yeah.

00:03:44.150 --> 00:03:45.719
And the cause of the condition?

00:03:45.740 --> 00:03:50.939
Is there any particular known cause for why this uterine lining study appears outside the uterus?

00:03:51.219 --> 00:03:51.530
Yeah,

00:03:51.530 --> 00:03:52.770
there are various theories.

00:03:52.780 --> 00:03:56.629
So, it's you know, everything is possible here.

00:03:56.629 --> 00:04:16.035
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.

00:04:16.404 --> 00:04:32.245
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.

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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.

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And then there is theory of coelomic metoplasia that the endo that the Peritoneum suddenly decides to change its character.

00:04:53.480 --> 00:04:58.199
So basically everything and we're not sure of what actually causes

00:04:58.220 --> 00:04:58.509
it.

00:04:58.660 --> 00:05:04.370
So retrograde menstruation is when the uterine lining actually goes back up the fallopian tubes into the pelvis, does it?

00:05:04.560 --> 00:05:08.490
So the menstrual blood, it backflows through the tubes.

00:05:08.899 --> 00:05:13.279
Back in the abdominal cavity, but normally body should be able to deal with that.

00:05:13.680 --> 00:05:24.879
But in some women, obviously the endometrium is perhaps more sticky or there are some immunological factors and it just decides to grow inside.

00:05:25.149 --> 00:05:25.389
So

00:05:26.180 --> 00:05:32.379
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?

00:05:32.785 --> 00:05:43.545
Yes, so these endometrial implants, they just swell up, they get inflamed, they release cytokines and interleukins and they cause fibrosis.

00:05:43.875 --> 00:05:54.454
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.

00:05:54.644 --> 00:05:55.055
Yeah, that must be

00:05:55.064 --> 00:05:55.384
awful.

00:05:55.384 --> 00:05:59.524
It's almost like someone injecting a cytotoxic agent into the peritoneum on a regular basis.

00:05:59.545 --> 00:06:04.894
The severity of the symptoms doesn't always correlate with the extent of the disease.

00:06:04.904 --> 00:06:25.180
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.

00:06:25.360 --> 00:06:25.509
Is

00:06:25.509 --> 00:06:30.269
there an increase in incidents with time as well or are they just identifying greater numbers?

00:06:30.350 --> 00:06:35.579
Probably the actual incidence would be the same but there is more awareness.

00:06:36.060 --> 00:06:38.870
Girls are delaying starting their families.

00:06:38.879 --> 00:06:42.800
So the average age of having first baby has gone up now.

00:06:42.939 --> 00:06:47.500
So it's kind of, you know, generally around 30 or even 31.

00:06:48.000 --> 00:06:57.370
So, pregnancy somewhat protects to some extent from endometriosis, but we see it more as the age goes up.

00:06:57.839 --> 00:06:59.879
And there is more awareness.

00:06:59.930 --> 00:07:06.040
Girls talk a lot about their periods to their parents and their general practitioners.

00:07:06.040 --> 00:07:10.889
There are there, there are educational talks from health professionals.

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They have been to school.

00:07:11.990 --> 00:07:15.629
So, generally there is better access.

00:07:15.629 --> 00:07:17.939
GPs are more open to it.

00:07:18.420 --> 00:07:18.899
The.

00:07:18.925 --> 00:07:29.165
We try conservative measures and if someone is not responding to pill and anti inflammatories, they do make a referral to gynecologist.

00:07:29.165 --> 00:07:35.745
So I think we are detecting it more, but the actual incidence probably would be the same.

00:07:36.035 --> 00:07:38.995
So the pathology is purely endometrial lining outside

00:07:39.024 --> 00:07:39.665
the uterus?

00:07:39.964 --> 00:07:50.754
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.

00:07:50.754 --> 00:07:54.185
So sometimes it can be just that diffuse change.

00:07:54.545 --> 00:07:58.714
Or it can be like plaques, which can be fibrous.

00:07:58.754 --> 00:08:00.745
They can be yellow, they can be white.

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Along with fibrosis and endometrial glands and stroma.

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Then it can be a nodular disease where it's quite lumpy.

