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What happens when two of the most prevalent gynecological conditions intersect? Join us as Dr. Sadikah Behbehani and Dr. Lora Liu shed light on the complexities and common misconceptions surrounding endometriosis and PCOS. These esteemed experts guide us through the landscape of these conditions, emphasizing that although both affect a significant number of women, their co-occurrence is more about chance than any causal relationship. Through their insights, we aim to clarify the confusions that often arise between these conditions and highlight the importance of precise diagnosis for effective treatment.
Discover the intricate process of diagnosing PCOS using the Rotterdam criteria, an approach that demands patience, particularly in young women. Dr. Behbehani and Dr. Liu walk us through the genetic and lifestyle factors that may predispose certain ethnicities to PCOS and discuss strategic interventions like weight management to alleviate symptoms. The conversation takes an enlightening turn as we unravel the frequent misdiagnoses between PCOS and endometriosis—a misunderstanding that can lead to inappropriate treatments and prolonged patient distress.
Our discussion doesn’t stop at diagnosis; we venture into the realm of treatment options, from hormonal management to the evolution of surgical procedures like ovarian drilling. Dr. Liu shares her experiences with the emotional and transformative effects of excision surgery, painting a vivid picture of the impact proper treatment can have on patients’ lives. We also address systemic issues in women’s healthcare, such as the inadequacies in endometriosis treatment and the challenges faced by patients navigating infertility and IVF. Tune in for a thought-provoking conversation that empowers both patients and healthcare providers to pursue informed and compassionate care.
Dr. Sadikah Behbehani–The Center for Endometriosis & Fertility
Dr. Lora Liu
Website endobattery.com
Endometriosis and PCOS Intersection
Speaker 1
0:03
Welcome
to
EndoBattery
,
where
I
share
about
my
endometriosis
and
adenomyosis
story
and
continue
learning
along
the
way
.
This
podcast
is
not
a
substitute
for
professional
medical
advice
or
diagnosis
,
but
a
place
to
equip
you
with
information
and
a
sense
of
community
,
ensuring
you
never
have
to
face
this
journey
alone
.
Join
me
as
I
navigate
the
ups
and
downs
and
share
stories
of
strength
,
resilience
and
hope
.
While
navigating
the
world
of
endometriosis
and
adenomyosis
,
from
personal
experience
to
expert
insights
,
I'm
your
host
,
alana
,
and
this
is
EndoBattery
charging
our
lives
when
endometriosis
drains
us
.
Welcome
back
to
EndoBattery
.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
at
the
table
.
Speaker 1
0:45
Today
I'm
excited
to
welcome
two
of
the
most
accomplished
experts
in
endometriosis
care
to
the
table
.
First
we
have
Dr
Sadiqa
Bebehani
,
a
double
fellowship
trained
OBGYN
,
specializing
in
reproductive
endocrinology
and
infertility
,
as
well
as
minimally
invasive
gynecological
surgery
.
Dr
Bebehani
completed
a
second
fellowship
at
the
prestigious
Mayo
Clinic
,
where
she
mastered
complex
pelvic
surgery
using
both
laparoscopy
and
robotics
.
As
an
associate
professor
at
the
University
of
California
Riverside
School
of
Medicine
,
she
is
also
deeply
involved
in
medical
research
and
publications
.
With
her
rare
combination
of
training
in
surgery
and
infertility
,
dr
Bebiani
is
uniquely
equipped
to
treat
complex
gynecologic
conditions
such
as
endometriosis
and
fibroids
that
affect
fertility
.
Speaker 1
1:32
We're
also
joined
by
Dr
Laura
Liu
,
a
highly
respected
board-certified
excision
surgeon
specializing
in
deep
excision
of
endometriosis
.
Dr
Liu
is
known
for
her
expertise
in
minimally
invasive
techniques
and
her
dedication
to
providing
patients
with
evidence-based
care
that
brings
long-lasting
relief
.
With
her
background
in
both
gynecology
and
robotic
surgery
,
she
has
helped
countless
individuals
find
a
path
to
healing
after
enduring
years
of
chronic
pain
.
Together
,
both
Dr
Bebehani
and
Dr
Laura
Liu
bring
an
incredible
wealth
of
knowledge
to
today's
discussion
.
Please
help
me
in
welcoming
to
the
table
Dr
Bebe
Hani
and
Dr
Laura
Lou
.
Thank
you
both
for
joining
me
today
.
I
am
so
honored
that
you
took
the
time
out
of
your
busy
schedules
to
sit
down
with
me
and
talk
about
something
that
I
feel
like
is
very
important
,
which
is
the
intersection
of
PCOS
and
endometriosis
.
So
thank
you
both
for
joining
me
today
.
Thanks
for
having
us
,
Alana
we're
excited
to
be
here
.
Speaker 1
2:28
Thank
you
.
So
,
as
I
talked
about
before
,
there's
a
big
correlation
maybe
not
a
correlation
,
but
there
tends
to
be
a
lot
of
crossover
between
endometriosis
and
PCOS
.
Dr
Baiba-Henny
,
can
you
tell
us
a
little
bit
more
about
the
PCOS
piece
of
it
and
what
it
is
,
how
it
kind
of
responds
in
the
body
,
and
just
kind
of
give
us
that
overview
?
Speaker 2
2:53
Yes
,
I'm
glad
that
you
bring
this
up
because
this
is
a
question
we
get
asked
often
in
clinical
practice
is
how
are
endometriosis
and
PCOS
related
?
We
have
to
remember
that
endometriosis
occurs
in
about
15%
of
the
population
.
So
,
not
looking
at
pelvic
pain
or
fertility
patients
,
just
in
the
general
population
,
about
15%
of
women
will
have
endometriosis
and
5
to
15%
of
the
population
will
have
PCOS
.
So
they
may
not
necessarily
be
caused
by
the
same
cause
,
like
in
utero
,
or
the
same
manifestation
that
created
the
disease
.
But
because
they
are
both
prevalent
and
common
,
it
is
definitely
possible
for
women
to
have
both
endometriosis
and
PCOS
.
So
I
often
get
asked
is
the
endo
causing
PCOS
?
Is
the
PCOS
causing
endo
?
No
,
there
are
no
studies
to
show
that
one
causes
the
other
.
It's
just
because
they're
both
prevalent
.
It
is
absolutely
possible
for
both
diseases
to
co-occur
in
some
way
.
Diagnosing and Treating PCOS and Endometriosis
Speaker 2
3:51
Now
,
what
is
PCOS
?
You
asked
me
what
PCOS
was
.
Pcos
,
for
those
of
you
who
don't
know
,
stands
for
polycystic
ovarian
syndrome
and
it
is
often
misdiagnosed
.
So
a
large
proportion
of
women
will
come
see
me
and
say
oh
well
,
my
doctor
diagnosed
me
with
PCOS
5
,
10
,
15
years
ago
.
The
first
question
I
ask
them
is
how
was
the
diagnosis
established
?
And
most
of
the
time
,
they're
not
able
to
provide
the
evidence
or
the
results
that
led
to
the
diagnosis
of
PCOS
.
So
PCOS
is
often
misdiagnosed
and
sometimes
is
overdiagnosed
.
But
when
we
are
correctly
diagnosing
PCOS
,
we
diagnose
it
based
on
a
criteria
called
the
Rotterdam
criteria
.
So
that's
the
scientific
way
of
diagnosing
PCOS
.
What
the
Rotterdam
criteria
looks
at
is
to
see
if
women
have
irregular
periods
or
no
periods
,
so
that's
one
of
the
criteria
.
