Send us a text with a question or thought on this episode ( We cannot replay from this link)
We reframe endometriosis as a whole-body disease and map how gut microbes, blood vessels, and lymphatics drive symptoms, pain, and fatigue. Dr. Gaby Moawad shares strategies for multidisciplinary care that builds trust, reduces inflammation, and improves long-term quality of life.
• endometriosis defined as multi-systemic, not just pelvic pain
• harms of dismissal and why trust and clear plans matter
• microbiome dysbiosis, estrobolome, LPS, and estrogen recycling
• targeted gut recovery beyond unnecessary antibiotics and laxatives
• angiogenesis via VEGF, HIF, MMPs, and leaky vessels
• lymphatic spread evidence and distant organ involvement
• metabolic dysfunction, insulin resistance, mitochondria, and fatigue
• multidisciplinary care beyond the OR and throughout recovery
• recurrence as multifactorial and the need for long-term strategy
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Website endobattery.com
Rethinking Endometriosis As Systemic
Speaker 4
0:00
What
if
endometriosis
isn't
just
a
gynecologic
condition,
but
a
whole
body
ecosystem
problem?
From
the
gut
microbiome
to
the
lymphatic
and
vascular
systems,
we're
uncovering
how
the
body's
networks
may
hold
the
clues
to
why
symptoms
spread,
persist,
and
often
differ
from
each
other.
How
would
you
define
systemic
disease?
Speaker 2
0:22
This
is
the
problem
of
medicine.
We
still
work
in
silos.
When
we
think
about
endometriosis,
doctors
think
it's
pain
and
fertility.
And
the
disease
is
beyond
that.
When
we
do
surgery,
we
think
healing
is
based
on
the
surgical
metrics
that
the
surgeon
perceived.
She
didn't
bleed,
we
removed
the
disease.
But
endometriosis,
when
we
talk
about
multisystemic,
when
we
do
a
review
of
system,
we
look
at
the
eyes,
the
nose,
the
breathing,
the
neurologic,
the
mental,
physical,
everything.
Every
system
is
assessed.
When
we
look
about
endometriosis,
endometriosis
is
beyond
pelvic
pain.
It
affects
the
gut,
it
affects
the
lung,
it
affects
the
breathing,
it
impacts
mental
health.
So
there
are
multiple
systems
affected.
So
now
you
wonder,
okay,
what
is
this
guy
saying?
Bacteria
and
voodoo
science.
How
does
it
work
in
real
life?
So
we
know
there
is
something
called
estroblem.
Estroblome
is
the
metabolism
of
estrogen.
Now,
the
uh
bacteria,
the
opportunistic
bacteria,
they
produce
what
we
call
beta-glucorin
glucoronidase
deconjugating
enzyme.
And
this
is
a
crazy
name.
But
what
does
it
do?
This
will
impair
the
reabsorption
and
the
recycling
of
estrogen
through
the
liver.
We
call
it
enterohepatic
cycle
of
estrogen.
What
it
leads
to,
it
leads
to
an
increase
in
estrogen
in
the
body.
And
we
know
endometriosis
is
an
estrogen-dependent
disease
that
leads
to
more
uh
inflammation
and
that
leads
to
more
pain
and
then
uh
deeply
infiltrative
endometriosis.
It's
beyond
only
a
surgery.
It's
the
endometriosis
treatment
is
a
multidisciplinary,
comprehensive,
and
that
requires
an
effort
from
a
lot
of
other
parties,
the
different
doctors,
different
pelvicular
therapists,
holistic
approaches
to
ensure
that
the
patient's
quality
of
life
is
restored
in
a
healthy
way.
Because
as
surgeons,
we
do
the
surgery,
patient
goes
home,
but
the
patients
probably
deal
with
gas
and
bloating
for
a
longer
period
after
their
surgery.
So
if
you
don't
provide
them
something
or
help
to
restore
their
normal
function,
we
would
be
suboptimally
treating
our
patients.
Patients
with
endometriosis
tend
to
have
more
gut
dysfunction,
they
are
more
constipated,
they
use
overtly
some
laxative
to
go
to
the
bathroom,
and
that
leads
to
a
major
disruption.
And
that
disruption
creates
more
inflammation,
and
that
inflammation
creates
poor
you
know,
excreting
of
estrogen
or
metabolizing
estrogen
that
will
put
them
at
the
hyper-estrogenic
states,
and
then
there
are
a
lot
of
consequences
on
the
inflammation
from
that.
Meet Dr. Gabby Mawad
Speaker 4
3:15
Dr.
Gaby
Moawad
and
I
sit
down
to
discuss
this
and
so
much
more.
So
stick
around.
This
podcast
is
not
a
substitute
for
medical
advice,
but
a
supportive
space
to
provide
community
and
valuable
information
so
you
never
have
to
face
this
journey
alone.
We
embrace
a
range
of
perspectives
that
may
not
always
align
with
our
own,
believing
that
open
dialogue
helps
us
grow
and
gain
new
tools.
Join
me
as
I
share
stories
of
strength,
resilience,
and
hope,
from
personal
experiences
to
expert
insights.
I'm
your
host,
Alana,
and
this
is
Endo Battery,
charging
our
lives
when
endometriosis
drains
us.
Welcome
back
to
Endo Battery.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
at
the
table.
Today's
guest
is
someone
who's
truly
changing
the
landscape
of
endometriosis
care.
Professor
Gaby
Moawad
is
a
globally
recognized
leader
in
robotic
surgery
and
endometriosis
management.
He's
a
board-certified
gynecologic
surgeon
and
the
founder
of
the
Center
for
Endometriosis
and
Advanced
Pelvic
Surgery
in
Washington,
D.C.
Dr.
Mawad
has
dedicated
his
career
to
advancing
minimally
invasive
and
robotic
techniques,
combining
surgical
innovation
with
deep,
compassionate,
patient-centered
care.
As
director
of
robotic
gynecologic
surgery
and
associate
professor
at
George
Washington
University,
he's
trained
surgeons
worldwide
and
helped
redefine
how
we
approach
complex
pelvic
disease.
He's
been
named
Top
Doctor
in
Washington,
D.C.
for
nearly
a
decade
and
has
authored
over
125
peer-reviewed
publications
leading
global
conversations
on
endometriosis
and
surgical
innovation.
It's
an
honor
to
sit
down
and
welcome
a
true
pioneer
and
advocate
for
better
outcomes
for
women
everywhere.
Please
help
me
in
welcoming
Dr.
Gaby
Moawad.
Thank
you,
Gaby,
for
sitting
down
with
me
today
and
coming
all
the
way
to
beautiful
Fort
Collins
to
spend
time
with
us
and
go
over
all
the
things
that
I
have
a
burning
question
Do No Harm And Patient Trust
Speaker 4
5:30
about.
But
one
of
the
burning
questions
I
want
to
start
with
is
what
made
you
so
passionate
to
continue
educating
and
educating
yourself
with
endometriosis
and
pursuing
greatness
in
endometriosis?
Speaker 2
5:42
First,
before
I
answer
your
question,
I
want
to
thank
you
and
thank
you
for
all
the
work
you
do
through
Endo village.
It's
great
that
we
have
advocacy
groups
like
you
being
able
to
change
the
paradigm
in
patients'
understanding
and
patient
education.
The
answer
to
your
question
is
a
little
bit
complex.
You
know,
every
everything
starts
from
lifetime
experience,
a
personal
journey.
So
through
my
encounters
with
healthcare
as
a
patient
before
I
became
a
doctor,
I
realized
that
listening
to
a
patient
and
the
trust
in
healthcare
is
at
the
core
of
the
value
of
the
care
that
we
provide
to
patients.
So
whenever
patients
are
dismissed,
whenever
patients
are
gaslit,
that
leads
to
poor
care.
