Endo Battery

Innovative Endometriosis Surgery and the Power of Mentorship: Dr. Cindy Mosbrucker

July 17, 2024 • Alanna • Episode 84

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Ever wondered how a childhood dream of becoming a veterinarian could evolve into a distinguished career in urogynecology? This week, we welcome Dr. Cindy Mosbrucker, a leading expert in minimally invasive excision of endometriosis. Her journey is nothing short of extraordinary—from hands-on experiences to impactful mentorships, and even a pivotal training encounter with the renowned Dr. David Redwine. Dr. Mosbrucker’s story is a testament to the power of perseverance and passion in transforming the landscape of women's health.

We also delve into the groundbreaking work of Dr. David Redwine, a pioneer in excision surgery for endometriosis. Despite facing fierce criticism, Dr. Redwine's innovative approach and dedication to patient outcomes have revolutionized our understanding of the condition. His humor and humanity shine through, making his contributions not just scientifically significant but also deeply personal and humane. This episode highlights the emotional and professional challenges specialists face and underscores the importance of better patient education and collaboration within the medical community.

Our discussion extends to the complexities of training and identifying skilled endometriosis surgeons. We explore the limitations of MIGS fellowships and the critical need for specialized education and experience in endometriosis care. Additionally, we touch on the slow but promising advancements in endometriosis research, focusing on genetics and immunotherapy. The episode is a comprehensive look at the multifaceted journey of improving patient care, from surgical expertise to addressing the psychological aspects of chronic pain. Join us for an insightful conversation that promises to inform, challenge, and inspire.

Website endobattery.com

Speaker 1:

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:

I'm joined by my guest, dr Cindy Mosbreker, who is a nationally recognized expert in minimally invasive excision of endometriosis and the diagnosis and treatment of pelvic pain in women. She completed her medical degree at Northwestern University and honed her skills in OBGYN during her residency at the National Naval Medical Center. Following her Navy service, she specialized in GYN and urogynecology surgery in Hawaii, before training under the renowned Dr David Redwine. Now based in Gig Harbor, washington, Dr Mossbrecher runs a private practice focusing on pelvic pain, endometriosis and incontinence, advocating for a multidisciplinary approach to patient care. Certified in female pelvic medicine and reconstructive surgery. She is dedicated to improving her patient's quality of life through a collaborative and comprehensive treatment plan. Please help me in welcoming Dr Cindy Mosbricker. Thank you, dr Mosbricker, for joining me today and taking your time out of your busy schedule and allowing us to be part of your information resource list, and that your history and everything else. Thank you for joining me.

Speaker 2:

You're very welcome, and it's my pleasure.

Speaker 1:

Thank you. Can we start because you have a history that no one else does. Your history career as far as surgery and medical career is very different than anyone I know, which is true to most people, but you have a special history. Can you explain what inspired you to pursue your career in urogynecology as well as specialize in endometriosis? Well, it's a long story.

Speaker 2:

When I was 15, I decided I want to be a veterinarian. Because I worked at a ranch for summers and the vet would come out and take care of the animals that got hurt. And the vet would come out like once a week and he'd need somebody to do the dressing, changes and whatever. And so I would volunteer and I'll do it. So, anyways, I came home that summer and I told my dad that I figured out what I wanted to do when I grew up and I wanted to be a veterinarian. And he's like why don't you be a people doctor? I'm like well, you got to be smart for that. And he's like well, you got to be smart to be a veterinarian too.

Speaker 2:

So my neighbor was an internal medicine doc and his best friend was an orthopod. And so I started spending time with those guys and decided, yeah, I kind of like orthopedics. I was into sports when I was younger and sports medicine was really interesting to me. And so I went to med school thinking that I was going to do orthopedics. And then I did my surgery rotation and loved the finesse of belly surgery, being in the abdomen and doing bowel surgery and all that kind of stuff. And then I went to do my ortho rotation and it was like this is sterile carpentry. It was just so unfinessed and hammer and chisel and stuff like that. And so I had a hard time in med school deciding between general surgery, urology and gynecology and the general surgeons were on call every other night and I knew my body couldn't handle that and so it came down to urology and GYN and I picked GYN because I would rather take care of women basically.