Have
irregular
periods
or
no
periods
?
So
that's
one
of
the
criteria
.
Speaker 2
4:49
Number
two
is
elevated
male
type
hormones
called
androgens
testosterone
,
dhea
,
17-hydroxyprogesterone
.
Those
fall
in
the
category
of
androgens
,
or
clinical
findings
of
elevated
androgens
,
like
having
increased
facial
hair
,
acne
,
sometimes
male
pattern
baldness
.
Those
are
all
called
clinical
findings
of
elevated
androgens
or
elevated
male
type
hormones
.
And
then
number
three
is
the
appearance
of
polycystic
ovaries
on
ultrasound
.
So
you
need
two
out
of
those
three
things
to
be
diagnosed
with
PCOS
,
and
the
reason
why
this
is
important
is
because
many
women
will
have
an
ultrasound
to
show
multiple
follicles
or
cysts
on
their
ovaries
and
be
automatically
told
that
they
have
PCOS
.
Speaker 2
5:29
You
cannot
diagnose
PCOS
based
on
just
one
of
the
three
things
.
You
cannot
just
have
polycystic
appearing
ovaries
and
have
PCOS
.
You
need
to
have
polycystic
appearing
ovaries
,
plus
one
of
the
other
two
things
on
the
criteria
,
which
are
either
irregular
periods
or
absent
periods
,
or
clinical
or
lab
findings
of
elevated
androgens
.
So
you
need
two
out
of
three
to
diagnose
PCOS
.
And
then
you
can't
be
really
young
and
diagnose
PCOS
.
Speaker 2
5:55
You
need
to
wait
a
certain
number
of
years
after
you
start
your
period
.
So
you
can't
have
a
15-year-old
who
started
her
two
years
ago
see
a
GYN
and
be
told
she
has
PCOS
.
She's
too
young
to
be
diagnosed
with
PCOS
.
You
need
at
least
six
to
eight
years
of
regular
menstrual
cycle
.
So
from
the
start
of
the
first
period
we
wait
six
to
eight
years
before
you
re-evaluate
the
situation
to
see
if
they
have
PCOS
or
not
,
because
it
takes
this
long
for
the
brain
to
stimulate
the
ovaries
to
produce
hormones
on
a
regular
basis
.
So
it's
very
common
for
girls
in
the
first
six
to
eight
years
of
starting
a
period
to
have
irregular
periods
,
elevated
androgens
and
polycystic
appearing
ovaries
on
ultrasound
.
But
they
will
not
have
PCOS
if
you
just
give
them
time
to
regulate
their
own
hormones
.
So
that's
another
important
thing
to
remember
is
you
need
to
give
your
body
time
to
adjust
to
having
periods
before
you're
able
to
diagnose
PCOS
.
Speaker 1
6:53
Do
they
know
what
causes
PCOS
?
Is
it
just
the
hormonal
imbalance
of
it
,
or
are
people
predisposed
to
having
PCOS
because
of
a
genetic
component
?
Speaker 2
7:03
Absolutely
.
That's
a
great
question
.
So
we
know
that
it
tends
to
run
in
certain
ethnicities
.
So
you
know
I
said
the
prevalence
is
about
5
to
15
percent
,
depending
on
where
we're
geographically
located
.
In
the
US
it's
closer
to
5
.
But
if
we
look
at
certain
populations
and
ethnicities
,
like
Mediterranean
people
or
people
of
Southeast
Asian
descent
,
those
populations
are
more
likely
to
have
PCOS
.
Speaker 2
7:27
It
definitely
has
a
genetic
predisposition
and
also
a
lifestyle
predisposition
.
So
women
who
are
obese
or
pre-diabetic
are
more
likely
to
have
PCOS
.
So
pre-diabetes
is
a
common
finding
in
PCOS
patients
.
It
could
be
the
insulin
resistance
that
has
led
to
the
PCOS
and
has
led
to
the
prediabetes
.
But
the
cause
of
PCOS
is
not
clearly
identifiable
,
just
like
with
endometriosis
.
We
don't
know
exactly
why
some
women
have
PCOS
and
others
don't
.
But
there's
definitely
a
genetic
component
and
a
lifestyle
component
.
So
women
who
are
lean
are
less
likely
to
have
PCOS
.
They
actually
have
a
different
subtype
.
We
call
it
lean
PCOS
as
opposed
to
the
regular
PCOS
,
because
PCOS
tends
to
occur
in
overweight
women
.
And
that's
another
thing
is
I
often
tell
my
patients
is
if
you
lose
10%
of
your
body
weight
,
there's
a
very
good
chance
that
you
will
establish
regular
cycles
and
then
you
will
not
fit
the
diagnostic
criteria
for
PCOS
.
So
we
cannot
say
you
have
PCOS
.
So
just
losing
weight
may
be
enough
to
help
regulate
hormones
and
establish
regular
cycles
.
Speaker 1
8:33
Interesting
.
And
now
you
both
do
endometriosis
excision
surgery
.
But
,
Dr
Liu
,
you
primarily
only
do
excision
surgery
for
endometriosis
.
Can
you
explain
to
those
who
maybe
are
trying
to
differentiate
between
PCOS
for
endometriosis
?
Can
you
explain
to
those
who
maybe
are
trying
to
differentiate
between
PCOS
and
endometriosis
what
endometriosis
is
,
as
well
as
how
you
go
about
diagnosing
and
treating
that
?
Speaker 3
8:57
Yeah
,
I
think
you
know
,
like
Sadiqa
mentioned
,
what
I
found
in
my
practice
is
a
lot
of
patients
are
diagnosed
or
they
come
to
me
and
they're
like
I
have
PCOS
,
I
have
really
painful
periods
,
I
have
heavy
periods
,
and
they
go
through
all
of
these
symptoms
saying
that
they
,
you
know
,
my
doctor
told
me
I
had
PCS
and
I
was
like
did
your
doctor
ever
mention
endometriosis
?
And
they're
like
no
,
I
you
know
,
I
kind
of
Googled
that
on
my
own
and
I
find
that
you
know
a
lot
of
patients
or
not
a
lot
,
but
there
are
patients
who
are
definitely
misdiagnosed
and
told
they
have
PCOS
when
actually
they
have
endometriosis
.
Managing PCOS and Endometriosis Symptoms
Speaker 3
9:30
So
one
of
the
biggest
,
or
what
I
believe
,
are
the
symptoms
of
endometriosis
.
So
one
of
the
biggest
differentiating
qualities
of
the
two
diseases
is
PCOS
really
shouldn't
cause
pain
.
It
shouldn't
cause
pain
,
it
shouldn't
cause
bowel
symptoms
,
it
shouldn't
cause
bladder
symptoms
.
It
can
cause
difficulties
getting
pregnant
,
it
can
cause
difficulties
with
ovulation
,
but
it
shouldn't
cause
pain
and
I
think
that's
something
that
can
differentiate
the
two
.
Speaker 3
9:57
For
patients
who
are
kind
of
wondering
do
I
have
PCOS
,
do
I
have
endometriosis
?
Do
I
have
both
?
I
think
if
you
have
a
lot
of
pain
and
your
quality
of
life
is
impaired
by
your
periods
.
That
sounds
more
like
endometriosis
to
me
than
PCOS
.
Now
,
if
you
have
difficulties
conceiving
and
you
don't
have
any
of
the
other
symptoms
,
with
pain
or
anything
like
that
,
that
could
be
quote
unquote
silent
endometriosis
or
unexplained
infertility
caused
by
endometriosis
,
or
it
could
also
be
from
PCS
.