00:08:09.795 --> 00:08:13.855
And it can be deeply infiltrative in organs.

00:08:13.855 --> 00:08:19.800
Like it can go in the bladder and it can involve the peritoneum of pouch of Douglas.

00:08:19.800 --> 00:08:25.569
And then it can also involve the rectal sigmoid, and also sigmoid colon.

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So that's quite hard to deal with because then you have to involve colorectal colleagues or urologists accordingly.

00:08:33.679 --> 00:08:37.480
So, it probably increases the risk of adenocarcinoma.

00:08:38.090 --> 00:08:41.740
I've seen that and that's generally in the rectovaginal septum.

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It's not, it's uncommon.

00:08:44.245 --> 00:08:46.164
But generally it's a benign disease.

00:08:46.565 --> 00:08:46.625
Are

00:08:46.625 --> 00:08:48.325
there any risk factors for endometriosis?

00:08:48.335 --> 00:08:52.014
Is there any particular genes that occur that actually make you at greater risk of developing it?

00:08:52.365 --> 00:08:56.605
Or are there any other particular factors that may make you at greater risk of having endometriosis?

00:08:57.929 --> 00:09:04.460
No particular chromosomal or gene factors which we can conclusively say that this is it.

00:09:04.460 --> 00:09:10.289
If you have this gene, then yes, you will get it, but there is some clustering in some families.

00:09:10.289 --> 00:09:18.419
So if mother or sister have had it, then probably that would increase the odds of that girl having endometriosis.

00:09:18.860 --> 00:09:23.600
Early menarche, starting of periods at an earlier age.

00:09:24.980 --> 00:09:42.370
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.

00:09:43.529 --> 00:09:43.830
Right.

00:09:44.139 --> 00:09:56.120
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.

00:09:56.409 --> 00:10:03.269
Is there an association also between endometriosis and breast cancer because of the same association with estrogen release as well?

00:10:03.279 --> 00:10:07.710
No nulliparity can increase the risk of breast cancer.

00:10:08.379 --> 00:10:22.695
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

00:10:22.695 --> 00:10:23.095
cancer.

00:10:23.184 --> 00:10:26.485
Okay, what about hormone replacement therapy in someone who's approaching menopause?

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Is endometriosis a contraindication to giving hormone replacement therapy in that scenario?

00:10:32.465 --> 00:10:44.889
So if someone has had severe endometriosis and they've gone through Menopause, in the early menopause hormonal replacement therapy can aggravate the endometriosis.

00:10:46.450 --> 00:10:49.269
symptoms but it's not contraindicated.

00:10:49.600 --> 00:10:58.940
And if they still have uterus, then we have to obviously give them combined HRT but cautiously, but it's not a contraindication.

00:10:59.210 --> 00:10:59.440
Okay.

00:10:59.440 --> 00:10:59.570
What

00:10:59.570 --> 00:11:02.210
about the younger person with someone on the oral contraceptive pill?

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Does endometriosis affect what dose or what type of pill you actually give in that scenario?

00:11:06.825 --> 00:11:24.625
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.

00:11:25.134 --> 00:11:28.764
So that way they can avoid periods and the related discomfort.

00:11:28.764 --> 00:11:31.304
So it's called a pseudopregnancy regime.

00:11:31.325 --> 00:11:36.815
So you're just producing an environment inside where they're not having a period.

00:11:36.835 --> 00:11:38.254
So that can help.

00:11:38.254 --> 00:11:47.115
It's a medical management of endometriosis and that can be successful I'll say 30 40 percent of girls, yes.

00:11:47.205 --> 00:11:49.715
Okay, how else would someone present with endometriosis?

00:11:49.715 --> 00:11:51.674
What other symptoms present to you?

00:11:52.034 --> 00:11:56.725
and make you aware that endometriosis may be a cause of a condition that's occurring.

00:11:56.835 --> 00:12:01.455
So it can present with having terrible periods as you have said.

00:12:02.125 --> 00:12:09.455
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.

00:12:09.465 --> 00:12:14.414
I used to be able to cope with my periods and now they're really affecting my life.