And
when
I
went
through
gynecology,
I
was
appealed
by
it
because
it
involves
intricate
surgical
skills
that
can
help
making
a
change
in
the
quality
of
life
of
patients.
Through
my
journey,
my
studies,
and
then
my
fellowship
in
minimally
invasive
surgery,
I
realized
there
is
a
subset
of
patients,
patients
with
endometriosis
or
with
chronic
pain.
This
subset
was
poorly
understood.
And
for
me,
it
was
like
a
puzzle.
Puzzle
that
made
me
delve
into
deciphering
that
code
and
understanding
better
how
we
can
provide
a
better
care
for
this
subset
of
patients.
That
led
to
educating
myself
more
about
the
disease,
more
about
the
impact
of
the
disease,
and
then
how
can
we
provide
a
better
quality
of
care
for
this
subset
of
patients?
And
in
addition
to
that,
the
challenges,
the
surgical
challenges
that
endometriosis
poses
for
a
surgeon
requires
extensive
training
and
standardization
of
the
surgical
care
to
have
better
and
superior
outcome
for
patients.
All
in
all,
here
I
am,
15
years
after
still
dealing
with
my
favorite
group
of
patients,
endometriosis
patients.
Speaker 4
7:49
And
we
thank
you
for
that
because
it's
not
an
easy
population.
Something
we've
talked
about
before
is
that
there
is
this
isn't
brought
up
in
medical
school
that
often.
This
is
not
something
that
you
learn
a
lot
about
in
medical
school.
So
for
you
to
continue
in
that
path
of
educating
yourself
and
what
we're
going
to
get
into
is
astonishing.
Like
I'm
always
blown
away
by
your
knowledge
and
the
way
that
you
dig
deep
into
endometriosis
and
how
to
help
your
patients
and
patients
worldwide,
not
just
your
patients,
but
everyone.
It's
just
astonishing.
Speaker 2
8:19
Well,
I
think
if
we
go
back
to
the
basics
of
medicine,
the
main
important
rule
of
medicine
is
do
no
harm.
Speaker 4
8:27
Right.
Speaker 2
8:28
Do
no
harm
is
very
deep
because
we're
doing
indirect
harm
by
dismissing
patients.
And
the
harm
does
not
need
to
be
physical,
it's
psychological
harm.
Most
of
the
patients
with
endometriosis
are
impacted
by
mental
health
problems
because
of
these
situations
that
we
indirectly,
with
our
poor
understanding
and
poor
knowledge
and
dismissal
of
patients,
lead
to
this
harm.
So
every
doctor
should
understand
the
value
of
referral
patients
that
they
do
not
know
or
they
don't
understand
their
conditions,
because
there
are
a
specialist,
they
could
maybe
provide
a
better
care
and
not
keep
the
patient
for
the
sake
of
having
a
patience
or
having
a
thriving
business
rather
than
referring
the
patients
to
a
specialist,
and
this
way
they
will
be
completing
their
oath
of
do
no
harm.
Speaker 4
9:25
Right.
One
of
the
things
that's
not
well
understood,
I
think,
for
most
OBGYNs
is
the
fact
that
endometriosis
is
a
whole
systemic
disease.
How
would
Defining Multisystemic Disease
Speaker 4
9:35
you
define
systemic
disease?
How
would
you
phrase
this
to
let
people
know
like
this
is
systemic
and
this
is
what
systemic
means?
Speaker 2
9:43
This
is
the
problem
of
medicine.
We
still
work
in
silos.
When
we
think
about
endometriosis,
doctors
think
it's
pain
and
fertility.
And
the
disease
is
beyond
that.
When
we
do
surgery,
we
think
healing
is
based
on
the
surgical
metrics
that
the
surgeon
perceived.
She
didn't
bleed,
we
removed
the
disease.
But
endometriosis,
when
we
talk
about
multisystemic,
when
we
do
a
review
of
system,
we
look
at
the
eyes,
the
nose,
the
breathing,
the
neurologic,
the
mental,
physical,
everything.
Every
system
is
assessed.
When
we
look
about
endometriosis,
endometriosis
is
beyond
pelvic
pain.
It
affects
the
gut,
it
affects
the
lung,
it
affects
the
breathing,
it
impacts
mental
health.
So
there
are
multiple
systems
affected.
And
this
is
when
we
say
multisystemic
disease,
because
that
disease
is
beyond
the
pelvis,
is
affecting
multiple
systems
in
the
body.
Speaker 4
10:41
Yeah.
I
mean
it
affects
everything.
Whole
life.
My
motto,
whole
body,
whole
life,
disease.
Speaker 2
10:48
You
know,
I'm
gonna
spill
a
secret.
I
was
not
the
same
doctor
five
years
ago
or
ten
years
ago.
If
I
will
be
the
same
doctor
five
years
from
now,
that
means
I
would
be
failing
myself
and
my
patients.
So
we
have
to
do
a
continuous
learning,
especially
about
the
area
of
expertise
or
our
niche
or
the
stuff
that
we
treat.
And
this
will
enable
us
to
serve
better
our
patients,
to
understand
better
the
disease,
and
to
contribute
better
to
research
and
emerging
therapies.
Speaker 4
11:18
Yeah.
And
we
should
always
strive
for
better.
Speaker 2
11:20
Yes.
Speaker 4
11:21
I
mean,
as
a
patient,
we
should
strive
for
better
and
expect
better.
Speaker 2
11:25
That's
why
you
have
a
crucial
job
of
educating
and
empowering
patients
with
endometriosis
through
advocacy
group
so
they
can
choose
better
and
they
can
enforce
the
paradigm
change
and
push
doctors
to
learn
more
and
then
serve
them
better
and
then
help
them
with
their
disease
to
improve
their
quality
of
lives.
Speaker 4
11:46
Yeah.
It's
it's
invaluable
to
continue
talking
about
it,
but
also
pushing
for
better
care
for
everyone.
And
I
think
that's
something
that
I
have
really
focused
on
is
making
sure
that
when
I
communicate,
it's
not
just
for
me,
it's
for
everyone.
Because
it
takes
the
whole
village,
as
you
know.
Yes,
yes.
Part
of
understanding
um
endo
and
its
systemic
nature
and
the
ecosystem
is
Continuous Learning And Advocacy
Speaker 4
12:10
understanding
how
it
affects
our
whole
body.
Can
we
go
into
how
it
affects
our
microbiome?
Because
this
is
a
big
topic
that's
been
talked
about
recently.
How
do
we
know
about
the
way
it
affects
our
gut
vaginally,
all
of
that?
What
is
the
microbiome,
first
of
all,
and
how
does
it
affect
us
living
within
triosis?
Speaker 2
12:28
So
microbiome
is
a
group
of
bacteria
that
coexist
together
and
survive
in
the
body
cavity
mainly,
the
gut,
the
mouth,
the
vagina.
And
then
any
disruption
of
that
microbiome,
we
call
it
dysbiosis.
When
there
is
a
problem
in
the
numbers
of
bacteria,
the
prevalence
of
certain
bacteria,
the
absence
of
certain
bacteria,
that
leads
to
a
lot
of
issues.
So
what
we
know
uh
from
human
studies,
and
I'm
gonna
stratify
between
the
gut,
the
oral,
and
then
the
vaginal,
uh,
the
gut
microbiome,
there
are
a
group
of
bacteria
that
are
called
alpha
taxa.
Taxa
is
a
group
of
bacteria.
They
are
reduced
in
the
gut
endometriosis.
And
then
the
opportunistic
bacteria
or
bacteria
like
enterobacteria
say,
this
is
a
group
of
bacteria,
prevotella,
there
are
more
prevalent
in
the
body.
And
that
has
been
correlated
with
pain
and
severity
of
the
disease.
