WEBVTT - Ep 88 Endometriosis: Menstrual Backwash

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<v Speaker 1>Hi. My name is Susie sol Aviv.

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<v Speaker 2>From a pretty young age, I taught myself not to

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<v Speaker 2>pay a lot of attention to my body. When I

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<v Speaker 2>was younger, I didn't really have any issues, but after puberty,

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<v Speaker 2>I started to have pretty bad cramps. I had to

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<v Speaker 2>go to the bathroom fairly often, and I also found

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<v Speaker 2>out that I was anemic, and I would occasionally, if

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<v Speaker 2>I was exercising too hard.

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<v Speaker 1>Start to black out.

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<v Speaker 2>Nobody really had a good explanation for this, and nobody

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<v Speaker 2>really directed me to a doctor or anything. So I

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<v Speaker 2>just ignored it and moved forward. Lots of other people

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<v Speaker 2>in my high school had period cramps, Plenty of people

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<v Speaker 2>were going on birth control to try to control the cramps,

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<v Speaker 2>and you know, it was easy enough for me to

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<v Speaker 2>get past it was a little bit of ibuprofen. I

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<v Speaker 2>was also raised very religious, and I'm still quite religious,

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<v Speaker 2>and unfortunately, some American puriody culture crept into my upbringing,

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<v Speaker 2>and so I didn't spend a lot of time thinking about,

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<v Speaker 2>for lack of a better word, my reproductive parts.

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<v Speaker 1>Spent a lot of.

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<v Speaker 2>Time ignoring them, spent a lot of time pretending nothing

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<v Speaker 2>was really going on, and generally being embarrassed about it,

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<v Speaker 2>so I got good at disassociating from those parts of

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<v Speaker 2>my body. After I got married, I ended up having

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<v Speaker 2>extremely painful sex, and I assumed that it was related

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<v Speaker 2>to purity culture, and I assumed it was psychological. I

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<v Speaker 2>talked to my PCP about it. I think I got

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<v Speaker 2>a referral to pelvic floor therapy at one point, but

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<v Speaker 2>nobody was really concerned, and again I just decided that

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<v Speaker 2>it wasn't a very big deal. It was just something

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<v Speaker 2>that was in my head and I was able to

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<v Speaker 2>move past it. In our first year of marriage, I

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<v Speaker 2>got pregnant unexpectedly and had no problems with the pregnancy

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<v Speaker 2>except that it was I was very nauseous through the

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<v Speaker 2>entire thing. I was in a lot of pain, and

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<v Speaker 2>then when I had to have cervical checks, I was

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<v Speaker 2>in tremendous amount of pain. Again, I told them that

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<v Speaker 2>I thought this was due to growing up with a

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<v Speaker 2>certain amount of purity culture and that it was psychological,

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<v Speaker 2>and nobody questioned it. So after I had my daughter,

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<v Speaker 2>eventually my period returned and I started having worse and

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<v Speaker 2>worse cramps. But everybody tells you that after you have

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<v Speaker 2>a baby, your periods get worse. That's just what people

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<v Speaker 2>tell you, and so once again I chose to disassociate

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<v Speaker 2>from it and ignore it. Some of the painful sex

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<v Speaker 2>symptoms subsided, others remained. Mostly I was just proceeding with

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<v Speaker 2>business as usual. Last year, I started having cramps so

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<v Speaker 2>bad that I would have bladder spasms, which means that

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<v Speaker 2>I would literally be my pants with no control. It

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<v Speaker 2>only happened a few times, thank goodness, but I also

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<v Speaker 2>ended up starting to have to lie down when I

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<v Speaker 2>had my cramps, and I was surprised that it wasn't great,

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<v Speaker 2>but I could generally manage it with like three to

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<v Speaker 2>four ibuprofen and heat pack. But by the fall, things

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<v Speaker 2>had escalated and the ibuprofen wasn't cutting it, and the

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<v Speaker 2>heat pack wasn't cutting it, but the killer was. When

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<v Speaker 2>I noticed that there was blood in my stool, I

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<v Speaker 2>didn't really want to do anything about it, but by January,

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<v Speaker 2>my sister told me that I had to do something

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<v Speaker 2>about it, so I went into urgent care. They took

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<v Speaker 2>some samples and told me that I needed a colonoscopy

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<v Speaker 2>and that I should not have any ibuprofen until after

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<v Speaker 2>I had the colonoscopy. Then on my thirty fifth birthday,

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<v Speaker 2>I spent the entire day in agony and the worst

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<v Speaker 2>pain I've ever had because I was experiencing my cramps

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<v Speaker 2>without any sort of pain blocker. I went in for

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<v Speaker 2>a colonoscopy at the beginning of March, and I didn't

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<v Speaker 2>expect them to find much of anything, because again I

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<v Speaker 2>didn't really believe that I had any problems, and I

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<v Speaker 2>thought to myself, the only problem that I could really

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<v Speaker 2>have is cancer, because cancer runs rampant in my family.

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<v Speaker 1>Both my father and my.

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<v Speaker 2>Brother died of fairly rare cancers, my father of uvial

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<v Speaker 2>melanoma and my brother of colanngiocarsonoma. So I was a

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<v Speaker 2>little anxious about the kolonoscopy, but not overly so. When

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<v Speaker 2>I woke up from the colonoscopy, the doctor went to

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<v Speaker 2>get my husband and took me to his office and

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<v Speaker 2>sat me down and told me that he had found

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<v Speaker 2>something and it was very likely to be cancer. So

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<v Speaker 2>this was incredibly traumatic for me because I was immediately

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<v Speaker 2>convinced I was going to die. I also delivered the

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<v Speaker 2>news to my family and told basically everyone I know,

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<v Speaker 2>because I decided that if I did indeed have cancer.

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<v Speaker 2>I wanted everybody to start praying as quickly as possible,

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<v Speaker 2>and I maintained that it worked, because a week later,

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<v Speaker 2>the same doctor called me back and told me that

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<v Speaker 2>the cell simples, to his great shock, had come back

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<v Speaker 2>not as cancer but as endometrisis. I literally fell to.

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<v Speaker 1>My knees on the ground.

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<v Speaker 2>I changed doctors, so I went in for a second opinion.

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<v Speaker 2>I had another, not another klonoscopy, but a flexible sigmoidoscopy,

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<v Speaker 2>and the doctor told me he thought that I had

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<v Speaker 2>endometriosis and maybe cancer, and I was referred to the

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<v Speaker 2>gynecological oncology department. I went in and met with one

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<v Speaker 2>of the directors of the GUYNANC department, who told me

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<v Speaker 2>that she thought, yes, there's a possibility of cancer, but

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<v Speaker 2>mostly it was horrible endometriosis. So she showed me the

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<v Speaker 2>images that they had taken of my body in the

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<v Speaker 2>MRI and everything, and you could see that there was

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<v Speaker 2>something growing out of my left ovary into my colon,

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<v Speaker 2>and we knew that it was probably in other places.

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<v Speaker 2>But there is no way to confirm endometriosis except by surgery,

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<v Speaker 2>so they could not confirm, and they thought there was

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<v Speaker 2>a possibility that there was still cancer. So the other

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<v Speaker 2>thing that the guynok told me was that she thought

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<v Speaker 2>I was going to have to have a complete hysterectomy

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<v Speaker 2>and eupherectomy. I had been trying for a second child

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<v Speaker 2>at this point for almost a year and this was devastating.

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<v Speaker 2>But because there was a chance of cancer, I was like,

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<v Speaker 2>just take it all.

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<v Speaker 1>I don't want it. Get rid of it.

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<v Speaker 2>So I had a period farewell party with my friends

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<v Speaker 2>over Zoom. We drank cranberry juice.

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<v Speaker 1>We toasted.

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<v Speaker 2>I wrote a letter to Aunt Flow, sending her out

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<v Speaker 2>into the worlds, and my surgery was scheduled for May fourth.

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<v Speaker 2>My last period was one of the worst pains I've

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<v Speaker 2>ever had in my life. The ibuprofen didn't ease it,

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<v Speaker 2>the heat didn't ease it. I was just lying in

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<v Speaker 2>bed for two days and was more or less silent screaming.

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<v Speaker 1>It was horrific.

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<v Speaker 2>I had surgery. They confirmed stage four endometriosis. I discussed

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<v Speaker 2>with my surgeon that I wanted to try to keep

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<v Speaker 2>my right ovary if possible, because I didn't want to

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<v Speaker 2>go into surgical menopause.

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<v Speaker 1>At thirty five.

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<v Speaker 2>There are a lot of issues associated with going into

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<v Speaker 2>menopause early, and I wanted to avoid them if I

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<v Speaker 2>could also have I struggle with my mental health. I

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<v Speaker 2>have depression anxiety, and I knew that the severe hormonal

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<v Speaker 2>shift would be very difficult. Although there was less than

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<v Speaker 2>a five percent chance that they could save my ovary,

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<v Speaker 2>the surgeon was able to do it. There is still

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<v Speaker 2>an insignificant amount of endometriosis on my right ovary, It's

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<v Speaker 2>less than one centimeter, but they were able to remove

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<v Speaker 2>fourteen point five centimeters of.

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<v Speaker 3>Colon, which is about the size of sharp.

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<v Speaker 2>B, a six centimeter rectovaginal septum tumor which is about

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<v Speaker 2>the size of an egg, and a seven centimeter left

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<v Speaker 2>ovarian tumor, which is about the size of peach.

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<v Speaker 1>And the left ovary.

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<v Speaker 2>I woke up to the very happy news that I

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<v Speaker 2>still had an ovary, which I did not expect, and

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<v Speaker 2>about a week later I got the even happier news

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<v Speaker 2>that there wasn't cancer, it was just ha nometriosis. So

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<v Speaker 2>after the surgery, it took me about three months to

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<v Speaker 2>feel normal again. The biggest shift since the surgery is

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<v Speaker 2>that I've had to relearn my body. I have to

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<v Speaker 2>relearn what feels good and bad, what's painful and what's not,

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<v Speaker 2>because I just disassociated from it so much that I

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<v Speaker 2>had no idea that I was in pain. The emotionally

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<v Speaker 2>challenging part of this, aside from thinking that I was

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<v Speaker 2>going to die of cancer for a fairly significant amount

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<v Speaker 2>of time, was that there's almost no chance of me

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<v Speaker 2>ever having another biological child, and so I've had to

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<v Speaker 2>give up on that particular dream because the hope was

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<v Speaker 2>just too much. But we got a puppy, and so

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<v Speaker 2>that's my replacement baby. I have also learned to be

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<v Speaker 2>a lot kinder to myself and to trust my body more.

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<v Speaker 2>I accept now that I am living with a chronic illness.

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<v Speaker 2>I try to take naps a lot, I try to

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<v Speaker 2>listen to what feels good and what feels bad. But

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<v Speaker 2>when I stopped to really think about it, the thing

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<v Speaker 2>that really makes me angry is that I had no

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<v Speaker 2>idea I had endometriosis before any of this started. It

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<v Speaker 2>is absurd that no one thought of endometriosis, that I

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<v Speaker 2>was never presented with any education about endometriosis, that no

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<v Speaker 2>one in my friend's circle ever talked about endometriosis, even

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<v Speaker 2>though I found out more and more people have it,

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<v Speaker 2>and I just feel like I know so little. In

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<v Speaker 2>a post I wrote on Reddit, i wrote, I've been

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<v Speaker 2>a feminist for my entire life without understanding that I've

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<v Speaker 2>been trapped in a patriarchal pain and trap. So thank

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<v Speaker 2>you for listening to my story.

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<v Speaker 3>Thank you so much Susie for taking the time and

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<v Speaker 3>being willing to share your story. It was, oh my gosh,

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<v Speaker 3>I mean yeah.

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<v Speaker 1>I can't wow. Thank you.

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<v Speaker 3>Yeah.

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<v Speaker 1>Hi, I'm erin Welsh and I'm Aaron Allman Updyke.

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<v Speaker 3>And this is this podcast We'll kill you.

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<v Speaker 1>It's uh, it's going to be a big episode, Darin.

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<v Speaker 3>This is certainly my longest notes like by I think

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<v Speaker 3>like kind of a bit so just yeah, I really

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<v Speaker 3>kind of it got away from me. But I'm excited

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<v Speaker 3>about it.

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<v Speaker 1>I am too. I have like a lot of feelings

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<v Speaker 1>about it. So it's going to be a good one.

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<v Speaker 3>Yeah, And what exactly is going to be a good one?

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<v Speaker 1>Oh? Yeah, that's right. Today we're covering endometriosis.

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<v Speaker 3>That's right, what even is endometriosis? At the end of

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<v Speaker 3>this episode, will we have a satisfactory answer to that question?

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<v Speaker 1>I think we'll have like, at least most of a

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<v Speaker 1>satisfactory answer will have a clinical definition.

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<v Speaker 3>That's true, that's true. Where does that leave us? I

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<v Speaker 3>guess we'll find out before we get into the nitty

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<v Speaker 3>gritty of all of that, though, Should we do quarantini?

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<v Speaker 1>We really should?

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<v Speaker 3>What are we drinking this week?

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<v Speaker 1>We're drinking the chocolate cyst? Of course? Oh boy, honestly,

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<v Speaker 1>that's I think that's a grosser name than our diabetes

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<v Speaker 1>one sweet pea. Yeah, I think this is grosser.

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<v Speaker 3>Is it grosser than our MRSA one?

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<v Speaker 1>Mm? No, maah, maybe I don't know. You tell us listeners,

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<v Speaker 1>You tell us listeners.

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<v Speaker 3>What's the grossest one? Yet? So why are we calling

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<v Speaker 3>it the chocolate cyst?

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<v Speaker 4>Though?

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<v Speaker 3>Yeah?

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<v Speaker 1>Okay, so a chocolate cyst is like one of the

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<v Speaker 1>descriptors for an endometrioma, which is when you get endometriosis

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<v Speaker 1>on your ovary. We're gonna get into all of it,

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<v Speaker 1>but basically, sometimes you get these things look like a

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<v Speaker 1>little chocolate truffle liquid.

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<v Speaker 3>Eir Okay, Well, definitely garnish this with a chocolate truffle

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<v Speaker 3>if you can.

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<v Speaker 1>So what's in the chocolate system.

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<v Speaker 3>Chocolate liquour, banana, liqueur, coffee, liquour and cream and then

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<v Speaker 3>of course garnish, like I said, with a chocolate truffle.

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<v Speaker 3>And also the placy Burita is just probably going to

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<v Speaker 3>be the most decadent, delicious chocolate milkshake you've ever had.

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<v Speaker 3>Chocolate banana milkshake.

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<v Speaker 1>Yeah, and you.

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<v Speaker 3>Can find our recipe for our quarantini as well as

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<v Speaker 3>our non alcoholic Placyburta on our website. This podcast will

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<v Speaker 3>kill You dot com and we'll also post it to

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<v Speaker 3>all of our social media channels.

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<v Speaker 1>On our website, This podcast will kill You dot com.

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<v Speaker 1>You will find everything that you could want to find.

0:13:54.360 --> 0:13:58.080
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0:13:58.120 --> 0:14:01.760
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0:14:01.840 --> 0:14:05.720
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0:14:05.760 --> 0:14:08.600
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0:14:08.600 --> 0:14:10.680
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0:14:10.679 --> 0:14:13.560
<v Speaker 1>all there, It's all there, It's all there, and more.

0:14:14.080 --> 0:14:18.800
<v Speaker 1>With that, Aaron, should we just get into the endometrium

0:14:20.480 --> 0:14:21.600
<v Speaker 1>of this episode?

0:14:21.720 --> 0:14:30.760
<v Speaker 3>Erin, yes, yes, please please. Let's take a quick break first.

0:15:03.240 --> 0:15:07.760
<v Speaker 1>I can kind of sum up this whole episode with

0:15:07.880 --> 0:15:10.600
<v Speaker 1>one of the more recent papers that I found. It's

0:15:10.600 --> 0:15:14.400
<v Speaker 1>the title of a paper from twenty twenty one and

0:15:14.480 --> 0:15:20.600
<v Speaker 1>the title is simply, the epidemiology of endometriosis is poorly

0:15:20.720 --> 0:15:24.600
<v Speaker 1>known as the pathophysiology and diagnosis are unclear.

0:15:25.920 --> 0:15:27.840
<v Speaker 3>And wow, that's the title.

0:15:28.360 --> 0:15:29.440
<v Speaker 1>I know that's the title.

0:15:30.120 --> 0:15:30.400
<v Speaker 3>Man.

0:15:30.640 --> 0:15:34.640
<v Speaker 1>Yeah, it's uh yeah, We're off to a really good start.

0:15:34.720 --> 0:15:38.960
<v Speaker 3>Strong yep, spoilers, I feel like, yes, we're in that title.

0:15:40.480 --> 0:15:45.520
<v Speaker 1>Okay, So endometriosis. I know there's probably a good subset

0:15:45.600 --> 0:15:48.240
<v Speaker 1>of our listenership who has never heard of this. And

0:15:48.280 --> 0:15:51.320
<v Speaker 1>I am going to get to the official definition really soon,

0:15:51.360 --> 0:15:57.840
<v Speaker 1>I promise, but some little lead in. Okay. Endometriosis is

0:15:58.000 --> 0:16:02.800
<v Speaker 1>almost always described as a disease of women of child

0:16:02.840 --> 0:16:09.280
<v Speaker 1>bearing age. That is how it is described. It's a

0:16:09.320 --> 0:16:15.120
<v Speaker 1>problem straight off the bat because this description ignores number one,

0:16:15.720 --> 0:16:19.000
<v Speaker 1>anyone who is trans or non binary that has a

0:16:19.120 --> 0:16:23.720
<v Speaker 1>uterus or has endometriosis. Number two. It ignores the fact

0:16:23.800 --> 0:16:29.800
<v Speaker 1>that endometriosis, pain, and endometriosis itself can persist or even

0:16:29.880 --> 0:16:36.760
<v Speaker 1>sometimes arise after menopause aka after quote child bearing. Number three.

0:16:36.880 --> 0:16:40.920
<v Speaker 1>It also ignores the fact that cases of endometriosis, though

0:16:41.400 --> 0:16:46.360
<v Speaker 1>very rare, have occurred in people assigned male at birth,

0:16:46.800 --> 0:16:51.680
<v Speaker 1>which means that a uterus isn't necessarily a prerequisite for

0:16:51.760 --> 0:16:57.480
<v Speaker 1>the disease. And finally, and I think most importantly, I

0:16:57.480 --> 0:17:01.000
<v Speaker 1>don't know they're all important, but by designing this disease

0:17:01.040 --> 0:17:04.399
<v Speaker 1>to this particular group, quote, women of child bearing age

0:17:04.960 --> 0:17:06.360
<v Speaker 1>and Aaron, I know you're going to talk a lot

0:17:06.359 --> 0:17:06.920
<v Speaker 1>more about this.

0:17:07.800 --> 0:17:10.400
<v Speaker 3>Oh yeah, yeah, so I thought, is it's also been

0:17:10.440 --> 0:17:11.639
<v Speaker 3>found in infants.

0:17:12.000 --> 0:17:15.520
<v Speaker 1>Oh that's a good point. Yeah, it can definitely be

0:17:15.640 --> 0:17:18.040
<v Speaker 1>in before child bearing age as well.

0:17:18.640 --> 0:17:20.880
<v Speaker 3>Everyone can get very trios.

0:17:21.520 --> 0:17:25.760
<v Speaker 1>But by designating it as the disease of women of

0:17:25.880 --> 0:17:29.360
<v Speaker 1>childbearing age, it makes it really really easy in our

0:17:29.520 --> 0:17:34.640
<v Speaker 1>society to dismiss it as a condition for oh, young

0:17:34.680 --> 0:17:38.040
<v Speaker 1>women just have poor pain tolerance, or oh this is

0:17:38.080 --> 0:17:44.119
<v Speaker 1>a women's problem, or even worse, as a normal part

0:17:44.640 --> 0:17:49.320
<v Speaker 1>of young womanhood. Spoiler alert, it is none of those things.

0:17:49.600 --> 0:17:53.400
<v Speaker 3>I'm going to be talking so much about this aspect

0:17:53.440 --> 0:17:53.840
<v Speaker 3>of it.

0:17:53.800 --> 0:17:58.000
<v Speaker 1>It's I can't wait. I'm gonna I'm gonna try and

0:17:58.119 --> 0:18:00.879
<v Speaker 1>just hit us all with the little that we do

0:18:01.040 --> 0:18:04.959
<v Speaker 1>know about the biology. So let's actually define the topic

0:18:05.000 --> 0:18:08.720
<v Speaker 1>of today's episode, shall we? Mm hmm? Okay, So the

0:18:08.800 --> 0:18:14.480
<v Speaker 1>technical definition of endometriosis is simply the finding of endometrial

0:18:14.680 --> 0:18:20.520
<v Speaker 1>glands and stroma, which just means endometrial like tissue outside

0:18:20.880 --> 0:18:25.399
<v Speaker 1>of the uterus. So what does that mean. Yeah, to

0:18:25.440 --> 0:18:28.000
<v Speaker 1>talk about that, I want to first talk about my

0:18:28.480 --> 0:18:33.359
<v Speaker 1>personal favorite organ, the uterus. That's my favorite one. Do

0:18:33.400 --> 0:18:34.320
<v Speaker 1>you have a favorite organ?

0:18:34.880 --> 0:18:37.080
<v Speaker 3>I've never thought about it.

0:18:37.080 --> 0:18:37.880
<v Speaker 1>It's a uterus.

0:18:38.400 --> 0:18:40.200
<v Speaker 3>No, I don't. I don't think I would need I

0:18:40.200 --> 0:18:41.000
<v Speaker 3>would need more time.

0:18:41.200 --> 0:18:44.560
<v Speaker 1>Okay, that's fine. Okay, So we talked I think a

0:18:44.600 --> 0:18:47.600
<v Speaker 1>fair bit about the uterus in our birth control episode

0:18:47.640 --> 0:18:50.600
<v Speaker 1>because we talked about the whole menstrual cycle. So I'm

0:18:50.640 --> 0:18:55.000
<v Speaker 1>just gonna briefly recap. The uterus is an organ that's

0:18:55.000 --> 0:18:58.680
<v Speaker 1>made up of a muscular wall, the myometrium, and an

0:18:58.720 --> 0:19:02.800
<v Speaker 1>inner layer, the end endometrium, that's composed of glandular cells.