But
I
think
if
you
have
pain
,
if
your
primary
symptom
is
pain
around
the
time
of
ovulation
or
periods
,
that's
going
to
be
endometriosis
.
Speaker 2
10:33
Right
and
we
know
,
Dr
Lu
,
may
I
add
something
please
?
So
actually
,
if
women
tell
me
that
they
have
pain
with
ovulation
,
it
is
unlikely
PCOS
,
because
PCOS
patients
don't
ovulate
.
Speaker 3
10:43
Pain
with
ovulation
,
it
is
unlikely
PCOS
,
because
PCOS
patients
don't
ovulate
.
They
don't
ovulate
,
so
they
don't
have
pain
.
Speaker 2
10:47
So
having
pain
is
an
unusual
symptom
that
,
like
Dr
Liu
said
,
is
more
likely
to
be
endometriosis
related
.
And
some
women
will
say
I
only
have
pain
once
every
three
or
four
months
.
Well
,
because
you're
only
ovulating
once
every
three
or
four
months
and
you
could
have
the
endo
that's
creating
the
pain
when
you're
ovulating
.
So
just
wanted
to
explain
that
point
a
little
further
,
since
Dr
Liu
is
absolutely
right
you
cannot
have
pain
with
PCOS
if
you're
not
ovulating
.
Speaker 1
11:12
Yeah
,
and
that's
interesting
to
think
about
because
I
think
a
lot
of
people
correlate
the
two
as
both
being
painful
.
So
the
fact
that
PCOS
really
in
theory
should
not
be
painful
is
a
good
indicator
that
it's
more
endometriosis
related
.
That's
fascinating
to
kind
of
put
that
correlation
together
.
The
other
thing
too
and
maybe
you
can
speak
on
this
either
one
of
you
is
the
fact
that
with
endometriosis
,
early
detection
and
diagnosis
is
key
for
proper
care
and
treatment
,
and
to
not
have
that
delay
in
diagnosis
is
key
to
being
able
to
preserve
fertility
,
other
symptoms
of
endometriosis
,
whether
that's
prolonged
pain
or
anything
like
that
.
What's
your
experience
with
providers
diagnosing
it
with
PCOS
before
endometriosis
?
Is
that
common
at
an
earlier
age
,
or
they
don't
even
put
the
two
together
at
all
.
Speaker 3
12:02
I'll
let
Sadiqa
speak
a
little
bit
more
in
detail
.
But
I
think
a
lot
of
providers
,
when
patients
present
at
a
young
age
,
either
with
painful
periods
or
irregular
periods
,
they
automatically
get
a
ticket
to
birth
control
pills
automatically
and
if
that
doesn't
work
then
they
try
a
different
birth
control
pill
and
then
they
try
10
others
and
birth
control
pills
and
again
I'm
going
to
let
Dr
Beva-Hondi
speak
a
little
bit
more
about
this
for
PCOS
.
But
birth
control
pills
,
it's
hormonal
suppression
.
It
prevents
ovulation
.
For
the
most
part
,
most
of
them
prevent
ovulation
If
a
young
patient
presents
with
irregular
periods
,
painful
periods
at
a
young
age
,
and
,
as
Dr
Babani
mentioned
too
,
you
really
can't
even
diagnose
PCOS
until
six
to
eight
years
after
their
first
menstrual
cycle
,
after
they
regulate
their
own
hormones
.
You
know
,
I
think
the
birth
control
pills
people
think
is
just
a
silver
magic
bullet
for
everything
.
Pcos
,
endometriosis
,
doesn't
matter
,
we're
going
to
treat
you
anyway
the
same
because
it
just
doesn't
matter
.
Speaker 2
13:02
Just
go
on
the
birth
control
pills
,
pill
versus
30
,
or
change
the
progesterone
from
Northendron
to
Drosperinone
,
the
results
will
likely
be
very
similar
.
We're
just
wasting
our
patients'
time
where
we
should
really
be
digging
into
the
root
cause
of
the
problem
so
we
know
how
to
fix
it
.
I
have
nothing
against
birth
control
pills
.
They
actually
play
an
excellent
role
in
the
management
of
PCOS
in
women
who
are
not
trying
to
get
pregnant
,
because
you
mentioned
early
detection
Early
detection
of
PCOS
is
actually
important
to
reduce
their
lifetime
risk
of
developing
uterine
cancer
.
So
women
who
have
undiagnosed
or
untreated
PCOS
for
many
,
many
years
,
they're
not
ovulating
,
they're
not
producing
their
own
progesterone
,
they
keep
producing
estrogen
only
,
and
that
estrogen
is
actually
stimulating
the
lining
of
the
uterus
to
produce
precancerous
cells
.
So
we
don't
want
that
.
We
want
to
give
our
patients
progesterone
,
either
through
progesterone
only
pills
or
through
the
birth
control
pill
,
to
reduce
that
risk
.
But
when
we're
talking
about
endometriosis
and
pelvic
pain
,
the
birth
control
pill
is
not
going
to
make
the
endo
go
away
,
just
like
it's
not
going
to
make
the
PCOS
go
away
.
Speaker 2
14:16
I
always
tell
my
patients
we
treat
the
symptoms
of
PCOS
and
we
don't
really
treat
the
disease
,
because
the
disease
may
go
away
once
we
remove
certain
lifestyle
factors
,
like
I
said
,
obesity
.
Once
it
resolves
,
or
insulin
resistance
.
Once
it
gets
treated
,
the
PCOS
may
go
away
.
But
we
treat
the
symptoms
while
they're
there
.
So
if
the
woman
has
irregular
periods
,
we
have
to
make
them
regular
because
,
like
I
said
,
the
irregularity
can
put
them
at
risk
for
developing
uterine
cancer
.
If
the
woman
has
infertility
,
we
have
to
treat
that
and
help
them
get
pregnant
.
If
they
have
heavy
periods
,
we
treat
those
heavy
periods
and
if
they
have
pelvic
pain
,
then
we
have
to
investigate
and
see
why
.
Because
pelvic
pain
does
not
fit
into
the
diagnostic
criteria
or
the
common
symptoms
of
PCOS
.
Speaker 1
14:59
Right
For
endometriosis
.
Gold
standard
is
excision
surgery
.
How
do
you
,
other
than
lifestyle
changes
,
help
with
PCOS
?
Speaker 2
15:07
That's
a
good
question
.
So
if
they
have
infertility
and
we're
helping
them
get
pregnant
,
then
helping
them
ovulate
is
where
we
start
,
because
they
are
usually
anovulatory
.
With
PCOS
they're
not
ovulating
,
so
we
either
give
them
a
pill
to
help
them
ovulate
and
they
can
have
regular
intercourse
at
home
.
Try
that
for
three
months
.
If
they're
pregnant
,
great
,
we
don't
do
anything
.
Or
if
that
doesn't
work
,
we
can
add
procedures
in
the
office
something
simple
like
an
intrauterine
insemination
,
where
we
inject
the
sperm
directly
into
the
uterus
to
help
get
the
sperm
and
the
egg
to
meet
faster
.
Or
it
can
even
be
as
invasive
as
in
vitro
fertilization
or
IVF
.
So
we
treat
the
infertility
just
like
any
other
infertility
,
but
with
certain
precautions
,
knowing
that
their
cause
of
infertility
is
anovulation
and
PCOS
.