Now,
we
go
to
the
vagina.
In
basically
all
the
study,
there
has
been
a
decreased
number
of
lactobacilli.
Lactobacillus
is
a
bacteria
that
is
present
in
a
healthy
gut
and
then
that's
transmitted
to
the
vagina.
And
then
the
bacteria
that
are
that
causes
in
many
patients
bacterial
vaginosis
or
smelly
discharge
are
more
prevalent
in
the
vagina
in
patients
with
endometriosis.
And
then
some
of
those
bacteria
we
know
Gardnerella,
Prevotella
as
well,
these
showed
that
they
correlate
also
with
the
inflammation
and
the
presence
of
endometriosis
lesions.
When
we
talk
about
the
oral
microbiome,
we
know
that
in
patients
with
endometriosis,
they
have
more
gum
issues.
A
lot
of
patients
with
endometriosis
have
bleeding
gum,
they
have
peridontitis.
And
this
was
this
disruption
was
associated
also
with
more
inflammatory
markers
that
we
can
detect
from
the
saliva
in
patients
with
endometriosis.
So
now
you
wonder,
okay,
what
is
this
guy
saying?
Bacteria
and
voodoo
science.
How
does
it
work
in
real
life?
So
we
know
there
is
something
called
estroblome.
Estroblom
is
the
metabolism
of
estrogen.
Now,
the
uh
bacteria,
the
opportunistic
bacteria,
they
produce
what
we
call
beta-glucorin
uh
glucorinidase
deconjugating
enzyme.
And
this
is
a
crazy
name.
But
what
does
it
do?
This
will
impair
the
reabsorption
and
the
recycling
of
estrogen
through
the
liver.
We
call
Microbiome Basics And Dysbiosis
Speaker 2
15:05
it
the
enterohepatic
cycle
of
estrogen.
What
it
leads
to,
it
leads
to
an
increase
in
estrogen
in
the
body.
And
we
know
endometriosis
is
an
estrogen-dependent
disease
that
leads
to
more
inflammation
and
that
leads
to
more
pain
and
then
uh
deeply
infiltrative
endometriosis.
We
go
on
the
other
end,
those
opportunistic
bacteria,
when
they
break
down,
they
produce
substances
like
LPS
or
lipopolysaccharides,
and
those
promote
inflammation
as
well
and
promote
the
aggressiveness
of
the
lesions
of
endometriosis.
And
even
in
some
studies,
they
found
DNA
of
bacteria
in
endometriotic
lesions.
So
there
is
a
clear
combination.
Now
go
back
to
also
the
good
bacteria
produces
what
we
call
short
chain
fatty
acids.
And
those
short
chain
fatty
acids
can
help
protecting
the
gut
barrier.
So
that's
why
we
have
leaky
guts
in
the
presence
of
the
opportunistic
bacteria
and
the
absence
of
those
bacteria
that
produces
those.
So
these
substances
also
promote
further
inflammation
and
it
will
become
a
cycle.
So
these
are
some
of
the
reasons
why
the
gut
is
extremely
important
and
the
microbiome
is
extremely
important
in
reducing
the
inflammation
and
decreasing
the
progression
and
the
pain
in
endometriosis.
Speaker 4
16:34
Sounds
really
complex
though.
Speaker 2
16:36
It's
not
it's
not
really
complex,
but
when
we
break
it
down
and
simplify
it,
we
know
there
is
a
link.
And
then
we
know
in
a
lot
of
studies,
even
though
the
studies
need
to
be
bigger
and
more
stronger
studies
to
try
to
identify
different
subtypes
of
endometriosis
that
would
be
affected.
Because
as
I
mentioned,
this
biosis
or
the
imbalance
of
the
bacteria
could
lead
to
the
increase
the
disease
burden
and
the
pain
and
the
infiltrativeness
of
the
disease.
But
the
the
studying
the
genetics,
how
we
treat
the
bacteria,
probiotic,
antibiotics,
or
even
some
enzymes
that
can
help
promoting
the
balance
of
the
bacteria
we
have
in
our
body.
So
that's
why
I
encourage
a
lot
of
patients
not
to
take
here
and
there
any
medications,
not
to
do
all
those
enemas
sometimes
because
they
have
a
gut
dysfunction,
because
these
help
flush
the
good
bacteria,
and
one
of
the
hardest
things
to
restore
is
the
microbiome.
Restoring
the
balance
takes
a
longer
period
of
time.
We
see
now
we
introduce
in
our
practice
as
part
of
the
recovery
a
gut
recovery
protocol
because
we
believe
it's
beyond
only
a
surgery.
It's
the
endometriosis
treatment
is
a
multidisciplinary,
comprehensive,
and
that
requires
an
effort
from
a
lot
of
other
parties,
the
different
doctors,
different
velvicular
therapists,
holistic
approaches
to
ensure
that
the
patient's
quality
of
life
is
restored
in
a
healthy
way.
Because
as
surgeons,
we
do
the
surgery,
patient
goes
home,
but
the
patients
probably
deal
with
gas
and
bloating
for
a
longer
period
after
their
surgery.
So
if
you
don't
provide
them
something
or
help
to
restore
their
normal
function,
we
would
be
suboptimally
treating
our
patients.
Speaker 4
18:32
How
could
microbiome-based
therapies
realistically
be
implemented
in
metriosis
care?
Speaker 2
18:39
So
again,
as
I
said,
the
microbiome,
now
we
understand
more
on
the
mechanism.
Some
of
the
proposed
therapy,
as
I
mentioned,
targeting
the
opportunistic
bacteria
or
the
bad
bacteria,
trying
to
reinforce
the
action
or
restore
the
good
bacteria
with
probiotic,
for
example,
antibiotics
try
to
kill
the
bad
bacteria.
Now,
also
targeting,
I
think
the
treatment
is
beyond
maybe
using
some
gene
sequences
of
bacteria
to
diagnose
the
disease
or
diagnose
the
severity
of
the
disease
or
identify
subtypes
of
the
disease
that
would
cause
more
imbalance
or
dysbiosis.
Estrobolome, LPS, And Estrogen Cycling
Speaker 2
19:20
So
these
combined
efforts
that
we
still
need
to
understand
more
the
accurate
impact
and
the
different
subtypes
of
endometriosis
that
could
benefit
from
these
kind
of
therapeutic.
Speaker 4
19:35
Would
antibiotics
play
a
huge
role
in
this?
Because
a
lot
of
patients
who
have
endometriosis
are
constantly
put
on
antibiotics
because
they're
told
they
have
UTIs
or
they
have
who
knows
what
else,
right?
We
get
all
the
diagnosis
that
you
can
think
of.
Does
this
impact
that
significantly?
Speaker 5
19:52
Yes.
Speaker 4
19:53
Therefore
increasing
the
inflammation,
the
growth
of
endometriosis.
Like
it
seems
like
it's
a
whole
rabbit
wheel
of
or
hamster
wheel
of
it.
It's
a
vicious
circle.
Speaker 2
20:03
Yes,
yes,
of
course.
And
that's
why
we
know
that
disrupting
that
microbiome,
whether
through
unnecessary
antibiotics,
whether
through
unnecessary
intervention,
you
know,
when
you
do
endometriosis
surgery
or
when
you
do
sometimes
an
MRI,
some
patients
are
given
laxatives.
Patients
with
endometriosis
tend
to
have
more
gut
dysfunction,
they
are
more
constipated,
they
use
overtly
some
laxative
to
go
to
the
bathroom,
and
that
leads
to
a
major
disruption.
And
that
disruption
creates
more
inflammation,
and
that
inflammation
creates
poor
excreting
of
estrogen
or
metabolizing
estrogen
that
will
put
them
at
a
hyper-estrogenic
state,
and
then
there
are
a
lot
of
consequences
on
the
inflammation
from
that.