Speaker 2:

And so during my residency this new field of urogyne was beginning. That really caught my interest because I liked both and I really wasn't nuts about OB. But it kind of came along with the package. So you kind of had to do a little bit of it. And back then in the early 90s there were only a few fellowships in urogyne and the thinking was that if you wanted to do research and be an academic, then you needed to do a fellowship, and if you just wanted to do it, you just did it.

Speaker 2:

I was in the Navy. I got the Navy to pay for med school, so I went to Guam and for my first three years and made friends with urologists and so I do bladder cases with them and learn how to do systos and stents and all that kind of stuff, and then did a lot of slings once slings were introduced in the early 2000s and prolapse repairs and all that kind of stuff. I wound up getting out of the Navy and moving to Hawaii and did kind of half general OBGYN and urogyne for about eight years over there and eventually I felt this little tap on my shoulder like in the cartoons where the angel sitting on your shoulder tapping you and it's like there's something more you're supposed to be doing. And I knew I had the potential to be a better surgeon and to do more challenging cases. And I also knew that what I'd been taught about endometriosis made no sense at all. And so we were looking to move back from Hawaii back to the mainland and our parents were in the Northwest and we didn't want to be too close to our parents but we wanted to be close enough that we could get there if we had to. And so Bend, oregon, seemed like a great place to go.

Speaker 2:

And lo and behold, david Redwine had put an ad in the Green Journal, which is the journal of OBGYN, looking for somebody to come join him. So I wrote to him and he wrote back with this like three page long email saying everything that he did and all the crazy surgical stuff that he did and how he took care of these women with endometriosis, and at first I thought he was just making it all up. I'm like he's doing bowel resections and ureteral reimplantations and all this stuff and I'm like that's crazy. And then, the more I wrote back and forth to him, the more I realized no, this is really what he does. It's everything that I had always ever wanted to do. So, anyways, I went out and spent a week with him in December of I think it was 2005, and came home thinking this this guy is an incredible surgeon and what he does is life changing for these women and I need to do this.

Speaker 2:

And so we we moved in the summer to Bend Oregon and I was there for two years and operated with David every day. And it was in 2008 when the two years was up. It kind of was the subprime mortgage financial crisis and it was kind of clear that his practice was a one person practice and, you know, not really enough volume. People didn't have the money to be traveling to crazy places like Bend Oregon for surgery, so I moved back home up to Gig Harbor, which is where I grew up. I grew up in Fort Crest, which is right across the Narrows Bridge, but spent a lot of time in Gig Harbor, so I felt like home. Fircrest, which is right across the narrows bridge, but spent a lot of time in gig harbors, so it felt like home.

Speaker 1:

So I've been here since 2008 doing initially it was like 50 50 endo and urogyne, and over the years it's become now now I do probably 90, 95 percent endo and very little urogyne that's what I mean, like that history, because correct me if I'm wrong, but you were Dr Redwine's only fellow, correct, which is something no one else obviously can say and you have a perspective that I think is so unique because you've seen the conception of excision and endometriosis from a different viewpoint with Dr Redwine, and from the very beginning of what many called crazy, so to speak. You know they said so many different things.

Speaker 2:

The medical staff board brought him in and was going to sanction him because he was removing endometriosis and some I think it was the chief of the department of OBGYN thought that he was being a cowboy and doing all this stuff that he shouldn't do. And they brought him in in front of the board of directors and said what are you doing and why are you doing this? And he's like well, let me explain it to you this way If a patient had appendicitis, would you take out their gallbladder? You know, if somebody had a kidney mass, would you take out their bladder? No, you would take out the disease. He's like I remove the disease and I leave normal reproductive organs alone. And they're like really, oh, why isn't everybody doing this? It seems to make so much sense, right, but you know? But yet that's the kind of ostracism that he got from the community.

Speaker 1:

Yeah.

Speaker 2:

And he was called crazy.

Speaker 2:

Didn't help that he lived in the middle of Central Oregon, which was when he moved there in 78, it was kind of the middle of nowhere, Right, but he, I really believe, is the father of excision surgery.