0:19:02.800 --> 0:19:05.200
<v Speaker 1>So there are these cells that basically form into little

0:19:05.240 --> 0:19:10.159
<v Speaker 1>glands as well as stroma or like support cells is

0:19:10.160 --> 0:19:13.200
<v Speaker 1>how you can think of them. That surround these glandular

0:19:13.240 --> 0:19:18.480
<v Speaker 1>cells and this endometrium, This inner lining of the uterus

0:19:18.560 --> 0:19:23.919
<v Speaker 1>is constantly in flux. This lining is what responds to

0:19:24.240 --> 0:19:28.000
<v Speaker 1>and changes with the influence of cyclic variation in our

0:19:28.040 --> 0:19:33.600
<v Speaker 1>hormone levels, most specifically estrogen and progesterone. This is the

0:19:33.680 --> 0:19:36.760
<v Speaker 1>menstrual cycle that we went over in our birth control episode,

0:19:36.760 --> 0:19:40.119
<v Speaker 1>which was now a couple of years ago. To recap it,

0:19:40.560 --> 0:19:45.760
<v Speaker 1>under the influence of an increase in estrogen, oocytes in

0:19:45.800 --> 0:19:49.359
<v Speaker 1>the ovaries begin to mature, and the uterus lining the

0:19:49.480 --> 0:19:55.840
<v Speaker 1>endometrium proliferates. It grows in number, these stromo cells and

0:19:56.040 --> 0:19:59.760
<v Speaker 1>these glandular cells, and this is known as the follicular

0:19:59.760 --> 0:20:05.160
<v Speaker 1>phase or the proliferative phase, where this lining is growing

0:20:06.880 --> 0:20:10.199
<v Speaker 1>and the endometril lining is becoming thicker in preparation for

0:20:10.280 --> 0:20:14.840
<v Speaker 1>the potential implantation of a blastocyst. Then that peak of

0:20:15.000 --> 0:20:18.679
<v Speaker 1>estrogen prompts a surge of another hormone that causes the

0:20:18.720 --> 0:20:22.600
<v Speaker 1>release of an egg aka ovulation. And then as that

0:20:22.840 --> 0:20:27.280
<v Speaker 1>surge of estrogen declines, progesterone, another hormone, begins to increase

0:20:28.080 --> 0:20:32.000
<v Speaker 1>and the uterus the endometrium enters what's known as the

0:20:32.040 --> 0:20:37.280
<v Speaker 1>secretary phase, where these glands thicken and the arteries within

0:20:37.400 --> 0:20:42.720
<v Speaker 1>their widen and proliferate in number, and the endometrium undergoes

0:20:42.760 --> 0:20:48.359
<v Speaker 1>this process further preparing it for receiving a blasticist and

0:20:48.400 --> 0:20:53.040
<v Speaker 1>then without anything that implants, fourteen days go by and

0:20:53.440 --> 0:20:58.440
<v Speaker 1>progesterone levels sharply decline, and this withdrawal leads to the

0:20:58.480 --> 0:21:01.520
<v Speaker 1>separation of all these cells from their basal layer and

0:21:01.560 --> 0:21:06.400
<v Speaker 1>they slough off, aka menstruation. All of that endometrial tissue

0:21:06.400 --> 0:21:10.399
<v Speaker 1>then exits through the cervix, which is the opening of

0:21:10.440 --> 0:21:17.639
<v Speaker 1>the uterus through the vagina, and that is menstruation, right, yep, right, okay.

0:21:17.680 --> 0:21:20.480
<v Speaker 1>So if that all is the menstrual cycle, and that's

0:21:20.480 --> 0:21:24.320
<v Speaker 1>what's happening inside of a uterus during that menstrual cycle,

0:21:25.240 --> 0:21:30.320
<v Speaker 1>then what is endometriosis If it's the finding of these

0:21:30.440 --> 0:21:34.200
<v Speaker 1>same type of cells that are found inside of a uterus,

0:21:34.240 --> 0:21:39.920
<v Speaker 1>these endometrial, glandular and stromal cells, but now they are

0:21:40.119 --> 0:21:46.119
<v Speaker 1>implanted in tissue outside of the uterus. So instead of

0:21:46.160 --> 0:21:51.080
<v Speaker 1>being inside the lining of this muscular organ, it's outside

0:21:51.119 --> 0:21:54.600
<v Speaker 1>on the wall of the organ, or on the wall

0:21:54.760 --> 0:21:57.720
<v Speaker 1>of your belly, which is called the peritoneum, the inside

0:21:57.760 --> 0:22:01.200
<v Speaker 1>wall of your abdomen. It could even be on your

0:22:01.200 --> 0:22:06.080
<v Speaker 1>bladder or in your Philippian tubes, or on your ovary,

0:22:06.800 --> 0:22:10.399
<v Speaker 1>or on your rectum. It could be anywhere literally in

0:22:10.440 --> 0:22:15.400
<v Speaker 1>your body. So then the question is how does this

0:22:15.560 --> 0:22:17.800
<v Speaker 1>become a disease or a problem, Like, why is it

0:22:17.840 --> 0:22:21.960
<v Speaker 1>a problem to have this tissue outside of the uterus. Well,

0:22:23.200 --> 0:22:28.880
<v Speaker 1>this tissue is still active. It's hormonally sensitive endometrial cells

0:22:29.320 --> 0:22:34.840
<v Speaker 1>that are undergoing the same proliferative and secretary and then

0:22:35.119 --> 0:22:39.719
<v Speaker 1>degeneration that happens within the uterus and would end in

0:22:39.840 --> 0:22:44.480
<v Speaker 1>mensies leaving the body through the vagina, but it's happening

0:22:44.560 --> 0:22:49.440
<v Speaker 1>in an abnormal location and therefore leading to not only

0:22:49.600 --> 0:22:54.760
<v Speaker 1>abnormal responses in our body and massive amounts of inflammation,

0:22:55.680 --> 0:22:58.360
<v Speaker 1>but it's also then not able to leave the body,

0:22:58.440 --> 0:23:03.240
<v Speaker 1>so this inflammation still contained within the body. That leads

0:23:03.280 --> 0:23:07.679
<v Speaker 1>to tissue damage, which can then lead to scarring and fibrosis,

0:23:08.320 --> 0:23:13.480
<v Speaker 1>which leads to the symptoms of endometriosis, which are chiefly pain,

0:23:14.119 --> 0:23:20.159
<v Speaker 1>which doesn't begin to describe adequately like the true symptoms,

0:23:21.400 --> 0:23:25.879
<v Speaker 1>and also infertility or difficulty conceiving or sustaining a pregnancy.

0:23:28.040 --> 0:23:30.400
<v Speaker 1>So that was a lot, like all in a very

0:23:30.400 --> 0:23:33.320
<v Speaker 1>short amount of time. And that's all we know about endometris'.

0:23:33.320 --> 0:23:37.680
<v Speaker 1>Is just kidding, We know like a tiny bit more

0:23:37.720 --> 0:23:42.439
<v Speaker 1>than that. Yeah, So that explanation left a lot of

0:23:42.720 --> 0:23:45.639
<v Speaker 1>open ended questions, and I think the first one that

0:23:45.680 --> 0:23:48.840
<v Speaker 1>I would like to be able to answer is how

0:23:50.600 --> 0:23:53.840
<v Speaker 1>how does this endometrial tissue end up in a place

0:23:53.880 --> 0:23:59.879
<v Speaker 1>where endometrium shouldn't be tissue types in our body, like

0:24:00.000 --> 0:24:03.399
<v Speaker 1>different cell types are actually pretty tightly regulated. So like,

0:24:03.480 --> 0:24:06.760
<v Speaker 1>the tissue that makes up our lining of our abdomen

0:24:06.960 --> 0:24:09.040
<v Speaker 1>is different than the tissue that makes up the lining

0:24:09.040 --> 0:24:11.399
<v Speaker 1>of your uterus, which is different than the tissue that

0:24:11.440 --> 0:24:14.639
<v Speaker 1>makes up your heart or your blood vessels, et cetera.

0:24:14.920 --> 0:24:18.919
<v Speaker 3>Right, Right, And so then because it's so tightly regulated,

0:24:20.040 --> 0:24:23.840
<v Speaker 3>shouldn't your body recognize that, like, hey, this isn't necessarily

0:24:24.720 --> 0:24:27.120
<v Speaker 3>in the right spot it.

0:24:27.400 --> 0:24:30.159
<v Speaker 1>Yeah, And in the case of adometrius, that's part of

0:24:30.200 --> 0:24:33.320
<v Speaker 1>the problem is that your body does recognize it as

0:24:33.359 --> 0:24:36.680
<v Speaker 1>something that's not in the right spot and therefore causes

0:24:36.720 --> 0:24:40.919
<v Speaker 1>a lot of inflammation within it, right, Yeah, And so

0:24:41.080 --> 0:24:43.119
<v Speaker 1>then that leads to part of the problem, or at

0:24:43.200 --> 0:24:45.679
<v Speaker 1>least we think that maybe that's how it's happening. And

0:24:45.960 --> 0:24:48.879
<v Speaker 1>with a lot to do with endometriosis, it's hard to

0:24:49.000 --> 0:24:52.520
<v Speaker 1>know who's the instigator, like which is the cause and

0:24:52.560 --> 0:24:58.440
<v Speaker 1>which is the effect? Right right, But yes, that can

0:24:58.480 --> 0:25:00.960
<v Speaker 1>be part of the problem because our body does recognize

0:25:01.000 --> 0:25:04.760
<v Speaker 1>when a tissue is not in the right place a

0:25:04.760 --> 0:25:07.560
<v Speaker 1>lot of times. But again, this doesn't happen very often

0:25:07.600 --> 0:25:10.960
<v Speaker 1>to have a tissue type in a location in the

0:25:10.960 --> 0:25:14.439
<v Speaker 1>body where it doesn't belong, because in general, as we

0:25:14.520 --> 0:25:17.280
<v Speaker 1>develop from a single cell all the way into our

0:25:17.359 --> 0:25:22.919
<v Speaker 1>multicellular human cells, our cells undergo this process of differentiation

0:25:23.320 --> 0:25:26.760
<v Speaker 1>into all of our specific tissue types in a very

0:25:26.960 --> 0:25:32.760
<v Speaker 1>characteristic pattern during the process of embryogenesis and development. So

0:25:32.920 --> 0:25:36.360
<v Speaker 1>all of our cells have very explicit sets of instructions

0:25:36.359 --> 0:25:40.399
<v Speaker 1>that they follow and explicit influences that they're under in

0:25:40.600 --> 0:25:44.560
<v Speaker 1>order to develop into these different tissue types in certain

0:25:44.600 --> 0:25:48.800
<v Speaker 1>areas and not in others, which is why we don't

0:25:48.880 --> 0:25:51.720
<v Speaker 1>see heart tissue in our bones or brain tissue in

0:25:51.760 --> 0:25:55.800
<v Speaker 1>our guts for the most part. So why on earth

0:25:55.920 --> 0:26:01.080
<v Speaker 1>do we sometimes get endometrial tissue outside of the inside

0:26:01.240 --> 0:26:06.600
<v Speaker 1>of the uterus? And the short answer is, we don't know,

0:26:07.119 --> 0:26:11.600
<v Speaker 1>we don't know, we do not know. Let me go

0:26:11.720 --> 0:26:15.320
<v Speaker 1>through the quote prevailing theories and then maybe erin you

0:26:15.359 --> 0:26:21.040
<v Speaker 1>and I can have some opinions. So the kind of

0:26:22.240 --> 0:26:28.720
<v Speaker 1>what's obnoxiously still called the prevailing theory on how this happens,

0:26:28.800 --> 0:26:32.639
<v Speaker 1>on how endometral glands end up implanting and then replicating

0:26:32.640 --> 0:26:37.800
<v Speaker 1>and proliferating outside our uterus is something called retrograde menstruation

0:26:38.280 --> 0:26:39.520
<v Speaker 1>or what do you call it erin.

0:26:39.560 --> 0:26:45.840
<v Speaker 3>As I've been calling it, menstrual backwash, stral backwash. Could not,

0:26:45.920 --> 0:26:48.520
<v Speaker 3>for the life of me remember retrograde menstruation.

0:26:49.640 --> 0:26:57.520
<v Speaker 1>It's a good visual menstrual backwash. Yeah, essentially, So if

0:26:57.560 --> 0:26:59.880
<v Speaker 1>you've not recently looked at a picture of a uterus,

0:27:00.040 --> 0:27:04.680
<v Speaker 1>let me paint you one. So, the uterus is connected

0:27:04.720 --> 0:27:07.639
<v Speaker 1>to Filippian tubes at the top. They look kind of

0:27:07.680 --> 0:27:10.880
<v Speaker 1>like ears that come off or maybe little arms, and

0:27:11.000 --> 0:27:13.679
<v Speaker 1>these Filippian tubes are open at the end. They have

0:27:13.760 --> 0:27:17.800
<v Speaker 1>these little thimbrae little fingers at the end, and just

0:27:17.960 --> 0:27:21.720
<v Speaker 1>outside of these Filippian tubes is where our ovaries sit.

0:27:22.840 --> 0:27:28.040
<v Speaker 1>So during menstruation, all of the endometril lining and tissue

0:27:28.520 --> 0:27:31.480
<v Speaker 1>comes out through the cervix, which is the base of

0:27:31.720 --> 0:27:36.000
<v Speaker 1>the uterus and also the top of the vaginal canal

0:27:37.240 --> 0:27:40.960
<v Speaker 1>that is the normal flow of menstrual products. But the

0:27:41.000 --> 0:27:44.680
<v Speaker 1>top of the uterus, those Filippian tubes are open at

0:27:44.680 --> 0:27:50.320
<v Speaker 1>the ends. So in fact, there is in many people

0:27:50.440 --> 0:27:56.480
<v Speaker 1>who menstright menstrual product aka endometrial tissue that goes backwards

0:27:56.600 --> 0:27:59.080
<v Speaker 1>and it goes out through those Filippian tubes and enters

0:27:59.119 --> 0:28:06.679
<v Speaker 1>our peritoneal cavity. That's it backwash, backwash, And it was

0:28:06.840 --> 0:28:12.960
<v Speaker 1>thought that this certainly must be the way that endometriosis happens.

0:28:13.000 --> 0:28:18.120
<v Speaker 1>These endometrial tissues are entering our peritoneal cavity. Boom, there

0:28:18.119 --> 0:28:18.440
<v Speaker 1>you go.

0:28:19.160 --> 0:28:22.399
<v Speaker 3>I think there's a really interesting parallel between this like

0:28:23.119 --> 0:28:29.520
<v Speaker 3>wandering endometrial tissue concept and the wandering uterus, the wandering

0:28:29.720 --> 0:28:31.080
<v Speaker 3>ysteria concept.

0:28:32.160 --> 0:28:34.080
<v Speaker 1>Yeah, it's the same, It totally is.

0:28:34.640 --> 0:28:35.960
<v Speaker 3>It's very interesting to me.

0:28:36.840 --> 0:28:40.040
<v Speaker 1>And you know, there is some evidence in support of this,

0:28:40.200 --> 0:28:46.600
<v Speaker 1>because a sizeable portion of endometrial implants occur in areas

0:28:47.040 --> 0:28:52.160
<v Speaker 1>where this menstrual backwash, this retrograde menstruation would end up.

0:28:53.040 --> 0:28:56.040
<v Speaker 1>And in a lot of people where they have looked

0:28:56.080 --> 0:28:59.640
<v Speaker 1>at does this person with endometriosis have retrograde menstruation, they

0:28:59.640 --> 0:29:04.280
<v Speaker 1>have found yes they do, and so there's a correlation there.

0:29:05.760 --> 0:29:09.560
<v Speaker 1>But as it turns out, this is very common and

0:29:09.720 --> 0:29:13.719
<v Speaker 1>happens in at least, if not more than about forty

0:29:13.760 --> 0:29:17.080
<v Speaker 1>percent of people with the uterus who men straight pretty

0:29:17.120 --> 0:29:21.520
<v Speaker 1>much every time they menstraight to varying degrees. So it

0:29:21.560 --> 0:29:24.800
<v Speaker 1>doesn't explain why some people then go on to develop

0:29:24.880 --> 0:29:30.600
<v Speaker 1>endometriosis and others don't. It also doesn't explain how endometriosis

0:29:30.640 --> 0:29:33.520
<v Speaker 1>can happen in people without a uterus to begin with,

0:29:34.000 --> 0:29:39.320
<v Speaker 1>which again is incredibly rare but has happened. And it

0:29:39.400 --> 0:29:44.560
<v Speaker 1>doesn't explain how endometrio cells can end up outside of

0:29:44.600 --> 0:29:50.440
<v Speaker 1>the abdominal cavity entirely, which it can. You can get

0:29:50.560 --> 0:29:54.480
<v Speaker 1>endometriosis in the diaphragm, in the thorax, in the lungs

0:29:54.920 --> 0:29:59.480
<v Speaker 1>uh huh. So this menstrual backwash theory doesn't quite some work,

0:30:00.200 --> 0:30:02.960
<v Speaker 1>need some work, or it just.

0:30:02.880 --> 0:30:05.960
<v Speaker 3>Needs to be discarded for a new one or integrated

0:30:06.000 --> 0:30:08.040
<v Speaker 3>with another passis.

0:30:07.880 --> 0:30:10.840
<v Speaker 1>Yeah, and we'll get there actually, because there's an interesting

0:30:11.160 --> 0:30:14.800
<v Speaker 1>integrative one. So then there is a theory of stem cells,

0:30:15.000 --> 0:30:17.440
<v Speaker 1>of which there are kind of two different schools of thought.

0:30:18.040 --> 0:30:21.160
<v Speaker 1>So stem cells, I think that I might have touched

0:30:21.200 --> 0:30:25.240
<v Speaker 1>on this in the HPV episode. I'm not positive we've

0:30:25.240 --> 0:30:28.040
<v Speaker 1>talked about them before, but anyways, I don't know a

0:30:28.080 --> 0:30:31.719
<v Speaker 1>stem cell is a cell that has the ability to

0:30:32.120 --> 0:30:37.920
<v Speaker 1>differentiate into other cell types. So, like I was saying,

0:30:37.960 --> 0:30:41.040
<v Speaker 1>how when we develop from a single cell into a

0:30:41.200 --> 0:30:47.800
<v Speaker 1>multicellular human, our cells are differentiating. They're becoming like grown

0:30:47.880 --> 0:30:51.960
<v Speaker 1>up quote unquote grown up cells that have a specific

0:30:52.080 --> 0:30:55.320
<v Speaker 1>job and function well. Stem cells are kind of like

0:30:55.400 --> 0:30:59.640
<v Speaker 1>baby cells that have the ability to grow up and

0:30:59.720 --> 0:31:02.600
<v Speaker 1>be any other type of cell or many other types

0:31:02.640 --> 0:31:07.120
<v Speaker 1>of cells. So there's a theory that perhaps bone marrow

0:31:07.200 --> 0:31:10.760
<v Speaker 1>stem cells, which have the ability to differentiate into a

0:31:10.840 --> 0:31:14.320
<v Speaker 1>number of cell types, might somehow find their way into

0:31:14.600 --> 0:31:18.400
<v Speaker 1>the peritoneum or the abdominal cavity, and then there they

0:31:18.400 --> 0:31:24.960
<v Speaker 1>would embed and under certain hormonal influences would differentiate into

0:31:25.440 --> 0:31:27.680
<v Speaker 1>endometrial cells for some reason.

0:31:28.480 --> 0:31:29.120
<v Speaker 3>Huh.

0:31:29.320 --> 0:31:33.320
<v Speaker 1>Yeah, that's one theory. It's not a great one.

0:31:34.600 --> 0:31:40.640
<v Speaker 3>Yeah, I'm like, how does that explain timing of things or.

0:31:41.200 --> 0:31:43.959
<v Speaker 1>Honestly or in it doesn't. Okay, it's not my favorite

0:31:43.960 --> 0:31:47.840
<v Speaker 1>of the theories. So another one that's I think at

0:31:47.920 --> 0:31:53.640
<v Speaker 1>least a little bit more easy to understand is a

0:31:53.680 --> 0:31:58.920
<v Speaker 1>theory that it's endometrial stem cells. Okay, this is coming

0:31:58.920 --> 0:32:03.360
<v Speaker 1>a little bit closer. Oh, and this theory can actually

0:32:03.480 --> 0:32:08.320
<v Speaker 1>kind of tie into the menstrual backwash theory, but adds

0:32:08.360 --> 0:32:10.760
<v Speaker 1>on to it a little bit. So in this case,

0:32:10.800 --> 0:32:13.960
<v Speaker 1>it's not the menstrual backwash per se.

0:32:14.240 --> 0:32:17.360
<v Speaker 3>I love that we're calling it menstrual backwash. Now we've just.

0:32:17.760 --> 0:32:24.200
<v Speaker 1>We're all in. Okay, So it's not the retrograde menstruation

0:32:24.600 --> 0:32:29.920
<v Speaker 1>of just any old endometrial cells, but of specifically endometrial

0:32:30.000 --> 0:32:33.920
<v Speaker 1>stem cells, like the basal cell layers that have the

0:32:33.960 --> 0:32:39.680
<v Speaker 1>ability to differentiate into the different endometrial cell types. If

0:32:39.840 --> 0:32:45.600
<v Speaker 1>those maybe are either backwashed or find their way into

0:32:45.600 --> 0:32:51.040
<v Speaker 1>our bloodstream or our lymphatics, then perhaps those can embed

0:32:51.720 --> 0:32:56.080
<v Speaker 1>and they already have the ability they're programmed to differentiate

0:32:56.160 --> 0:32:59.960
<v Speaker 1>into endometrial cells. So it's logical then that they would

0:33:00.000 --> 0:33:04.280
<v Speaker 1>could be responsive to the same hormonal influences that they

0:33:04.320 --> 0:33:07.800
<v Speaker 1>would if they were still in the inside of the uterus.

0:33:07.880 --> 0:33:08.720
<v Speaker 1>Does that make sense?

0:33:09.320 --> 0:33:13.040
<v Speaker 3>Yeah, that's interesting. And so are there any studies, animal

0:33:13.080 --> 0:33:16.640
<v Speaker 3>studies or something showing support for this or even just

0:33:16.680 --> 0:33:19.000
<v Speaker 3>like tissue culture studies showing support for this.

0:33:20.040 --> 0:33:24.280
<v Speaker 1>There are certainly studies that show that these stem cell

0:33:24.320 --> 0:33:29.479
<v Speaker 1>types exist and can embed and then become you know,

0:33:29.840 --> 0:33:31.920
<v Speaker 1>endometral like tissue.

0:33:32.120 --> 0:33:37.200
<v Speaker 3>Okay, And how then would those stem cells so these

0:33:37.200 --> 0:33:39.960
<v Speaker 3>are like these would be like the deepest basis layer.

0:33:40.720 --> 0:33:42.080
<v Speaker 1>Yes, that's my understanding.

0:33:42.520 --> 0:33:44.880
<v Speaker 3>Okay, so then how do they escape?

0:33:45.000 --> 0:33:47.120
<v Speaker 1>Yea the uterus. That's the question that we don't have

0:33:47.160 --> 0:33:53.040
<v Speaker 1>an answer to. Interesting, there's another theory, and this is

0:33:53.120 --> 0:33:58.320
<v Speaker 1>the sillomic metaplasia theory, which is your celum is the

0:33:58.360 --> 0:34:02.480
<v Speaker 1>inside of your abdomen. So in this theory, regular old

0:34:02.880 --> 0:34:09.680
<v Speaker 1>abdominal cells wherever in your abdomen just undergo metaplasia. Metaplasia

0:34:09.760 --> 0:34:14.799
<v Speaker 1>means they develop mutations and then they change and so

0:34:15.000 --> 0:34:20.920
<v Speaker 1>instead of being a differentiated let's say, abdominal wall cell,

0:34:21.719 --> 0:34:27.920
<v Speaker 1>they dedifferentiate and then redifferentiate into endometrial cells.

0:34:28.280 --> 0:34:30.480
<v Speaker 3>Huh huh.

0:34:30.480 --> 0:34:34.520
<v Speaker 1>So in this theory, instead of like a baby undifferentiated

0:34:34.560 --> 0:34:38.240
<v Speaker 1>stem cell that has the potential to become any cell type,

0:34:38.719 --> 0:34:44.480
<v Speaker 1>you're taking a fully formed adult cell and changing it

0:34:44.960 --> 0:34:46.239
<v Speaker 1>into an endometrial cell.

0:34:46.880 --> 0:34:51.080
<v Speaker 3>Yeah. Yeah, that seems Okay, that seems a little complicated.

0:34:51.760 --> 0:34:56.480
<v Speaker 3>So currently today in we're recording this in twenty twenty one,

0:34:57.440 --> 0:35:00.480
<v Speaker 3>I know that like the prevailing hypothesis is still this

0:35:00.560 --> 0:35:03.920
<v Speaker 3>menstrul backwash thing, But is that, like, what is the

0:35:03.960 --> 0:35:06.960
<v Speaker 3>timeline for these other hypotheses and is there are there

0:35:07.000 --> 0:35:10.600
<v Speaker 3>any of them that are seeking to dethrone so that

0:35:10.680 --> 0:35:12.040
<v Speaker 3>one the thing is.

0:35:13.440 --> 0:35:16.799
<v Speaker 1>Not really okay because the thing is. And here's the

0:35:16.840 --> 0:35:19.560
<v Speaker 1>problem is that none of these theories in and of

0:35:19.600 --> 0:35:25.279
<v Speaker 1>themselves fully or adequately address the question of how exactly

0:35:25.480 --> 0:35:30.240
<v Speaker 1>endometriosis occurs, right, And they also don't answer the question

0:35:30.360 --> 0:35:34.040
<v Speaker 1>of why do some people get endometriosis and other people don't?