00:12:14.434 --> 00:12:24.085
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.

00:12:24.335 --> 00:12:28.434
Also, they can have painful intercourse, deep dyspareunia.

00:12:28.894 --> 00:12:32.384
They can have trouble on holding urine.

00:12:32.384 --> 00:12:34.934
They can have bladder sensitization.

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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.

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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.

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So, they can say that , they get quite distended and uncomfortable and bloating.

00:13:14.284 --> 00:13:16.495
We see that a lot as well.

00:13:16.985 --> 00:13:22.514
And the diagnosis is harder and natural periods also are not pleasant.

00:13:22.534 --> 00:13:33.059
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.

00:13:33.809 --> 00:13:34.409
Right.

00:13:34.929 --> 00:13:39.179
So, you obviously got these symptoms that makes you think that it may be endometriosis.

00:13:39.200 --> 00:13:39.470
Yes.

00:13:39.470 --> 00:13:40.240
What's the next step?

00:13:40.460 --> 00:13:44.460
How do we go down the path of diagnosis and then also staging the condition as well?

00:13:44.860 --> 00:13:45.059
What staging

00:13:45.059 --> 00:13:46.019
options do you have?

00:13:46.019 --> 00:13:57.769
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.

00:13:58.169 --> 00:14:09.845
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.

00:14:10.445 --> 00:14:13.995
We also see non menstrual pain in severe cases.

00:14:14.534 --> 00:14:18.855
So, in terms of diagnosis careful history taking.

00:14:19.434 --> 00:14:21.774
Looking at what has been tried.

00:14:22.465 --> 00:14:24.975
And then getting a pelvic ultrasound.

00:14:24.985 --> 00:14:35.414
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.

00:14:35.414 --> 00:14:54.095
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.

00:14:54.164 --> 00:14:56.095
And it is a diffuse change.

00:14:56.664 --> 00:15:02.225
And so once we have done this, then we'll also make sure that at the same time.

00:15:03.125 --> 00:15:15.534
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.

00:15:16.250 --> 00:15:22.340
Family, or if they are very young, then, you know, we have to also address their contraceptive needs.

00:15:22.820 --> 00:15:32.450
If there are any psychological factors, lifestyle factors whether they have regular cycles or whether there's a component of polycystic ovaries there.

00:15:33.100 --> 00:15:40.289
And then generally for diagnosis we have to do a laparoscopy which is under general anesthesia.

00:15:40.289 --> 00:15:41.899
It's a hospital procedure.

00:15:41.899 --> 00:15:47.779
Laparoscopy is extremely common, but one in 750 cases anywhere in the world.

00:15:49.125 --> 00:16:13.424
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.

00:16:14.799 --> 00:16:30.700
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.

00:16:31.690 --> 00:16:39.980
Quite often, we propose, most gynecologists will propose, Putting in a Mirena, which is a progesterone IUD.

00:16:40.429 --> 00:16:44.210
So that will help in dealing with the periods post surgery.

00:16:44.960 --> 00:16:47.840
Because we can't cure endometriosis.

00:16:47.840 --> 00:17:02.960
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.

00:17:03.379 --> 00:17:05.470
In somewhere between three to five years.

00:17:05.480 --> 00:17:08.319
Severe cases, it can actually recur very soon.

00:17:08.319 --> 00:17:11.859
And then, you know, you're back to square one with pain and dealing with it.

00:17:12.299 --> 00:17:14.789
And repeated surgeries get challenging.

00:17:16.065 --> 00:17:23.515
So endometriosis is always in tricky locations and it is not in convenient locations.

00:17:23.515 --> 00:17:35.984
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.

00:17:35.984 --> 00:17:38.404
It can be in the ovarian fossa.

00:17:38.835 --> 00:17:41.984
It can be on the peritoneum overlying the ureter.

00:17:42.494 --> 00:17:48.095
It can be, close to the rectum and sigmoid in the pararectal region.

00:17:48.095 --> 00:17:52.075
So, we don't want to go there again and again if possible.

00:17:52.625 --> 00:18:02.224
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.

00:18:02.884 --> 00:18:08.654
If they say that, yeah, no, maybe, you know, I'll have endometriosis surgery done.