Speaker 2:

And when you go through and read all of his papers and you were at the end of summit and Sally asked me to speak about David's life and I went through all of his papers and kind of briefly summarized them in that talk and it really made me think again about how the genius of that man and how he thought to create this database and how he knew at the get-go that he was doing something that was going to change medical practice and that he needed to record that. And then he needed to keep track of those patients and their outcomes and in doing so he kind of defined how well does excision work? What does endo look like? What does it look like in a teenager versus in a 40-year-old woman? Does it spread? No, 40-year-olds have as many areas of endo as 20-year-olds do. And so some of the kind of existential questions about endometriosis he answered.

Speaker 1:

Right. And he you know it's interesting because right before he passed away he was on the podcast and I, you know same way I always start when I have guests on I say, how would you like me to refer to you, because I think that's important to understand. And he's like, well, I'd like to be called the emperor, because I think that's important to understand. And he's like, well, I'd like to be called the emperor. And I said, okay, you're the emperor.

Speaker 1:

And I think, beyond just his fight for endometriosis and patience with endometriosis, you know, I think his humor really allowed people to see the human side of him and how much he genuinely cared for those in the endometriosis community. And I think that it was shown within his papers. It was shown in the way that he would teach about endometriosis and the way that he continuously, until his passing, would educate and fight for those with endometriosis to get proper care. And that didn't happen just over one night. It was, it was a progression. And he fought, and he fought hard against those who criticized, who bashed him, whom you know wanted to defeat the emperor, so to speak.

Speaker 2:

And he didn't let them and he kept fighting.

Speaker 1:

I think that should be a role model, beyond just the endometriosis piece, but be a role model that we can't give up at just the criticism of what you're doing when you know it's right. So you're saying I can't retire, you can't retire, that's it right there. You're not allowed to retire. Nancy hasn't retired from advocacy. You're not allowed to retire.

Speaker 2:

Nancy hasn't retired from advocacy.

Speaker 2:

You're an interest in me.

Speaker 2:

I think they saw a potential, you know, and they really helped me learn how to dissect and how to approach surgery, which I think gave me a leg up in my residency and allowed me to become a better surgeon than most of my peers just out of residency.

Speaker 2:

But I never learned how to dissect out a ureter. I never learned how to divide the uterine artery lateral to the ureter and basically do a radical hysterectomy, which is what we have to do sometimes for endo, when there's really deeply infiltrating disease on the uterus sacral. We have to treat it like a cancer case. And I had learned how to do ovarian cystectomies but we never closed the ovary and it makes so much more sense to put a suture in it and close it and prevent the adhesions that happen after you don't close it and so many things that you don't close it and so many things that you know. I thought I was a good surgeon and I was nothing until I spent two years with David and he taught me as far as surgical technique goes. He taught me 90% of what I do today.

Speaker 1:

Did that also affect the way that you interact with patients, seeing it different from the fellowship perspective and getting into endometriosis, versus not doing a fellowship and potentially not knowing anything about endometriosis? How do you think that shaped?

Speaker 2:

you. Before I spent time with him. I did not specialize in endometriosis and you know, occasionally we'd have somebody that had endo and I'd operate on them and do the ablation techniques. And I had one girl that had these recurrent cysts in her pelvis despite having done oophorectomy on her for endometriomas, and I didn't realize what was happening and I didn't know what I didn't know because I'd never been taught. And now I know exactly what was happening with that girl and I wish I could go back and say, hey, let me do your surgery the correct way, because she had an ovarian remnant and we never got the disease out from a retroperitoneal approach. And so I know now what I should have done in some of those cases before I learned what I learned from him. But I will tell you the first I don't know a couple of months that I was there in Bend I would cry when I heard these women's stories about surgery after surgery after surgery and people not treating them right and doctors making the patients feel like they're crazy because the doctors didn't know what was wrong with them.

Speaker 2:

And initially it made me sad and made me upset and then it just made me mad. And it still angers me when I see 28 year olds who had normal ovaries removed and they weren't told what the repercussions were of that, they weren't told what their life was going to be like, you know, for the next 25 years, until they should have normally gone through menopause, and the patients who are dismissed because they're just looking for secondary gain, oh, you know, nothing's really wrong with you. You know, why are you here? Why are you on my doorstep asking for meds? You must be drug seeking. You know. You must be crazy, you must have been raped sometime in the past and you just don't remember it. So you need to go do psychotherapy. So you, you know, so that you can deal with this, or you're just stressed. That's why your pelvic floor is tight. There's really nothing wrong with you.