0:35:34.120 --> 0:35:38.040
<v Speaker 1>What are the risk factors? And so I think where

0:35:38.040 --> 0:35:42.439
<v Speaker 1>there is more research being done is trying to understand

0:35:42.600 --> 0:35:45.240
<v Speaker 1>the second part of that question, why do some people

0:35:45.280 --> 0:35:48.560
<v Speaker 1>get endometriosis and others don't? Maybe it is one of

0:35:48.600 --> 0:35:51.000
<v Speaker 1>these theories that we already have, Maybe it really is

0:35:51.120 --> 0:35:54.920
<v Speaker 1>menstrual backwash, But it still doesn't answer the question of

0:35:55.040 --> 0:35:59.560
<v Speaker 1>why forty percent of people have menstrual backwash and not

0:35:59.600 --> 0:36:05.960
<v Speaker 1>forty percent of people have endometriosis? Right, right, And part

0:36:06.040 --> 0:36:08.600
<v Speaker 1>of the answer to that question at least seems to

0:36:08.640 --> 0:36:14.000
<v Speaker 1>be genetic. So in a number of genome wide association studies,

0:36:14.040 --> 0:36:16.520
<v Speaker 1>which is when you look at someone's entire genome and

0:36:16.560 --> 0:36:19.840
<v Speaker 1>you try and figure out what's going on, there have

0:36:19.920 --> 0:36:23.080
<v Speaker 1>been I think at least like ten or fifteen different

0:36:23.239 --> 0:36:27.720
<v Speaker 1>gene low size, so different locations that have been shown

0:36:27.800 --> 0:36:31.919
<v Speaker 1>to be associated with endometriosis. So we know that there's

0:36:31.920 --> 0:36:35.879
<v Speaker 1>a strong genetic component, but knowing that there's at least

0:36:35.880 --> 0:36:39.640
<v Speaker 1>ten or fifteen different genes is also maybe not all

0:36:39.719 --> 0:36:44.359
<v Speaker 1>that helpful because it's hard to know what that means. Right.

0:36:45.000 --> 0:36:48.200
<v Speaker 1>It does seem like all of these gene regions are

0:36:48.320 --> 0:36:52.360
<v Speaker 1>in some way related to hormonal regulation in some respect,

0:36:53.640 --> 0:36:57.600
<v Speaker 1>so a lot of this is a hormonally driven disease

0:36:57.680 --> 0:37:01.040
<v Speaker 1>and really an estrogen dependent disease in a lot of ways.

0:37:02.160 --> 0:37:05.000
<v Speaker 1>But really one of the prevailing thoughts is that it

0:37:05.440 --> 0:37:10.600
<v Speaker 1>is this kind of genetic and epigenetic factors combined with

0:37:10.719 --> 0:37:17.720
<v Speaker 1>these unknown environmental insults that leads to endometriosis, and endometriosis

0:37:17.800 --> 0:37:22.400
<v Speaker 1>is associated with a number of other autoimmune disorders, and

0:37:22.560 --> 0:37:26.080
<v Speaker 1>that's kind of the thinking with autoimmune disorders as well. Right,

0:37:26.120 --> 0:37:32.440
<v Speaker 1>It's these genetic predispositions and some kind of environmental influences

0:37:32.480 --> 0:37:36.920
<v Speaker 1>that combine together to then lead to this disease.

0:37:37.320 --> 0:37:40.479
<v Speaker 5>It's not satisfying, but it does make sense in that

0:37:41.120 --> 0:37:45.520
<v Speaker 5>if there's a high level of inflammatory response to this

0:37:45.760 --> 0:37:50.240
<v Speaker 5>self tissue, even like in places it shouldn't be compared

0:37:50.280 --> 0:37:52.600
<v Speaker 5>to people who may not have as high as a strong,

0:37:53.239 --> 0:37:55.560
<v Speaker 5>you know, inflammatory response, and so might not have a

0:37:55.640 --> 0:38:00.400
<v Speaker 5>strong symptoms, or might not have the development of endometrio lesions.

0:38:00.120 --> 0:38:03.040
<v Speaker 3>Or whatever exactly. Then that sort of that kind of

0:38:03.080 --> 0:38:03.880
<v Speaker 3>goes along with it.

0:38:04.160 --> 0:38:09.719
<v Speaker 1>Yeah, especially because while this is if you look at

0:38:09.880 --> 0:38:15.040
<v Speaker 1>endometriosis tissue histologically, like under a microscope, it looks just

0:38:15.080 --> 0:38:20.040
<v Speaker 1>like endometrial tissue. It's histologically it is endometrial tissue, and

0:38:20.080 --> 0:38:22.839
<v Speaker 1>in some ways it does behave in the same way

0:38:23.000 --> 0:38:28.360
<v Speaker 1>as endometrial tissue inside your uterus, right, it proliferates with estrogen,

0:38:28.880 --> 0:38:36.000
<v Speaker 1>it degrades, et cetera. But what's different is that outside

0:38:36.000 --> 0:38:39.880
<v Speaker 1>of the uterus, this endometrial tissue is associated with hugely

0:38:39.960 --> 0:38:43.960
<v Speaker 1>increased amounts of inflammation. And this we do know. So

0:38:44.040 --> 0:38:47.960
<v Speaker 1>we know that local inflammation and immune dysregulation is a

0:38:48.000 --> 0:38:52.560
<v Speaker 1>really big part of the pathogenicity of endometriosis, and this

0:38:52.719 --> 0:38:56.719
<v Speaker 1>inflammation itself is what then leads to the fibrosis, which

0:38:56.840 --> 0:38:59.920
<v Speaker 1>leads to these adhesions, which can lead to such signific

0:39:00.360 --> 0:39:04.240
<v Speaker 1>pain and symptoms. So one way to think of it

0:39:04.280 --> 0:39:09.040
<v Speaker 1>is that it's all related to the bleeding because endometral

0:39:09.080 --> 0:39:13.399
<v Speaker 1>proliferation and then degeneration leads to so much bleeding. The

0:39:13.680 --> 0:39:17.800
<v Speaker 1>bleeding itself, like blood itself, is a very very inflammatory.

0:39:17.880 --> 0:39:20.560
<v Speaker 1>So the fact that it's trapped somewhere inside your body

0:39:21.000 --> 0:39:24.759
<v Speaker 1>rather than traveling through the vaginal canal leads to a

0:39:24.800 --> 0:39:29.320
<v Speaker 1>lot of inflammation, which leads to immune cell infiltration, which

0:39:29.520 --> 0:39:32.680
<v Speaker 1>et cetera, et cetera, all the way down the line.

0:39:33.440 --> 0:39:36.040
<v Speaker 1>But it's also not clear that that's the order in

0:39:36.080 --> 0:39:38.319
<v Speaker 1>which things go. It could be that do you have

0:39:38.520 --> 0:39:43.879
<v Speaker 1>underlying inflammatory changes, differences in the way that your inflammatory

0:39:43.920 --> 0:39:49.319
<v Speaker 1>markers react that then leads to the increased inflammation. Does

0:39:49.360 --> 0:39:50.320
<v Speaker 1>that make sense?

0:39:50.520 --> 0:39:52.600
<v Speaker 3>Yeah, so it's like a chicken in the egg, but

0:39:52.680 --> 0:39:55.719
<v Speaker 3>it's like the chocolate system the inflammation.

0:39:56.000 --> 0:40:04.400
<v Speaker 1>That's exactly right, Aaron. Yeah, so that is what we

0:40:04.600 --> 0:40:08.520
<v Speaker 1>know about the kind of pathogenicity of endometriosis.

0:40:09.080 --> 0:40:14.200
<v Speaker 3>I'm still confused, like it's so yeah, same okay. Questions okay,

0:40:14.640 --> 0:40:18.440
<v Speaker 3>or rather question what do these lesions look like? How

0:40:18.480 --> 0:40:23.160
<v Speaker 3>big do they get, what are the variations in them?

0:40:23.400 --> 0:40:25.080
<v Speaker 3>How do you know when you have one? Et cetera,

0:40:25.120 --> 0:40:25.479
<v Speaker 3>et cetera.

0:40:25.640 --> 0:40:29.800
<v Speaker 1>Yeah. So, typically endometriosis is classified into kind of three

0:40:30.080 --> 0:40:36.040
<v Speaker 1>main subtypes. So there's superficial peritoneal legions, which means these

0:40:36.080 --> 0:40:41.520
<v Speaker 1>little endometrial implants that are primarily within the abdominal cavity,

0:40:42.000 --> 0:40:45.880
<v Speaker 1>either on like the cerrosa, which is the outside lining

0:40:46.080 --> 0:40:50.480
<v Speaker 1>of other organs, or on the walls of your abdominal cavity,

0:40:50.520 --> 0:40:54.360
<v Speaker 1>maybe tucked behind your uterus or up on the front

0:40:54.600 --> 0:41:00.000
<v Speaker 1>anywhere really, but they don't extend deeply into the tissue.

0:41:00.040 --> 0:41:04.600
<v Speaker 1>Use these superficial lesions, and they're generally small. I don't

0:41:04.600 --> 0:41:07.680
<v Speaker 1>have an exact size for you, but they don't extend

0:41:07.760 --> 0:41:13.719
<v Speaker 1>very deeply. That's the first type. Then there are ovarian endometriomas,

0:41:13.760 --> 0:41:16.720
<v Speaker 1>which is where we got the name for our drink.

0:41:19.040 --> 0:41:23.600
<v Speaker 1>This basically just means that the endometriosis has implanted on

0:41:24.000 --> 0:41:27.279
<v Speaker 1>or within the ovary. It's actually thought that it might

0:41:27.320 --> 0:41:32.840
<v Speaker 1>be like where the eggs pop out. If endometrill implants

0:41:32.920 --> 0:41:36.080
<v Speaker 1>find their way in there, they then become enclosed and

0:41:36.120 --> 0:41:40.120
<v Speaker 1>then they form. They can form these really rather large cysts,

0:41:41.000 --> 0:41:45.200
<v Speaker 1>and because they are enclosed within kind of ovarian tissue

0:41:45.239 --> 0:41:50.359
<v Speaker 1>and scar tissue around them, they undergo the same cycles

0:41:50.680 --> 0:41:56.400
<v Speaker 1>of proliferation and degeneration, and within time that blood is

0:41:56.480 --> 0:42:00.040
<v Speaker 1>like contained inside this cyst, and over time that be

0:42:00.120 --> 0:42:03.480
<v Speaker 1>comes a very dark like chocolate color, which is how

0:42:03.480 --> 0:42:05.280
<v Speaker 1>they got the name chocolate cysts.

0:42:05.560 --> 0:42:09.040
<v Speaker 3>It also sounds horribly painful.

0:42:09.080 --> 0:42:12.960
<v Speaker 1>Yes, and they can get very quite large. And then

0:42:13.400 --> 0:42:20.400
<v Speaker 1>the third subtype is deeply infiltrating endometriosis, literally acronymed as dye.

0:42:20.680 --> 0:42:24.000
<v Speaker 1>Mm hmmmm, Like who came up with that?

0:42:24.360 --> 0:42:27.280
<v Speaker 3>Mm hmm, Yeah, it's not great, yep.

0:42:28.719 --> 0:42:34.120
<v Speaker 1>And this deeply infiltrating form, by definition, invades into deeper structures,

0:42:34.160 --> 0:42:37.600
<v Speaker 1>which means instead of just being on the surface of

0:42:37.840 --> 0:42:41.600
<v Speaker 1>say your abdominal wall or on the surface of your bladder,

0:42:42.280 --> 0:42:46.320
<v Speaker 1>it's invading deeper into the muscles of your bladder, into

0:42:46.320 --> 0:42:50.480
<v Speaker 1>the walls of your rectum through your urethra for for

0:42:50.600 --> 0:42:54.840
<v Speaker 1>your urytor for example. God, yeah, it can be horrific,

0:42:55.480 --> 0:43:01.480
<v Speaker 1>and so especially deeply infiltrating endometriosis can cause not only

0:43:01.760 --> 0:43:05.680
<v Speaker 1>incredible pain, but also can then cause damage to and

0:43:05.880 --> 0:43:11.799
<v Speaker 1>blockage of really important structures like your colon or your

0:43:11.800 --> 0:43:13.760
<v Speaker 1>bladder or your urtors.

0:43:15.440 --> 0:43:18.839
<v Speaker 3>So what is the association with these different stages and

0:43:19.480 --> 0:43:24.040
<v Speaker 3>pain intensity or is there any association or with infertility

0:43:24.239 --> 0:43:26.239
<v Speaker 3>or subfertility yeah.

0:43:26.040 --> 0:43:28.840
<v Speaker 1>It's a really good question. There's not a solid answer

0:43:28.880 --> 0:43:34.399
<v Speaker 1>to that. In general, deeply infiltrating lesions are kind of

0:43:34.440 --> 0:43:40.520
<v Speaker 1>the worst as well as endometriomas, especially the ovarian endometriomas

0:43:40.600 --> 0:43:47.080
<v Speaker 1>are also associated with infertility. But the problem is that

0:43:48.080 --> 0:43:53.120
<v Speaker 1>just by looking at somebody's endometriosis, like during a surgery,

0:43:53.200 --> 0:43:57.719
<v Speaker 1>for example, you can't tell how bad their symptoms are

0:43:57.719 --> 0:44:02.319
<v Speaker 1>going to be. So but it looks like doesn't correspond

0:44:02.480 --> 0:44:06.759
<v Speaker 1>very well with actual symptom severity, which can be problematic,

0:44:07.200 --> 0:44:13.080
<v Speaker 1>very problematic. But of course the deeply infiltrating endometriosis has

0:44:13.120 --> 0:44:18.480
<v Speaker 1>the most potential to cause problems in other organs, for example.

0:44:19.000 --> 0:44:22.279
<v Speaker 1>But in terms of pain, which is kind of the

0:44:22.320 --> 0:44:27.840
<v Speaker 1>biggest symptom of endometriosis, any of the types can cause pain,

0:44:28.080 --> 0:44:30.560
<v Speaker 1>or any of the types might not be associated with pain,

0:44:32.200 --> 0:44:43.439
<v Speaker 1>So in that respect, it's difficult. In terms of pain, Aaron, Yeah,

0:44:44.200 --> 0:44:50.920
<v Speaker 1>So pain is classically like the hallmark symptom I guess

0:44:50.960 --> 0:44:56.759
<v Speaker 1>of endometriosis, and most classically it's dysmenorrhea, which is painful periods,

0:44:58.040 --> 0:45:01.840
<v Speaker 1>which sounds like h that doesn't everyone have painful periods?

0:45:01.920 --> 0:45:08.320
<v Speaker 1>This is not so period pain typical period. Pain should

0:45:08.360 --> 0:45:13.040
<v Speaker 1>not be so bad that you are missing school, that

0:45:13.120 --> 0:45:16.319
<v Speaker 1>you are missing work, that you are laid out in

0:45:16.360 --> 0:45:19.360
<v Speaker 1>your bed for an entire week because you can't function

0:45:19.400 --> 0:45:22.640
<v Speaker 1>as a human being. And that's the kind of pain

0:45:22.800 --> 0:45:26.960
<v Speaker 1>that is often associated with endometriosis. You're not able to

0:45:27.040 --> 0:45:30.279
<v Speaker 1>function because of how much pain is associated with it.

0:45:31.120 --> 0:45:36.920
<v Speaker 1>But it's not just with menstruation, especially as these endometrial

0:45:36.960 --> 0:45:42.000
<v Speaker 1>implants sort of just persist over time. It can also

0:45:42.040 --> 0:45:45.839
<v Speaker 1>be dysperunea, which is pain with penetrative sex, which can

0:45:45.880 --> 0:45:51.680
<v Speaker 1>be hugely impactful on somebody's life, pain with defecation, dyskesia,

0:45:52.600 --> 0:46:00.560
<v Speaker 1>painful urination, just pain, pain with everything, pain all the time, chronically. So,

0:46:00.600 --> 0:46:05.480
<v Speaker 1>but here's the thing about pain. I'm probably not going

0:46:05.560 --> 0:46:07.719
<v Speaker 1>to do this justice, but i want to just briefly

0:46:07.760 --> 0:46:11.359
<v Speaker 1>talk about the like neurobiology of pain. If we have time,

0:46:12.640 --> 0:46:14.120
<v Speaker 1>let's do it long episodes.

0:46:14.239 --> 0:46:15.960
<v Speaker 3>This is gonna be a long episode, but you know,

0:46:16.400 --> 0:46:19.200
<v Speaker 3>take a break if you need to come back to it.

0:46:19.360 --> 0:46:21.319
<v Speaker 1>Have a chocolate sista.

0:46:21.680 --> 0:46:22.480
<v Speaker 3>Yeah.

0:46:22.880 --> 0:46:26.800
<v Speaker 1>So, pain at its core, like the definition of pain,

0:46:27.480 --> 0:46:33.560
<v Speaker 1>I guess is when specific receptors no susceptors are activated

0:46:34.000 --> 0:46:38.000
<v Speaker 1>and send signals to our brain, which are then interpreted

0:46:38.239 --> 0:46:41.160
<v Speaker 1>by the brain, processed in certain areas of the brain,

0:46:41.760 --> 0:46:46.719
<v Speaker 1>and then transmitted and we then experience pain. Like that's

0:46:46.760 --> 0:46:51.560
<v Speaker 1>a really general description of it. But there's a few

0:46:51.680 --> 0:46:56.440
<v Speaker 1>things about endometriosis pain, and about chronic pain in general

0:46:56.480 --> 0:46:59.959
<v Speaker 1>that I think are really important to kind of understand. First,

0:47:00.000 --> 0:47:04.800
<v Speaker 1>FIR studies have found that endometriotic implants, this endometriosis in

0:47:04.840 --> 0:47:09.719
<v Speaker 1>your abdomen, often has higher densities of nerve fibers, so

0:47:09.760 --> 0:47:15.280
<v Speaker 1>they're more densely enervated than the surrounding tissue. They're also

0:47:15.719 --> 0:47:20.480
<v Speaker 1>more highly sensitized, so they actually respond at a lower

0:47:20.719 --> 0:47:24.840
<v Speaker 1>threshold of stimuli, which leads to both of those things

0:47:24.840 --> 0:47:29.799
<v Speaker 1>combined lead to an increase in pain signal transmission to

0:47:29.920 --> 0:47:30.320
<v Speaker 1>the brain.

0:47:30.640 --> 0:47:35.400
<v Speaker 3>Yeah, it's just like efficiency in signals traveling. They're like, oh,

0:47:35.440 --> 0:47:37.279
<v Speaker 3>I've gone down this route before, Oh I know how

0:47:37.320 --> 0:47:39.120
<v Speaker 3>to get there, Oh exactly way.

0:47:39.320 --> 0:47:47.359
<v Speaker 1>Really, but also there are literally brain architecture changes that

0:47:47.600 --> 0:47:52.040
<v Speaker 1>happen with chronic pain, right, And this is something that

0:47:52.120 --> 0:47:55.600
<v Speaker 1>we do not fully understand, and people are finally just

0:47:55.760 --> 0:47:57.920
<v Speaker 1>now doing a lot of research.

0:47:57.560 --> 0:48:01.600
<v Speaker 3>On finally just now acknowledging that it might be real right.

0:48:01.480 --> 0:48:04.120
<v Speaker 1>That it's not just psychosomatic, which is what it was

0:48:04.160 --> 0:48:07.120
<v Speaker 1>thought to be for the longest time. But there are

0:48:07.200 --> 0:48:09.200
<v Speaker 1>now a lot of really good studies on this, that

0:48:09.320 --> 0:48:16.480
<v Speaker 1>the brain changes in relation to experiencing chronic pain. And

0:48:16.680 --> 0:48:19.640
<v Speaker 1>while there aren't as many studies on this in relation

0:48:19.719 --> 0:48:24.480
<v Speaker 1>to endometriosis related pain specifically or to pelvic pain specifically,

0:48:25.000 --> 0:48:27.920
<v Speaker 1>there are a few, and the ones that do exist

0:48:28.239 --> 0:48:31.200
<v Speaker 1>that have looked at people, for example, with dysminaria or

0:48:31.320 --> 0:48:36.120
<v Speaker 1>very painful periods. People who have chronic pelvic pain have

0:48:36.200 --> 0:48:41.319
<v Speaker 1>a lower peripheral input at which they experience pain and

0:48:41.360 --> 0:48:46.040
<v Speaker 1>a higher activity higher activation of their central nervous system

0:48:46.120 --> 0:48:50.120
<v Speaker 1>in response to that pain. They are literally primed by

0:48:50.239 --> 0:48:54.320
<v Speaker 1>experiencing chronic pain to then experience more pain.

0:48:54.880 --> 0:48:57.279
<v Speaker 3>Uh huh, And yeah.

0:48:57.000 --> 0:48:58.759
<v Speaker 1>I want to be clear that this is not the

0:48:58.800 --> 0:49:00.799
<v Speaker 1>same thing as saying like, well, you have a low

0:49:00.840 --> 0:49:04.720
<v Speaker 1>pain tolerance, right right, But that's not what this means.

0:49:04.800 --> 0:49:09.799
<v Speaker 1>This means that in response to pain, your body reacts

0:49:09.880 --> 0:49:14.560
<v Speaker 1>and changes and experiences a greater amount of pain from

0:49:14.600 --> 0:49:18.200
<v Speaker 1>the same stimuli as someone else because of these changes

0:49:18.200 --> 0:49:18.720
<v Speaker 1>to your brain.

0:49:19.400 --> 0:49:22.200
<v Speaker 3>It makes complete sense, and it's so frustrating that it's

0:49:22.480 --> 0:49:31.680
<v Speaker 3>frustrating not widely known about, right, understood or taught or researched, right, yep.

0:49:32.440 --> 0:49:35.160
<v Speaker 1>And it's also not saying, like I said, that this

0:49:35.239 --> 0:49:39.480
<v Speaker 1>pain is psychological in origin, because it's not. However, it's

0:49:39.520 --> 0:49:43.600
<v Speaker 1>also really important to point out just how comorbid chronic

0:49:43.640 --> 0:49:48.719
<v Speaker 1>pain conditions like endometriosis and mood disorders like depression and

0:49:48.760 --> 0:49:54.840
<v Speaker 1>anxiety are because this comorbidity. Having these two things together

0:49:55.400 --> 0:50:00.600
<v Speaker 1>leads to further exacerbation of the experience of pain because

0:50:00.640 --> 0:50:06.160
<v Speaker 1>of disruptions that depression or anxiety have on your brain function.

0:50:06.800 --> 0:50:09.840
<v Speaker 3>Right, And I know that, like there has been a

0:50:09.880 --> 0:50:13.640
<v Speaker 3>lot of oh, well, you know your depression or anxiety

0:50:13.960 --> 0:50:19.680
<v Speaker 3>is probably causing your your chronic pain, instead of maybe

0:50:19.680 --> 0:50:25.840
<v Speaker 3>considering that it might be that persistent, never ending, excruciating,

0:50:26.400 --> 0:50:30.160
<v Speaker 3>inescapable pain might lead to I don't know, say a

0:50:30.160 --> 0:50:35.120
<v Speaker 3>bit of depression or anxiety, Like couldn't that be the case? Yeah?

0:50:35.320 --> 0:50:37.600
<v Speaker 1>Yeah, and then both of those things change your brain

0:50:37.760 --> 0:50:41.000
<v Speaker 1>architecture to make them both worse, like a self fulfilling prophecy.

0:50:41.480 --> 0:50:42.080
<v Speaker 3>Uh huh.

0:50:42.200 --> 0:50:47.279
<v Speaker 1>Yeah, it's not great. Yeah, it's really not great. The

0:50:47.320 --> 0:50:53.040
<v Speaker 1>other biggest sequelee of endometriosis is infertility or difficulty conceiving.