Speaker 2
15:53
And
the
good
thing
about
PCOS
when
we
do
decide
to
do
IVF
is
that
they're
the
best
responders
.
We
actually
worry
about
over-responding
with
PCOS
patients
.
So
it's
very
,
very
normal
to
get
20
and
30
and
40
eggs
with
PCOS
patients
.
So
it's
not
an
egg
quantity
issue
,
it's
not
even
always
a
quality
issue
.
I
always
tell
them
it's
the
fact
that
the
egg
is
just
not
being
released
from
its
shell
.
So
you've
got
plenty
of
eggs
on
your
ovaries
,
those
cysts
that
we're
calling
polycystic
ovaries
.
Those
cysts
are
not
cysts
,
they're
eggs
in
their
early
stages
of
development
.
Speaker 2
16:25
So
having
PCOS
is
a
good
problem
to
have
when
we're
treating
fertility
,
because
it
means
that
we
have
a
great
reserve
of
eggs
to
choose
from
.
There
are
plenty
of
eggs
on
the
ovary
.
We
just
need
to
help
those
ovaries
release
the
eggs
on
a
regular
basis
.
So
that's
how
we
would
treat
the
infertility
aspect
.
If
someone
has
irregular
periods
and
they're
bothering
them
because
they're
heavy
so
when
they
finally
have
a
period
two
or
three
months
later
they're
clotty
,
they're
heavy
,
they're
soaking
through
their
clothes
then
we
want
to
prevent
that
from
happening
by
either
putting
them
on
birth
control
pills
or
having
them
take
a
week
off
progesterone
every
month
so
that
their
body
sheds
the
lining
every
month
rather
than
have
it
accumulate
towards
the
end
.
And
if
someone
has
insulin
resistance
,
which
we
typically
see
with
PCOS
,
I
put
them
on
metformin
.
So
we
need
to
get
their
sugars
regulated
and
that
metformin
will
actually
help
regulate
their
cycles
.
It'll
help
them
have
more
regular
periods
when
we
resolve
the
insulin
resistance
issue
.
Speaker 1
17:19
Fascinating
.
When
you
have
a
patient
come
in
and
they
have
both
PCOS
and
endometriosis
,
how
do
you
address
that
when
we're
faced
with
both
of
those
things
?
Speaker 2
17:29
So
I
always
tell
patients
I'm
treating
you
as
a
whole
,
I'm
treating
all
your
symptoms
.
What
makes
me
a
little
different
than
my
other
REI
colleagues
is
I'm
also
an
endometriosis
specialist
.
So
if
someone
and
I
always
tell
patients
it
depends
on
who
you
go
to
see
first
.
If
you
go
see
the
endometriosis
surgeon
first
,
they'll
definitely
treat
your
endo
and
they
will
not
really
care
about
your
irregular
periods
as
much
until
the
endo
is
all
gone
.
Then
they'll
be
like
,
okay
,
now
you
need
to
see
a
hormone
specialist
,
an
REI
,
who
can
help
treat
your
PCOS
.
If
you
go
see
a
fertility
doctor
first
,
all
they
want
to
do
is
treat
the
PCOS
,
because
that's
what
they
do
every
day
.
They'll
ignore
the
pain
.
They'll
ignore
the
endo
.
They'll
say
we'll
get
back
to
that
later
.
Now
let's
focus
on
why
your
periods
are
irregular
,
or
let's
help
you
ovulate
and
see
if
that
will
get
you
pregnant
.
So
it
depends
on
who
you
see
first
.
Speaker 2
18:14
But
I
have
the
advantage
of
being
trained
or
board
certified
in
infertility
and
also
being
mixed
trained
in
endometriosis
.
So
when
I
see
my
patients
my
approach
is
a
little
different
.
I
talk
to
them
and
see
what's
bothering
them
first
.
Is
the
pain
interfering
with
their
quality
of
life
?
If
so
,
then
we
definitely
need
to
get
that
first
.
First
,
are
they
bothered
by
their
irregular
periods
and
they
just
want
to
have
a
regular
cycle
where
they
can
track
ovulation
and
try
and
conceive
that
way
?
Speaker 2
18:41
Because
,
yes
,
they
may
have
endo
,
but
we
don't
know
if
the
endo
is
affecting
their
fertility
,
because
about
70%
of
women
with
endometriosis
can
get
pregnant
naturally
.
It's
only
30%
of
women
with
endo
that
have
infertility
.
But
if
you're
not
ovulating
at
all
,
we're
not
giving
your
buddy
a
chance
at
getting
pregnant
at
all
.
Your
chance
is
almost
zero
.
So
if
they
say
you
know
,
my
pain
is
not
bothering
me
,
maybe
I
have
endo
,
maybe
I
don't
,
I'm
not
interested
in
pursuing
that
just
yet
.
I
want
to
see
if
I
ovulate
,
will
I
get
pregnant
naturally
first
.
Then
I'll
try
that
first
.
But
usually
ultimately
it'll
involve
a
combination
of
both
treating
the
pelvic
pain
,
doing
surgery
for
the
endo
,
finding
out
if
it's
there
and
removing
it
if
we
find
it
,
and
then
also
getting
them
on
a
regimen
where
they're
going
to
ovulate
consistently
to
give
them
the
best
chance
of
getting
pregnant
naturally
.
Speaker 1
19:28
Do
you
notice
a
significant
difference
for
those
who
have
the
surgery
for
endometriosis
first
,
as
opposed
to
having
it
after
trying
,
like
IVF
or
other
methods
,
to
becoming
pregnant
?
Speaker 2
19:40
Absolutely
.
I
wouldn't
even
proceed
with
IVF
if
we
had
a
strong
suspicion
for
endo
,
because
the
surgery
may
save
them
the
cost
of
IVF
.
If
we
do
the
surgery
and
we
find
endo
and
we
treat
it
,
then
they
may
have
a
good
chance
of
getting
pregnant
naturally
without
IVF
.
And
if
they
don't
get
pregnant
and
we
still
do
IVF
,
their
chances
of
pregnancy
with
IVF
is
going
to
be
significantly
better
than
if
the
endo
was
still
there
and
we
hadn't
removed
it
.
And
I'm
going
to
add
one
more
thing
to
the
discussion
,
and
I'm
not
sure
if
Dr
Liu
does
that
or
not
,
but
when
I
have
my
PCOS
patients
go
in
for
surgery
for
endometriosis
,
I
actually
will
do
ovarian
drilling
,
since
I'm
there
,
you
know
Ovarian Drilling and Ovary Removal Debate
Speaker 2
20:19
might
as
well
.
Speaker 2
20:19
Ovarian
drilling
is
a
surgical
procedure
that
was
done
very
often
in
the
older
days
when
fertility
treatment
was
not
as
available
.
So
we
would
go
in
and
surgically
poke
holes
in
the
ovary
.
Those
holes
are
meant
to
release
that
thick
layer
where
the
androgens
are
being
produced
.
Remember
I
mentioned
the
elevated
male
type
androgens
that
we
see
with
PCOS
patients
.
So
those
are
produced
by
cells
called
the
theca
cells
.
The
theca
cells
are
around
the
cortex
,
the
superficial
layer
of
the
ovary
.
So
if
we
poke
multiple
holes
in
the
ovary
.
That's
called
ovarian
drilling
and
it
actually
helps
women
ovulate
and
overcome
that
problem
of
elevated
androgens
.
We
don't
nowadays
take
women
to
surgery
just
for
that
,
and
20
years
ago
people
used
to
do
that
.