Speaker 1:

Yeah.

Speaker 2:

So I mean, you see these things all the time and I don't know how to deal with it, because general OBGYNs it seems like a lot of them aren't really interested in what I have to say. Some of them are, some of them are wonderful, and I've developed a relationship with some generalists who you know, when they're, when they have patients that have pain and you know endo that they know that they can't deal with, they're like you need to go see Cindy. Yeah, I really appreciate that and I would love to nurture those relationships and I would love to make more of them, but it seems hard because a lot of them are like yeah, yeah, yeah, fine, whatever.

Speaker 1:

It's uncomfortable for them to be faced with that.

Speaker 1:

Yeah, absolutely. It sounds like I mean, and I haven't really thought of it this way, but I see it time and time again with doctors who specialize with endometriosis. They almost go through a grieving process with their patients, like it's not. You go into the office, you tell your story, they find a solution. They kind of just grieve with you because it impacts them and impacts the way that they treat other patients down the road when they are faced with certain situations or circumstances. And I think that we forget that as a patient, that when we go to see an endometriosis specialist, yes, they care, yes, they validate, but they also grieve because they're hearing this time and time again. And it's the different stages of grief it's the sadness, it's the anger, it's the how could they, the denial. You know, I think they all go through that. I mean that just is an impactful statement for those that have dealt with it to understand that they grieve with you.

Speaker 2:

Yes, I think, I mean, I certainly do.

Speaker 1:

What has changed? What have you seen in the progression with fellowships in the years that you've been doing this? Because now you know you've gone through your fellowship, you've practiced, you have started creating a space for other fellows to come in. What is the biggest difference you're seeing in endometriosis and fellowships?

Speaker 2:

Well, there really aren't many. I mean, I had a fellow from 2019 to 2021, and then she went away for two years and then she came back last fall, dr Newville, and she's phenomenal, she's just an awesome human being and she's an amazing surgeon and she right now is probably capable of doing 90% of what I can do. The you know, the last 10% is going to take a while because it's the hardest and you know the frozen pelvises and the you know digging out ureters and all that kind of stuff. And then last summer I had a new fellow come, dr Yagy, who was on your podcast, and so she started last August and I think her mind is blown on a daily basis with what she hears from these people and it's a honor and a pleasure and I think my mission in life to educate the next generation of endosurgeons, and David's mission in life was to define the disease and I think my mission is to try to train the next generation.

Speaker 2:

There are a lot of minimally invasive GYN fellowships now.

Speaker 2:

They started probably 25, 30 years ago with basically mentorships where surgeons would go work with an established gynecologist who did a lot of minimally invasive stuff, like Tom Lyons and Dan Martin and people like that and so gradually over time, aagl developed minimally invasive gynecologic surgery or MIGS fellowships, and now there's probably I don't know 20, 25 locations, maybe more than that, maybe 30 across the country.

Speaker 2:

But some of them do a pretty good job at endo and others don't really do much of anything with respect to endo, and so there's a little bit of a problem when it comes to who's an endo specialist. You know, because a lot of these kids that have finished a MIGS fellowship they're like oh, I'm a specialist in endo, you know I can do endo, but they really don't understand. Yeah, maybe they can do a cystectomy decently and maybe they can suture laparoscopically so they can sew the ovary closed, but they don't understand the deep disease, they don't understand how deep they have to go to get around the base of it. There's a lot of stuff they don't do, and they can't do because they were not taught adequately how to take care of endopatients. It would be wonderful if there were true endometriosis fellowships, if there were more of them, but the problem is that you have to have a mentor and you have to have somebody who's an expert endosurgeon in order to be the trainer.

Speaker 1:

Right, it's true. I mean, I think that that also brings up the next point of why it's important to know where your surgeon has gotten their education and why it's important to know if they've done a fellowship and where that fellowship was done. Because you can go to a MIGS certified doctor but doesn't necessarily mean they know enough about endometriosis to do a good surgery for endometriosis Like, yes, they can maybe do a good surgery for other gynecological issues because that's what they're trained in. But it doesn't mean that endometriosis is going to be the same, because endometriosis, like many of us know, is almost like a cancer, so it responds differently for everyone, it's different presentation for everyone and it can be really scary to go in there. Dr Yagi was actually talking about that. How, when she went in one time, she was like this is beyond my scope. The same can be true with a MIGS certified surgeon or a MIGS fellow surgeon.