So
it's
all
a
vicious
circle.
That's
why
I
believe
endometriosis
patients
or
endometriosis
suspected
patients
need
to
at
least
see
a
specialist
so
they
can
create
a
strategy,
a
long-term
strategy,
a
comprehensive
strategy
for
their
care.
Because
the
care
is
beyond
surgery,
is
beyond
birth
control
pill,
is
beyond
any
uh
of
these
interventions.
It's
more
of
a
total
body
intervention.
Speaker 4
21:16
I
think
that's
something
that
we
struggle
with
though,
because
most
of
the
time
we
don't
feel
good
on
top
of
all
of
these
other
things
that
we're
going
through.
So
to
rebuild
or
to
make
our
gut
feel
better
is
a
chore.
It's
a
challenge.
Speaker 5
21:28
Of
course.
Speaker 4
21:29
So
that's
what
is
challenging
from
the
patient
side
is
it's
a
constant
trial
and
error
for
us.
And
it's
we
work
so
hard
to
just
try
to
get
to
feel
a
little
bit
normal,
to
understand
the
gut
and
uh
working
with
someone
that
can
understand
your
gut
microbiome
better,
I
think
could
help
us
in
the
long
run.
Speaker 2
21:46
Yes,
yes,
definitely.
Speaker 4
21:47
So
we've
talked
about
the
invisible
microbiome
and
shaping
and
everything
else
from
the
disease.
Let's
shift
into
something
that's
a
little
bit
more
visible,
blood
vessels.
And
we're
gonna
go
into
blood
vessels
and
lymphatic
pathways
and
how
they
might
actually
feed
or
spread
with
endometriosis.
Speaker 2
22:05
Well,
if
you
you're
looking
for
complexity,
here's
your
complex
answer.
So
there
are
there
are
a
few
substances
that
I
think
every
endometriosis
patient
should
at
least
try
to
remember
some
names
or
understand
what
they
do
in
endometriosis.
Every
endometriotic
cell
needs
oxygen
to
grow,
needs
nutrients
to
grow,
and
then
needs
blood
vessels
to
evacuate
their
waste.
This
is
part
of
almost
every
cell
in
the
body
rather
than
endometriosis
cells
only.
So
in
endometriosis
cells,
there
are
what
we
call
VEGF,
vascular
endothelial
growth
factor,
and
then
VEGF
receptors.
So
there
is
a
more
higher
prevalence
of
VEGF
that
help
producing
what
we
call
angiogenesis
and
vasculogenesis,
angiogenesis
creating
new
blood
vessels.
So
those
lesions,
because
of
the
scarring
that
happens,
they
are
in
a
hypoxic
state
or
poor
oxygen
comes
there.
So
they
develop
what
we
call
hypoxia-induced
factor,
Gut Recovery And Multidisciplinary Care
Speaker 2
23:10
HIF
alpha.
That
what
this
produces,
it
upregulates
the
receptor
to
attract
more
VEGF
to
produce
more
blood
vessels.
So
that
CIF
is
a
substance
that
says,
I
don't
have
any
vessels
coming
to
bring
me
oxygen,
so
let's
bring
in
more
of
the
vascular
endelial
growth
factor,
so
they
produce
more
blood
vessels.
Now,
in
addition
to
that,
the
inflammatory
mediators,
interleukin
A,
tumor
necrosis
factor,
they
also
promote
inflammation
and
increase
the
VEGF
in
the
endometriosis
cells.
So
you
can
see
how
the
circles
is
doing
things,
and
the
estrogen
is
present
in
high
concentration
in
endometriosis
lesions
because
there
is
the
aromatase.
They
produce
their
own
estrogen,
the
endometriosis
cells.
Now
add
to
this
through
all
that
concoction,
there
is
what
we
call
MMPs.
This
is
metalloproteinase.
These
are
substances
that
break
down
the
matrix
around
the
cells
for
endometriosis,
break
down
those
proteins
to
create
space
for
blood
vessels
to
form.
So
now
we
see
all
those
blood
vessels
have
space
to
form,
they
start
forming.
And
we
can
see
a
higher
density
even
on
imaging
of
endometriosis
lesions
when
we
do
the
contrast
on
MRI,
they're
hypervascularized.
Now,
throughout
that
whole
medium,
what
happens?
Those
inflammation
start
promoting
the
bone
marrow
to
produce
EPCs,
EPC
endothelial
progenitor
cells.
So
these
are
cells
that
come
and
cheerlead
the
formation
of
vessels.
So
you
have
a
higher
number
of
those
cells,
so
everybody
is
engaged
to
produce
more
vessels
in
the
endometriosis
lesions.
Then
we
do
say,
oh,
endometriosis
lesions
bleeds.
Why?
Because
there
is
on
every
blood
vessels
a
lining
of
cells.
We
can
call
them
pericytes.
Peri
means
near,
they
lines,
those
sites
mean
cells,
they
line
the
blood
vessels.
So
there
is
an
immature
support
of
those
pericytes.
That's
why
those
blood
vessels
are
leaky,
and
that's
why
they
tend
to
leak
blood
outside,
and
that's
what
they
bleed.
So
you
can
see
how
that
angiogenesis
or
the
formation
of
blood
vessel
is
led
by
inflammation,
by
hyperestrogenism,
local
hyperestrogenism
in
the
lesions,
by
all
those
substances
created
to
promote
from
the
body,
from
the
bone
marrow,
to
promote
further
formations
of
immature
cells
that
leads
to
bleeding
and
then
engage
further
the
body
to
inflame
more.
Speaker 4
25:55
Is
that
why
we
get
variation
in
color
for
the
lesions
as
well?
Speaker 2
26:00
Yes,
yes,
yes,
yes.
Speaker 4
26:02
And
you
know,
we
hear
about
the
powder
burn
lesions,
but
there's
also
a
rainbow
of
color
in
lesions.
Speaker 2
26:08
So
when
the
blood
leaks
from
those
vessels,
it
is
digested
by
the
enzymes,
and
they're
part
of
the
metabolites
of
the
digestion
is
hemosiderin
and
they
deposit
there
and
it
gives
the
color
of
purple
or
powder
burn
lesion.
And
then
you
can
have
at
different
level
vascular
or
scarring
because
whenever
you
produce
inflammation,
your
body
reacts
to
scarring.
And
since
we
have
an
immune
dysfunction
with
endometriosis,
so
the
scarring
is
there
is
an
over-reaction
to
the
inflammation
with
extensive
scarring.
Speaker 3
26:40
Yeah.
Speaker 2
26:41
So
it's
mostly
really
well
understood
on
the
molecular
level.
And
this
is
help
us
a
lot
in
trying
to
figure
out
therapeutic
approaches.
So
there
have
been
trials
that
did
target
the
VEGF
or
anti-angiogenic
therapeutic
medication.
These
showed
promising
results,
but
they
led
to
poor
wound
healing,
Antibiotics, Laxatives, And Vicious Cycles
Speaker 2
27:05
and
then
their
impact
on
fertility
is
unknown.
So
further
study
maybe
about
the
delivery
method
of
those
substances,
maybe
direct
delivery
through
the
lesions,
might
help
improving
with
minimizing
the
systemic
side
effects.
So
when
we
understand
what's
causing
what,
we
can
further
our
research
to
try
to
help
through
targeted
therapies
or
cellular
therapies
for
endometriosis.
Speaker 4
27:31
So
fascinating.
Does
this
also
contribute,
though,
to
what
many
call
like
the
pelvic
floor
congestion,
where
the
blood
vessels
are
overactive
in
there
or
no,
the
pelvic
floor
congestion
is
from
the
mostly
from
the
cytokines.