But
nowadays
,
because
we
have
so
much
more
advancement
in
medicine
,
we
give
them
pills
rather
than
,
you
know
,
take
them
to
the
OR
.
But
if
I'm
there
doing
their
endo
excision
surgery
and
I
know
they
have
PCOS
,
I
will
add
ovarian
drilling
to
my
procedure
.
Speaker 3
21:14
But
Sadiqa
.
It
has
to
be
confirmed
.
Speaker 2
21:17
PCOS
Correct
.
So
if
I've
diagnosed
them
already
based
on
their
hormone
checks
the
Rotterdam
criteria
they
fit
the
diagnosis
of
PCOS
.
They
have
infertility
.
They're
trying
to
get
pregnant
.
We
also
suspect
endo
.
When
I
go
in
for
my
surgery
to
remove
and
treat
the
endo
since
I'm
there
,
it
literally
takes
10
seconds
to
poke
10
holes
on
each
ovary
.
There
.
It
literally
takes
10
seconds
to
poke
10
holes
on
each
ovary
and
there
are
no
significant
side
effects
.
Help
,
that's
the
data
.
It's
maybe
not
as
consistent
in
helping
get
pregnant
,
but
there
are
no
side
effects
or
harm
,
since
we're
there
already
doing
something
else
.
Speaker 1
21:51
Right
For
those
with
PCOS
that
maybe
they've
tried
all
these
different
methods
.
Is
there
ever
conversation
about
removing
the
ovaries
at
any
point
?
They're
past
fertility
stage
or
you
know
they
are
past
wanting
to
have
kids
but
they're
having
symptoms
of
PCOS
.
Maybe
that's
the
hair
growth
or
the
imbalance
of
hormones
,
or
whatever
the
case
may
be
.
Is
there
ever
that
conversation
that
you
have
with
your
patients
about
removing
your
ovaries
and
the
side
effects
of
that
?
Speaker 2
22:19
I'll
start
by
talking
about
PCOS
patients
and
Dr
Liu
,
you
can
also
talk
about
endo
patients
and
having
their
ovaries
removed
.
So
from
a
PCOS
perspective
,
I
don't
think
removing
the
ovaries
is
a
good
idea
,
because
the
disease
is
a
lot
more
multifactorial
than
just
the
ovaries
and
we
have
ways
of
managing
the
symptoms
of
PCOS
without
removing
the
ovary
.
Removing
the
ovary
will
not
solve
the
problem
.
It
may
actually
create
worse
problems
when
women
go
into
menopause
.
Because
if
they
go
into
menopause
and
they
will
,
if
we
remove
their
ovaries
before
the
natural
age
of
menopause
,
that
I
have
to
give
them
hormones
to
replace
the
ovary
that
we've
removed
.
Speaker 2
23:00
I
would
rather
keep
their
ovary
and
give
them
different
types
of
hormones
that
are
safer
,
that
will
resolve
the
symptoms
they're
experiencing
from
PCOS
,
without
it
being
hormone
replacement
therapy
for
menopause
.
So
,
for
example
,
if
they're
bothered
by
the
hair
growth
,
the
androgens
,
then
there
are
medications
that
we
can
prescribe
.
One
popular
one
is
called
fenestride
.
That
will
reduce
the
hair
growth
,
reduce
the
male
type
hormones
,
but
it
is
very
toxic
to
an
embryo
so
they
cannot
get
pregnant
while
they're
on
it
.
So
they
need
to
be
on
reliable
contraception
,
iud
or
birth
control
pills
or
they
can
do
more
dermatology
and
cosmetic
things
like
laser
hair
removal
.
Those
things
are
usually
safer
and
will
probably
resolve
the
problem
in
a
way
that's
more
convenient
for
the
patient
without
creating
new
symptoms
and
new
issues
like
removing
the
ovaries
.
Would
Dr
Liu
,
would
you
talk
about
how
you
would
approach
your
endo
patients
if
they've
had
PCOS
and
you're
concerned
about
removing
an
ovary
?
Speaker 3
24:00
Yeah
,
no
,
I
don't
like
to
remove
ovaries
in
premenopausal
women
,
I
mean
even
if
when
they
approach
the
age
of
menopause
around
the
age
of
50
,
maybe
we'll
have
that
conversation
and
it's
really
only
to
reduce
the
risk
of
developing
ovarian
cancer
in
the
future
.
I
generally
don't
like
to
remove
ovaries
healthy
ovaries
on
patients
,
even
if
they're
PCOS
.
I
would
prefer
to
control
the
symptoms
of
PCOS
with
medication
.
First
of
all
,
you
need
your
ovaries
for
bone
health
,
brain
health
,
heart
health
,
cardiovascular
health
,
all
of
that
stuff
.
And
it's
very
easy
to
remove
an
ovary
I
mean
it
takes
20
seconds
.
But
I
just
don't
think
it's
the
right
thing
to
do
for
patients
either
with
PCOS
or
for
patients
with
endometriosis
.
Speaker 3
24:46
The
only
time
that
I
will
ever
remove
an
ovary
generally
on
a
premenopausal
woman
is
if
the
other
ovary
looks
good
and
healthy
.
If
the
offending
ovary
has
had
multiple
endometriomas
or
they
have
lots
of
pain
on
that
side
of
the
head
,
it's
very
stuck
and
it's
not
it's
.
There's
really
no
healthy
ovarian
tissue
left
for
me
to
salvage
after
doing
a
deep
dissection
or
after
removing
an
ovarian
cyst
.
But
again
,
I
always
want
to
look
and
make
sure
that
other
ovary
is
healthy
,
just
because
that
other
ovary
will
take
over
the
function
of
the
missing
ovary
.
So
I
I
have
a
really
hard
time
when
I
have
patients
who
come
to
me
when
they're
young
and
they've
lost
one
or
both
ovaries
for
really
no
good
reason
at
all
that
I
can
figure
out
.
You
know
again
,
you
know
they've
had
surgery
by
other
physicians
.
Speaker 3
25:31
I
just
I
feel
so
sad
I
really
do
when
that
happens
and
I
really
try
to
preserve
ovaries
at
all
costs
,
all
the
while
speaking
with
the
patient
.
You
know
,
at
the
end
of
the
day
,
if
the
patient's
like
I've
had
problems
with
my
right
ovaries
ever
since
I
started
menstruating
and
I
am
48
or
I'm
45
,
my
left
side
is
beautiful
.
I've
never
had
an
issue
with
my
left
side
.
Please
take
out
my
right
ovary
.
It's
just
.
You
know
,
that's
a
conversation
that
we
will
definitely
have
.
It
has
to
be
a
conversation
between
myself
and
the
patient
,
but
I
will
present
all
the
data
and
at
the
end
of
the
day
,
you
know
,
I
will
make
a
recommendation
and
the
patient
can
decide
what
the
patient
wants
to
do
in
regards
to
that
.
But
I
have
a
hard
time
removing
ovaries
.
I
really
do
,
yeah
.
Speaker 1
26:14
As
someone
who's
had
both
ovaries
removed
,
the
outcome
of
that
is
much
harder
than
I
had
anticipated
.
Speaker 1
26:19
In
fact
,
prior
to
that
,
I
didn't
really
understand
what
the
long-term
effects
of
having
both
ovaries
removed
would
be
,
and
I
think
that
needs
to
be
a
conversation
that's
had
with
your
provider
and
a
good
,
evidence-based
approach
to
talking
to
the
patient
about
what
we'll
be
facing
after
we
do
that
,
if
we
choose
to
have
our
ovaries
removed
.