Speaker 1:

And so it is important, I think, to have an understanding of, before you decide on surgery or treatment, where your doctor got their education on endometriosis Not just their education as a whole, but their education on endometriosis. Maybe a few extra pieces of that. What do you think is the most important part to look for when you're looking for that, because most of us don't know where these fellowships are, but what can help us identify a good education on endometriosis?

Speaker 2:

That is, the $100,000 question. You know because you know. Nancy says there's a hundred or 200 people in the country who do excision and I say, well, that may be true, but there's probably 20 people in the country who do excision. Well, and there are doctors at academic institutions who write lots and lots of papers on endometriosis, yet they are not very good surgeons and I see their videos at meetings and online and places like that. And I look at these people who claim to be experts in endometriosis and I'm watching them operate and I'm watching them operate and I'm like you should have done this. You should have done that. Why did you do that? This makes no sense, and so, unless you know how to evaluate somebody's videos, it makes it hard to know how good of a surgeon they are, right, how good of a surgeon they are. And so there are gynecologists who they write lots and lots of articles and I've seen patients that they have operated on and it's like this just this doesn't look like a true excision specialist has been here.

Speaker 2:

I mean, I even had a patient who had surgery by one of the top dog people and after that surgery she was told well, you have endo on your rectum and there's nothing you can do about it. There's nothing anybody can do about it. You just have to go meditate and do Chinese herbs and, you know, come to peace with it. And she came out to see us and she had a five centimeter mass in her rectum and we did a bowel resection and you know she was better. But these are well-known academic centers and it's so frustrating because it's like, well, how should a patient know, right? So we we tried to start this thing and we're trying to put our heads together to figure out how do we create a way to look at surgeons videos to say, yes, they know what they're doing, or no, they don't know how what they're doing.

Speaker 1:

Right.

Speaker 2:

And we met this guy. You know he's like well, I have the platform that I can facilitate this. So we started working together and initially there were probably 20, 25 people who were vetted, and everybody, including me, had to submit de-identified videos of our surgeries and each other reviewed it and said, yes, this is good, we know what we're doing. And then we vetted other people and then the vetted people would be able to vet other doctors, and so initially it was a really good program. Recently, I have heard that he is allowing people to pay him to put them on this list, and so I haven't actually been to the website to see what it looks like. But it's sad because it dilutes the effectiveness of knowing that, okay, this doctor has been reviewed, their surgical technique has been reviewed by all the true expert excision specialists and you know they've been deemed adequate to do X, y and Z, and meaning stage one, stage two, stage three, stage four, diaphragm, you know whatever. So originally it was.

Speaker 2:

It was a great idea. It was something that was drastically needed, because patients need to know how good is this person sitting in front of me? Because a lot of doctors are very nice. A lot of doctors are very persuasive they're, they're very sweet, they seem to care about their patients, but they can't operate their way out of a paper bag and you're not going to know that. Patients aren't going to know that, unless there's some way to identify who they are.

Speaker 2:

Nancy keeps a list on the Nook, but her list is based on patient feedback, right, which is important, which is definitely important, but it's not necessarily based on outcomes or let's watch your surgical technique and see how things looked. So I don't know that there is a way to know other than word of mouth knowing who was originally vetted, knowing who trained with the people who have been vetted, knowing who trained with the people who have been vetted. So if somebody trained with Vidali or Cenervo or somebody with a name like that, somebody that's known to be in a known quantity of expertise, somebody who came from Brazil and the University of Sao Paulo, where they do amazing work, and some of the Italian hospitals are pretty amazing Horace Roman in France, but it's you know, how do you find these people?

Speaker 1:

Yeah, that's a challenge.

Speaker 2:

It is.