00:18:08.694 --> 00:18:12.575
And then, you know, maybe in a year or two, I'll start family.

00:18:12.575 --> 00:18:20.734
So in that case, we can skip the long acting progesterone IUD and consider other short acting measures.

00:18:21.164 --> 00:18:23.335
But I'll normally not do a MRI.

00:18:24.930 --> 00:18:47.829
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.

00:18:48.329 --> 00:18:50.559
So that case we need their help.

00:18:50.650 --> 00:18:51.970
Yeah A few

00:18:51.970 --> 00:18:54.269
questions come to mind in what you're saying there.

00:18:54.539 --> 00:18:56.220
The first one is the Pelvic Ultrasound.

00:18:56.220 --> 00:19:00.509
Is that a transvaginal Pelvic Ultrasound that's required or is it done just through the abdominal

00:19:00.769 --> 00:19:01.190
wall?

00:19:01.430 --> 00:19:01.650
Yeah.

00:19:02.049 --> 00:19:17.000
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.

00:19:17.579 --> 00:19:23.880
Which is fine, , but, you know, if you're heading towards laparoscopy, I don't worry too much about transvaginal.

00:19:24.859 --> 00:19:27.829
Someone is very shy and very young.

00:19:28.420 --> 00:19:33.940
I won't push for a transvaginal in that case, but generally speaking, it's transvaginal.

00:19:34.579 --> 00:19:38.779
The endometriosis specific ultrasound actually goes a step forward.

00:19:38.789 --> 00:19:45.660
So they need little bit of bowel prep also, and only specialized centers can do that.

00:19:45.799 --> 00:19:47.579
The routine ultrasound.

00:19:48.055 --> 00:19:50.345
Is not endometriosis specific.

00:19:50.875 --> 00:20:07.125
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.

00:20:07.755 --> 00:20:26.365
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,

00:20:26.414 --> 00:20:27.105
so it's getting better

00:20:27.105 --> 00:20:27.795
the investigation.

00:20:27.884 --> 00:20:28.454
It is getting

00:20:28.674 --> 00:20:29.494
better, yeah.

00:20:29.934 --> 00:20:37.644
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?

00:20:38.349 --> 00:20:41.630
So, it can be either ablation or excision.

00:20:42.160 --> 00:20:46.759
Ablation is really suitable only when it is a superficial disease.

00:20:47.339 --> 00:20:56.730
Generally speaking, if it is anything nodular or significant if we ablate it, the thermal spread will happen to the underlying structure.

00:20:57.654 --> 00:20:59.015
So that's not advisable.

00:20:59.805 --> 00:21:04.625
So in that case, I'll say more often it is excision.

00:21:05.194 --> 00:21:11.575
But if it is, in a tricky location, like I had one spot recently on.

00:21:12.454 --> 00:21:14.960
external iliac vessel, very close to it.

00:21:14.960 --> 00:21:19.500
So, and it was superficial, so I just retracted it and diathermied it.

00:21:20.130 --> 00:21:22.470
But it is a combination.

00:21:22.470 --> 00:21:36.309
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.

00:21:36.609 --> 00:21:38.769
Modality how they want to do it.

00:21:38.769 --> 00:21:43.750
So, bipolar cautery is very common to do the ablation.

00:21:44.079 --> 00:21:52.920
And for excision, we can go traditional with monopolar cautery, or else we can use ultrasound based energy sources.

00:21:52.950 --> 00:21:56.019
So like harmonic scalpel or thunder beat.

00:21:56.529 --> 00:21:58.670
Laser used to be a thing in the past.

00:21:58.670 --> 00:22:02.359
I've never used laser, so I think that was more in 80s.

00:22:03.400 --> 00:22:15.779
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.

00:22:15.839 --> 00:22:25.450
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.

00:22:25.460 --> 00:22:46.019
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

00:22:46.019 --> 00:22:46.339
track.

00:22:46.690 --> 00:22:47.109
Brilliant.

00:22:47.109 --> 00:22:47.730
Very clever.