Speaker 2
27:45
So
the
cytokines,
the
interleukins
could
produce
dilations
of
the
vessels.
And
then
where
is
an
overly
inflammatory
activity
there
that
could
lead
to
a
dilation
of
the
vessel,
furthermore,
to
exchange
those,
bring
in
the
soldier
that
fight
inflammation
and
take
away
the
uh
substances
or
the
metabolites
of
inflammation.
It's
also
more
correlated
because
we
see
on
MRI
the
higher
density
in
vessels.
You
know,
now
with
machine
learning
and
artificial
intelligence,
maybe
these
could
help
as
a
markers
of
diagnosis.
Unfortunately,
there's
no
standardization
of
the
intensity
of
the
signals
yet.
So
there
are
a
lot
of
work
being
done
behind
the
scenes
on
these
kind
of
molecular
therapies
or
targeted
therapies
through
precision
medicine
to
help
create
a
hope
for
future
treatment
of
endometriosis.
Speaker 4
28:39
It's
interesting
that
we're
thinking
about
treatment
of
endometriosis
through
a
vascular
pathway,
because
I
would
have
never
even
thought
of
that.
Speaker 2
28:46
Because
every
cell
like
needs
food
to
grow,
needs
nutrients,
needs
oxygen,
and
then
needs
to
discard
their
waste
because
the
waste
are
toxic
for
the
cells.
Speaker 3
28:56
Right.
Speaker 2
28:57
So
whenever
these
we
can
cut
the
supply
to
those
that
would
lead
to
uh
cell
apoptosis
or
death.
Speaker 4
29:05
So
fascinating.
I
would
I
just
and
that
I've
never
put
that
together.
Like
it's
not
something
that
most
people
even
think
about.
Speaker 2
29:11
When
we
this
is
extremely
important
because
when
we
understand
the
disease
better,
we
can
understand
its
impact,
we
can
start
thinking
about
the
different
ways
of
therapeutic
approaches,
we
can
understand
more
how
we
can
help
treating
that.
So
endometriosis
is
beyond,
yes,
I
have
pain
or
pain
during
the
period
is
not
normal.
We
all
do
agree
on
that,
and
this
is
an
important
part.
But
caring
for
endometriosis
patients
requires
a
further
delving
into
the
depth
and
the
mechanisms
of
the
disease
to
help
contributing
in
the
understanding
and
explaining
the
disease
and
helping
to
empower
your
patients
to
understand
their
body
better
and
provide
them
better
therapeutic
approaches.
Speaker 4
29:57
I'm
just
blown
away.
You
just
like
something
I
Never
even
considered,
so
I'm
excited
that
we're
talking
about
this.
What
evidence
is
there
for
lymphatic
involvement
with
endometriosis
and
the
spread
of
endometriosis?
Speaker 2
30:09
Same
thing.
Uh,
there
are
a
lot
of
studies
that
showed
the
presence
of
endometrial-like
cells
within
the
lymphatics,
the
presence
of
estrogen
Blood Vessels, VEGF, And Hypoxia
Speaker 2
30:20
and
progesterone
receptors
within
those
cells
in
the
lymphatics
that
would
make
us
understand
how
the
disease
can
be
transmitted.
And
in
animal
model,
it
was
proven
that
the
disease
can
be
transmitted
through
distant
organs.
That
would
explain
that
endometriosis
is
beyond
the
pelvic
disease.
It
could
be
transmitted
to
distant
organs
like
the
diaphragm,
the
lung,
the
brain,
anywhere
you
believe,
through
the
lymphatic
channels.
So
it's
not
like
something
we
really
need
to
demonstrate.
It
was
proven
that
this
could
be
one
of
the
theories
of
distant
endometriosis
spread.
Speaker 4
30:57
This
is
very
similar
to
the
way
they
even
test
for
cancers,
which
is
ironic
given
the
fact
that
endometriosis
is
not
treated
with
the
same
respect
as
like
a
cancer
would
be
in
treatment
and
approaches,
surgical
and
otherwise.
I
think
it's
fascinating
that
when
we're
looking
at
the
lymphatic
aspect
of
this,
that
we
blow
over
the
fact
that
it's
very
similar
in
regards
to
the
way
that
cancer
can
progress.
Speaker 2
31:22
For
me,
I
I
think
the
medical
community
needs
to
understand
what
appeals
a
lot
of
people
to
the
cancer
stuff
is
the
fact
there
is
the
death
halo.
Speaker 4
31:34
Right.
Speaker 2
31:35
But
death
is
not
physical
only.
Speaker 4
31:38
Yeah.
Speaker 2
31:38
A
lot
of
patients
are
dead
in
their
relationship,
are
dead
in
their
physical
activity,
are
dead
in
their
mental
health.
So
we
don't
need
to
lose
somebody
physically
to
start
putting
more
money
onto
the
research.
It's
very
important.
But
also
we
should
look
at
whatever
incapacitates
our
patients
from
doing
daily
activity
and
they
will
become
socially
dead,
emotionally
dead.
And
this
is
for
me
something
that
should
be
an
alarm
for
all
the
medical
community
to
open
their
eyes
and
to
try
to
find
funds
to
improve
the
research
and
the
care
of
endometriosis.
Speaker 4
32:19
Yes.
And
I
I
mean,
we
can
get
into
this
in
another
time,
but
one
of
the
things
that
I've
always
said
is
that
you
can't
specialize
in
something
if
you're
trying
to
specialize
in
everything.
And
that's
where
I
don't
want
to
go
to
someone
who
doesn't
specialize
in
such
a
complex
disease
when
they
know
only
a
half
a
day
in
medical
school
from
it
or
what
they
hear
through
Google.
You
know,
like
I
want
the
research
behind
it
too.
I
want
to
know
that
my
provider
is
well
informed
and
this
is
all
they
deal
with.
Speaker 2
32:49
I
I
think
we
need
to
start
with
a
major
definition,
what
is
an
expert?
Because
now
an
expert
is
a
loosely
used
term.
And
then
that
is
misleading
a
lot
of
patients.
Expertise
is
beyond
only
just
doing
one
thing,
because
you
can
do
the
same
thing
all
the
time.
You
become
a
technician
if
you
don't
understand
it.
Speaker 5
33:10
That's
true.
Speaker 2
33:10
And
I
think
expertise,
you
can
be
an
expert
in
a
surgical
procedure
because
if
you
do
it
over
and
over.
But
whenever
it
comes
to
endometriosis,
the
expertise
should
emanate
not
only
from
the
surgery,
but
from
understanding
the
disease,
from
trying
to
help
publishing
and
increasing
the
global
understanding
of
the
disease.
It's
not
how
much
followers
I
have
on
that
makes
me
an
expert,
or
how
many
posts
do
I
post
on
makes
me
an
expert.
The
expertise
is
beyond
that.
It
it
encompasses
a
multifaceted
learning
and
skill
acquiring
and
training
and
then
knowing
how
to
create
strategy
for
patients
that
would
involve
a
multidisciplinary
and
a
comprehensive
approach.
And
when
we
say
multidisciplinary,
we
think
only
about
the
multidisciplinary
surgical
aspect.
I
have
a
colorectal
and
I
have
a
urologist
on
board,
and
then
that
means
I
do
multidisciplinary
care.
No.
Speaker 4
34:08
Right.
Speaker 2
34:08
Multidisciplinary
care
starting
from
providing
the
patient
coaching
and
support
through
life,
trying
to
explore
functional
medicine
capabilities
in
helping
patients,
continuing
with
gut
recovery
protocols,
helping
the
patient
through
mental
health,
cognitive
behavioral
therapies,
helping
the
patient
through
pelvic
floor
therapy,
long-term
follow-up
with
patients.
This
is
a
multidisciplinary
care.
It's
outside
the
OR.