Speaker 1:

Absolutely, I mean, I think, as a patient, when you are in the midst of trying to navigate your care through pain, through medical trauma, through mental trauma, and years and years of being dismissed or not understanding your own body. It is hard, though, to find someone that you can truly trust, because it is a decision that will affect the rest of your life one way or the other, and it doesn't necessarily mean that it's a drastic change all the time, but it certainly can be, and so it's hard for patients to understand who is good, who isn't good, and it's also hard for patients to decide who is good for their care, because I think there is a difference between who's just good and who's good for what they need in their care and who's going to be a good fit for them. I think that makes a huge difference in their care, and who's going to be a good fit for them.

Speaker 2:

I think that makes a huge difference, Absolutely. I think that there's a lot of docs who are just fine for stage one, stage two and probably a lot of endometriomas, but they can't really do stage four. They're not really experts at getting the deep disease out of the uterus sacral or off of the sciatic nerve and things like that, where you really do need a true expert.

Speaker 1:

Absolutely. That's a lasting outcome right there, one way or the other, yeah.

Speaker 2:

I kind of look at surgeons like baseball players. I love baseball, I do too. My dad used to take me to. You know, my, my mom loved baseball too, so we'd all go to baseball games from when I was a kid and you know, it's like there's there's only so many Justin Verlanders, there's only so many doctors who are like a household name and, yeah, they're who you'd want on your team, no matter what. But there's a lot of major leaguers who are. Nobody knows them unless you know. You go to the games all the time and you follow your team. And people like cal raleigh, the mariners catcher yeah, he's, he's a great player, but nobody knows him outside of seattle, right, you know, that's like char.

Speaker 1:

Blackman here. My husband and I were just talking about this.

Speaker 2:

He cut his hair.

Speaker 1:

I bet he will when he retires. I bet he'll retire, but it's his luck. You know how superstitious they are.

Speaker 2:

He's not going to cut his hair.

Speaker 1:

He doesn't care. He doesn't care, but he's got some of the best stats in the league, but he's widely under-recognized across the board. I feel like that's it's true. Now that you're saying this, this is really good, it is similar.

Speaker 2:

Yeah, because I mean, there are some. There are some people who are like you know, derek Jeter A-Rod, you know everybody, even people who don't follow sports. They're like oh yeah, I know who Derek Jeter is, but you don't need Derek Jeter if you have stage one endometriosis, you need Ty France, my favorite first baseman from the Mariners. He's a great player, he's a great guy. And so one of my good friends has three boys and their dad is MIA, and so I've tried to kind of step in, not to replace their father, but to do things with them, like take them to sporting events and teach them how to ski. And her oldest son he's my 15-year-old best friend. We ski together and we used to golf together and stuff like that, but so, anyways, they took the boys to the baseball game and it was during COVID, so we were sitting in the front row and Ty France came over and handed after the warmups, handed each one of those boys a baseball, and I'm like this guy is my new favorite player anywhere. Yeah, is my new favorite player anywhere.

Speaker 1:

Yeah, and that could be said for turning it back, but, like those doctors who listen and validate and can assess what is right for you, you just changed my outlook on how we approach this. But it is true, I mean this could be a whole other discussion about staging and understanding and mapping out the endometriosis and what the patient needs, but I think there's something to be said about finding a provider that meets your needs where you're at in your journey. And if it's a doctor, firstly that validates you and can treat where you're at.

Speaker 2:

Yeah, it starts with listening Absolutely and believing and saying, yes, there's something going on with you. I don't know what it is, but I'm not going to rest until I figure it out.

Speaker 1:

Stage one is not the minor leagues Stage one, in the sense that an excision specialist still needs to address that stage one Stage.

Speaker 2:

one is like your routine everyday guy on the Colorado Rockies or the Seattle Mariners that you and I know who they are because we follow the teams but nobody else knows.

Speaker 1:

Yeah, but the minor leagues are the ablation surgeons, yeah.

Speaker 2:

Triple A, double A is general OBGYNs who make a mess out of things, and you know. You said your mission in life was to educate people on hormones and castrations and why to not get their ovaries out. My mission in life is to stop average gynecologists from taking care of endometriomas and operating on them because they just make a mess out of it.