00:22:48.644 --> 00:22:53.924
What about the, I can imagine with these tight spaces, the robotic surgery might have a place.

00:22:53.924 --> 00:23:02.154
Does that have a role in this sort of area?

00:22:55.414 --> 00:23:04.184
, Dr Monika Juneja: yes, robotic You don't need it for every case.

00:23:04.184 --> 00:23:07.210
And the vision will be much better.

00:23:07.259 --> 00:23:09.670
It will be less tiring for the surgeon.

00:23:10.299 --> 00:23:13.619
I haven't taken it on because it wasn't there.

00:23:15.009 --> 00:23:46.674
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.

00:23:46.674 --> 00:23:53.164
You can't really stage it prior to a laparoscopy unless on ultrasound you are seeing.

00:23:53.265 --> 00:23:55.055
Two big endometriomas.

00:23:55.555 --> 00:23:57.625
We call it as kissing ovaries.

00:23:57.625 --> 00:24:02.474
You can get indication of the ovaries are stuck to each other.

00:24:02.525 --> 00:24:09.325
They're big, they're stuck to back of the uterus and on ultrasound they can say it's fixed retroversion.

00:24:09.335 --> 00:24:16.214
Uterus is not moving and it's really pathologically retroverted, which is it's pointing backwards.

00:24:17.345 --> 00:24:24.569
And There you know before you go in that, okay, this is a stage four case of endometriosis.

00:24:24.579 --> 00:24:33.670
So there is a American Fertility Society classification which goes from minimal to mild to moderate to severe.

00:24:34.269 --> 00:24:41.509
Even in stage four, there is variation and practically I don't find it very useful.

00:24:42.059 --> 00:25:02.200
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.

00:25:02.569 --> 00:25:04.769
So, practically that is more.

00:25:05.234 --> 00:25:29.394
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.

00:25:29.394 --> 00:25:33.325
So that is more of a practical approach.

00:25:33.325 --> 00:25:37.335
Location based and visual.

00:25:38.505 --> 00:25:39.164
Excellent.

00:25:39.355 --> 00:25:43.795
What about the patients having problems with fertility and they've got endometriosis?

00:25:44.704 --> 00:25:46.884
What's the options for treatment in this scenario?

00:25:48.515 --> 00:25:57.045
So it will depend on symptoms and say if a woman is Close to 40.

00:25:57.295 --> 00:26:01.085
She hasn't got any symptoms of endometriosis.

00:26:01.654 --> 00:26:05.065
And ovarian reserve is on the lower side.

00:26:05.779 --> 00:26:08.049
She may have endometriosis, we don't know.

00:26:08.299 --> 00:26:16.970
She has got regular cycles, so we don't think it's an ovulatory infertility due to not producing eggs in a timely manner.

00:26:17.720 --> 00:26:23.670
So in those sort of cases, we can go straight for IVF.

00:26:25.365 --> 00:26:26.934
Provided the ultrasound is normal.

00:26:27.884 --> 00:26:38.325
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.

00:26:39.095 --> 00:26:52.345
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.

00:26:53.035 --> 00:27:02.125
So the outcome improves with treatment of endometriosis laparoscopically prior.

00:27:02.125 --> 00:27:12.515
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.

00:27:13.125 --> 00:27:16.265
So,, prioritize Conceiving first.

00:27:16.275 --> 00:27:21.884
So the best thoughts of conception will be when we have just cleared endometriosis.

00:27:21.944 --> 00:27:24.964
It hasn't had a chance to grow back.

00:27:25.384 --> 00:27:27.714
So that's the best time actually to conceive.

00:27:27.724 --> 00:27:30.494
Now if someone is 20, obviously they are not ready.

00:27:31.005 --> 00:28:04.670
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.

00:28:05.089 --> 00:28:12.690
So even if Every bit of endometriosis is cleared up it's not a surety that everyone will conceive naturally.

00:28:13.130 --> 00:28:26.619
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?

00:28:27.299 --> 00:28:35.240
So we're not sure how exactly endometriosis affects the Fertility, what the mechanism is.

00:28:35.930 --> 00:28:42.500
So there are various theories and what is happening in a particular person is anybody's guess.