0:50:54.520 --> 0:50:58.560
<v Speaker 1>And again here we don't know why. Huh really, yeah,

0:50:58.600 --> 0:51:01.600
<v Speaker 1>we don't know if it's because of scar tissue that

0:51:01.640 --> 0:51:07.040
<v Speaker 1>can form, especially if it's from endometriomas on the ovary

0:51:07.360 --> 0:51:11.840
<v Speaker 1>like scarring the ovary or disrupting the number of ovarian

0:51:11.880 --> 0:51:15.279
<v Speaker 1>follicles that you have left, or if it can cause

0:51:15.320 --> 0:51:18.799
<v Speaker 1>scarring in the Filippian tubes, or there's some thought that

0:51:18.840 --> 0:51:23.200
<v Speaker 1>it's just from how much inflammation exists in the pelvis

0:51:23.719 --> 0:51:29.120
<v Speaker 1>because of endometriosis, because again it's an open cavity between

0:51:29.280 --> 0:51:32.040
<v Speaker 1>your ovary and your Filippian tubes, so small space, but

0:51:32.080 --> 0:51:35.520
<v Speaker 1>it's all bathed in the same fluid. And so if

0:51:35.520 --> 0:51:39.200
<v Speaker 1>that fluid is full of inflammation, then how is that

0:51:39.280 --> 0:51:42.520
<v Speaker 1>egg supposed to make it safely into the uterus? Right,

0:51:43.080 --> 0:51:47.799
<v Speaker 1>So we don't really know the mechanisms, but endometriosis is

0:51:48.120 --> 0:51:51.719
<v Speaker 1>strongly associated with difficulty either getting pregnant or carrying a

0:51:51.719 --> 0:51:55.399
<v Speaker 1>pregnancy to term, but especially in getting pregnant. And let's

0:51:55.400 --> 0:51:58.200
<v Speaker 1>talk about something that can have a huge impact on

0:51:58.239 --> 0:52:02.160
<v Speaker 1>your mental and emotional well being, especially in a society

0:52:02.200 --> 0:52:07.120
<v Speaker 1>that often ties a uterus holder's worth to their ability

0:52:07.120 --> 0:52:11.640
<v Speaker 1>to conceive. Like, that's not small potatoes. That's a big deal, right, yep,

0:52:12.080 --> 0:52:14.480
<v Speaker 1>yeah it is. What else do you want to know

0:52:14.520 --> 0:52:16.800
<v Speaker 1>about endometriosiserin because that was a lot.

0:52:17.719 --> 0:52:21.759
<v Speaker 3>I mean I would ask about treatment.

0:52:21.680 --> 0:52:24.880
<v Speaker 1>But mm hm you want you want me to answer that,

0:52:24.920 --> 0:52:29.640
<v Speaker 1>I'll will answer it. Yeah, Okay, treatment is a mixed bag.

0:52:30.360 --> 0:52:31.000
<v Speaker 3>Yeah.

0:52:31.320 --> 0:52:36.560
<v Speaker 1>So, some people with endometriosis respond very well to hormonal

0:52:36.600 --> 0:52:42.160
<v Speaker 1>birth control, either combined contraceptives or something like an implant

0:52:42.239 --> 0:52:46.279
<v Speaker 1>or an IUD, and that can be hugely beneficial. It

0:52:46.280 --> 0:52:49.719
<v Speaker 1>can lighten periods, it can make them stop altogether, it

0:52:49.760 --> 0:52:55.120
<v Speaker 1>can substantially reduce pelvic pain. But for anywhere from a

0:52:55.239 --> 0:52:58.359
<v Speaker 1>quarter to a third of people that doesn't work at all,

0:52:59.200 --> 0:53:02.839
<v Speaker 1>or they can't even try it because of other comorbidities

0:53:02.920 --> 0:53:05.879
<v Speaker 1>or risk factors they might have, or maybe they want

0:53:05.880 --> 0:53:07.880
<v Speaker 1>to become pregnant.

0:53:07.560 --> 0:53:10.600
<v Speaker 3>Or maybe hormonal birth control pills have just never really

0:53:10.760 --> 0:53:14.200
<v Speaker 3>have messed with other parts of their right, there's day

0:53:14.239 --> 0:53:14.920
<v Speaker 3>to day life.

0:53:14.960 --> 0:53:18.160
<v Speaker 1>There's a lot of risk factors associated with birth control

0:53:18.239 --> 0:53:23.480
<v Speaker 1>as well. So for some then the next kind of

0:53:23.600 --> 0:53:29.399
<v Speaker 1>step can be what are called GnRH ganadotropin releasing hormone agonists,

0:53:30.280 --> 0:53:35.160
<v Speaker 1>which essentially put you into early menopause. That's what they do.

0:53:35.400 --> 0:53:38.440
<v Speaker 1>They block all of the hormones associated with the menstrual cycle,

0:53:38.520 --> 0:53:44.480
<v Speaker 1>like much more completely than combined contraceptives alone. But again

0:53:44.719 --> 0:53:49.120
<v Speaker 1>they have their very long list of side effects hot flashes,

0:53:49.200 --> 0:53:53.839
<v Speaker 1>skin changes, acne, mood changes. These can also affect your

0:53:53.840 --> 0:53:57.200
<v Speaker 1>bone mineralization and bone density, so they put you at

0:53:57.280 --> 0:54:01.080
<v Speaker 1>risk for like osteoporosis. And even these don't always work,

0:54:02.239 --> 0:54:06.880
<v Speaker 1>So then there's surgery, and surgery sometimes is still cited

0:54:07.000 --> 0:54:10.440
<v Speaker 1>as the kind of gold standard or the only quote

0:54:10.680 --> 0:54:17.400
<v Speaker 1>real way whatever to diagnose endometriosis. Yeah, the trend is

0:54:17.440 --> 0:54:20.160
<v Speaker 1>moving away from that, thankfully, Okay, Okay.

0:54:19.840 --> 0:54:22.160
<v Speaker 3>And how much does that vary country by country.

0:54:22.280 --> 0:54:26.600
<v Speaker 1>It's a good question that I don't know the answer to. Okay, Yeah,

0:54:26.640 --> 0:54:30.239
<v Speaker 1>But in general, the consensus in the medical literature is

0:54:30.320 --> 0:54:36.120
<v Speaker 1>moving away from surgery as a necessary diagnostic step because

0:54:36.160 --> 0:54:38.799
<v Speaker 1>it used to be that you had to have histological

0:54:38.920 --> 0:54:42.759
<v Speaker 1>proof of endometrial tissue outside of the uterus to call

0:54:42.760 --> 0:54:45.799
<v Speaker 1>it endometriosis, and the only way you could get that

0:54:46.040 --> 0:54:51.120
<v Speaker 1>was from surgery. But now we have other methods of

0:54:51.200 --> 0:54:53.960
<v Speaker 1>being able to identify it, not only just with like

0:54:54.160 --> 0:54:59.800
<v Speaker 1>clinical history, but also with imaging modalities like MRI and ultrasound,

0:55:00.000 --> 0:55:04.799
<v Speaker 1>which can help to identify some kinds of endometriosis. But

0:55:05.080 --> 0:55:09.560
<v Speaker 1>surgery is often also seen as a treatment option. So

0:55:09.920 --> 0:55:14.960
<v Speaker 1>ablation or excision of the endometriolesians can help improve pain

0:55:15.200 --> 0:55:19.000
<v Speaker 1>for a lot of people, but it can also in

0:55:19.080 --> 0:55:23.719
<v Speaker 1>some cases create more inflammation and more adhesions, which can

0:55:23.760 --> 0:55:29.640
<v Speaker 1>then exacerbate symptoms or possibly even lead to more endometriosis lesions.

0:55:29.960 --> 0:55:33.640
<v Speaker 1>If we think that it's inflammation that's the driver rather

0:55:33.680 --> 0:55:34.480
<v Speaker 1>than vice versa.

0:55:34.880 --> 0:55:35.520
<v Speaker 3>That makes sense.

0:55:35.600 --> 0:55:41.000
<v Speaker 1>Yeah, right. And hysterectomy or removal of the uterus with

0:55:41.239 --> 0:55:45.879
<v Speaker 1>or without removal of the ovaries along with it used

0:55:45.920 --> 0:55:48.399
<v Speaker 1>to be seen as curative, used to be done all

0:55:48.400 --> 0:55:53.160
<v Speaker 1>the time. Oh still is done a lot. It is

0:55:53.440 --> 0:56:00.359
<v Speaker 1>not curative, but it is still done sometimes for people. So, yeah,

0:56:01.120 --> 0:56:05.200
<v Speaker 1>that's the treatment for endometriosis. It's not great. We don't

0:56:05.200 --> 0:56:07.480
<v Speaker 1>have a lot and especially when it comes to the pain,

0:56:08.480 --> 0:56:12.839
<v Speaker 1>Medicine today in twenty twenty one is bad at treating pain,

0:56:13.080 --> 0:56:15.560
<v Speaker 1>especially chronic pain. We don't have a lot of good

0:56:15.600 --> 0:56:21.680
<v Speaker 1>options for it, so that part of endometriosis is very difficult.

0:56:22.520 --> 0:56:27.920
<v Speaker 1>If these other therapies aren't effective. So it's a bummer Erin.

0:56:28.920 --> 0:56:34.279
<v Speaker 3>I mean, it's it's infuriating what it is.

0:56:34.600 --> 0:56:38.400
<v Speaker 1>Yeah, and that was the longest biology section I've ever done.

0:56:38.960 --> 0:56:43.160
<v Speaker 3>How there's a lot to unback despite the fact that

0:56:43.200 --> 0:56:44.800
<v Speaker 3>we are still left with so many questions.

0:56:44.920 --> 0:56:46.960
<v Speaker 1>Right, we don't know anything, and yet I talked for

0:56:47.000 --> 0:56:51.279
<v Speaker 1>an hour, so Erin, tell me all about it. How

0:56:51.280 --> 0:56:54.000
<v Speaker 1>did we get here? And why? Why?

0:56:54.480 --> 0:56:58.000
<v Speaker 3>Why? Yeah? I will start on the longest history section

0:56:58.480 --> 0:57:37.400
<v Speaker 3>right after this break. Before reading about endometriosis, I figured

0:57:37.440 --> 0:57:40.400
<v Speaker 3>that it would be one of those episodes that followed

0:57:40.440 --> 0:57:44.920
<v Speaker 3>like a relatively straightforward formula, like what evolutionary significance does

0:57:44.960 --> 0:57:48.200
<v Speaker 3>it have? When was it first written about or first

0:57:48.240 --> 0:57:51.880
<v Speaker 3>identified as a medical condition? Who discovered it? How has

0:57:51.880 --> 0:57:55.760
<v Speaker 3>our knowledge about the pathophysiology changed over the last hundred years,

0:57:56.320 --> 0:57:57.920
<v Speaker 3>and how have we gotten better at treating it?

0:57:59.680 --> 0:57:59.919
<v Speaker 1>Yeah?

0:58:00.680 --> 0:58:03.240
<v Speaker 3>And it's true I did come across a lot of

0:58:03.240 --> 0:58:07.479
<v Speaker 3>information while researching that would answer those questions and fit

0:58:07.600 --> 0:58:11.640
<v Speaker 3>into that formula, But as I read more, I felt

0:58:11.720 --> 0:58:14.680
<v Speaker 3>like that wasn't what I wanted to talk about. What

0:58:14.760 --> 0:58:18.200
<v Speaker 3>I found more compelling, and in my opinion, more important,

0:58:18.560 --> 0:58:22.880
<v Speaker 3>was how the entire story of endometriosis kind of perfectly

0:58:23.120 --> 0:58:28.200
<v Speaker 3>encapsulates many aspects of misogyny and gender inequality in medicine,

0:58:28.640 --> 0:58:32.960
<v Speaker 3>and the implicit and explicit biases that often keep women

0:58:33.040 --> 0:58:39.080
<v Speaker 3>from getting the healthcare they need and deserve. So that's

0:58:39.440 --> 0:58:41.959
<v Speaker 3>what I'm going to talk a lot about today. Good,

0:58:42.640 --> 0:58:45.240
<v Speaker 3>and before I dive in, I want to briefly discuss

0:58:45.280 --> 0:58:49.760
<v Speaker 3>the language I'll be using. The story of endometriosis involves

0:58:49.840 --> 0:58:54.160
<v Speaker 3>aspects of both sex aka common biological differences between males

0:58:54.160 --> 0:58:58.320
<v Speaker 3>and females, as well as gender aka the socially constructed

0:58:58.400 --> 0:59:01.360
<v Speaker 3>roles that vary between gender as that people identify with.

0:59:02.520 --> 0:59:06.600
<v Speaker 3>And as you mentioned, Aaron, endometriosis can affect people who

0:59:06.720 --> 0:59:10.440
<v Speaker 3>don't identify as women. It can affect people assign female, male,

0:59:10.560 --> 0:59:13.720
<v Speaker 3>or intersex at birth, and its label as a female

0:59:13.760 --> 0:59:17.400
<v Speaker 3>only or women's disease can be very damaging and can

0:59:17.440 --> 0:59:21.120
<v Speaker 3>delay diagnosis even further for those that don't fit the

0:59:21.120 --> 0:59:26.000
<v Speaker 3>description of a typical ENDO patient, whatever that means. But

0:59:26.600 --> 0:59:29.080
<v Speaker 3>much of what I'll be talking about today is a

0:59:29.160 --> 0:59:32.080
<v Speaker 3>gendered issue. It has to do with the way that

0:59:32.120 --> 0:59:36.040
<v Speaker 3>women are perceived in medicine and how that impacts their treatment.

0:59:36.840 --> 0:59:40.720
<v Speaker 3>The fact that endometriosis primarily occurs in people assigned female

0:59:40.760 --> 0:59:43.480
<v Speaker 3>at birth has given rise to many of the social

0:59:43.520 --> 0:59:48.640
<v Speaker 3>issues and medical disparities surrounding endometriosis. Many of these issues,

0:59:48.840 --> 0:59:53.080
<v Speaker 3>such as how people experiencing pain are perceived by medical providers,

0:59:53.560 --> 0:59:56.840
<v Speaker 3>are discussed in the literature and in scientific studies using

0:59:56.880 --> 1:00:00.560
<v Speaker 3>the terms men and women without saying whether they mean

1:00:00.640 --> 1:00:04.920
<v Speaker 3>sex or gender, but generally we're speaking referred to cisgender people.

1:00:05.760 --> 1:00:09.200
<v Speaker 3>This is definitely a huge limitation of these studies and

1:00:09.520 --> 1:00:12.720
<v Speaker 3>of this discussion as well, especially since there are many

1:00:12.760 --> 1:00:15.920
<v Speaker 3>ways that trans or gender non binary people are treated

1:00:15.960 --> 1:00:19.400
<v Speaker 3>differently than CIS people in medicine, often in ways that

1:00:19.480 --> 1:00:22.960
<v Speaker 3>negatively impact their health. And I'm going to try my

1:00:23.080 --> 1:00:26.840
<v Speaker 3>best to be inclusive and not to ignore the experiences

1:00:26.880 --> 1:00:30.080
<v Speaker 3>of those people or exclude them from this history. But

1:00:30.200 --> 1:00:34.520
<v Speaker 3>studies examining those aspects are scarcer, Yeah.

1:00:34.400 --> 1:00:37.760
<v Speaker 1>Like horrifically scarcer, as in almost non existent.

1:00:38.360 --> 1:00:44.560
<v Speaker 3>Basically yeah, almost non existent. Okay, So let's dive in.

1:00:46.280 --> 1:00:49.240
<v Speaker 3>Like I said, I want to talk broadly about medical

1:00:49.280 --> 1:00:53.120
<v Speaker 3>bias against women and what that means for endometriosis. But

1:00:53.160 --> 1:00:55.280
<v Speaker 3>in order to do that, I should first tell you

1:00:55.440 --> 1:00:57.800
<v Speaker 3>a bit about the history of endometriosis.

1:00:57.920 --> 1:01:01.360
<v Speaker 1>Yeah, tell me a little, right first.

1:01:02.360 --> 1:01:07.520
<v Speaker 3>Why does endometriosis exist? I mean, I have no idea, No,

1:01:08.200 --> 1:01:11.560
<v Speaker 3>let's be clear, but you know I have some food

1:01:11.600 --> 1:01:15.960
<v Speaker 3>for thought. Maybe so. As you said erin, endometriosis is

1:01:16.000 --> 1:01:20.400
<v Speaker 3>often associated with infertility or subfertility. And while we don't

1:01:20.440 --> 1:01:24.800
<v Speaker 3>have a complete grasp on what causes endometriosis, like you

1:01:24.880 --> 1:01:28.320
<v Speaker 3>said Aaron, heredity does seem to play a part, and

1:01:28.360 --> 1:01:31.720
<v Speaker 3>many diseases are caused by a mixture of genetic predisposition

1:01:31.840 --> 1:01:34.400
<v Speaker 3>and environmental factors. And it seems like in the case

1:01:34.400 --> 1:01:38.480
<v Speaker 3>of endometriosis, I've read that it's about fifty percent genes

1:01:38.480 --> 1:01:40.400
<v Speaker 3>and fifty percent environmental factors.

1:01:40.560 --> 1:01:41.919
<v Speaker 1>Yeah, that's what I read as well.

1:01:42.400 --> 1:01:47.480
<v Speaker 3>Yeah, so it seems like it should be selected against

1:01:47.560 --> 1:01:49.960
<v Speaker 3>at least a little bit, just by virtue of the

1:01:50.040 --> 1:01:53.840
<v Speaker 3>fact that people with endometriosis tend to be less likely

1:01:53.880 --> 1:01:57.720
<v Speaker 3>to pass on those alleles or the predisposition for ENDO.

1:01:58.400 --> 1:02:02.280
<v Speaker 3>But that's not what the numbers seem to show. And

1:02:02.360 --> 1:02:07.640
<v Speaker 3>as I'm sure you'll talk more about, endometriosis is incredibly common.

1:02:08.200 --> 1:02:12.640
<v Speaker 3>Like I've seen estimates from ten to fifteen percent, and

1:02:13.160 --> 1:02:17.320
<v Speaker 3>those frankly seem like they could be conservative estimates or underestimates,

1:02:17.400 --> 1:02:20.520
<v Speaker 3>because I'm sure many people with endometriosis never get a

1:02:20.560 --> 1:02:23.920
<v Speaker 3>diagnosis for any number of reasons, such as whether they

1:02:23.920 --> 1:02:26.080
<v Speaker 3>can afford to see a doctor, to take time off

1:02:26.080 --> 1:02:29.320
<v Speaker 3>work and find reliable transport to a doctor, or even

1:02:29.360 --> 1:02:31.880
<v Speaker 3>if they can see a doctor, maybe they're just dismissed

1:02:31.960 --> 1:02:35.480
<v Speaker 3>or called dramatic, or maybe they just don't know that

1:02:35.640 --> 1:02:40.360
<v Speaker 3>debilitating periods aren't normal because periods are a taboo discussion topic.

1:02:40.640 --> 1:02:43.080
<v Speaker 1>I feel like that's such an important one because it's

1:02:43.120 --> 1:02:46.760
<v Speaker 1>still so common today that people have no idea that

1:02:46.800 --> 1:02:50.320
<v Speaker 1>they don't have to exist or they shouldn't have to

1:02:50.440 --> 1:02:53.800
<v Speaker 1>exist in that much pain, like that shouldn't be normal.

1:02:54.480 --> 1:02:58.560
<v Speaker 3>I mean even periods themselves. Do we need to have periods?

1:02:58.720 --> 1:02:58.800
<v Speaker 1>Like?

1:02:59.240 --> 1:03:06.200
<v Speaker 3>No, no, oh we don't. It's very interesting anyway. So yeah,

1:03:06.240 --> 1:03:08.800
<v Speaker 3>and then of course, on top of all of those factors,

1:03:09.160 --> 1:03:12.240
<v Speaker 3>there are these racial and economic disparities in obtaining a

1:03:12.280 --> 1:03:17.400
<v Speaker 3>diagnosis that are very frustrating. Doesn't really begin to cover it,

1:03:17.480 --> 1:03:21.680
<v Speaker 3>but yeah, but whether it's ten to fifteen percent or

1:03:22.080 --> 1:03:28.400
<v Speaker 3>likely much higher, endometriosis is extremely prevalent, and again more

1:03:28.440 --> 1:03:31.200
<v Speaker 3>than it seems like it should be maybe for something

1:03:31.200 --> 1:03:34.680
<v Speaker 3>that can affect fertility. But remember that it's not just

1:03:34.760 --> 1:03:37.960
<v Speaker 3>your genes determining whether or not you get endometriosis. It's

1:03:38.000 --> 1:03:42.360
<v Speaker 3>also environmental factors. And it turns out that endometriosis might

1:03:42.400 --> 1:03:47.160
<v Speaker 3>not deserve the reputation it has for causing infertility. So

1:03:47.360 --> 1:03:49.320
<v Speaker 3>it seems like in a lot of the literature and

1:03:49.520 --> 1:03:53.760
<v Speaker 3>estimate around thirty percent is often reported, but more recent

1:03:53.800 --> 1:03:57.880
<v Speaker 3>studies put it actually lower at about ten to thirteen percent.

1:03:58.600 --> 1:04:02.439
<v Speaker 1>Of people with endometriosi that will have infertility, got it right?

1:04:02.520 --> 1:04:05.360
<v Speaker 1>I think most of the most of this numbers that

1:04:05.400 --> 1:04:08.800
<v Speaker 1>I saw cited was like, of people with infertility, how

1:04:08.840 --> 1:04:11.840
<v Speaker 1>many of them have endometriosis, which is a very interesting

1:04:11.880 --> 1:04:13.360
<v Speaker 1>way to look at the statistics.

1:04:13.600 --> 1:04:17.160
<v Speaker 3>It is, yeah, but yeah, So it seems like this

1:04:17.240 --> 1:04:22.360
<v Speaker 3>reputation that endometriosis has for basically being a one to

1:04:22.440 --> 1:04:26.840
<v Speaker 3>one infertility is not necessarily yeah the case. And I

1:04:26.880 --> 1:04:30.400
<v Speaker 3>also read a couple of papers that proposed an evolutionary

1:04:30.480 --> 1:04:35.000
<v Speaker 3>explanation for endometriosis. So I will admit I feel a

1:04:35.040 --> 1:04:37.200
<v Speaker 3>little bit out of my depth here, but I'm going

1:04:37.280 --> 1:04:41.080
<v Speaker 3>to just attempt to do my best, essentially. In these papers,

1:04:41.120 --> 1:04:44.880
<v Speaker 3>which were from twenty twenty one, the authors suggested that

1:04:45.000 --> 1:04:49.840
<v Speaker 3>endometriosis and polycystic ovarian syndrome are opposites. Did you know

1:04:49.960 --> 1:04:50.320
<v Speaker 3>this paper?

1:04:50.400 --> 1:04:52.240
<v Speaker 1>I saw that paper and I was like, ooh, what's

1:04:52.280 --> 1:04:55.440
<v Speaker 1>this baby? Interesting? Or and interesting?