And
the
OR
is
extremely
important,
but
it
expands.
Outside
the
OR,
it
expands
to
much
more
specialties
beyond
a
colorectal
or
urologist.
And
this
is
multidisciplinary
and
comprehensive
care.
Speaker 4
34:51
Well,
because
we're,
as
we've
talked
about,
it's
a
whole
body
issue.
And
so
we're
only
addressing
one
area.
There
leaves
room
for
more
breakdown
within
your
body.
I
mean,
I
just
I
this
is
something
that
I've
learned
in
my
journey
with
endometriosis.
I
was
very
much
presented
that
endometriosis
was,
you
know,
you
can
do
X,
Y,
and
Z
and
get
rid
of
it.
But
no
one
ever
touched
on
the
mental
aspect
of
it,
the
emotional
aspect
of
it,
the
relational
aspect
of
it,
which
you
need
someone
that
can
help
you
navigate
that
and
someone
that's
specialized
in
chronic
illness
or
trauma
therapies.
And
then
you
also
have,
you
know,
relational
therapies
that
suffer
from
this.
And
so
if
you
don't
address
those,
you're
gonna
always
feel
in
this
state
of
fight
or
flight,
you
know?
I
think
that
I
really
Imaging, MMPs, And Leaky Vessels
Speaker 4
35:40
think
a
lot
of
it,
we
do
have
to
address
like
the
emotional
component
to
it,
the
mental
component.
Speaker 2
35:45
What
does
emotion
do
to
you?
What
does
stress
do
to
you?
Emotion
is
a
stress
on
your
body.
Absolutely.
Stress
increases
your
cortisol.
Cortisol
is
a
pro-inflammatory
hormone.
Right.
So
you're
inducing
more
inflammation
that
worsens
your
pain.
This
is
a
vicious
circle,
comes
back
to
the
same
thing.
More
inflammation,
more
pain,
more
disease,
more
impact
on
mental
health.
So
everybody
is
living
into
that
vicious
cycle
that
someone
needs
to
break.
And
now
this
is
a
message
for
endometriosis
patients.
The
the
treatment
is
frustrating
of
endometriosis,
because
the
treatment
is
long,
sternuous,
time
consuming,
effort
consuming.
So
I
will
encourage
a
lot
of
patients
with
endometriosis
to
create
a
strategy,
a
long-term
strategy
with
their
doctor.
Because
this
is
what
minimizes
the
unnecessary
intervention,
the
fragmented
care
of
endometriosis
patients,
is
when
somebody
put
a
strategy
and
then
all
the
parties
of
the
care
team
can
work
through
that
strategy.
Because
if
you've
ever
been
told
that
the
surgery
is
the
only
treatment
for
endometriosis,
probably
they're
missing
a
big
part
of
the
story.
If
you're
ever
told
that
all
your
problems
will
go
away,
endometriosis
impacts
a
lot
of
systems
in
the
body,
and
that
impact
is
irreversible
in
the
absence
of
the
disease.
We
need
to
intervene
to
restore
that
impact.
When
you
break
your
leg,
they
take
an
x-ray,
they
say,
Oh,
you
look
fantastic,
your
leg
heal.
You
cannot
go
run
a
marathon.
There
needs
to
be
a
lot
of
training,
a
lot
of
rehab
to
be
able
to
get
back
to
the
same
pace
and
be
able
to
run
them.
And
this
is
the
same.
Endometriosis
is
a
life
marathon
for
the
patients.
Find
a
good
coach
that
will
walk
you
through
that
training
so
you
can
be
able
to
do
whatever
you
want
to
do
and
restore
your
quality
of
life.
Speaker 4
37:38
The
other
thing
I
would
say
to
that
though
is
that
that
coach
can
change
in
different
stages
of
your
journey.
Of
course.
And
I
think
it
should
at
some
point
because
you
don't
want
to
be
seeing
someone
and
doing
the
same
thing
over
and
over
again
with
minimal
to
no
results.
That's
when
it's
okay
to
look
for
someone
new.
And
I
think
that
we
get
so
stuck
in
being
loyal
to
those
who
we
first
find
and
we
have
relationship
with.
And
I'm
not
saying
that
you
need
to
sever
your
relationship.
I'm
just
saying
it's
okay
to
find
someone
that
will
serve
you
better.
Speaker 2
38:10
No,
no,
I
completely
agree
with
you.
That's
why
I
believe
educating
the
patient
about
the
long-term
strategy
is
the
most
powerful
tool
because
they
can
understand
what
they
should
do,
what
is
the
next
step
rather
than
I've
done
this,
but
no
result.
What
should
I
do
next?
Speaker 4
38:25
Yeah.
Talking
about
all
of
that,
and
we've
talked
about
it
being
a
whole
lifelong
journey
and
going
back
to
the
lymphatic
pathways,
if
those
are
involved,
does
this
change
how
we
think
about
reoccurrence?
Speaker 2
38:38
Reoccurrence
is
like
you
get
me
started
on
the
most
complex
topic.
Reoccurrence
is
a
very
complex
issue.
Reoccurrence
is
is
extremely
poorly
understood.
Because
when
we
do
research
on
endometriosis,
we
do
research
on
endometriosis
as
a
whole.
We
don't
have
any
subtypes
of
the
disease,
we
don't
have
any
yet
well-established
understanding
of
the
phenotypes
of
the
disease.
How
does
the
disease
express
it?
How
is
it
why
is
it
deeply
infiltrative
in
you?
Why
does
it
affect
the
bowel
in
you?
Why
doesn't
it
affect
severity
of
the
disease,
the
genetics
and
the
gene
expression
of
everybody?
Also,
like
the
completeness
of
your
therapy,
Anti‑Angiogenic Ideas And Limits
Speaker 2
39:20
your
therapeutic
approaches
plays
a
role
in
persistence
rather
than
recurrence,
but
we
call
it
recurrence
most
of
the
time.
So
it's
a
multifaceted
complex
situation.
Yes,
definitely,
lymphatic
could
play
a
role,
inflammation,
understanding
the
inflammation,
the
immune
system
plays
a
tremendous
role
in
that.
So
it's
a
it's
a
multifactorial.
Most
of
the
stuff
cannot
be
answered
as
of
now
by
one
theory
or
by
one
causality
equation.
So
there
are
multiple
factors
that
come
together
that
we
still
poorly
understand
that
could
increase
the
chances
of
recurrence
for
some
patients
versus
not
for
other
patients.
Speaker 4
39:58
Yeah.
It's
it's
and
I
think
that
we
oversimplify
it
sometimes
in
saying
if
you
just
get
the
right
treatment,
if
you
just
get
the
right
surgeon,
then
you
won't
have
any
recurrence.
And
that's
just
not
true.
We're
too
complex
for
that.
Speaker 2
40:13
No,
it's
you
know,
there
are
multiple
inter
interventions
that
we
can
do,
but
the
most
important
thing
is
trying
to
educate
the
patient.
Because
patients,
when
we
talk
about
recurrence,
patients
understand
there
is
no
cure
for
this
disease.
And
patients
understand
there
is
a
chance
of
recurrence.
But
trying
to
help
improving
the
quality
of
life
and
minimizing
the
unnecessary
surgery
is
something,
is
a
goal
that
could
help
tremendously
impact
their
quality
of
life.
So
if
a
patient
require
another
surgery
in
five
years
or
ten
years,
but
in
the
interim
time
they
had
a
very
good
quality
of
life,
patients
are
completely
on
board.
They
understand
really
well
that.
But
if
a
patient
has
to
do
surgery
every
six
months
and
most
of
them
are
unnecessary
or
emanate
from
the
poor
understanding
of
the
disease
or
poor
implementing
of
long-term
therapeutic
or
uh
approaches,
this
will
lead
to
a
lot
of
frustration
and
this
will
lead
to
a
lot
of
changing
doctors.