Speaker 1
26:40
Mind
you
,
I
had
mine
removed
because
mine
continued
to
have
endometriomas
that
were
massive
in
size
and
a
lot
of
adhering
was
happening
and
no
,
it
was
different
for
my
case
.
But
I
also
would
say
that
I
hear
patients
time
and
time
again
say
they
just
went
ahead
and
removed
my
ovaries
so
that
it
would
solve
my
hormonal
imbalance
of
endometriosis
,
which
is
what
I
hear
,
which
is
not
,
you
know
,
evidence-based
.
It's
not
providing
the
best
accurate
information
to
the
patient
,
and
I
think
that's
an
issue
that
we
have
in
women's
health
in
general
is
that
the
information
that
we
are
given
isn't
complete
information
.
It's
just
essentially
throwing
a
Band-Aid
at
the
issue
and
not
addressing
the
actual
situation
with
evidence
and
with
expertise
a
lot
of
times
which
I
think
both
of
you
have
amazing
expertise
,
Dr
Liu
,
for
you
because
you
do
primarily
endometriosis
excision
.
When
you
have
these
patients
that
come
in
with
both
PCOS
and
endometriosis
and
you
address
the
endometriosis
piece
,
what
is
your
role
after
that
in
addressing
the
PCOS
piece
?
Speaker 3
27:40
I
fortunately
work
with
really
good
REIs
.
I
have
a
list
of
them
,
we
text
each
other
,
we
refer
to
each
other
and
I
tell
my
patients
look
,
I
am
very
good
at
what
I
do
.
I
can
definitely
get
rid
of
your
endometriosis
,
but
you
definitely
want
somebody
other
than
me
to
manage
your
PCOS
just
because
I
am
not
up
to
date
on
all
that
stuff
.
I
have
not
been
trained
as
extensively
as
Dr
Bebehani
or
the
other
REI
counterparts
and
you
deserve
the
best
person
to
help
you
with
this
particular
issue
.
So
I
will
refer
out
.
I
wish
Dr
Bebehani
was
closer
and
I
would
send
all
my
patients
to
her
because
I
think
she's
amazing
.
But
look
,
I
know
my
limitations
.
I'm
very
good
at
what
I
do
and
I
also
know
when
there's
somebody
else
who
does
a
better
job
at
certain
things
than
I
do
a
lot
of
things
better
than
I
do
and
I
have
no
problems
with
sending
my
patient
to
the
person
who
can
help
them
the
most
,
because
they
deserve
the
best
.
Speaker 1
28:38
Dr
Abubahani
,
when
you
have
patients
come
in
that
have
seen
other
providers
before
you
,
are
there
challenges
with
that
?
Are
there
challenges
when
they've
been
provided
with
extensive
hormones
or
maybe
multiple
rounds
of
IVF
or
whatever
the
case
is
?
Is
there
more
challenges
associated
with
seeing
a
provider
that
isn't
as
well-rounded
trying
to
treat
the
PCOS
piece
and
the
endometriosis
,
absolutely
so
you
have
to
remember
I
practice
in
Southern
California
.
Speaker 2
29:08
There's
a
fertility
office
every
two
miles
.
There
are
tons
of
IVF
centers
here
,
and
so
patients
will
often
go
on
Google
,
find
the
fertility
clinic
,
see
excellent
reviews
about
the
doctors
,
go
see
them
and
then
don't
understand
why
they've
had
two
or
three
unsuccessful
IVFs
.
Then
they
go
see
the
doctor
next
door
and
then
it's
the
same
case
scenario
until
they
come
and
see
me
and
I
review
their
IVF
history
and
this
poor
patient
has
had
six
embryo
transfers
,
four
egg
retrievals
,
multiple
beautiful
blastocysts
created
that
have
just
not
resulted
in
a
pregnancy
.
And
it
breaks
my
heart
that
no
one
ever
mentioned
the
possibility
of
endometriosis
to
those
patients
,
because
no
one
even
asked
about
their
pelvic
pain
.
They've
all
been
dismissed
,
not
a
problem
.
Maybe
the
other
doctor
didn't
put
you
on
the
right
protocol
.
Let's
try
a
different
protocol
.
Speaker 2
29:52
Or
maybe
the
lab
didn't
create
good
embryos
.
Speaker 2
29:54
Their
ICSI
rates
are
not
as
good
as
our
ICSI
rates
.
Let
me
do
your
IVF
and
I'll
get
you
better
embryos
that
will
definitely
get
you
pregnant
,
and
so
it
just
it
saddens
me
.
I
really
get
invested
in
my
patient's
care
and
I
feel
for
them
,
and
it
just
bugs
me
that
no
one
had
the
courage
to
say
,
like
Dr
Lu
said
,
you
know
your
limits
,
you
know
what
you
can
do
and
what
you
cannot
do
.
So
you
should
want
what's
best
for
your
patients
and
if
you
see
that
the
patient
has
gone
through
this
many
IVF
cycles
that
are
unsuccessful
,
you
should
now
think
outside
the
box
and
say
,
okay
,
this
may
be
outside
of
my
jurisdiction
,
let
me
find
them
someone
that
can
explore
the
possibility
of
endometriosis
,
because
we're
all
smart
physicians
,
we've
all
went
to
medical
school
and
OBGYN
residency
.
We've
all
heard
of
endometriosis
.
Yes
,
it
may
not
be
their
specialty
,
but
there's
ample
data
now
to
show
that
endometriosis
is
a
huge
part
of
the
unexplained
infertility
category
.
And
if
we
fix
it
,
then
we've
identified
the
problem
,
we've
solved
the
problem
and
now
they
can
get
pregnant
.
Speaker 3
30:52
So
if
you're
not
,
and
I'm
also
sorry
to
say
,
though
,
dr
Bebehani
,
but
then
they
lose
the
business
,
and
I
know
that
sounds
terrible
to
say
.
Empowering Patients in Women's Healthcare
Speaker 3
31:07
You
know
.
You
said
it
breaks
your
heart
when
you
see
patients
like
that
.
It
boils
my
blood
.
When
I
see
patients
like
that
,
I
have
a
visceral
reaction
.
I
get
angry
because
these
poor
patients
now
they're
like
late
thirties
,
they've
gone
through
and
they've
had
a
known
endometrioma
for
this
entire
time
nine
IVF
cycles
later
and
they
still
can't
hydrostat
pinks
,
and
I'm
just
like
it
doesn't
break
my
heart
anymore
.
I'm
like
over
being
sad
.
I'm
actually
very
angry
and
that
is
why
I
think
,
um
,
like
you
said
,
you
know
I'm
in
New
York
city
.
There's
IVF
centers
on
every
corner
too
,
and
it's
just
it's
not
okay
,
for
sure
,
dr
lou
.
Speaker 2
31:43
But
you
know
why
I
don't
get
mad
or
upset
or
show
my
emotions
in
front
of
patients
,
because
it's
not
fair
to
them
.
They
did
their
,
they
did
their
research
.
They
know
.
Speaker 3
31:50
I
know
it's
not
it's
not
fair
to
them
at
all
but
I
am
,
I
am
,
I
know
,
not
mad
at
the
patient
.
Obviously
I
am
mad
on
behalf
of
the
patient
.
I
know
the
patient
did
nothing
wrong
.
They
trusted
physicians
.
They
trust
and
I'm
not
bashing
,
listen
,
I'm
not
bashing
anyone
.