1:04:56.000 --> 1:05:00.520
<v Speaker 3>Mm hmmmm hmmm. And so endo and PCO or at

1:05:00.560 --> 1:05:03.520
<v Speaker 3>these like two extremes of a spectrum. This is what

1:05:03.560 --> 1:05:09.760
<v Speaker 3>the author suggested that is determined by levels of prenatal

1:05:09.800 --> 1:05:15.480
<v Speaker 3>testosterone exposure, with high prenatal levels equaling PCOS and low

1:05:15.520 --> 1:05:21.040
<v Speaker 3>prenatal levels equaling endometriosis. So during development, if a fetus

1:05:21.080 --> 1:05:23.960
<v Speaker 3>is exposed to levels of testosterone that are outside the

1:05:24.120 --> 1:05:28.480
<v Speaker 3>quote normal range, certain traits associated with fertility or fecundity

1:05:29.040 --> 1:05:32.480
<v Speaker 3>are brought to their extremes. And the way that I

1:05:32.560 --> 1:05:34.920
<v Speaker 3>started thinking about this was like too much of a

1:05:34.960 --> 1:05:40.560
<v Speaker 3>good thing. So individually, these traits might be helpful for fertility,

1:05:41.160 --> 1:05:43.840
<v Speaker 3>but when you have too many of those traits or

1:05:43.880 --> 1:05:47.120
<v Speaker 3>they are expressed too highly, it can be hurtful. So

1:05:47.280 --> 1:05:50.840
<v Speaker 3>something like uterine contractions, it's great for when you have

1:05:51.040 --> 1:05:53.760
<v Speaker 3>fetus with a big head in there, but horrible for

1:05:53.840 --> 1:05:57.120
<v Speaker 3>when you have menstrual cramps that lay you flat, or

1:05:57.400 --> 1:06:01.960
<v Speaker 3>like inflammation right, high level like inflammation is good, it

1:06:02.080 --> 1:06:05.480
<v Speaker 3>helped what keeps us healthy. To high levels of inflammation

1:06:05.920 --> 1:06:09.840
<v Speaker 3>can be really, really bad. So taking all that together,

1:06:10.160 --> 1:06:13.320
<v Speaker 3>I feel like we can start to see why endometriosis

1:06:13.360 --> 1:06:16.400
<v Speaker 3>exists and why we see it in fairly prevalent numbers today.

1:06:17.000 --> 1:06:20.680
<v Speaker 3>So my next question is do we have more endo

1:06:20.760 --> 1:06:23.880
<v Speaker 3>today than we've had in the past. How long has

1:06:23.960 --> 1:06:29.560
<v Speaker 3>endometriosis been around. Endometriosis often gets called a modern disease

1:06:29.680 --> 1:06:32.360
<v Speaker 3>or a modern epidemic. Did you come across papers describing

1:06:32.360 --> 1:06:32.760
<v Speaker 3>it that way?

1:06:32.920 --> 1:06:34.280
<v Speaker 1>No, but I'm not surprised.

1:06:34.520 --> 1:06:40.760
<v Speaker 3>Okay, I don't like this for a number of reasons. First,

1:06:41.000 --> 1:06:44.160
<v Speaker 3>I don't love the term modern epidemic to describe endometriosis

1:06:44.280 --> 1:06:47.040
<v Speaker 3>because I'm not convinced that we have enough data about

1:06:47.080 --> 1:06:50.400
<v Speaker 3>historical rates to say whether there's an actual increase or

1:06:50.400 --> 1:06:52.040
<v Speaker 3>if it's just that we're more aware of it so

1:06:52.080 --> 1:06:56.040
<v Speaker 3>it's diagnosed more often. Second, is that calling it a

1:06:56.080 --> 1:06:59.800
<v Speaker 3>modern disease implies that it has emerged only recently, which

1:06:59.840 --> 1:07:04.880
<v Speaker 3>is untrue. Humans have probably been experiencing endometriosis for millennia,

1:07:05.040 --> 1:07:08.080
<v Speaker 3>as I'll get into and some people who defend the

1:07:08.200 --> 1:07:11.920
<v Speaker 3>use of the term modern to describe endometriosis say that

1:07:11.960 --> 1:07:15.360
<v Speaker 3>it's because it was only defined as a clinical entity

1:07:15.480 --> 1:07:18.040
<v Speaker 3>within the past one hundred to one hundred and fifty years,

1:07:18.600 --> 1:07:22.440
<v Speaker 3>and that definitive diagnosis by examining tissue under a microscope

1:07:22.760 --> 1:07:26.080
<v Speaker 3>was only possible in the last one hundred years. So

1:07:27.240 --> 1:07:31.480
<v Speaker 3>despite the existence of ancient medical texts describing abnormal bleeding

1:07:31.520 --> 1:07:36.120
<v Speaker 3>associated with pelvic pain and infertility, those descriptions apparently aren't

1:07:36.120 --> 1:07:40.760
<v Speaker 3>specific enough to be called endometriosis, which I'll grant is fair.

1:07:41.320 --> 1:07:44.160
<v Speaker 3>Retrospective diagnosis is always a problem.

1:07:44.360 --> 1:07:46.640
<v Speaker 1>Yeah, and there's a lot of things that can cause

1:07:46.760 --> 1:07:48.360
<v Speaker 1>pelvic plane and abnormal bleeding.

1:07:48.840 --> 1:07:53.720
<v Speaker 3>Absolutely, but I still think it's misleading to call endometriosis modern.

1:07:53.840 --> 1:07:56.880
<v Speaker 3>I agree because I feel like by that definition, there

1:07:56.880 --> 1:07:59.520
<v Speaker 3>are a whole lot of diseases that have likely been

1:07:59.600 --> 1:08:04.880
<v Speaker 3>with heus for millennia, but quote discovered only recently. Does

1:08:04.920 --> 1:08:07.280
<v Speaker 3>a disease exist only when it's been given a name

1:08:07.360 --> 1:08:14.440
<v Speaker 3>and a clinical description, No, of course not. All that said,

1:08:14.680 --> 1:08:18.800
<v Speaker 3>it is possible that endometriosis is on the rise, and

1:08:18.920 --> 1:08:21.280
<v Speaker 3>we should look to see if it is and if

1:08:21.320 --> 1:08:23.479
<v Speaker 3>it is the case, we should obviously try to find

1:08:23.479 --> 1:08:29.519
<v Speaker 3>out why. But endometriosis is an ancient disease. There are

1:08:29.560 --> 1:08:33.400
<v Speaker 3>descriptions of painful menstruation which could be endo, dating back

1:08:33.439 --> 1:08:37.880
<v Speaker 3>to eighteen fifty five BCE from ancient Egypt, and then

1:08:38.040 --> 1:08:41.040
<v Speaker 3>again in ancient Greece in the Hippocratic text from the

1:08:41.080 --> 1:08:46.040
<v Speaker 3>fifth and fourth centuries BCE, describing menstrual dysfunction as a

1:08:46.080 --> 1:08:50.880
<v Speaker 3>cause of disease, with pain and infertility resulting if left untreated,

1:08:51.040 --> 1:08:56.200
<v Speaker 3>and pregnancy as a possible cure, which, despite not being

1:08:56.320 --> 1:09:01.000
<v Speaker 3>true not being a cure, is often still reckon mended today.

1:09:02.040 --> 1:09:06.800
<v Speaker 3>In fact, I read in one book, uh for this episode,

1:09:06.920 --> 1:09:10.360
<v Speaker 3>that somebody commented on a Facebook page for a group

1:09:10.400 --> 1:09:15.400
<v Speaker 3>called endoactive about this quote. My doctor told me having

1:09:15.479 --> 1:09:20.599
<v Speaker 3>a baby would help my pain. I'm only eleven. What

1:09:21.720 --> 1:09:30.599
<v Speaker 3>uh huh yeah, oh no, mm hmm oh no erin yeah,

1:09:30.760 --> 1:09:35.200
<v Speaker 3>I've been mad for the fast time I've been researching this.

1:09:35.400 --> 1:09:37.439
<v Speaker 1>I'm not going to get over that one, I know,

1:09:38.160 --> 1:09:38.400
<v Speaker 1>I know.

1:09:39.320 --> 1:09:41.200
<v Speaker 3>Yeah.

1:09:41.240 --> 1:09:41.320
<v Speaker 1>So.

1:09:42.280 --> 1:09:46.000
<v Speaker 3>In these Hippocratic texts are also the descriptions of the

1:09:46.040 --> 1:09:52.320
<v Speaker 3>group's most susceptible to these gynecological disorders, women who remained childless,

1:09:52.880 --> 1:09:57.320
<v Speaker 3>young widows, and virgins who had already menstruated but remained unmarried,

1:09:58.360 --> 1:10:01.360
<v Speaker 3>some of which sounds disturbingly familiar to the nickname that

1:10:01.439 --> 1:10:04.600
<v Speaker 3>was given to endometriosis in the nineteen sixties to the

1:10:04.640 --> 1:10:09.040
<v Speaker 3>nineteen eighties or so, the quote career woman's disease.

1:10:09.400 --> 1:10:11.720
<v Speaker 1>Oh my god, I saw that in one paper and

1:10:11.760 --> 1:10:14.080
<v Speaker 1>I barfed in my mouth. I do.

1:10:15.320 --> 1:10:18.559
<v Speaker 3>Basically, it's like, well, you put off your child bearing

1:10:18.640 --> 1:10:22.000
<v Speaker 3>duties and rejected your social and gender role, so this

1:10:22.040 --> 1:10:22.719
<v Speaker 3>is what you get.

1:10:22.920 --> 1:10:24.640
<v Speaker 1>It's the natural consequence.

1:10:25.080 --> 1:10:29.280
<v Speaker 3>Uh huh. Obviously, the Hippocratic texts didn't refer to these

1:10:29.360 --> 1:10:34.240
<v Speaker 3>symptoms as endometriosis or as even like one specific disease,

1:10:35.000 --> 1:10:38.600
<v Speaker 3>but rather they were part of what was called hysteria,

1:10:39.040 --> 1:10:42.639
<v Speaker 3>after the Greek word for the uterus. And I'll talk

1:10:42.720 --> 1:10:45.960
<v Speaker 3>more about the history of hysteria and it's wandering definitions

1:10:46.000 --> 1:10:48.840
<v Speaker 3>in a bit, but first I want to wrap up

1:10:48.920 --> 1:10:52.200
<v Speaker 3>the history of endometriosis. Even though they are tied together,

1:10:52.720 --> 1:10:58.160
<v Speaker 3>so many people who were diagnosed with hysteria probably had endo. Anyway,

1:10:58.360 --> 1:11:01.640
<v Speaker 3>from those ancient texts describe be pain during menstruation and

1:11:01.760 --> 1:11:04.880
<v Speaker 3>abnormal periods, there doesn't really seem to be a ton

1:11:04.960 --> 1:11:09.360
<v Speaker 3>of other mentions of what could be endometriosis, not because

1:11:09.400 --> 1:11:13.360
<v Speaker 3>people weren't experiencing it, but likely because there was and

1:11:13.560 --> 1:11:20.280
<v Speaker 3>still is a huge taboo surrounding menstruation from Leviticus in

1:11:20.320 --> 1:11:24.160
<v Speaker 3>the Old Testament quote if a woman has a discharge,

1:11:24.360 --> 1:11:27.120
<v Speaker 3>and the discharge from her body is blood, she shall

1:11:27.160 --> 1:11:30.280
<v Speaker 3>be set apart seven days, and whoever touches her shall

1:11:30.320 --> 1:11:36.240
<v Speaker 3>be unclean until evening. Fast forward to the first time

1:11:36.520 --> 1:11:40.640
<v Speaker 3>that the word period was said on television like you know,

1:11:40.680 --> 1:11:46.599
<v Speaker 3>like menstrual period nineteen eighty five, no way, by Courtney

1:11:46.600 --> 1:11:48.120
<v Speaker 3>Cox in a tampon commercial.

1:11:48.760 --> 1:11:51.800
<v Speaker 1>Wow, uh huh, so I'm sorry. Before that they had

1:11:51.800 --> 1:11:54.320
<v Speaker 1>tampon commercials without saying the word period.

1:11:54.280 --> 1:11:55.679
<v Speaker 3>Or did they have tampon commercials?

1:11:55.800 --> 1:11:57.080
<v Speaker 1>Maybe they didn't have tampons.

1:12:00.000 --> 1:12:01.920
<v Speaker 3>The history of the tampon would be a fascinating one

1:12:01.960 --> 1:12:02.679
<v Speaker 3>to research.

1:12:02.920 --> 1:12:06.240
<v Speaker 1>There is we haven't even done, just like regular menstruation,

1:12:06.720 --> 1:12:10.240
<v Speaker 1>I know, I know, know anyways.

1:12:09.920 --> 1:12:13.520
<v Speaker 3>Anyways, but we have been conditioned to think of periods,

1:12:13.800 --> 1:12:20.040
<v Speaker 3>these absolutely normal things, as gross and shameful when they

1:12:20.040 --> 1:12:24.080
<v Speaker 3>are neither, and that stigma surrounding periods can lead to

1:12:24.120 --> 1:12:28.240
<v Speaker 3>this damaging silence where because we are shamed from talking

1:12:28.280 --> 1:12:33.000
<v Speaker 3>about periods because it's not polite conversation. We don't know

1:12:33.040 --> 1:12:36.760
<v Speaker 3>whether our own periods are normal because we don't hear

1:12:36.880 --> 1:12:42.320
<v Speaker 3>the experiences of others. Right, The persistent labeling of menstrual

1:12:42.320 --> 1:12:47.120
<v Speaker 3>periods as a distasteful and shameful subject has profound implications

1:12:47.200 --> 1:12:50.719
<v Speaker 3>for public health, and it creates enormous inequities for people

1:12:50.760 --> 1:12:55.160
<v Speaker 3>who menstruate. In most states, tampons, for example, are subject

1:12:55.200 --> 1:12:59.400
<v Speaker 3>to sales tax, and also in most states, prisons charge

1:12:59.439 --> 1:13:04.920
<v Speaker 3>inmates for menstrual products. I know, there's just so much,

1:13:05.479 --> 1:13:08.800
<v Speaker 3>so much, there's so much. But circling back to the

1:13:08.880 --> 1:13:13.000
<v Speaker 3>history part of this, maybe the reason that endometriosis doesn't

1:13:13.040 --> 1:13:16.880
<v Speaker 3>show up very much until basically the eighteen hundreds is

1:13:16.920 --> 1:13:21.080
<v Speaker 3>because the people writing medical texts were primarily men, most

1:13:21.120 --> 1:13:24.839
<v Speaker 3>of whom would have considered it deeply improper and probably

1:13:24.880 --> 1:13:29.880
<v Speaker 3>gross to ask a woman about her periods. It's absolutely

1:13:29.920 --> 1:13:34.920
<v Speaker 3>possible and likely that women discuss periods amongst themselves, and

1:13:35.200 --> 1:13:37.800
<v Speaker 3>there was probably a great deal of knowledge held by

1:13:37.840 --> 1:13:41.759
<v Speaker 3>women healers, which was mostly lost as medical licensing laws

1:13:41.800 --> 1:13:46.400
<v Speaker 3>came into effect, which both prohibited them from practicing reasonable

1:13:46.560 --> 1:13:51.680
<v Speaker 3>licenses are good and even applying to medical school. If

1:13:51.720 --> 1:13:54.599
<v Speaker 3>you weren't a white wealthy man, you weren't getting in.

1:13:55.960 --> 1:13:59.960
<v Speaker 3>But with the increasing popularity of autopsies in the nineteenth century,

1:14:00.360 --> 1:14:04.200
<v Speaker 3>people begin linking more and more signs and symptoms of

1:14:04.240 --> 1:14:09.280
<v Speaker 3>disease with pathological changes in the body. Karl Vaughan Rokotansky,

1:14:09.479 --> 1:14:13.120
<v Speaker 3>whose name you may remember from our pupil Fever episode.

1:14:13.600 --> 1:14:14.080
<v Speaker 1>There it is.

1:14:14.720 --> 1:14:17.160
<v Speaker 3>He was friends with and worked at the same hospital

1:14:17.200 --> 1:14:20.760
<v Speaker 3>as Semmelweis, and he was like the King of autopsies.

1:14:20.760 --> 1:14:25.639
<v Speaker 3>He performed an incredible number of autopsies. Rokatansky is usually

1:14:25.640 --> 1:14:30.080
<v Speaker 3>credited with being the first person to describe endometrio lesions.

1:14:31.360 --> 1:14:33.960
<v Speaker 3>In the eighteen sixties, he published a paper where he

1:14:34.000 --> 1:14:37.799
<v Speaker 3>wrote that quote some fibrous tumors of the uterus contain

1:14:38.000 --> 1:14:42.640
<v Speaker 3>gland like structures that resemble endometrio glands end quote YEA.

1:14:43.960 --> 1:14:46.599
<v Speaker 3>And there was a series of autopsy studies done by

1:14:46.640 --> 1:14:50.280
<v Speaker 3>other physicians from England, Germany, Holland and Scotland also in

1:14:50.320 --> 1:14:54.320
<v Speaker 3>the eighteen hundreds that went further than Rokatansky to characterize

1:14:54.320 --> 1:14:58.479
<v Speaker 3>the disease, but it wasn't until nineteen twenty one that

1:14:58.560 --> 1:15:01.959
<v Speaker 3>It was given the name endemtri triosis by John Sampson,

1:15:02.520 --> 1:15:05.679
<v Speaker 3>who is an American gynecologist who also did the first

1:15:05.800 --> 1:15:10.080
<v Speaker 3>systematic study of the disease and proposed a hypothesis that

1:15:10.240 --> 1:15:15.640
<v Speaker 3>is still the most popular today, the menstrual backwash hypothesis.

1:15:17.600 --> 1:15:20.720
<v Speaker 3>The papers published by Samson marked a turning point in

1:15:20.760 --> 1:15:24.240
<v Speaker 3>the history of endometriosis. They turned it from a medical

1:15:24.280 --> 1:15:28.080
<v Speaker 3>curiosity into a clinical entity, and now that it had

1:15:28.120 --> 1:15:31.360
<v Speaker 3>a name, it meant that information could be compiled and

1:15:31.439 --> 1:15:35.600
<v Speaker 3>shared under that name. Receiving a diagnosis itself didn't do

1:15:35.960 --> 1:15:40.360
<v Speaker 3>much good, similar to today, in many cases and often

1:15:40.400 --> 1:15:44.320
<v Speaker 3>did harm because, like you said, Aaron, usually a complete

1:15:44.320 --> 1:15:48.040
<v Speaker 3>removal of the uterus was suggested as the only effective treatment.

1:15:49.240 --> 1:15:54.120
<v Speaker 3>A couple of decades after Samson's papers, endometriosis of the lungs,

1:15:54.240 --> 1:15:58.439
<v Speaker 3>large bowel, colon, rectum, bladder, lymph node, cervix, round ligaments,

1:15:58.479 --> 1:16:01.640
<v Speaker 3>and so on had been reported, and physicians began to

1:16:01.720 --> 1:16:04.599
<v Speaker 3>realize that it was a lot more prevalent than Samson

1:16:04.640 --> 1:16:09.600
<v Speaker 3>had thought, who described it as a rare disease. Laparoscopic

1:16:09.680 --> 1:16:12.759
<v Speaker 3>surgery began to be more regularly used for the removal

1:16:12.840 --> 1:16:16.320
<v Speaker 3>of lesions starting in around the late nineteen seventies early

1:16:16.400 --> 1:16:21.559
<v Speaker 3>nineteen eighties. But frankly, is as you went over, not

1:16:21.760 --> 1:16:26.200
<v Speaker 3>a whole lot of progress seems to have been made since. Like, yes,

1:16:26.360 --> 1:16:29.840
<v Speaker 3>we know more about endometriosis now than we did one

1:16:29.920 --> 1:16:33.680
<v Speaker 3>hundred years ago, but we're still limited in treatment and

1:16:33.880 --> 1:16:38.200
<v Speaker 3>hugely lacking in awareness among both medical professionals as well

1:16:38.240 --> 1:16:41.479
<v Speaker 3>as the general public, which has led in part to

1:16:41.600 --> 1:16:46.040
<v Speaker 3>the ridiculous delay in endometriosis diagnosis. I mean, I've seen

1:16:46.120 --> 1:16:48.360
<v Speaker 3>estimates of six to twelve years.

1:16:48.880 --> 1:16:52.439
<v Speaker 1>Yeah, I've seen even higher sometimes like ten to fifteen

1:16:52.520 --> 1:16:56.360
<v Speaker 1>years lag between symptoms and diagnosis.

1:16:55.720 --> 1:16:59.240
<v Speaker 3>Right, And this delay is of course not equal across

1:16:59.320 --> 1:17:01.920
<v Speaker 3>racial and economic groups, with people of color and those

1:17:01.960 --> 1:17:06.800
<v Speaker 3>in lower economic classes experiencing a much longer delay. So

1:17:06.840 --> 1:17:09.559
<v Speaker 3>what I wanted to take time to explore in more

1:17:09.640 --> 1:17:15.280
<v Speaker 3>depth was why this damaging diagnostic delay exists. Why is

1:17:15.320 --> 1:17:19.599
<v Speaker 3>it six to twelve years or ten to fifteen years.

1:17:19.840 --> 1:17:23.120
<v Speaker 3>Why do we still not seem to know very much

1:17:23.160 --> 1:17:26.519
<v Speaker 3>about endometriosis, what causes it, how to treat it, why

1:17:26.560 --> 1:17:30.480
<v Speaker 3>do some people get it and others don't? And exploring

1:17:30.520 --> 1:17:33.759
<v Speaker 3>those questions kind of led me into reading more generally

1:17:33.920 --> 1:17:37.439
<v Speaker 3>about the pervasive mistreatment and under treatment of women by

1:17:37.439 --> 1:17:40.720
<v Speaker 3>the medical system. Right off the bat, I want to

1:17:40.760 --> 1:17:43.120
<v Speaker 3>mention the books that I read for this because I'll

1:17:43.120 --> 1:17:46.480
<v Speaker 3>probably be quoting from them a lot, one in particular,

1:17:46.640 --> 1:17:49.280
<v Speaker 3>and they are phenomenal and I learned so much and

1:17:49.320 --> 1:17:55.160
<v Speaker 3>got so angry along the way. Doing Harm by Maya

1:17:55.240 --> 1:17:59.120
<v Speaker 3>duson Berry and Pain and Prejudice by Gabrielle Jackson are

1:17:59.160 --> 1:18:02.720
<v Speaker 3>both nonfiction books about the systemic issues in medicine and

1:18:02.760 --> 1:18:06.000
<v Speaker 3>how women are treated. Ask Me About My Uterus by

1:18:06.000 --> 1:18:08.960
<v Speaker 3>Abbie Norman and Giving Up the Ghost by Hillary Mantel

1:18:09.120 --> 1:18:13.240
<v Speaker 3>are memoirs about endometriosis. Hillary Mantel's book includes a section

1:18:13.400 --> 1:18:16.720
<v Speaker 3>on her experience with enemetriosis. It's not entirely about ENDO.

1:18:17.760 --> 1:18:21.439
<v Speaker 3>I loved them all and you should read them all, Okay.

1:18:22.400 --> 1:18:24.760
<v Speaker 3>So the way that I wanted to structure this discussion

1:18:25.240 --> 1:18:29.559
<v Speaker 3>is taken directly from Maya Dusenberry's Doing Harm. In this

1:18:29.920 --> 1:18:33.479
<v Speaker 3>incredible book, she lays out what she calls the knowledge

1:18:33.479 --> 1:18:37.640
<v Speaker 3>gap and the trust gap. The knowledge gap is basically

1:18:37.800 --> 1:18:40.960
<v Speaker 3>that there isn't as much scientific and medical knowledge about

1:18:40.960 --> 1:18:44.320
<v Speaker 3>women's bodies and health issues than there is about men's

1:18:45.000 --> 1:18:47.879
<v Speaker 3>and this goes all the way from the very basic

1:18:47.960 --> 1:18:52.240
<v Speaker 3>biomedical research only including male animals and studies all the

1:18:52.280 --> 1:18:57.000
<v Speaker 3>way to women being underrepresented in clinical trials and diseases

1:18:57.040 --> 1:19:02.800
<v Speaker 3>specific to women receiving less funding. The trust gap is

1:19:02.880 --> 1:19:06.719
<v Speaker 3>simply that quote women's accounts of their symptoms are too

1:19:06.760 --> 1:19:11.519
<v Speaker 3>often not believed. The trust gap and the knowledge gap

1:19:11.600 --> 1:19:15.559
<v Speaker 3>don't operate independently. They reinforce each other to perpetuate the

1:19:15.560 --> 1:19:19.200
<v Speaker 3>mistreatment and under treatment of women by the medical system.