And
so
the
most
important
thing
we
can
do
as
a
healthcare
provider,
advocacy
group,
is
to
try
to
educate
the
patients
about
the
real
reality
of
the
disease.
Speaker 5
41:30
Yes.
Speaker 2
41:30
Rather
than
taking
patients'
emotional
vulnerability
to
provide
them
a
cheerleading
support.
Patients
with
endometriosis,
they
need
more
understanding.
They
don't
need
cheerleader.
Cheerleading
is
sometimes
important.
But
simplifying
endometriosis,
to
go,
girl,
be
strong,
that
kind
of
approach,
which
is,
I
agree,
it's
important
to
lift
up
people
sometimes.
But
the
most
empowering
comes
from
trying
to
understand
the
disease
and
explain
it
to
the
patient,
trying
to
understand
their
body,
trying
Lymphatic Spread And Distant Lesions
Speaker 2
42:05
to
individualize
their
treatment,
trying
to
provide
them
a
longer-term
strategy,
how
they
can
cope
with
such
a
disease.
Speaker 4
42:13
Right.
That's
something
that
I
didn't
have.
It
was
a
good
explanation
when
I
started.
And
I
think
part
of
advocacy
is
being
aware
of
your
role
in
helping
people
find
a
better
quality
of
life.
Again,
cheerleading
is
great
and
validation
is
wonderful.
Of
course.
But
at
the
end
of
the
day,
if
you
don't
have
steps
moving
forward,
you're
not
going
to
get
a
better
quality
of
life.
If
you
don't
have
the
support
to
say,
have
you
looked
at
X,
Y,
and
Z
as
a
way
to
help
X,
Y,
and
Z
is
very
different
for
everyone.
But
I
think
that's
where
community
matters.
That's
where
stepping
into
a
space
where
others
have
lived
experience
can
make
a
huge
difference
in
the
way
that
you
navigate
a
disease
that
consumes
so
much
of
our
lives
and
so
much
of
our
stories.
But
it
doesn't
have
to
all
the
time.
That's
the
other
thing.
Speaker 2
43:04
And
I
say
it
all
the
time,
but
the
trust
is
established
at
the
beginning
by
listening
and
validating.
This
is
something
that
should
be
done.
But
beyond
that,
the
work
will
start
by
educating,
empowering
through
science,
through
evidence,
through
different
therapeutic
approach.
And
the
support
continues
by
providing
a
longer
term
strategies
for
patients
with
endometriosis.
Speaker 4
43:31
Yeah.
And
the
more
we
look
at
it
that
way,
the
better
we'll
be.
Because
we'll
be
able
to
figure
it
out
and
have
steps
in
place.
I
know
I
have
I
always
thought
this
is
where
this
is
what
was
so
frustrating
in
this
disease.
I
thought
once
I
had
surgery,
I
was
gonna
be
good.
I'd
magically
wake
up
and
be
healed.
And
I
wouldn't
have
any
other
issues.
I
wouldn't
have
any
pain.
And
the
mental
toll
and
the
emotional
toll
it
took
on
me
to
realize
that
that
wasn't
going
to
be
the
case
for
me
was
really
hard.
But
when
I
came
to
terms
and
realized
that
there
was
a
community
there
to
support
me
who
understood
me,
it
has
changed
so
much.
And
I
think
it
changes
your
health
outlook
too
to
have
that,
to
have
a
good
team
behind
you,
have
providers
who
believe
you,
who
have
providers
that
don't
look
at
you
as
if
you're
crazy
when
you
tell
them
really
weird
things
that
happen
to
you,
you
know?
And
so
I
think
it
does
make
a
huge
difference.
But
to
go
into
that
realistically,
what
does
this
disease
realistically
look
like?
You
know,
and
I
think
that's
when
we
talk
about
all
these
different
variations
and
facets
of
it,
it's
to
bring
evidence
and
to
inform
so
that
you
don't
have
this
false
sense
of
hope.
Speaker 2
44:42
Because
you
know,
if
you're
gonna
break
down
gaslighting,
could
be
directly,
gaslighting
could
be
saying
like,
oh
no,
you
don't
have
anything,
you're
crazy,
but
could
be
indirectly
by
giving
you
the
false
hope
or
by
giving
you
the
wrong
information.
Speaker 4
44:56
Yeah,
absolutely.
Speaker 2
44:57
So
gaslighting
is
not
always
intentional.
Yes,
it
is
sometimes
unintentional
by
creating
a
certain
excuse
to
prove
to
your
patients
you
understand
more
about
medicine,
and
then
this
implementing
wrong
information
in
your
patients,
making
them
disbelieve
the
reality
sometimes,
and
then
that
will
create
either
further
therapeutic
challenges
with
the
patients
when
they
understand
an
idea
that
was
given
by
a
random
doctor.
Because
for
me,
when
I
go
to
the
doctor,
whatever
they
tell
you
impacts
you
far
more
to
what
they
believe
they
say.
What Expertise And True Team Care Mean
Speaker 2
45:40
They
forgot
what
they
said.
But
the
idea
that
I
can
carry
through
years
is
the
idea
that
continues
to
gaslight
me
or
torture
me
if
it
is
based
on
erroneous
or
false
information.
Speaker 4
45:52
Yeah.
Which
is
something
I
never
even
I
didn't
even
hear
the
word
gaslighting
until
like,
you
know,
three
years
ago.
Speaker 5
45:58
Yeah.
Speaker 4
45:59
It
wasn't
as
it
wasn't,
but
I
wish
I
would
have
known
that
it
wasn't
always
my
fault.
You
know,
I
wish
I
would
have
known.
Like
it
is
based
on
with
good
intentions.
Like
my
my
provider
had
good
intentions,
but
bad
information.
So
I
think
that
there's
so
much
to
play
in
patient
care.
It's
not,
it's
not
linear.
Speaker 2
46:18
It's
okay
to
tell
your
patient,
like,
I
don't
know.
Speaker 4
46:21
Yeah.
Speaker 2
46:22
Let
me
it.
Sometimes
I
would
say,
like,
what
is
this
medication?
I
don't
know.
Let
me
it.
Or
let
me
understand
more
about
it
so
I
can
answer
your
question.
It's
okay.
Patients
don't
look
at
us
knowing
that
we
should
know
everything.
And
then
this
should
be
a
good
learning
experience
for
all
the
doctors.
They
learn
more
from
their
patients.
Because
when
patients
bring
in
something
that
should
incite
something
to
click
in
your
brain
to
go
research
this,
try
to
find
answers
so
you
can
try
to
get
back
to
your
patients
and
try
to
help
them.
Speaker 4
46:54
Yeah.
I
wish,
I
wish
so
many
times
the
doctor
would
be
like,
you
know,
I'm
really
not
sure.
Instead
of
like
leaving
with
bad
information.
And
then
here's
the
other
part
of
this.
When
I
was
given
bad
information,
I
wanted
to
tell
everyone
this
bad
information
because
I
finally
had
information.
Yes.
So
that
it's
that
cycle,
right?
It's
a
it's
a
toxic
cycle,
but
it's
a
cycle
nonetheless.
And
I
I
just
which
is
why
I'm
doing
what
I'm
doing,
because
I
wanted
to
break
this
cycle
of
bad
information
from
just
me.
You
know,
I
I
think
that
I
had
such
guilt
over
what
I
was
told
that
I
wanted
to
express
to
everyone.
And
I'm
like,
I
can't
do
that
anymore.
It's
so
harmful.
But
that's
another
story
for
another
day.
Yeah.
We've
touched
on
how
endo
can
spread
and
sustain
itself,
but
what
about
how
it
affects
the
whole
body's
energy
system,
which
is
something
that
many
of
us
struggle
with?