00:28:42.500 --> 00:29:11.920
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.

00:29:12.559 --> 00:29:16.819
In severe cases, it can also be due to the egg quality.

00:29:17.250 --> 00:29:18.950
That the ovarian reserve is low.

00:29:18.950 --> 00:29:21.609
The quality of the eggs is not good.

00:29:21.650 --> 00:29:25.730
That could be affecting their odds of conceiving.

00:29:25.730 --> 00:29:27.730
So, the per cycle fecundity.

00:29:28.414 --> 00:29:41.464
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%.

00:29:41.664 --> 00:29:51.815
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.

00:29:52.940 --> 00:29:59.140
It's amazing if you are doing a laparoscopic surgery to ablate or to remove the endometrial tissue.

00:29:59.319 --> 00:29:59.650
Yes.

00:29:59.700 --> 00:30:04.174
And the person's thinking about a family and they're in, say they're an order age group.

00:30:04.654 --> 00:30:07.265
Is there a role for harvesting eggs exit at the same time?

00:30:07.265 --> 00:30:11.644
Would that be considered or is that something that's a separate group that would do that through a second laparoscopy?

00:30:11.924 --> 00:30:15.265
So harvesting the egg is we can't do it at the same time.

00:30:15.474 --> 00:30:15.565
Right.

00:30:15.865 --> 00:30:17.755
So basically they have to.

00:30:18.285 --> 00:30:20.194
see the fertility specialist.

00:30:20.194 --> 00:30:23.704
I have to refer them on to an IVF clinic.

00:30:24.035 --> 00:30:25.474
It's a separate process.

00:30:25.494 --> 00:30:32.505
So you have to give a lot of hormones, gonadotropins to stimulate the ovaries.

00:30:33.005 --> 00:30:44.204
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.

00:30:45.595 --> 00:30:51.634
So we normally cannot just cut the ovary and save it for use at a later date.

00:30:51.765 --> 00:30:53.095
There's an orthopaedic based question.

00:30:54.625 --> 00:30:56.644
I get that asked a lot by patients.

00:30:56.825 --> 00:31:01.045
Oh, can you just save my eggs at the same time that you are doing the surgery?

00:31:01.744 --> 00:31:04.444
So it is a common question.

00:31:06.414 --> 00:31:07.684
Right, so I'm not alone then.

00:31:07.724 --> 00:31:09.085
No, you're not alone there.

00:31:09.625 --> 00:31:09.734
Okay.

00:31:10.174 --> 00:31:12.684
It's a question off the top of my head as we're speaking.

00:31:13.654 --> 00:31:16.305
What is multidisciplinary approach for endometriosis?

00:31:16.335 --> 00:31:23.434
Obviously it sounds like it's basically gynecologist treatment, and you mentioned the colorectal teams when it's involving the rectum and other areas.

00:31:23.734 --> 00:31:26.134
Are there any other teams that you have involved in the treatment?

00:31:26.134 --> 00:31:29.555
I mean, is there a specialist nurse that is involved in intermediate treatment as well?

00:31:29.575 --> 00:31:34.505
Or is there other teams that are involved like there are for other conditions we have around medicine?

00:31:35.244 --> 00:31:41.375
So, in terms of specialties I involve urologists, fortunately not very often.

00:31:41.375 --> 00:32:00.785
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.

00:32:01.164 --> 00:32:12.994
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.

00:32:13.835 --> 00:32:15.015
Also a psychologist.

00:32:15.684 --> 00:32:21.585
Quite often, you know, you have treated the endometriosis, but about 20 percent can still have persistent pain.

00:32:22.115 --> 00:32:35.515
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.

00:32:35.515 --> 00:32:39.744
So that can cause dyspareunia and ongoing pain.

00:32:40.934 --> 00:32:51.894
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.

00:32:51.954 --> 00:32:56.555
And having a good support from the GP is of course very important.

00:32:56.914 --> 00:33:03.914
So someone who is sympathetic and can be the anchor point to coordinate the care as well.

00:33:05.265 --> 00:33:05.815
Brilliant.

00:33:05.875 --> 00:33:07.265
There's a huge team involved.