1:19:19.920 --> 1:19:24.439
<v Speaker 3>Quote from Dusomberry. Women's symptoms are not taken seriously because

1:19:24.479 --> 1:19:28.160
<v Speaker 3>medicine doesn't know as much about their bodies and health problems.

1:19:28.600 --> 1:19:31.439
<v Speaker 3>And medicine doesn't know as much about their bodies and

1:19:31.479 --> 1:19:37.200
<v Speaker 3>health problems because it doesn't take their symptoms seriously. End quote.

1:19:38.200 --> 1:19:41.840
<v Speaker 3>Dousomberry points out that these issues aren't about a few

1:19:41.880 --> 1:19:45.360
<v Speaker 3>bad apples in the medical system mistreating women, but rather

1:19:45.439 --> 1:19:50.720
<v Speaker 3>the unconscious bias that is structurally embedded in medicine. So

1:19:50.840 --> 1:19:53.839
<v Speaker 3>let's explore these two facets in a bit more depth,

1:19:54.200 --> 1:19:59.320
<v Speaker 3>starting with the knowledge gap. As with any structurally embedded issue,

1:19:59.320 --> 1:20:03.360
<v Speaker 3>we discuss the podcast. The knowledge gap has deep roots,

1:20:03.400 --> 1:20:06.040
<v Speaker 3>stemming from the hundreds of years during which women were

1:20:06.040 --> 1:20:09.439
<v Speaker 3>seen as biologically inferior to men and whose bodies were

1:20:09.479 --> 1:20:13.400
<v Speaker 3>either not worthy of study or improper to examine. And

1:20:13.479 --> 1:20:16.080
<v Speaker 3>if they were studied, for instance, by the so called

1:20:16.120 --> 1:20:19.920
<v Speaker 3>father of gynecology, Mary and Simms, who built the profession

1:20:19.960 --> 1:20:23.880
<v Speaker 3>on the backs of enslaved women, they were essentially tortured,

1:20:24.160 --> 1:20:27.720
<v Speaker 3>given no anesthesia or pain relief, seen to be subhuman.

1:20:28.680 --> 1:20:32.879
<v Speaker 3>The ideal baseline that defined what was medically quote normal

1:20:33.200 --> 1:20:37.519
<v Speaker 3>or human was a white adult male, and let's be honest,

1:20:37.560 --> 1:20:40.960
<v Speaker 3>a wealthy one. This is pretty clear when we look

1:20:41.000 --> 1:20:44.200
<v Speaker 3>at how menstrual periods were described in medical texts throughout

1:20:44.200 --> 1:20:49.280
<v Speaker 3>the eighteen hundreds as times of ill health. Anytime a

1:20:49.360 --> 1:20:53.920
<v Speaker 3>woman was either pregnant, menstruating, or in menopause, she was

1:20:54.000 --> 1:20:58.680
<v Speaker 3>considered unwell and her thoughts scattered and disturbed, which was

1:20:58.840 --> 1:21:02.680
<v Speaker 3>used in arguments against women being allowed to attend universities

1:21:03.320 --> 1:21:07.160
<v Speaker 3>and higher education. Anyway was thought to atrophy the uterus.

1:21:08.080 --> 1:21:12.400
<v Speaker 1>Atrophy the uterus, you can't have that, absolutely not that

1:21:12.640 --> 1:21:13.720
<v Speaker 1>brain thinking.

1:21:15.880 --> 1:21:19.120
<v Speaker 3>And this perception of periods, of course, didn't just disappear

1:21:19.160 --> 1:21:23.720
<v Speaker 3>suddenly in nineteen hundred. There's even a textbook from the

1:21:23.840 --> 1:21:28.800
<v Speaker 3>nineteen seventies that describes dysmenorrhea as a symptom of a

1:21:28.840 --> 1:21:30.120
<v Speaker 3>personality disorder.

1:21:32.400 --> 1:21:35.080
<v Speaker 1>I don't have any words. I'm just going to keep

1:21:35.280 --> 1:21:36.479
<v Speaker 1>fish mouthing over here.

1:21:39.479 --> 1:21:42.600
<v Speaker 3>So that just made me think that there are probably

1:21:43.080 --> 1:21:46.559
<v Speaker 3>some physicians still practicing today that may have been trained

1:21:46.760 --> 1:21:47.920
<v Speaker 3>on that information.

1:21:48.439 --> 1:21:54.240
<v Speaker 4>Oh definitely, yeah, up until at least the nineteen nineties,

1:21:54.560 --> 1:21:58.160
<v Speaker 4>although you could argue, probably successfully that it's still the

1:21:58.200 --> 1:21:59.479
<v Speaker 4>case today.

1:21:59.560 --> 1:22:02.719
<v Speaker 3>It was that science knew nothing about women's bodies and health.

1:22:02.840 --> 1:22:04.880
<v Speaker 3>It was just that they knew a lot less than

1:22:04.920 --> 1:22:08.519
<v Speaker 3>they did about men's And let's look at why this is.

1:22:09.280 --> 1:22:12.479
<v Speaker 3>As I mentioned earlier, the medical licensing laws enacted in

1:22:12.520 --> 1:22:15.640
<v Speaker 3>the eighteen hundreds in effect excluded women and people of

1:22:15.680 --> 1:22:19.679
<v Speaker 3>color from practicing medicine and contributing to the field. Those

1:22:19.720 --> 1:22:22.920
<v Speaker 3>that remained were white, wealthy men, and so a white

1:22:22.920 --> 1:22:25.799
<v Speaker 3>male as the baseline for comparison, and the health ideal

1:22:25.880 --> 1:22:29.720
<v Speaker 3>became entrenched in medical training and medical knowledge well into

1:22:29.760 --> 1:22:34.360
<v Speaker 3>the twentieth century. The nineteen sixties and nineteen seventies saw

1:22:34.400 --> 1:22:37.240
<v Speaker 3>a great deal of change in terms of medical ethics,

1:22:37.320 --> 1:22:42.320
<v Speaker 3>as things like Tuskegee and tholidamide revealed the enormous failings

1:22:42.360 --> 1:22:47.479
<v Speaker 3>of informed consent and protections for vulnerable individuals. Many of

1:22:47.520 --> 1:22:51.760
<v Speaker 3>these developments in drug safety studies were overwhelmingly positive in

1:22:51.880 --> 1:22:55.560
<v Speaker 3>terms of preventing people from being coerced into unsafe studies

1:22:55.600 --> 1:23:00.280
<v Speaker 3>and being harmed, But one unintended consequence was when protection

1:23:00.880 --> 1:23:06.000
<v Speaker 3>turned paternalistic, essentially preventing women from being included in drug

1:23:06.040 --> 1:23:09.960
<v Speaker 3>trials simply because they were women, or, more specifically, in

1:23:10.000 --> 1:23:14.160
<v Speaker 3>the nineteen seventy seven FDA policy excluding women of quote

1:23:14.360 --> 1:23:20.920
<v Speaker 3>child bearing potential from early phase drug studies. This meant

1:23:21.360 --> 1:23:26.120
<v Speaker 3>anyone who potentially could get pregnant.

1:23:26.080 --> 1:23:33.240
<v Speaker 1>Right, anyone with a uterus that was presumed to be working, right, yeah, yeah,

1:23:33.360 --> 1:23:34.479
<v Speaker 1>any does it? Any of them?

1:23:34.720 --> 1:23:40.080
<v Speaker 3>Any any of them, doesn't matter, doesn't matter. This is

1:23:40.120 --> 1:23:43.960
<v Speaker 3>a complicated subject, of course, because ensuring that no coercion

1:23:44.000 --> 1:23:47.280
<v Speaker 3>occurs with informed consent is still tricky and there are

1:23:47.360 --> 1:23:52.160
<v Speaker 3>potential risks associated with participating in clinical trials. But also

1:23:52.360 --> 1:23:56.200
<v Speaker 3>without the inclusion of women of quote child bearing potential

1:23:56.720 --> 1:23:59.799
<v Speaker 3>in these studies, how would we know if that drug

1:23:59.880 --> 1:24:05.200
<v Speaker 3>is safe or effective for them? This is especially problematic

1:24:05.240 --> 1:24:08.599
<v Speaker 3>and tricky in terms of pregnant people, where it's kind

1:24:08.640 --> 1:24:11.799
<v Speaker 3>of like a rock and a hard placed situation, basically

1:24:11.840 --> 1:24:15.320
<v Speaker 3>forcing a choice between including pregnant people in clinical trials

1:24:15.439 --> 1:24:17.679
<v Speaker 3>which could put the fetus and the person at risk,

1:24:18.320 --> 1:24:20.800
<v Speaker 3>or in effect testing it out on them later in

1:24:20.840 --> 1:24:24.200
<v Speaker 3>an uncontrolled fashion, hoping that the studies showing it safe

1:24:24.240 --> 1:24:27.040
<v Speaker 3>in people who are not pregnant will mean that it's

1:24:27.080 --> 1:24:33.400
<v Speaker 3>safe for pregnant people. It's complicated, and I'm not going

1:24:33.439 --> 1:24:35.519
<v Speaker 3>to go into it here because I just don't have

1:24:35.600 --> 1:24:38.680
<v Speaker 3>the background knowledge to do so. But one thing that

1:24:38.720 --> 1:24:42.680
<v Speaker 3>does seem to be clear is that there is underrepresentation

1:24:43.240 --> 1:24:46.640
<v Speaker 3>of women and pregnant people in clinical trials.

1:24:47.280 --> 1:24:51.000
<v Speaker 1>That's why all drugs during pregnancy just have these like

1:24:51.200 --> 1:24:54.360
<v Speaker 1>wacky like well, we don't know if it's safe, but

1:24:54.720 --> 1:24:57.280
<v Speaker 1>we don't know if it's harmful, so it's probably fine.

1:24:57.320 --> 1:25:00.600
<v Speaker 1>Like the scales that you use to define whether or

1:25:00.640 --> 1:25:02.960
<v Speaker 1>not something is safe and pregnancy or not the same

1:25:03.040 --> 1:25:05.240
<v Speaker 1>as when you're not pregnant.

1:25:05.479 --> 1:25:08.840
<v Speaker 3>Uh huh. It's far from a perfect system, and it

1:25:08.880 --> 1:25:11.720
<v Speaker 3>means a lot of work. Yeah, but the lack of

1:25:11.760 --> 1:25:15.840
<v Speaker 3>inclusion of women in medical studies can't all be chalked

1:25:15.880 --> 1:25:20.800
<v Speaker 3>up to this protective policy. Women were also explicitly excluded

1:25:21.080 --> 1:25:26.519
<v Speaker 3>simply because they were women. Explanations ranged from, well, men

1:25:26.520 --> 1:25:29.040
<v Speaker 3>and women are so similar that results from an all

1:25:29.120 --> 1:25:33.479
<v Speaker 3>men's study can be extrapolated to women. To women's menstrual

1:25:33.479 --> 1:25:36.799
<v Speaker 3>cycles and hormonal shifts could confuse the study results.

1:25:39.880 --> 1:25:42.920
<v Speaker 1>You can't have it both ways, exactly A.

1:25:43.560 --> 1:25:47.679
<v Speaker 3>If results from men only studies could be extrapolated to women,

1:25:48.160 --> 1:25:51.760
<v Speaker 3>then why weren't there any all women studies that were

1:25:51.800 --> 1:25:57.040
<v Speaker 3>extrapolated to men. B If there were no meaningful differences

1:25:57.120 --> 1:26:00.160
<v Speaker 3>between men and women, why not include them both in

1:26:00.160 --> 1:26:05.559
<v Speaker 3>the clinical trial? See if menstruation could significantly affect the

1:26:05.560 --> 1:26:08.720
<v Speaker 3>results of a drug trial, why on earth is it

1:26:08.840 --> 1:26:13.160
<v Speaker 3>not a reason then to include women rather than to

1:26:13.400 --> 1:26:19.000
<v Speaker 3>exclude them? And the answer to all of these here's

1:26:19.000 --> 1:26:21.360
<v Speaker 3>another quote, And I just I should say that unless

1:26:21.400 --> 1:26:24.000
<v Speaker 3>I say differently, these quotes are from doing harm by

1:26:24.040 --> 1:26:29.200
<v Speaker 3>Maya Dusonberry quote. In short, studying only one sex was

1:26:29.280 --> 1:26:32.439
<v Speaker 3>cheaper and easier, and men were the chosen ones because

1:26:32.479 --> 1:26:34.960
<v Speaker 3>women's bodies were thought to be too complicated.

1:26:35.760 --> 1:26:36.000
<v Speaker 1>Yeah.

1:26:36.720 --> 1:26:42.600
<v Speaker 3>Yeah, And there's also the matter that the medical community,

1:26:43.120 --> 1:26:46.400
<v Speaker 3>which since its infancy had been comprised primarily of men,

1:26:46.920 --> 1:26:51.000
<v Speaker 3>either consciously or subconsciously, felt that to know the health

1:26:51.040 --> 1:26:55.439
<v Speaker 3>effects on men was enough, right, Like, well, we know

1:26:55.520 --> 1:26:57.439
<v Speaker 3>it on men, so that's good, right, Like.

1:26:57.640 --> 1:26:58.759
<v Speaker 1>Yep, that's all we need.

1:26:58.800 --> 1:27:01.880
<v Speaker 3>And maybe it wasn't this malicious thing. Maybe it just

1:27:02.040 --> 1:27:06.280
<v Speaker 3>wasn't even thought about. Women didn't even enter into the consideration,

1:27:06.360 --> 1:27:10.280
<v Speaker 3>which feels malicious, even though I'm saying it as it

1:27:10.320 --> 1:27:13.880
<v Speaker 3>wasn't malicious. I don't know. But it wasn't until the

1:27:13.960 --> 1:27:17.800
<v Speaker 3>late nineteen eighties that enough women were involved in the

1:27:17.800 --> 1:27:21.920
<v Speaker 3>medical community to bring these enormous gender disparities in medical

1:27:21.960 --> 1:27:25.360
<v Speaker 3>research to light. At this time, a group of scientists

1:27:25.360 --> 1:27:28.280
<v Speaker 3>who were women formed what is now known as the

1:27:28.320 --> 1:27:31.960
<v Speaker 3>Society for the Advancement of Women's Health Research, and they

1:27:31.960 --> 1:27:35.680
<v Speaker 3>demanded an audit by the Government Accounting Office the GOAO

1:27:36.080 --> 1:27:39.680
<v Speaker 3>of the NIH's research efforts to see how well they

1:27:39.680 --> 1:27:42.800
<v Speaker 3>had stuck to the nineteen eighty five Policy for the

1:27:42.840 --> 1:27:48.920
<v Speaker 3>Inclusion of Women in research. This GOAO report, which was

1:27:49.000 --> 1:27:54.960
<v Speaker 3>published in nineteen ninety, was staggering. They had done next

1:27:54.960 --> 1:27:58.559
<v Speaker 3>to nothing in most of the studies that the NIH funded.

1:27:58.720 --> 1:28:01.840
<v Speaker 3>They couldn't say what other women were included, or if

1:28:01.880 --> 1:28:06.280
<v Speaker 3>they were how many. So far, I've talked about this

1:28:06.320 --> 1:28:11.120
<v Speaker 3>more generally right, more and more descriptive, abstract women are

1:28:11.200 --> 1:28:15.160
<v Speaker 3>excluded from studies. So let's get into some more solid

1:28:15.200 --> 1:28:20.040
<v Speaker 3>examples that illustrate the knowledge gap. For example, there's a

1:28:20.040 --> 1:28:23.400
<v Speaker 3>famous study called the Baltimore Longitudinal Study of Aging that

1:28:23.520 --> 1:28:27.400
<v Speaker 3>was started in nineteen fifty eight and aimed to study quote,

1:28:27.439 --> 1:28:31.519
<v Speaker 3>normal human aging. This was the one that found that

1:28:31.560 --> 1:28:34.519
<v Speaker 3>a baby aspirin a day could be protective against heart disease.

1:28:34.600 --> 1:28:38.080
<v Speaker 3>You know that, Like, now that's conventional wisdom or whatever. Yeah,

1:28:38.200 --> 1:28:43.160
<v Speaker 3>that study didn't include women, included thousands of men. It

1:28:43.200 --> 1:28:48.519
<v Speaker 3>didn't include women for twenty years. Another large scale study

1:28:48.560 --> 1:28:51.599
<v Speaker 3>started in nineteen eighty two, whose aim was to study

1:28:51.640 --> 1:28:55.360
<v Speaker 3>the effects of dietary change and exercise on heart disease,

1:28:56.280 --> 1:29:02.040
<v Speaker 3>included thirteen thousand men and zero men, despite the fact

1:29:02.040 --> 1:29:05.479
<v Speaker 3>that heart disease is and was then one of the

1:29:05.560 --> 1:29:11.240
<v Speaker 3>leading causes of death in women. And then there's this

1:29:12.360 --> 1:29:15.559
<v Speaker 3>I think it takes the cake quota directly again from

1:29:16.120 --> 1:29:19.280
<v Speaker 3>doing harm by Maya Dusonberry. There's a quote and then

1:29:19.320 --> 1:29:24.040
<v Speaker 3>a quote within a quote. So the inception of quotes

1:29:24.600 --> 1:29:30.439
<v Speaker 3>quote and nih supported pilot study from Rockefeller University that

1:29:30.520 --> 1:29:34.960
<v Speaker 3>looked at how obesity affected breast and uterine cancer didn't

1:29:35.120 --> 1:29:36.920
<v Speaker 3>enroll a single woman.

1:29:38.200 --> 1:29:42.240
<v Speaker 1>I'm sorry, breast and uterine cancer.

1:29:43.120 --> 1:29:45.840
<v Speaker 3>It is true that people assigned mail at birth do

1:29:46.040 --> 1:29:47.800
<v Speaker 3>develop breast cancer.

1:29:48.000 --> 1:29:52.920
<v Speaker 1>Uh huh and uterine cancer, Aaron, I don't think so. Yeah, No,

1:29:52.920 --> 1:29:54.439
<v Speaker 1>you need a uterus for that.

1:29:55.520 --> 1:30:01.000
<v Speaker 3>Yeah, continuing the quote as representative Snow noted dryly at

1:30:01.000 --> 1:30:02.240
<v Speaker 3>the congressional hearings.

1:30:03.000 --> 1:30:03.320
<v Speaker 1>Quote.

1:30:04.080 --> 1:30:07.479
<v Speaker 3>Somehow, I find it hard to believe that the male

1:30:07.560 --> 1:30:11.599
<v Speaker 3>dominated medical community would tolerate a study of prostate cancer

1:30:11.960 --> 1:30:15.280
<v Speaker 3>that used only women as research subjects.

1:30:16.520 --> 1:30:17.400
<v Speaker 1>And quotes.

1:30:22.439 --> 1:30:25.519
<v Speaker 3>I can't. That one just echoed in my head for days.

1:30:30.400 --> 1:30:33.880
<v Speaker 3>Nearly anywhere they looked, there was a striking lack of

1:30:33.920 --> 1:30:38.960
<v Speaker 3>inclusion of women and enormous consequences because of that. Biological

1:30:38.960 --> 1:30:42.160
<v Speaker 3>differences between people assigned male at birth and people assigned

1:30:42.160 --> 1:30:45.880
<v Speaker 3>female at birth have historically been used to claim inferiority

1:30:46.000 --> 1:30:50.040
<v Speaker 3>or superiority while failing to examine the potential health impact

1:30:50.200 --> 1:30:54.440
<v Speaker 3>of that difference, such as in the way drugs are metabolized,

1:30:54.760 --> 1:30:59.240
<v Speaker 3>which is impacted by fat distribution and hormones, among other factors.

1:31:00.280 --> 1:31:03.080
<v Speaker 3>So when women aren't included in drug trials, should we

1:31:03.160 --> 1:31:06.320
<v Speaker 3>be surprised by the finding that women are quote fifty

1:31:06.360 --> 1:31:09.240
<v Speaker 3>to seventy five percent more likely than men to have

1:31:09.280 --> 1:31:12.879
<v Speaker 3>an adverse drug reaction. Like, that's not a surprising finding,

1:31:14.200 --> 1:31:15.640
<v Speaker 3>it's horrible.

1:31:16.400 --> 1:31:20.360
<v Speaker 1>Well, and I also just wonder how many of those

1:31:20.880 --> 1:31:25.280
<v Speaker 1>adverse drug reactions are often just passed off as being oh, well,

1:31:25.439 --> 1:31:27.800
<v Speaker 1>like not real you know, uh huh, discounted.

1:31:27.880 --> 1:31:32.439
<v Speaker 3>I'm sure many. Yeah, the dosing of too many drugs

1:31:32.479 --> 1:31:35.479
<v Speaker 3>has been determined by how it affects men's bodies and

1:31:35.920 --> 1:31:40.960
<v Speaker 3>also overall, like people within a certain BMI range. Or

1:31:41.160 --> 1:31:44.640
<v Speaker 3>take chronic pain for example, which women are known to

1:31:44.640 --> 1:31:49.720
<v Speaker 3>be disproportionately affected by, and studies indicate that women experience

1:31:49.840 --> 1:31:54.360
<v Speaker 3>pain differently than men. And again, these studies didn't make

1:31:54.400 --> 1:31:56.960
<v Speaker 3>the distinction between whether they were talking about sex or

1:31:57.040 --> 1:32:03.000
<v Speaker 3>gender or whatever these pain differences. There was a study

1:32:03.040 --> 1:32:06.559
<v Speaker 3>from two thousand and five that found that almost eighty

1:32:06.640 --> 1:32:12.720
<v Speaker 3>percent of animal pain studies used male animals only. And

1:32:12.760 --> 1:32:16.479
<v Speaker 3>while the lack of sex analysis in animal studies of

1:32:16.560 --> 1:32:20.280
<v Speaker 3>all kinds is hugely problematic, it really only captures one

1:32:20.360 --> 1:32:23.360
<v Speaker 3>aspect of the knowledge gap. These studies don't take into

1:32:23.400 --> 1:32:26.920
<v Speaker 3>account the gender bias and social factors that influence health

1:32:27.200 --> 1:32:31.679
<v Speaker 3>and are hugely important to examine. The nineteen ninety GAO

1:32:31.800 --> 1:32:34.720
<v Speaker 3>Report did change some things for the better, but were

1:32:34.760 --> 1:32:38.400
<v Speaker 3>still not even close to equitable, and many studies simply

1:32:38.400 --> 1:32:41.840
<v Speaker 3>failed to report any sex or gender analysis of results.

1:32:42.160 --> 1:32:45.040
<v Speaker 3>There have been suggestions to require the inclusion of such

1:32:45.080 --> 1:32:48.920
<v Speaker 3>analysis for publication in peer reviewed journals, but that has

1:32:49.000 --> 1:32:53.599
<v Speaker 3>been met with some resistance for vague scientific reasons, whatever

1:32:53.640 --> 1:32:57.439
<v Speaker 3>that means. But still, even though things are getting better,

1:32:57.560 --> 1:33:00.360
<v Speaker 3>there is a huge lag time in between and when

1:33:00.360 --> 1:33:03.760
<v Speaker 3>those studies are conducted to when the results are analyzed

1:33:03.800 --> 1:33:08.519
<v Speaker 3>and published, to when it becomes presented to the interested field,

1:33:08.960 --> 1:33:11.800
<v Speaker 3>to then the wider community, to then when it becomes

1:33:11.840 --> 1:33:14.479
<v Speaker 3>included in textbooks, to then when it trickles out to

1:33:14.520 --> 1:33:20.400
<v Speaker 3>the rest of the public. Let's illustrate picture someone having

1:33:20.439 --> 1:33:24.080
<v Speaker 3>a heart attack. Okay, what do they look like? What

1:33:24.120 --> 1:33:27.080
<v Speaker 3>are they doing? What are those signs and symptoms they

1:33:27.120 --> 1:33:28.479
<v Speaker 3>seem to be feeling.

1:33:28.960 --> 1:33:30.439
<v Speaker 1>This is a really good example.