Speaker 3
32:12
I
just
feel
like
there's
maybe
there's
a
lack
of
awareness
.
I
think
that's
a
huge
part
,
even
in
the
GYN
world
,
absolutely
in
the
GYN
world
,
I
mean
,
everyone's
known
about
endometriosis
,
but
it's
like
a
paragraph
in
medical
school
.
I
still
ask
my
medical
students
what
do
you
know
about
endometriosis
?
And
it's
like
,
oh
,
we
learned
a
little
bit
.
Like
you
retrograde
menstruate
,
and
it's
like
it
causes
,
and
it's
like
it's
something
having
to
do
with
,
like
I
don't
know
,
you
have
pain
and
you
have
to
miss
school
.
Like
they
have
no
idea
.
So
if
that's
what
they're
teaching
in
medical
school
and
then
in
residency
,
you
don't
get
a
lot
either
.
I
mean
,
I
was
fortunate
I
did
.
Speaker 3
32:48
But
I
think
that
the
majority
of
residencies
do
not
have
good
endometriosis
training
.
They
think
that
,
oh
,
let's
go
in
there
,
let's
burn
a
couple
of
things
that
look
like
black
dots
,
let's
stick
a
laparoscope
in
and
let's
take
a
look
around
.
No
,
everything
looks
fine
.
Five
minutes
later
they
go
out
.
They
tell
the
patient
you
don't
have
endo
because
they
don't
recognize
it
.
And
so
,
yeah
,
I'm
not
mad
at
the
patient
,
I'm
not
even
mad
at
the
healthcare
provider
because
,
honestly
,
they
may
not
even
know
,
they
may
not
even
know
,
they
may
just
think
it's
unexplained
infertility
and
let's
keep
on
going
.
But
I
am
mad
that
this
is
such
a
prevalent
common
disease
and
patients
are
suffering
,
and
it's
years
and
decades
of
pain
and
being
ignored
,
and
so
that's
that's
what
really
makes
me
upset
.
It's
it's
the
whole
,
it's
the
whole
system
.
Speaker 2
33:38
I
completely
agree
with
you
and
you
know
what
I
actually
try
and
educate
my
REI
colleagues
.
So
I've
gone
around
,
knocked
on
their
doors
,
talked
to
them
about
what
I
am
here
to
add
on
to
their
care
.
I'm
not
here
to
steal
their
patients
away
.
I'm
here
to
help
help
their
patients
achieve
their
goal
of
fertility
.
I'm
happy
to
do
their
surgery
,
send
them
back
to
you
,
but
they
will
not
refer
them
for
two
reasons
.
One
is
because
,
like
Dr
Liu
said
,
they're
worried
that
they're
going
to
come
see
me
and
then
not
go
back
to
them
.
And
number
two
,
they
don't
believe
that
endometriosis
is
anything
to
do
?
Speaker 3
34:05
They
don't
believe
it
.
Speaker 2
34:06
I've
gone
to
medical
conferences
.
I've
taught
lectures
.
I've
been
attacked
after
lectures
.
Your
data
is
weak
.
Your
data
doesn't
really
support
that
IVF
helps
improve
,
or
excision
of
surgery
helps
improve
IVF
outcomes
.
We're
not
going
to
change
our
clinical
practice
.
We're
still
going
to
keep
doing
10
and
11
and
12
IVF
cycles
.
Why
,
you
know
that's
what
bothers
me
is
I've
tried
,
dr
Lu
,
I've
gone
out
on
,
you
know
,
every
conference
I
talk
about
endometriosis
and
fertility
.
It's
one
of
my
,
you
know
,
most
cherished
talks
because
I
feel
like
I'm
definitely
one
of
the
best
people
to
talk
about
it
given
that
I'm
trained
in
both
aspects
.
Speaker 2
34:41
but
you
know
,
even
I
have
and
not
all
REIs
are
like
that
,
I
have
to
say
I
have
a
bunch
of
REIs
who
are
excellent
at
referring
their
patients
to
me
for
surgery
.
Yes
,
but
but
always
after
they've
tried
a
bunch
of
IVF
cycles
like
it's
right
.
Speaker 2
34:54
It's
never
a
first
line
on
their
treatment
but
after
trying
a
bunch
,
a
couple
,
or
if
the
patient
brings
it
up
,
then
they
will
admit
that
they're
not
the
best
people
to
talk
about
the
disease
and
send
them
over
to
see
me
.
But
the
majority
will
just
,
you
know
,
not
interested
.
No
.
Speaker 1
35:09
Yeah
.
At
what
point
do
we
stop
listening
fully
at
the
system
and
listen
to
the
patients
?
Because
this
is
where
I
,
as
a
patient
,
I
get
frustrated
because
patients
have
said
so
many
times
I'm
frustrated
with
women's
health
,
I'm
frustrated
with
the
fact
that
no
one
knows
what
I'm
going
through
and
I
see
10
,
12
providers
before
I
get
an
answer
.
I'm
frustrated
because
I
spent
all
these
thousands
of
dollars
trying
to
get
pregnant
and
yet
I
still
can't
get
pregnant
and
I'm
in
a
lot
of
pain
and
no
one
can
tell
me
why
.
Speaker 1
35:36
At
what
point
do
providers
start
listening
to
patients
and
their
experiences
?
Speaker 1
35:40
Because
if
you
ask
a
majority
of
patients
who
have
gone
through
excision
surgery
for
endometriosis
,
not
all
are
successful
with
fertility
but
and
not
all
are
successful
at
being
,
you
know
,
100%
pain
free
,
because
the
reality
is
that
the
is
the
disease
doesn't
often
leave
us
able
to
be
100%
pain
free
because
of
other
things
going
on
.
And
so
at
what
point
do
we
step
back
and
say
but
my
quality
of
life
has
been
significantly
increased
because
of
excision
surgery
,
and
if
patients
are
saying
this
has
been
extremely
helpful
for
me
,
can
we
as
a
community
just
listen
to
that
?
I
think
that
many
patients
are
feeling
unheard
,
invalidated
,
and
I
think
a
lot
of
that
is
because
of
that
system
.
But
when
will
the
patient
start
having
that
voice
in
the
educational
system
?
And
of
course
,
there
are
doctors
that
do
like
you
,
ladies
,
but
is
that
even
a
feasible
thing
?
Walking
into
fellowships
and
med
schools
as
a
patient
saying
this
really
increased
my
quality
of
life
or
this
increased
my
ability
to
have
kids
Is
that
even
heard
anymore
?
Or
is
it
just
backed
by
data
?
Speaker 2
36:46
For
us
,
dr
Lu
and
myself
,
we
definitely
hear
that
that's
what
we're
here
for
to
listen
to
our
patients
and
that's
why
Dr
Lu
said
I
give
them
the
evidence-based
material
on
removing
ovaries
,
I
give
them
my
clinical
recommendation
,
but
at
the
end
of
the
day
they're
the
boss
.
They
tell
me
what
they
want
and
if
someone
comes
in
and
says
,
well
,
I
really
want
a
hysterectomy
,
I
talk
to
them
about
the
pros
and
cons
,
but
if
that's
what
they
want
ultimately
,
you
know
my
job
as
their
physician
is
to
guide
them
and
then
also
respect
their
wishes
.
So
for
the
REIs
or
the
GYNs
that
are
dismissing
and
ignoring
patients'
pain
,
that's
not
okay
.
That's
what
we
are
treating
our
students
and
residents
and
fellows
.