00:33:07.275 --> 00:33:09.494
There's a lot more than I expected and it's great to hear it.

00:33:10.125 --> 00:33:16.134
It's a it's an amazing condition and I'm still so surprised I don't know more about it.

00:33:16.434 --> 00:33:22.494
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.

00:33:22.494 --> 00:33:24.775
Where do you think the advances are in the future?

00:33:24.775 --> 00:33:26.664
Where do you think things are heading for this condition?

00:33:26.664 --> 00:33:30.355
Can you see light at the end of the tunnel or is it still far away at this stage?

00:33:30.954 --> 00:33:34.710
I think we'll have better imaging modalities.

00:33:35.480 --> 00:33:39.869
So the ultrasound diagnosis will continue to improve.

00:33:40.730 --> 00:33:48.009
There is funding now for MRI, so it is rebatable if we are suspecting severe endometriosis.

00:33:48.009 --> 00:34:00.325
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.

00:34:01.045 --> 00:34:17.655
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.

00:34:17.655 --> 00:34:23.445
That might improve the outcome and it can also hopefully reduce the size of fibroids.

00:34:23.695 --> 00:34:36.304
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.

00:34:36.855 --> 00:34:48.344
The IUDs which have got a different hormone and combination of medications to, Help to deal with the problem long term.

00:34:49.014 --> 00:34:52.594
And perhaps better pain control measures.

00:34:53.144 --> 00:34:55.704
This stage, that's what I can think of.

00:34:56.344 --> 00:34:56.554
That's

00:34:56.565 --> 00:34:56.855
brilliant.

00:34:56.954 --> 00:35:00.454
There's a lot of better things on the horizon there, which is good news for the future.

00:35:00.534 --> 00:35:08.425
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.

00:35:08.445 --> 00:35:11.835
I'm really pleased you're able to come along and give us some more information about this topic.

00:35:11.835 --> 00:35:14.385
So I'd like to thank you very much for your time.

00:35:14.385 --> 00:35:15.003
And we'll see you next time.

00:35:15.052 --> 00:35:18.293
Really appreciate the advice and the information you've given us today.

00:35:18.373 --> 00:35:18.943
Thank you very much,

00:35:18.943 --> 00:35:19.342
Monika.

00:35:19.793 --> 00:35:21.402
Thanks a lot for having me here.

00:35:21.402 --> 00:35:23.172
It was my pleasure to be here.

00:35:23.603 --> 00:35:24.003
Excellent.

00:35:24.052 --> 00:35:25.003
Thank you very much.

00:35:25.166 --> 00:35:27.056
Thank you very much for listening to our podcast today.

00:35:27.346 --> 00:35:33.266
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.

00:35:33.666 --> 00:35:38.356
If you have any concerns or questions about what we've discussed, you should seek advice from your general practitioner.

00:35:38.876 --> 00:35:43.635
I'd like to thank you very much for listening to our podcast and please subscribe to the podcast for the next episode.

00:35:43.786 --> 00:35:45.536
Until then, please stay safe.

Dr Monika Juneja

Dr Monika Juneja became visiting medical specialist at the Women’s and Children Hospital in 2007 and commenced private practice in Adelaide in August, 2008. She is extensively trained in laparoscopic and vaginal surgery.

She did a Masters in minimally invasive surgery(MMIS) from the University of Adelaide in 2010. She also works as senior staff specialist at the Flinders Medical Centre. She is a recognised teacher for advanced laparoscopic surgery training program and has passion for teaching. She is also examiner for MD program at the Flinders University.

She is accredited with the highest level of advanced gynaecological laparoscopic surgery- RANZCOG level VI at Flinders Private hospital, Ashford Hospital, Glenelg Community hospital and at the Flinders Medical Centre.

Dr Juneja completed MD in O&G from the prestigious Christian Medical College, Vellore in India in 1999. She gained extensive experience in obstetrics and gynaecological procedures as well as completed thesis on effect of Tamoxifen therapy on post-menopausal women.

Endometriosis Unmasked A Conversation with Dr. Monika Juneja

Dr Monika Juneja

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