How
might
the
metabolic
dysfunction
explain
symptoms
like
chronic
fatigue
or
fatigue
in
general?
Speaker 2
47:55
We'll
we'll
all
go
back
to
the
inflammation.
The
inflammation
mediators
or
the
substances
produced
when
you
have
inflammation
like
cytokine,
TNF
alpha,
IL6,
interleukin
6,
interleukin
1
beta,
they
do
affect
the
insulin
signaling
and
they
create
an
insulin
resistance
and
they
can
impair
the
glucose.
So
the
first
thing.
Second
thing,
estrogen
is
known.
The
high
levels
of
estrogen
present
in
endometriosis
patients
also
produces
an
abnormal
fat
tissue
deposition.
So
that
leads
to
insulin
resistance
and
that
leads
to
obesity.
Speaker 5
48:32
Right.
Speaker 2
48:32
Add
to
this
the
adipoine
system,
which
is
two
main
hormones,
the
leptin
and
adiponectin,
both
hormones.
The
adiponectin
plays
a
role
in
inflammation,
it
decreases
the
inflammation.
So
in
endometriosis
patients,
it's
slower
because
of
the
inflammation.
And
the
leptin,
the
most
important,
the
leptin
suppresses
your
appetite
and
increases
your
energy.
And
in
endometriosis
patients,
the
leptin
is
low
as
well.
So
you
have
more
appetite
and
then
you
have
reduced
energy.
And
that
leads
to
increase
in
weight.
Add
to
this
the
inflammation
impacts
the
mitochondria
energy
expenditure.
So
the
mitochondria
are
small
organs
that
are
contained
in
the
cells.
They
produce
energy.
So
whenever
there
is
a
dysfunction,
you
feel
fatigued.
Speaker 4
49:22
Yeah.
Speaker 2
49:23
You
feel
drained,
whatever
you
do.
So
all
this
combined,
you
have
less
ability
to
do
activity,
you
have
abnormal
deposition
of
fat,
you
have
an
increased
weight,
you
have
uh
an
impaired
insulin
resistance,
you
have
impaired
glucose
or
elevated
glucose,
even
sometimes
diabetes,
all
that
together
leads
to
a
metabolic
syndrome.
So
it's
uh
everything
is
interconnected
in
a
way
the
body
works
in
a
way
that
is
easily
understood
if
you
search
for
the
answers.
And
then
all
the
body
have
messengers
that
talk
to
each
other.
And
whenever
we
create
a
disruption,
that
leads
to
a
cascade
of
events
that
will
affect
multiple
systems.
Speaker 4
50:04
But
Gaslighting, Information, And Trust
Speaker 4
50:05
it
also
explains
for
a
lot
of
people
the
other
side
of
this
where
it
does
play
with
you
mentally.
Again,
it's
the
cycle,
right?
And
we
can't
always
control
that.
Speaker 2
50:16
This
is
the
circle
that
you
need
to
break
it
at
one
point.
Either
you
start
breaking
it
with
surgery
by
removing
the
disease,
or
you
start
breaking
it
with
interventions
that
helps
doing
melt
mental
health
support
is
extremely
important
into
managing
or
encouraging
because
if
you're
depressed,
whatever
they
offer
you,
I
tried
it
before,
it's
not
gonna
work.
This
will
not
do
stuff.
So
patients
with
endometriosis,
we
have
to
understand
there
are
a
lot
of
traumas
from
pain,
from
the
disease,
from
the
impact,
societal
impact
of
the
disease,
that
lead
to
behavioral
changes
sometimes.
Sometimes
they
dismiss
the
therapy
because
they're
being
gaslit
or
they've
been
burned
before
or
they've
been
traumatized
by
care.
Speaker 3
51:04
Right.
Speaker 2
51:04
So
that's
why
a
cognitive
behavioral
intervention
can
help
restoring
that
mental
ability
to
just
pull
up
your
sleeve
and
get
to
work
with
the
right
provider
that
will
support
them
with
the
right
support
network.
So
what
we
thought
these
are
things
that
happen,
it's
okay.
No,
it's
not
okay.
There
is
a
treatment
for
that,
there
is
a
care
for
that,
there
is
a
light
at
the
end
of
the
tunnel,
but
we
need
to
work
together,
we
need
to
partner
with
the
patients
to
get
to
the
end
of
the
tunnel.
Speaker 4
51:37
When
you
work
with
patients
or
when
you
approach
have
patients
with
a
metabolic
disorder,
what
are
some
practical
steps
maybe
for
them
to
heal
from
that?
Speaker 2
51:47
So
at
the
beginning,
when
we
start,
most
of
the
patients
that
come
see
me
are
in
pain,
they
have
endometriosis.
So
there
is
a
source
of
inflammation.
And
then
we
need
to
reduce
that
source
of
inflammation
by
intervening
and
removing
the
lesions.
So
we
need
to
break
or
to
minimize
the
generator
of
inflammation.
Once
you
take
away
the
generator
of
the
inflammation,
you
can
do
far
more
interventions
that
will
be
minimalistic,
that
would
lead
to
a
better
perception
for
patients
and
improvement
in
quality
of
life.
If
you,
for
example,
uh
you
cut
your
muscle,
right?
You
cannot
go,
even
if
you
do
rehabilitation,
you
need
first
to
suture
that
muscle,
rehabilitate
from
that
before
you
run.
So
we
cannot
start
running
thinking
like
only
in
the
movie
that
happens
they
shoot
the
hero
and
they
continue
to
run.
I
don't
understand
this,
but
in
real
life,
no,
we
fix
the
uh
issue
and
then
we
run.
It's
amazing.
They
get
beaten
if
I
uh
hit
my
elbow
somewhere,
I'm
sitting
for
two
minutes.
I
get
beaten
to
death
and
they
still
run.
Speaker 4
52:51
I
know.
I
would
like
to
just
be
able
to
go
up
the
stairs
without
like
groaning
and
moaning
to
get
up
there,
you
know.
But
I
do
think
that
that's
something
that
I
always
have
said
show
yourself
grace
because
it's
not
an
overnight
thing.
You
can't
do
you
can't
heal
overnight.
Your
body
is
not
meant
to
do
that.
It
didn't
break
overnight
either,
right?
Like
we
shouldn't
expect
it
to
heal
overnight.
Speaker 2
53:12
Yes,
yes.
And
as
I
mentioned
again,
in
the
absence
of
the
disease,
the
sequelae
of
endometriosis
need
to
be
rehabilitated
and
treated
separately.
Because
even
though
in
some
young
and
healthy
patients,
your
body
restores
itself,
but
it
takes
a
longer
period
of
time
in
patients
who
have
an
impact
on
their
immune
system.
Speaker 5
53:34
Yeah.
Speaker 2
53:34
Like
at
my
age,
I
used
to
twist
my
leg
and
then
go
play
soccer
the
next
day.
But
now
if
you
twist
your
leg,
you
put
the
boots,
you
it
doesn't
our
immune
system
is
getting
old,
but
imagine
if
the
immune
system
is
impacted,
and
that
leads
to
a
cascade
of
multiple
dysfunctions.
And
that's
why
the
normal
healing
process
is
lengthier
than
somebody
who
has
an
intact
immune
system.
Speaker 4
53:58
Yeah.
Or
is
younger.
We
won't
talk
about
that.
Thank
you
for
taking
the
time
coming
out
here
and
spending
this
quality
time
with
us.
I'm
excited
to
see
what's
next.
We'll
do
it
together.
If
this
episode
helped
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leave
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living
Metabolic Dysfunction And Fatigue
Speaker 4
54:35
with
endometriosis
and
chronic
illness
and
reminds
them
they're
not
alone.
Until
next
time,
continue
advocating
for
you
and
for
others.