Speaker 1:

There's so much value in that and you have to start out growing and learning along the way, because you're not going to be the A-Rods first. You can be a fantastic surgeon, but lived experience and working with patients day in and day out is what really makes you one of the biggest in the league. Right, like? It is not something you learn overnight and you have to grow into that. What do you look forward to and what is your hope for the future? In fellowships and in endometriosis care and endometriosis treatment? Do you see promise and hope in the future, and what is that for you?

Speaker 2:

Well, I mean there are a lot more people doing excision now than there were what is it 18 years ago when I started? And so that's a good thing. There are a lot of video resources now that there didn't used to be, and so a doctor who's really interested in learning how to do surgery can go to SurgeryU can go to. There's a kind of a European surgery video repository that has a ton of really good videos on how to do excision and how to do it right. You know you can watch Arnold Wattier, you can watch, you can watch all these Mauricio Abreu, all these kind of godfathers of endosurgery, and you can watch their techniques. And you know you don't have to be in a fellowship to learn anymore. You can learn on your own by watching and doing and gradually get better. Hopefully some of the MIGS fellowships will do more endo and will graduate more people who understand at least the basics of excision. But it's a long road and it's a very slow process and I don't think anything is going to happen overnight. Working on the genetic basis of endo and immunotherapy and things like that I mean maybe there's some promise there.

Speaker 2:

My friend Vicky Vargas, who's I kind of mentored her from afar, she's a MIG surgeon in DC. She had finished her MIGS fellowship and recognized that she really didn't know as much as she should have known about endo, and so we got together and shared videos and, you know, spent probably a year doing video reviews and coaching and, you know, teaching from afar. And she's an amazing young surgeon I mean, she's the hope for the future because she's brilliant. She and Dr Yege actually did their residencies together, and so they went to Switzerland for some endoconference I think it was the WERF conference or something and they were plotting about all the things that they needed to do for research and creating a database so that we can document how well excision works. And I think that's kind of going a little bit off track, but that's what we need to do in order to convince everybody, including insurance companies, that excision is worthwhile.

Speaker 2:

And I've said for a long time that we need to collect a bunch of data beforehand not only like standardized pain scores, but standardized anxiety, depression, central sensitization and catastrophizing pain catastrophizing prior to surgery and then follow people, stratify them out based on stage and then see what their outcomes are and then correlate their outcomes with their surgical stage and also their degree of central sensitization and then I think if we follow these people out long enough, we will get better data on how successful excision is and then I think we'll be able to show that the people who are more likely to fail excision surgery have more central sensitization and that their nerves are just so sensitive and whether it's a process in their brain or whether it's the peripheral nervous system and they have almost like a CRPS of the pelvis.

Speaker 2:

Crps is complex regional pain syndrome and it's kind of like phantom limb syndrome where patients have people have traumatic amputations and their arm is gone or their leg is gone.

Speaker 2:

It's no longer there, but they still feel pain in their legs or their arm and it's because of partly because of the trauma, I think, that that their brain got so sensitized that they you know these nerves are still sending input to the brain, whether it's the fault of the peripheral nerve that's still sending the impulse or the brain. That's so sure less than 5% that have something like that going on in the pelvis and that that's why they have persistent pain. But if we can correlate surgical outcomes, stratify them, like I said, by stage, and then look at their degree of central sensitization and then see if the central sensitization reverses itself. Because there was a study out of China, I think probably 10 years ago, where they did look at markers of central sensitization before they did excision and then what they found was that six to 12 months after surgery people's nervous systems the tendency was that they normalized and that that central sensitization went away.

Speaker 1:

Interesting and I resonate with that because you know, after I had my ovaries out, I would still feel like I had ovary pain occasionally and it was a very and there are still times I will say like there's times I'm like is that that feels like an ovary pain? But I know I don't have my ovaries, so is it something else? And this is what the common thought process is is my endo is back. That's what the patient's thought process is right.

Speaker 2:

Yeah, yeah, exactly.

Speaker 1:

But the endo can't be back on my ovary. I don't have an ovary, so that doesn't make sense, right? So it's understanding how our brain works in conjunction with the trauma that it's had with our bodies, and who is heightened in that area as opposed to others, and understanding that component of it. I think that's magnificent, because this is a huge part of realistic expectations of surgery, as well as healing expectations of surgery and understanding the disease from the psychological standpoint too. Right, like it's not just a physical standpoint. It does alter the way our body perceives pain.