To
do
is
listen
to
your
patient
and
if
your
patient
is
not
happy
,
find
out
why
and
what
you
can
do
to
help
them
,
even
if
it
is
not
within
the
realm
of
your
rotation
.
So
if
you're
in
an
ER
rotation
and
you
don't
know
what
to
do
to
help
this
patient
with
pelvic
pain
,
go
on
the
internet
,
look
it
up
on
UpToDate
,
see
what
it
could
be
and
if
you
find
something
that
you
think
may
help
them
,
then
you
go
back
there
and
you
give
them
recommendations
on
who
to
see
that
may
be
able
to
understand
their
problem
.
So
it's
not
okay
to
just
follow
data
blindly
without
listening
to
your
patient
and
see
how
they
feel
about
it
.
And
then
also
,
the
patients
are
very
smart
nowadays
.
You
ask
when
are
we
gonna
start
listening
to
our
patients
?
Speaker 2
37:58
I
love
that
social
media
has
empowered
women
to
find
the
resources
that
are
right
for
them
.
My
kids
always
make
fun
of
how
long
my
business
name
is
Center
for
Endometriosis
and
Fertility
,
but
I
tell
them
this
is
the
best
way
for
patients
to
find
me
,
because
when
they
endometriosis
and
fertility
,
I
pop
up
and
then
they
can
read
the
resources
that
are
there
set
up
for
their
type
of
disease
.
You
don't
have
to
dig
through
textbooks
nowadays
or
the
yellow
pages
to
find
doctors
.
You
go
on
the
internet
,
you
search
things
and
social
media
pops
up
.
You've
got
accounts
,
accounts
.
Dr
Lu
posts
excellent
surgical
videos
.
Patients
are
educated
now
.
They
watch
those
and
they're
like
this
is
the
type
of
surgery
I
want
for
myself
.
Or
they
read
patient
reviews
.
You
mentioned
that
not
all
women
will
get
pregnant
100%
.
Not
all
patients
will
get
rid
of
their
pain
,
but
when
you
read
other
women's
experiences
,
you
want
that
for
yourself
.
You're
like
this
is
what
I
want
for
me
.
So
this
is
where
you
end
up
going
,
yeah
.
Speaker 1
38:52
What
should
people
be
aware
of
for
both
the
PCOS
piece
but
also
the
endometriosis
,
when
they
are
seeking
out
new
providers
?
Because
this
is
a
very
hard
thing
for
a
patient
to
do
to
know
where
to
go
and
what
to
look
for
when
they
are
seeking
out
educated
,
well-rounded
providers
.
Maybe
they
don't
specialize
in
everything
,
but
they
understand
where
they
do
specialize
and
can
refer
out
.
I
think
is
a
huge
part
of
it
.
But
what
should
they
look
for
?
Oh
,
that's
a
good
question
.
Let's
start
with
endometriosis
care
,
because
that's
kind
of
your
ballgame
.
What
should
they
be
looking
for
for
an
endometriosis
doctor
or
surgeon
?
Speaker 3
39:27
I
think
one
of
the
biggest
things
is
well
,
first
of
all
,
low-hanging
fruit
Make
sure
that
the
surgeon
does
excision
,
not
ablation
,
which
excision
means
cutting
out
the
endometriosis
lesions
.
Ablation
means
burning
it
.
We
do
know
that
excision
is
the
gold
standard
and
that
is
what
provides
you
with
pathological
diagnosis
,
which
means
that's
how
you
cut
out
the
endometriosis
.
You
send
it
to
the
pathologist
.
They
look
at
it
under
microscope
and
they're
like
yes
,
this
is
endometriosis
and
that's
how
you
get
diagnosis
and
that's
also
how
you
get
treated
,
because
you
remove
the
lesion
or
the
disease
that
could
be
causing
the
symptoms
,
such
as
pain
,
the
bowel
symptoms
,
the
bladder
symptoms
,
the
infertility
.
That's
treatment
for
the
disease
.
So
I
think
that's
the
number
one
thing
is
make
sure
it's
excision
.
Second
of
all
,
you
know
,
I
think
it
would
be
good
for
patients
to
really
focus
on
surgeons
who
really
only
do
endometriosis
surgery
.
Dr
Bebe
Hane
is
specialized
because
she
does
both
and
she's
very
good
at
both
.
But
you
see
a
lot
of
these
endometriosis
treatment
centers
popping
up
all
over
the
country
because
it's
very
fashionable
these
days
.
Endometriosis
is
which
is
good
,
which
is
good
.
I'm
not
saying
it's
a
bad
thing
,
but
I
also
think
that
a
lot
of
their
surgeons
are
,
first
of
all
,
they're
fellowship
trained
,
which
is
excellent
,
which
means
that
they've
had
extra
years
of
training
in
surgery
after
residency
.
Speaker 3
40:53
But
they're
probably
not
just
doing
endometriosis
surgery
.
They're
probably
doing
a
lot
of
big
fibroids
.
They're
probably
doing
a
lot
of
large
uteruses
.
They're
doing
hysterectomies
.
They're
doing
a
lot
of
big
fibroids
.
They're
probably
doing
a
lot
of
large
uteruses
.
They're
doing
hysterectomies
.
They're
doing
a
lot
of
different
things
,
which
I
think
,
when
it
comes
to
endometriosis
,
it's
really
good
if
you
can
find
someone
who
does
it
all
day
,
every
day
,
and
that's
all
they
do
,
because
endometriosis
is
such
a
tricky
disease
and
it
can
grow
on
literally
any
organ
you
can
think
of
.
And
if
really
you're
only
doing
one
endometriosis
surgery
a
month
and
the
rest
of
your
surgeries
are
fibroids
,
you
may
not
be
equipped
when
you
get
into
the
OR
with
a
difficult
endometriosis
case
to
really
do
a
thorough
surgery
and
really
give
the
patient
the
best
outcomes
just
with
one
surgery
.
So
I
think
that's
another
thing
is
look
and
make
sure
that
they're
specialized
.
That
is
all
they
do
.
Speaker 2
41:49
Like
Dr
Liu
said
,
I
can
definitely
do
both
of
us
.
We
can
do
fibroids
,
we
can
do
hysterectomies
,
we
can
do
pelvic
inflammatory
disease
,
we
can
do
everything
.
But
the
reason
why
we
choose
to
do
only
endometriosis
because
the
more
you
do
of
it
the
better
you
get
at
it
,
because
it's
a
very
complex
disease
and
it
presents
in
so
many
different
ways
.
That's
one
thing
,
and
the
other
thing
is
there
are
other
surgeons
that
can
do
fibroids
or
PID
or
o't
have
to
see
the
low
volume
surgeons
or
the
surgeons
that
may
have
a
lower
understanding
of
the
disease
.
Speaker 1
42:17
Yeah
,
oh
,
that's
great
advice
.
Thank
you
both
so
much
for
taking
the
time
and
breaking
this
down
.
I
appreciate
it
.
Thank
you
for
your
wisdom
.
You're
welcome
here
anytime
,
so
thank
you
.
Speaker 2
42:39
Thank
you
so
much
.
We
appreciate
it
.
Thanks
for
having
us
.
Speaker 1
42:43
I
hope
this
episode
was
helpful
and
if
you
have
more
questions
,
go
ahead
and
info
at
endobatterycom
and
I'd
be
happy
to
reach
out
to
experts
to
help
answer
those
questions
and
,
until
next
time
,
continue
advocating
for
you
and
for
those
that
you
love
.
Thank
you
.