1:33:30.560 --> 1:33:34.840
<v Speaker 3>Arin I love this example. Is it an older man,

1:33:35.680 --> 1:33:39.799
<v Speaker 3>probably an older white man, clutching at his left arm

1:33:39.880 --> 1:33:40.719
<v Speaker 3>and his chest.

1:33:41.120 --> 1:33:44.120
<v Speaker 1>Salt and pepper hair, saltan pepper hair.

1:33:44.680 --> 1:33:47.760
<v Speaker 3>Maybe he's got like a short sleeve button up, shirt on.

1:33:48.320 --> 1:33:48.799
<v Speaker 1>Definitely.

1:33:49.080 --> 1:33:51.920
<v Speaker 3>Uh huh, it's like sweating a lot, sweaty.

1:33:51.640 --> 1:33:57.479
<v Speaker 1>Super sweaty. He describes a pressure in the center of

1:33:57.520 --> 1:34:00.360
<v Speaker 1>his chest, which radiates to his left arm and maybe

1:34:00.479 --> 1:34:04.240
<v Speaker 1>up into his jaw. He clutches at his chest and

1:34:04.240 --> 1:34:08.840
<v Speaker 1>then gasping for breath. Yeah.

1:34:08.880 --> 1:34:11.760
<v Speaker 3>How many of you pictured a woman with maybe some

1:34:11.960 --> 1:34:14.840
<v Speaker 3>uncomfortable back pain or flu like symptoms?

1:34:17.560 --> 1:34:19.200
<v Speaker 1>Did anyone anybody?

1:34:19.520 --> 1:34:21.479
<v Speaker 3>Maybe? I thought there are some out there for sure,

1:34:22.520 --> 1:34:25.320
<v Speaker 3>because much of the early research on heart attacks was

1:34:25.360 --> 1:34:29.320
<v Speaker 3>focused on men. That's the search image we have, and

1:34:29.360 --> 1:34:32.200
<v Speaker 3>it can be deadly, like when a study from two

1:34:32.200 --> 1:34:36.400
<v Speaker 3>thousand found that quote young women and I think by

1:34:36.439 --> 1:34:40.280
<v Speaker 3>this was meant like under the age of fifty are

1:34:40.439 --> 1:34:43.720
<v Speaker 3>seven times more likely to be sent home from the

1:34:43.800 --> 1:34:47.400
<v Speaker 3>hospital in the middle of having a heart attack. Seven

1:34:47.439 --> 1:34:50.760
<v Speaker 3>times those have fatal consequences.

1:34:51.720 --> 1:34:55.559
<v Speaker 1>There. Oh god, Aaron, there's so many good examples of this. Uh.

1:34:56.439 --> 1:35:02.640
<v Speaker 1>Do you know about the testicular torsion? One m testicular torsion.

1:35:03.320 --> 1:35:07.439
<v Speaker 1>It's when your testicle twists on itself and it can

1:35:07.439 --> 1:35:11.040
<v Speaker 1>cut off the blood flow. It's an absolute emergency, causes

1:35:11.080 --> 1:35:16.200
<v Speaker 1>excruciating pain. Okay, in the testicles, and they say time

1:35:16.280 --> 1:35:19.920
<v Speaker 1>is tissue. You have six hours to like diagnose and

1:35:19.960 --> 1:35:22.960
<v Speaker 1>treat testicular torsion, and people are really good at it.

1:35:23.000 --> 1:35:25.200
<v Speaker 1>There's a lot of studies in hospitals, like the time

1:35:25.240 --> 1:35:28.880
<v Speaker 1>from into the emergency room to treatment and like into

1:35:28.880 --> 1:35:32.320
<v Speaker 1>the or it's super short ovaryan torsion.

1:35:32.600 --> 1:35:33.960
<v Speaker 3>I knew you were gonna say that.

1:35:35.680 --> 1:35:40.000
<v Speaker 1>Same exact thing. Okay, you're ovary twists around itself. The

1:35:40.280 --> 1:35:44.080
<v Speaker 1>time from diagnosis to OAR is like I think, at

1:35:44.160 --> 1:35:48.240
<v Speaker 1>least twice as long, if not missed entirely, Like it

1:35:48.360 --> 1:35:49.720
<v Speaker 1>is staggering.

1:35:50.080 --> 1:35:54.439
<v Speaker 3>Oh yeah, yeah, there are I mean, honestly, just grab

1:35:54.479 --> 1:36:00.320
<v Speaker 3>bags full of examples about the diagnostic delay for any thing,

1:36:00.760 --> 1:36:05.639
<v Speaker 3>the treatment delay, what kind of treatment that's received. I mean,

1:36:05.960 --> 1:36:10.240
<v Speaker 3>in general, men are seen as sick while women are

1:36:10.280 --> 1:36:14.880
<v Speaker 3>seen as stressed. And this, all of these examples that

1:36:14.920 --> 1:36:18.000
<v Speaker 3>you and I just sort of went through, these are

1:36:18.040 --> 1:36:20.920
<v Speaker 3>tied to both the knowledge gap and the trust gap.

1:36:21.520 --> 1:36:24.479
<v Speaker 3>Medical doctors only know what heart attacks look like in men,

1:36:25.320 --> 1:36:28.360
<v Speaker 3>and they are disinclined to believe that women's symptoms are real.

1:36:29.360 --> 1:36:34.120
<v Speaker 3>So now let's get into the trust gap. If you

1:36:34.200 --> 1:36:37.040
<v Speaker 3>thought the knowledge gap had deep roots, wait until you

1:36:37.120 --> 1:36:42.160
<v Speaker 3>hear about the trust gap. In order to explain these roots,

1:36:42.200 --> 1:36:44.720
<v Speaker 3>I'm going to take us through a brief history of hysteria,

1:36:45.240 --> 1:36:48.200
<v Speaker 3>which was first described in ancient Egypt and got its

1:36:48.240 --> 1:36:50.719
<v Speaker 3>name from ancient Greece. Like I said, from the Greek

1:36:50.720 --> 1:36:55.920
<v Speaker 3>word for uterus histra, what is hysteria. It's basically the

1:36:55.960 --> 1:36:58.880
<v Speaker 3>idea that a woman's health and mental status is tied

1:36:58.920 --> 1:37:02.400
<v Speaker 3>directly to her utter and that all disease in a

1:37:02.439 --> 1:37:06.960
<v Speaker 3>woman came from the uterus wandering around the body like

1:37:07.160 --> 1:37:14.799
<v Speaker 3>literally wandering, but just like these restless uteri. The definition

1:37:14.840 --> 1:37:20.599
<v Speaker 3>of hysteria has also wandered substantially throughout history. In ancient Greece,

1:37:20.760 --> 1:37:24.439
<v Speaker 3>in Hippocratic texts from around the fifth century BCE, it

1:37:24.560 --> 1:37:28.760
<v Speaker 3>seemed to be thought of as an organic biological process,

1:37:29.080 --> 1:37:31.519
<v Speaker 3>one which was likely to happen if marriage was put

1:37:31.520 --> 1:37:33.760
<v Speaker 3>off for too long or if a woman didn't get

1:37:33.800 --> 1:37:37.880
<v Speaker 3>pregnant early enough after puberty. In Europe and the centuries after,

1:37:38.160 --> 1:37:41.519
<v Speaker 3>throughout the medieval period, the meaning changed and became more

1:37:41.840 --> 1:37:44.920
<v Speaker 3>spiritually based, and it was thought that the uterus could

1:37:44.920 --> 1:37:49.120
<v Speaker 3>be inhabited by a demon or evil spirits, or possessed

1:37:49.240 --> 1:37:53.320
<v Speaker 3>via witchcraft. And the uterus became the scapegoat for any

1:37:53.320 --> 1:37:56.640
<v Speaker 3>disease or complaint that a woman had. In hysteria, the

1:37:56.720 --> 1:37:57.920
<v Speaker 3>catch all diagnosis.

1:38:00.479 --> 1:38:02.880
<v Speaker 1>It's so maligned, Aaron, it is.

1:38:03.280 --> 1:38:07.320
<v Speaker 3>It is. Yeah, it hasn't gotten that much better, but

1:38:07.840 --> 1:38:13.200
<v Speaker 3>it's kind somewhat yeah. And this quality of hysteria as

1:38:13.280 --> 1:38:18.080
<v Speaker 3>a disease of exclusion, it was useful to physicians, especially

1:38:18.120 --> 1:38:22.360
<v Speaker 3>as the field of medicine itself evolved. I've talked before

1:38:22.560 --> 1:38:26.400
<v Speaker 3>on this podcast about how medicine changed substantially when measuring

1:38:26.439 --> 1:38:29.479
<v Speaker 3>tools began to be introduced and measurements began to be

1:38:29.640 --> 1:38:34.519
<v Speaker 3>compiled for certain diseases like blood pressure. You know, what's

1:38:34.520 --> 1:38:37.679
<v Speaker 3>a normal range, what's not? Heart rate, red blood cell count,

1:38:37.760 --> 1:38:41.760
<v Speaker 3>body temperature, etc. All these things. I think in our

1:38:41.840 --> 1:38:45.320
<v Speaker 3>sickle cell episode, I talked about how these tools, in

1:38:45.320 --> 1:38:49.640
<v Speaker 3>addition to medical specialization, led to medicine shifting to be

1:38:49.960 --> 1:38:55.080
<v Speaker 3>less about the person and more about the body or

1:38:55.320 --> 1:38:59.120
<v Speaker 3>a part of the body. It also led to this

1:38:59.360 --> 1:39:04.240
<v Speaker 3>important distinction between signs and symptoms. Signs being something that

1:39:04.280 --> 1:39:07.120
<v Speaker 3>someone who is not the patient can measure or see

1:39:07.240 --> 1:39:10.759
<v Speaker 3>or feel. Symptoms are the things that only the patient

1:39:10.840 --> 1:39:17.559
<v Speaker 3>can feel and describe. Signs are objective, symptoms subjective. As

1:39:17.600 --> 1:39:22.480
<v Speaker 3>the ability to detect disease signs became more refined, diagnosis

1:39:22.520 --> 1:39:27.240
<v Speaker 3>increasingly relied on signs rather than symptoms, and a physician

1:39:27.240 --> 1:39:30.559
<v Speaker 3>could listen less or not at all to their patient

1:39:30.680 --> 1:39:34.559
<v Speaker 3>and still end up successfully treating them, offering a not

1:39:34.640 --> 1:39:39.160
<v Speaker 3>so great precedent. But it also meant that if there

1:39:39.160 --> 1:39:41.960
<v Speaker 3>were no signs or the signs didn't tell them anything,

1:39:42.760 --> 1:39:47.560
<v Speaker 3>they could and often did, disregard the symptoms as hysterical.

1:39:48.880 --> 1:39:52.320
<v Speaker 3>In of the eighteen hundreds, Jean Martin Charcot tried to

1:39:52.560 --> 1:39:57.559
<v Speaker 3>reclassify hysteria as a neurological disorder rather than a personality flaw,

1:39:58.120 --> 1:40:03.000
<v Speaker 3>believing that believing that the ovaries, rather than the uterus,

1:40:03.439 --> 1:40:10.640
<v Speaker 3>diverted energy from the brain during menstruation, pregnancy, lactation, menopause, ovulation,

1:40:10.880 --> 1:40:14.439
<v Speaker 3>et cetera, and that the brain, drained of all this energy,

1:40:14.520 --> 1:40:17.400
<v Speaker 3>could barely function and left women weak.

1:40:18.720 --> 1:40:20.719
<v Speaker 1>Poor things just all the time.

1:40:22.400 --> 1:40:26.320
<v Speaker 3>Plaques and lesions that Charco found around the ovaries and

1:40:26.439 --> 1:40:31.360
<v Speaker 3>uterus during autopsies confirmed his hypothesis to him and led

1:40:31.400 --> 1:40:35.920
<v Speaker 3>to an increase in gynecological surgeries, such as the removal

1:40:36.040 --> 1:40:41.599
<v Speaker 3>of the ovaries, the uterus or the clitoris surgeries which

1:40:41.640 --> 1:40:46.519
<v Speaker 3>were permanently damaging, if not fatal, which around fifty to

1:40:46.600 --> 1:40:51.880
<v Speaker 3>seventy percent were in like the mid eighteen hundreds. I'm

1:40:51.880 --> 1:40:57.639
<v Speaker 3>not going to get into Charco's ovary presser, but suffice

1:40:57.640 --> 1:41:01.280
<v Speaker 3>it to say that he carried out extensive medicalized torture

1:41:01.360 --> 1:41:04.680
<v Speaker 3>on women and asylums to try to confirm his ideas

1:41:04.800 --> 1:41:13.880
<v Speaker 3>about hysteria from a wandering uterus to demonic possession to

1:41:14.120 --> 1:41:20.879
<v Speaker 3>a neurological disease. Hysteria had one more major transformation to undergo,

1:41:21.760 --> 1:41:24.720
<v Speaker 3>and it was this final one that left such an

1:41:24.880 --> 1:41:28.879
<v Speaker 3>enduring mark on how women are perceived in medicine today.

1:41:30.240 --> 1:41:37.320
<v Speaker 1>Enter Freud, one of the worst, one of the worst.

1:41:37.320 --> 1:41:39.120
<v Speaker 3>I'm going to try not to talk about him too much,

1:41:40.120 --> 1:41:43.559
<v Speaker 3>simply because, like any more your time, Well, I think

1:41:43.600 --> 1:41:46.160
<v Speaker 3>he's important to talk about because of the damage that

1:41:46.240 --> 1:41:50.479
<v Speaker 3>he's done, but I also want to get past him

1:41:50.479 --> 1:41:53.479
<v Speaker 3>because there's just there's not enough time in the world

1:41:53.520 --> 1:41:59.120
<v Speaker 3>to do all of this. So Freud initially jumped on

1:41:59.200 --> 1:42:03.479
<v Speaker 3>the charcot of hysteria as a neurological disorder, but then

1:42:03.640 --> 1:42:07.360
<v Speaker 3>changed his mind, turning it into a disease that was

1:42:07.760 --> 1:42:13.960
<v Speaker 3>entirely psychological, often attributed to the underdevelopment of libido or sexuality,

1:42:14.520 --> 1:42:19.000
<v Speaker 3>or the rejection of feminine values or feminine traits, cured

1:42:19.160 --> 1:42:25.200
<v Speaker 3>through talk therapy. What this did was turn real things

1:42:25.520 --> 1:42:31.920
<v Speaker 3>that women were experiencing, pain, fatigue, heavy or irregular periods, infertility,

1:42:32.000 --> 1:42:35.599
<v Speaker 3>even into something that she was doing with her mind.

1:42:36.360 --> 1:42:40.240
<v Speaker 3>It's all in your head. This probably sounds familiar to

1:42:40.600 --> 1:42:44.280
<v Speaker 3>many people listening today who have maybe been told something

1:42:44.360 --> 1:42:47.240
<v Speaker 3>similar by a doctor they thought they could trust. To listen,

1:42:48.320 --> 1:42:53.040
<v Speaker 3>because despite how this story is sometimes told, hysteria didn't

1:42:53.080 --> 1:42:57.360
<v Speaker 3>disappear after Freud. It may have fallen out of fashion

1:42:57.720 --> 1:43:00.880
<v Speaker 3>and lost credibility as a medical diet dignosis a bit.

1:43:01.479 --> 1:43:06.040
<v Speaker 3>But number one, it wasn't actually removed from the DSM,

1:43:06.280 --> 1:43:10.599
<v Speaker 3>the Diagnostic and Statistical Manual of Mental Disorders until nineteen

1:43:10.840 --> 1:43:17.400
<v Speaker 3>eighty and number two, it never really went away, but

1:43:17.560 --> 1:43:26.400
<v Speaker 3>was rather repackaged. Out of this umbrella term hysteria came endometriosis, MS,

1:43:26.960 --> 1:43:33.719
<v Speaker 3>chronic pelvic pain, many autoimmune diseases, samatitization, psychogenic illness, medically

1:43:33.840 --> 1:43:41.639
<v Speaker 3>unexplained symptoms, so many things. Freud's transformation of hysteria into

1:43:41.640 --> 1:43:46.639
<v Speaker 3>a psychological disorder turned women into unreliable sources on their

1:43:46.680 --> 1:43:50.360
<v Speaker 3>own body. Essentially, a woman is thought to be lying

1:43:50.479 --> 1:43:54.520
<v Speaker 3>about her symptoms unless there is observable proof to the contrary,

1:43:55.120 --> 1:43:59.000
<v Speaker 3>or her symptoms are real but psychogenic unless you can

1:43:59.040 --> 1:44:04.639
<v Speaker 3>prove otherwise. A gynecology textbook from nineteen seventy one said

1:44:04.680 --> 1:44:10.880
<v Speaker 3>that quote many women wittingly or unwittingly exaggerate the severity

1:44:10.920 --> 1:44:16.759
<v Speaker 3>of their complaints to gratify neurotic desires end quote, and

1:44:17.040 --> 1:44:23.360
<v Speaker 3>in the same textbook that morning sickness quote may indicate resentment, ambivalence,

1:44:23.560 --> 1:44:32.240
<v Speaker 3>and inadequacy in women ill prepared for motherhood. Ooh as

1:44:32.240 --> 1:44:34.280
<v Speaker 3>if you needed more things to get angry about.

1:44:34.160 --> 1:44:41.880
<v Speaker 1>Right, and I can't rage in front of the microphone.

1:44:42.080 --> 1:44:47.160
<v Speaker 3>It's it all explains so much about today and how

1:44:47.200 --> 1:44:53.880
<v Speaker 3>women are treated. Women began being seen as mentally ill

1:44:54.200 --> 1:44:58.320
<v Speaker 3>rather than physically sick, and throughout the twentieth century the

1:44:58.439 --> 1:45:03.439
<v Speaker 3>rate of psychogenic illness diagnoses increased enormously. If you were

1:45:03.479 --> 1:45:07.800
<v Speaker 3>experiencing pain and complained too little, you weren't taken seriously

1:45:07.880 --> 1:45:11.639
<v Speaker 3>because you weren't experiencing enough pain. But if you complain

1:45:11.760 --> 1:45:15.640
<v Speaker 3>too much, you were labeled as an exaggerator, as dramatic

1:45:15.680 --> 1:45:21.200
<v Speaker 3>as crazy. One proponent of psychogenic diagnoses says that quote

1:45:21.400 --> 1:45:25.080
<v Speaker 3>the vehemence with which many patients insist their illness is

1:45:25.200 --> 1:45:29.400
<v Speaker 3>medical rather than psychiatric, has become one of the hallmarks

1:45:29.560 --> 1:45:33.479
<v Speaker 3>of the conditions. So like, the more you say no,

1:45:33.800 --> 1:45:37.160
<v Speaker 3>this is a real pain, the more likely you are

1:45:37.200 --> 1:45:39.400
<v Speaker 3>to be diagnosed with the psychogenic illness.

1:45:40.000 --> 1:45:41.559
<v Speaker 1>Yeah, yeah, what.

1:45:43.560 --> 1:45:47.559
<v Speaker 3>There are scientific studies backing up these implicit gender biases

1:45:47.600 --> 1:45:51.479
<v Speaker 3>in medicine, and it's not just male doctors that are

1:45:51.520 --> 1:45:56.120
<v Speaker 3>mistreating women. Women on average are more likely to report

1:45:56.200 --> 1:45:59.280
<v Speaker 3>pain and less likely to receive pain treatment. And this

1:45:59.400 --> 1:46:01.240
<v Speaker 3>is not just a gendered issue, of course, but a

1:46:01.320 --> 1:46:04.800
<v Speaker 3>racial one as well, with people of color incredibly undertreated

1:46:04.800 --> 1:46:09.720
<v Speaker 3>for pain. One study showed that after undergoing a coronary

1:46:09.800 --> 1:46:11.200
<v Speaker 3>artery bypass graft.

1:46:11.560 --> 1:46:13.439
<v Speaker 1>Oh my gosh, I hate this study.

1:46:13.680 --> 1:46:18.519
<v Speaker 3>Uh huh, men were more likely to receive painkillers, while

1:46:18.560 --> 1:46:24.080
<v Speaker 3>women were more likely to receive sedatives. A study from

1:46:24.120 --> 1:46:27.040
<v Speaker 3>two thousand and six by Kiara Monte at All found

1:46:27.160 --> 1:46:30.320
<v Speaker 3>that when med students and residents were presented with the

1:46:30.360 --> 1:46:35.040
<v Speaker 3>description of a patient experiencing symptoms, they initially diagnosed these

1:46:35.080 --> 1:46:39.439
<v Speaker 3>patients similarly regardless if the patient was described as male

1:46:39.560 --> 1:46:44.400
<v Speaker 3>or female, but if a stressful life event was added

1:46:44.400 --> 1:46:49.280
<v Speaker 3>to the description quote. Only fifteen percent of medical students

1:46:49.360 --> 1:46:53.160
<v Speaker 3>or residents diagnosed heart disease in the woman, compared to

1:46:53.360 --> 1:46:56.960
<v Speaker 3>fifty six percent for the man, and only thirty percent

1:46:57.040 --> 1:47:00.120
<v Speaker 3>referred the woman to a cardiologist compared to sixty two

1:47:00.120 --> 1:47:05.440
<v Speaker 3>percent for the man that quotes from pain and prejudice.

1:47:05.520 --> 1:47:10.160
<v Speaker 3>The explanation given for the woman's symptoms turned from biological

1:47:10.280 --> 1:47:14.559
<v Speaker 3>to psychological, and there was no difference in the results

1:47:14.600 --> 1:47:19.280
<v Speaker 3>based on the gender of the doctors. It seems that

1:47:19.439 --> 1:47:22.719
<v Speaker 3>too often when physicians meet with the patient, they see

1:47:22.720 --> 1:47:25.920
<v Speaker 3>the diagnosis in the identity of the patient based on

1:47:26.000 --> 1:47:30.200
<v Speaker 3>implicit biases built into the medical training system. If you're

1:47:30.240 --> 1:47:33.360
<v Speaker 3>a woman, it's in your head or your uterus. If

1:47:33.360 --> 1:47:36.679
<v Speaker 3>you're a black person, you're drug seeking. If you're trans

1:47:36.760 --> 1:47:39.480
<v Speaker 3>and you're on hormone therapy, it's because of the hormones.

1:47:40.000 --> 1:47:41.920
<v Speaker 3>If you're fat, it's because you need to lose weight.

1:47:42.240 --> 1:47:45.400
<v Speaker 3>If you've ever been diagnosed with anxiety or depression, clearly

1:47:45.479 --> 1:47:48.800
<v Speaker 3>that's what's causing your pelvic pain or your chronic fatigue.

1:47:49.520 --> 1:47:53.760
<v Speaker 3>It's rarely that endometriosis could be a source of anxiety

1:47:53.800 --> 1:47:58.240
<v Speaker 3>or depression, right instead of depression causing your pelvic pain.

1:48:00.200 --> 1:48:05.360
<v Speaker 3>This anecdote paraphrased from doing harm. There was an eleven

1:48:05.400 --> 1:48:08.880
<v Speaker 3>year old girl who had severe abdominal pain and nausea.

1:48:09.080 --> 1:48:11.680
<v Speaker 3>She went to the er. The doctor told her it

1:48:11.760 --> 1:48:14.680
<v Speaker 3>was menstrual cramps, despite the fact that she had not

1:48:14.800 --> 1:48:19.000
<v Speaker 3>yet gotten her period. Ever, the pain didn't go away,

1:48:19.680 --> 1:48:22.519
<v Speaker 3>so the next day, in agony, she had to be

1:48:22.600 --> 1:48:25.559
<v Speaker 3>rushed back to the er, and at this point her mom,

1:48:25.600 --> 1:48:30.799
<v Speaker 3>who was a physician, demanded an ultrasound, and they found

1:48:30.880 --> 1:48:35.639
<v Speaker 3>the largest unruptured appendix that the surgeon had ever removed.

1:48:36.960 --> 1:48:39.760
<v Speaker 3>Would that have happened if it had been eleven year

1:48:39.760 --> 1:48:41.760
<v Speaker 3>old boy instead of an eleven year old girl?