Speaker 2:

So Well, and it's hard for some people because they've been so dismissed for so long and they've been told well, it's all in your head. But pain really is all in your head because because the pain signals are not really painful until they get to the brain and they're processed, and so that's why we talk about nociceptive signals, which means that it's the nerve transmission of potentially painful experiences, but it's not really turned into pain until it's processed in your brain. And so I've had discussions with patients and trying to explain the role of the brain and their history of trauma and their anxiety and how that plays a role in how they perceive pain. And most of I will say most of my patients are like oh well, that makes a lot of sense. But a few of them are like they get really mad and really upset and they think that I'm trying to dismiss them and tell them that you know their pain's all in their head and there's nothing wrong with them. But that's not the point. The point is to say, you know, we need to think. When we're taking care of women with endo and pelvic pain, we need to think not only of what's going on in the pelvis, but how is this affecting their brain? How is it affecting their emotions? How are their emotions affecting their pain? What can they do about it? How can cognitive behavioral therapy and other things like this try to ramp down the emotion of the pain? You know, I kind of understand why it's a bit of a slippery slope, but it's also necessary because it's basic biology and it's you know how our bodies work.

Speaker 2:

I realized that firsthand because I had a labral tear in my hip and I had surgery.

Speaker 2:

Probably 10 years ago, 12 years ago now I'd been home for I don't know a week and hadn't gone anywhere and I was going stir crazy.

Speaker 2:

I got in my car and went to Costco and went a couple other places. By the time I got into the back of Costco I was dying and it's like where's the furniture section? I need to sit down for a while, and and so, anyways, I got home and when I got home things were not calm and I got all upset and my hip was just killing me and my pain just went through the roof and I laid down on the bed and I thought, oh my gosh, this is what my patients are feeling when their anxiety gets out of control and then their pain gets worse, because it wasn't like this ephemeral thing, it was like boom, you know. And as soon as I, as soon as I recognize that, I'm like, okay, I need to calm down, I need to not be so upset. And you know, it helped because I connection and the role that anxiety and trauma play into people's pain perception and how that affects them.

Speaker 1:

Absolutely Well, and I think too, once you down-regulate that system, you're able to better pinpoint where the not the emotional pain of what you've carried for so long is, but where actual pain and where your body is really telling you what's going on. I think it's easier to pinpoint where things are coming from better, and that's a physiological fact, right?

Speaker 2:

So when, when pain becomes more emotional and it gets upregulated in the brain, it becomes less localized and more diffuse and it's like everything hurts.

Speaker 1:

Exactly, absolutely. Oh, that's going to be fascinating. So what I'm hearing that you say is that you're hopeful that, with new fellows coming on and people getting excited about endometriosis, we're going to see more research, we're going to see more change and progression within the knowledge and the base of the disease, as well as the treatment of the patients who have the disease. I think that's huge because you're getting, like this new blood, so to speak. You're getting rejuvenated through these people coming on that are excited to talk about it.

Speaker 2:

And that data will allow us to change standard of care. And that's what needs to happen, because right now, standard of care is people doing ablations. It's okay for doctors to remove totally normal ovaries in a 25-year-old. If the patient decided to take them to court to say you took my ovaries out, all they have to do is say you signed the consent form Because it's within standard of care. If somebody has persistent pain and thought to be from endometriosis, it's okay to castrate a 25-year-old.

Speaker 2:

To me, that's not okay in any world and it certainly isn't okay without a very long discussion, even in my 40 year old patients who come in and say you know, I really want you to take my ovaries out. I talked to them for a long, long, long time about what are you going to feel? You're going to be menopausal. Your bones are going to get brittle, your brain is going to get old, your vagina is going to dry up, your bladder is going to be irritable, you're going to have to pee all the time. You're going to be incontinent. You're going to you know all these things are going to happen to your body, not right away, but over time. And going to happen to your body not right away, but over time, and your aging process is going to be accelerated.

Speaker 1:

Thank you for joining us for part one of this fascinating discussion. If you found this thought provoking and intriguing, make sure that you tune in for part two of this discussion with Dr Mossbrucker, and until next time, everybody continue advocating for you and for those that you love.