1:48:42.600 --> 1:48:43.400
<v Speaker 1>No, probably not.

1:48:44.960 --> 1:48:47.519
<v Speaker 3>Did the doctor even ask have you ever had your

1:48:47.520 --> 1:48:50.920
<v Speaker 3>period before? Does this feel like period crabs?

1:48:51.120 --> 1:48:51.200
<v Speaker 1>Like?

1:48:52.120 --> 1:48:54.320
<v Speaker 3>Are period cramps so bad that you should go to

1:48:54.360 --> 1:48:54.720
<v Speaker 3>the er?

1:48:55.080 --> 1:48:56.439
<v Speaker 1>No? They shouldn't be.

1:48:56.880 --> 1:48:59.479
<v Speaker 3>Right, Like, if they are that bad and you're in

1:48:59.520 --> 1:49:02.080
<v Speaker 3>the er, if you're there for a good reason, you're

1:49:02.120 --> 1:49:04.479
<v Speaker 3>not just they're not just Oh well, you know, deal

1:49:04.520 --> 1:49:09.000
<v Speaker 3>with it. Take some mbuprofen and go home. And that's

1:49:09.240 --> 1:49:13.439
<v Speaker 3>with an observable, detectable condition right like you could look

1:49:13.560 --> 1:49:19.360
<v Speaker 3>to find the unruptured appendix. Women who seek medical care

1:49:19.479 --> 1:49:23.800
<v Speaker 3>for a condition that's not objectively observable or measurable or

1:49:23.840 --> 1:49:28.360
<v Speaker 3>easily measurable. And as you went into Aaron Boy, we

1:49:28.400 --> 1:49:33.840
<v Speaker 3>are inadequate at describing and measuring pain. I mean absolutely inadequate.

1:49:35.160 --> 1:49:38.519
<v Speaker 3>These women, these mystery women, are often a source of

1:49:38.560 --> 1:49:44.080
<v Speaker 3>frustration for physicians, and they're dismissively called malingerers, never wells

1:49:44.320 --> 1:49:49.519
<v Speaker 3>et cetera. Concern turns to resentment as nothing seems to

1:49:49.560 --> 1:49:52.880
<v Speaker 3>work and the answer to the problem seems forever out

1:49:52.880 --> 1:49:56.120
<v Speaker 3>of reach. I can't see anything wrong with you, so

1:49:56.280 --> 1:49:59.920
<v Speaker 3>there must not be anything wrong with you. A physician

1:50:00.200 --> 1:50:03.240
<v Speaker 3>sense of self worth shouldn't be tied up in having

1:50:03.280 --> 1:50:06.759
<v Speaker 3>an answer or the right answer. There's an incredible power

1:50:06.880 --> 1:50:10.559
<v Speaker 3>in empathy in saying I don't know, but let's find out.

1:50:11.640 --> 1:50:16.640
<v Speaker 3>So where does that all leave us with endometriosis. We

1:50:16.680 --> 1:50:19.120
<v Speaker 3>have come a long way since the early days of

1:50:19.240 --> 1:50:22.600
<v Speaker 3>hysteria and endometriosis, and the people who have made the

1:50:22.640 --> 1:50:28.040
<v Speaker 3>biggest strides in raising awareness of endometriosis are patient advocacy groups,

1:50:28.520 --> 1:50:31.799
<v Speaker 3>people who have had to become experts in a disease

1:50:31.880 --> 1:50:35.439
<v Speaker 3>that their own physicians often failed to communicate with them about.

1:50:36.200 --> 1:50:40.680
<v Speaker 3>But we haven't come nearly far enough. Stereotypes about endometriosis

1:50:40.720 --> 1:50:45.559
<v Speaker 3>have persisted long after being disproven, such as endometriosis is

1:50:45.720 --> 1:50:48.760
<v Speaker 3>rare in women of color or only happens to women

1:50:48.800 --> 1:50:53.280
<v Speaker 3>who put off marriage and childbearing. These stereotypes, combined with

1:50:53.320 --> 1:50:57.799
<v Speaker 3>the outrageous lack of knowledge about how endometriosis actually works,

1:50:58.160 --> 1:51:01.920
<v Speaker 3>and the tendency for physicians to dismiss or downplay the

1:51:01.960 --> 1:51:05.320
<v Speaker 3>pain experienced by women, these all contribute to the long,

1:51:05.800 --> 1:51:11.080
<v Speaker 3>often excruciating years people have to wait for a diagnosis,

1:51:11.120 --> 1:51:15.920
<v Speaker 3>and still endometriosis is too often made to be about

1:51:15.960 --> 1:51:21.919
<v Speaker 3>a woman's social or gender role. Endometriosis can absolutely impact

1:51:21.960 --> 1:51:25.400
<v Speaker 3>a person's fertility, and for someone who wants or thinks

1:51:25.439 --> 1:51:29.400
<v Speaker 3>they might want to have children, that's hugely important. But

1:51:29.520 --> 1:51:33.840
<v Speaker 3>often fertility is preserved as a default without asking the

1:51:33.880 --> 1:51:38.000
<v Speaker 3>patient whether or not subfertility or infertility would be acceptable

1:51:38.080 --> 1:51:42.040
<v Speaker 3>if it meant reducing the pain. Yea and A two

1:51:42.120 --> 1:51:45.280
<v Speaker 3>thousand and three study found that women who sought out

1:51:45.320 --> 1:51:49.920
<v Speaker 3>doctors because of infertility received a diagnosis of endometriosis in

1:51:50.160 --> 1:51:53.880
<v Speaker 3>half the time that women complaining of menstrual pain did.

1:51:54.560 --> 1:52:01.120
<v Speaker 1>It's not surprising and infuriating, exactly like infertility matters. But

1:52:01.200 --> 1:52:04.000
<v Speaker 1>it shouldn't have to cause infertility to matter.

1:52:04.640 --> 1:52:07.200
<v Speaker 3>Yes, that's exactly frustrating.

1:52:07.320 --> 1:52:07.559
<v Speaker 1>Yeah.

1:52:07.720 --> 1:52:12.120
<v Speaker 3>Yeah, And I think a large part of this is

1:52:12.439 --> 1:52:16.080
<v Speaker 3>due to the fact that menstrual pain is so normalized,

1:52:16.160 --> 1:52:19.559
<v Speaker 3>it's so accepted, and it's reinforced intergenerationally.

1:52:19.960 --> 1:52:20.839
<v Speaker 1>Yep, totally.

1:52:21.160 --> 1:52:25.240
<v Speaker 3>It's not viewed as interesting or worthy of research, despite

1:52:25.280 --> 1:52:29.880
<v Speaker 3>being described for over one hundred years and affecting approximately

1:52:29.920 --> 1:52:34.000
<v Speaker 3>the same number of women as diabetes. En demitriosis gets

1:52:34.040 --> 1:52:37.960
<v Speaker 3>about five percent of the research funds that diabetes gets.

1:52:38.280 --> 1:52:42.920
<v Speaker 1>I almost use diabetes as my expoint. What did you use,

1:52:43.240 --> 1:52:46.160
<v Speaker 1>I'm going with breast cancer. Oh, okay, it's not too far.

1:52:46.280 --> 1:52:53.080
<v Speaker 3>I'm curious. Yeah, but periods aren't fit for polite conversation.

1:52:53.600 --> 1:52:56.720
<v Speaker 3>There's simply the price of being a woman, right, No,

1:52:57.400 --> 1:53:01.120
<v Speaker 3>not true. Periods shouldn't be painful. People don't even need

1:53:01.160 --> 1:53:03.639
<v Speaker 3>to have periods, and if there is pain, it should

1:53:03.640 --> 1:53:07.960
<v Speaker 3>be believed and understood. Let's talk more about periods. Let's

1:53:07.960 --> 1:53:10.479
<v Speaker 3>talk about consistency. Let's talk about the number of times

1:53:10.560 --> 1:53:12.800
<v Speaker 3>you have to empty your diva cup or change your

1:53:12.840 --> 1:53:15.719
<v Speaker 3>pad or change your tampon. What brands do like the best?

1:53:16.240 --> 1:53:18.599
<v Speaker 3>Are there any things that you do that you help

1:53:18.640 --> 1:53:21.240
<v Speaker 3>your period and make you feel better? Like all these

1:53:21.280 --> 1:53:23.000
<v Speaker 3>things so important?

1:53:23.960 --> 1:53:27.040
<v Speaker 1>Ah? Okay ye say it, Aaron.

1:53:28.240 --> 1:53:31.879
<v Speaker 3>I want to end, finally, after this very long history,

1:53:32.479 --> 1:53:37.639
<v Speaker 3>with a quote from of course again Maya Dusonberry from

1:53:37.680 --> 1:53:42.719
<v Speaker 3>her book Doing Harm. Quote. There is always a gap

1:53:42.840 --> 1:53:46.920
<v Speaker 3>between when a symptom begins and when it is medically explained.

1:53:47.920 --> 1:53:51.320
<v Speaker 3>It is unreasonable to expect that doctors, who are fallible

1:53:51.400 --> 1:53:55.760
<v Speaker 3>human beings doing a difficult job can close this gap instantaneously,

1:53:56.640 --> 1:54:00.760
<v Speaker 3>And given that medical knowledge is and probably always will

1:54:00.800 --> 1:54:04.479
<v Speaker 3>be incomplete, they may at times not be able to

1:54:04.520 --> 1:54:08.000
<v Speaker 3>close it at all. But it shouldn't be unreasonable to

1:54:08.120 --> 1:54:12.000
<v Speaker 3>expect that during this period of uncertainty, the benefit of

1:54:12.040 --> 1:54:15.280
<v Speaker 3>the doubt be given to the patient. The default assumption

1:54:15.760 --> 1:54:18.880
<v Speaker 3>be that their symptoms are real, their description of what

1:54:18.920 --> 1:54:22.320
<v Speaker 3>they are feeling in their own bodies be believed, and

1:54:22.400 --> 1:54:26.800
<v Speaker 3>if it is medically unexplained, the burden be on medicine

1:54:26.920 --> 1:54:30.400
<v Speaker 3>to explain it. Such basic trust has been denied to

1:54:30.479 --> 1:54:37.360
<v Speaker 3>women for far too long end quote. So erin, I

1:54:37.440 --> 1:54:42.600
<v Speaker 3>have a feeling I might just get angrier. But can

1:54:42.640 --> 1:54:45.200
<v Speaker 3>you tell me where we stand with endometrios's today?

1:54:48.160 --> 1:54:51.760
<v Speaker 1>I can try Aaron, Okay, maybe we should take a

1:54:51.760 --> 1:55:22.440
<v Speaker 1>break first, well last break break. Almost every single paper

1:55:22.440 --> 1:55:24.680
<v Speaker 1>that I read, and I read a lot of papers,

1:55:26.000 --> 1:55:31.880
<v Speaker 1>universally cited the statistic that ten percent of women of

1:55:32.080 --> 1:55:39.480
<v Speaker 1>child bearing age have endometriosis. And that's it. That's that's it.

1:55:39.600 --> 1:55:40.960
<v Speaker 1>That's the number that I have.

1:55:41.080 --> 1:55:49.560
<v Speaker 3>Ar Okay, it's and these numbers, like where are these

1:55:49.600 --> 1:55:52.520
<v Speaker 3>papers from? And so would those diagnoses have been based

1:55:52.560 --> 1:55:54.240
<v Speaker 3>on surgical.

1:55:56.320 --> 1:56:00.800
<v Speaker 1>Or yeah. I basically only looked at papers from twenty

1:56:00.960 --> 1:56:05.240
<v Speaker 1>ten and sooner, so like within the last ten years, okay,

1:56:05.400 --> 1:56:08.400
<v Speaker 1>and universally that is what they all said. I have

1:56:08.560 --> 1:56:13.480
<v Speaker 1>found no papers that tried to dig deeper and really

1:56:13.480 --> 1:56:16.320
<v Speaker 1>get a sense of like are these numbers changing? Are

1:56:16.320 --> 1:56:23.120
<v Speaker 1>we seeing it more? Et cetera like, And what's really

1:56:23.160 --> 1:56:29.360
<v Speaker 1>frustrating is that none of the papers dug down into

1:56:29.400 --> 1:56:33.080
<v Speaker 1>like what what does that actually mean? Because people who

1:56:33.120 --> 1:56:37.760
<v Speaker 1>are not child bearing age can have endometriosis. Lots of

1:56:37.800 --> 1:56:41.880
<v Speaker 1>people with the uterus that aren't women of child bearing

1:56:41.920 --> 1:56:47.120
<v Speaker 1>age can have endometriosis. And so does that ten percent

1:56:47.200 --> 1:56:50.400
<v Speaker 1>actually mean like ten percent of people with a uterus

1:56:50.840 --> 1:56:56.320
<v Speaker 1>have endometriosis? Or is that number higher because people with

1:56:56.480 --> 1:56:59.760
<v Speaker 1>the uterus maybe had entometriosis when they were younger, and

1:56:59.800 --> 1:57:03.560
<v Speaker 1>now they're older, the symptoms have gone away, but those

1:57:03.600 --> 1:57:07.240
<v Speaker 1>people still count, right, So I don't have an answer

1:57:07.240 --> 1:57:07.720
<v Speaker 1>for you.

1:57:07.680 --> 1:57:10.560
<v Speaker 3>Right, Or what about people who have endometriolesians and might

1:57:10.600 --> 1:57:13.680
<v Speaker 3>not have symptoms that have led them to go seek

1:57:14.000 --> 1:57:14.920
<v Speaker 3>a diagnosis?

1:57:15.040 --> 1:57:17.400
<v Speaker 1>Right? And that's what's so infuriating is that this ten

1:57:17.440 --> 1:57:22.520
<v Speaker 1>percent number assumes that it includes those people. Yeah, and

1:57:22.560 --> 1:57:25.360
<v Speaker 1>so it says that like thirty to fifty percent of

1:57:25.400 --> 1:57:30.880
<v Speaker 1>those ten percent will then have pain from this endometrisis, which, like,

1:57:32.040 --> 1:57:33.240
<v Speaker 1>give me strength.

1:57:32.960 --> 1:57:34.360
<v Speaker 3>I doubt no.

1:57:35.960 --> 1:57:42.280
<v Speaker 1>But statistics also cite that upwards of sixty percent of women,

1:57:42.560 --> 1:57:46.000
<v Speaker 1>by which I assume what they mean is sixty percent

1:57:46.040 --> 1:57:50.800
<v Speaker 1>of people with a uterus that suffer from chronic pelvic

1:57:50.840 --> 1:57:54.640
<v Speaker 1>pain have endometriosis as the likely cause of this pain.

1:57:57.160 --> 1:58:00.720
<v Speaker 1>And those statistics, both of them, no matter how they are,

1:58:01.480 --> 1:58:07.440
<v Speaker 1>are incredibly high, I mean, staggering ten percent. Even if

1:58:07.480 --> 1:58:10.480
<v Speaker 1>we assume that ten percent of people with the uterus

1:58:10.560 --> 1:58:14.240
<v Speaker 1>is the real number ten percent of people with uterus. Okay,

1:58:14.560 --> 1:58:19.800
<v Speaker 1>let's compare that, Aaron, you mentioned diabetes. Almost used that.

1:58:20.400 --> 1:58:25.880
<v Speaker 1>But let's talk about breast cancer, shall we. Thirteen percent

1:58:25.920 --> 1:58:30.760
<v Speaker 1>of women in the US will develop breast cancer. Thirteen percent.

1:58:31.240 --> 1:58:34.560
<v Speaker 1>That's really close to ten percent. We have a whole

1:58:34.840 --> 1:58:38.520
<v Speaker 1>month dedicated to breast cancer, don't we.

1:58:38.520 --> 1:58:40.520
<v Speaker 3>We have one for endometriosis too.

1:58:40.760 --> 1:58:42.160
<v Speaker 1>Oh really, but no one's heard of it.

1:58:42.600 --> 1:58:44.400
<v Speaker 3>Yeah, that's fair.

1:58:45.800 --> 1:58:49.960
<v Speaker 1>But everybody knows about breast cancer. Everybody knows how important

1:58:49.960 --> 1:58:53.760
<v Speaker 1>breast cancer is. Everybody knows somebody who has survived breast cancer,

1:58:53.880 --> 1:58:58.560
<v Speaker 1>or everyone has lost someone from breast cancer, right, and

1:58:58.760 --> 1:59:04.440
<v Speaker 1>so many people have no idea what endometriosis is, let

1:59:04.480 --> 1:59:08.720
<v Speaker 1>alone care enough to I don't know, like encourage funding

1:59:08.720 --> 1:59:13.080
<v Speaker 1>of research for it. Uh huh. And I think I

1:59:13.160 --> 1:59:17.720
<v Speaker 1>think this is now my soapbox. This is for a

1:59:17.720 --> 1:59:22.040
<v Speaker 1>lot of reasons that Aaron, you really kind of focused

1:59:22.080 --> 1:59:24.320
<v Speaker 1>on so many of them, and if we really drill

1:59:24.400 --> 1:59:27.080
<v Speaker 1>down to it, like it comes back to the patriarchy,

1:59:27.320 --> 1:59:31.520
<v Speaker 1>as it always does, but at its core, it also

1:59:31.720 --> 1:59:37.200
<v Speaker 1>is because I think endometriosis is classified in all of

1:59:37.240 --> 1:59:43.560
<v Speaker 1>the literature as a quote benign condition. What So, endometriosis

1:59:43.680 --> 1:59:47.080
<v Speaker 1>is classified as a quote benign condition.

1:59:46.920 --> 1:59:48.840
<v Speaker 3>And so by this means it doesn't kill you.

1:59:49.240 --> 1:59:53.080
<v Speaker 1>So what this is in contrast to is a malignant

1:59:53.320 --> 1:59:57.880
<v Speaker 1>condition such as cancer, And what that means is yes,

1:59:58.120 --> 2:00:01.880
<v Speaker 1>in general, a benign condition is not going to kill

2:00:01.920 --> 2:00:07.520
<v Speaker 1>you if left untreated, at least not directly. Cancers which

2:00:07.560 --> 2:00:12.960
<v Speaker 1>are malignant, invade and metastasized. That is, they spread in

2:00:13.000 --> 2:00:17.000
<v Speaker 1>a way that, if left untreated, is often fatal. Now

2:00:17.320 --> 2:00:23.920
<v Speaker 1>I can see your face. Erin. Endometriosis is really really

2:00:24.000 --> 2:00:28.800
<v Speaker 1>interesting because it in fact does metastasize. It can metastasize

2:00:28.840 --> 2:00:31.320
<v Speaker 1>in a way right. It can be found well outside

2:00:31.320 --> 2:00:35.520
<v Speaker 1>the peritoneal cavity, and by definition it is tissue found

2:00:35.600 --> 2:00:38.800
<v Speaker 1>outside where it's supposed to be. And in the case

2:00:38.880 --> 2:00:44.000
<v Speaker 1>of deeply infiltrating endometriosis, it does invade deeper tissues in

2:00:44.040 --> 2:00:49.520
<v Speaker 1>the same way that cancer can. But endometriosis causes pain,

2:00:50.240 --> 2:00:55.400
<v Speaker 1>causes suffering, causes infertility, and that, my friends, is seen

2:00:55.440 --> 2:01:01.960
<v Speaker 1>as benign. It can in made your bowels and cause obstruction,

2:01:02.480 --> 2:01:06.120
<v Speaker 1>but it usually doesn't. That's uncommon. It can invade your

2:01:06.160 --> 2:01:09.280
<v Speaker 1>bladder or your urroters and cause obstruction. It can cause

2:01:09.320 --> 2:01:13.880
<v Speaker 1>destruction of your urrotors, but it doesn't often. And because

2:01:13.880 --> 2:01:20.240
<v Speaker 1>it's a histologically recognizable tissue type, and because it generally

2:01:20.400 --> 2:01:24.200
<v Speaker 1>quote unquote doesn't invade to the extent that a cancer would,

2:01:24.960 --> 2:01:30.400
<v Speaker 1>and because it generally subsides after menopause, after the withdrawal

2:01:30.480 --> 2:01:37.720
<v Speaker 1>of those hormones, it is quote benign. Okay, it's clearly

2:01:37.760 --> 2:01:38.280
<v Speaker 1>nothing of the.

2:01:38.240 --> 2:01:45.840
<v Speaker 3>Sort, obviously, So in non medical language, benign is like

2:01:46.600 --> 2:01:50.400
<v Speaker 3>not harmful, not bad. So is there a different interpretation

2:01:50.560 --> 2:01:52.040
<v Speaker 3>in metal? I'm just trying to give that a little

2:01:52.080 --> 2:01:53.600
<v Speaker 3>bit of the benefit of the doubt, because this is

2:01:53.640 --> 2:01:55.920
<v Speaker 3>so staggeringly appalling.

2:01:56.080 --> 2:02:00.200
<v Speaker 1>It is it does mean in the medical sense that

2:02:00.280 --> 2:02:02.040
<v Speaker 1>it is not a malignant condition.

2:02:02.480 --> 2:02:05.640
<v Speaker 3>But I mean, does the use of the word benign

2:02:05.840 --> 2:02:10.880
<v Speaker 3>in medicine then influence people who are practicing medicine to

2:02:11.120 --> 2:02:15.600
<v Speaker 3>view a condition as benign as in the popular interpretation

2:02:15.680 --> 2:02:16.160
<v Speaker 3>of the term.

2:02:16.600 --> 2:02:20.360
<v Speaker 1>In my opinion, how can it not. Yeah, when we're

2:02:20.400 --> 2:02:24.440
<v Speaker 1>talking about pain, and we've talked so much about how

2:02:24.720 --> 2:02:31.720
<v Speaker 1>difficult pain is to understand, to explain to, and to

2:02:31.840 --> 2:02:36.880
<v Speaker 1>sympathize with and to empathize with. If your pain perception

2:02:37.080 --> 2:02:41.880
<v Speaker 1>is different than someone else's pain perception or pain sensitization. Right.

2:02:42.560 --> 2:02:45.640
<v Speaker 1>I also do want to point out that the risk

2:02:45.800 --> 2:02:51.200
<v Speaker 1>of eventual ovarian cancer diagnosis, so cancer the malignant condition,

2:02:52.400 --> 2:02:56.040
<v Speaker 1>in people with long standing endometriosis, is two to threefold

2:02:56.160 --> 2:03:02.800
<v Speaker 1>higher than in people without endometriosis. So even though endometriosis

2:03:02.840 --> 2:03:08.600
<v Speaker 1>itself is not a cancerous condition, it's not without its risks. Yeah, right,

2:03:08.880 --> 2:03:13.440
<v Speaker 1>I mean, so far as that goes ah, isn't that

2:03:14.200 --> 2:03:14.840
<v Speaker 1>just fascinating?

2:03:14.840 --> 2:03:15.080
<v Speaker 3>Though?

2:03:15.120 --> 2:03:21.520
<v Speaker 1>So I found that to be a very sort of problematic.

2:03:23.240 --> 2:03:25.880
<v Speaker 1>What I think is likely a big contributor to why

2:03:26.080 --> 2:03:31.440
<v Speaker 1>endometriosis kind of has maybe the rap that it has, right,

2:03:32.040 --> 2:03:36.240
<v Speaker 1>just this classification of it with and it's medically I

2:03:36.280 --> 2:03:38.560
<v Speaker 1>actually found one paper that was kind of like, is

2:03:38.600 --> 2:03:42.160
<v Speaker 1>it correct to call it a benign or is it

2:03:42.240 --> 2:03:45.920
<v Speaker 1>not in terms of the medical definition of the term benign? Okay,

2:03:46.200 --> 2:03:52.000
<v Speaker 1>because it does behave in ways that benign tissue doesn't,

2:03:52.360 --> 2:03:54.760
<v Speaker 1>and yet it doesn't behave the way that a cancer does,

2:03:56.000 --> 2:03:58.720
<v Speaker 1>and it doesn't fit the definition of a cancer. There

2:03:58.840 --> 2:04:03.760
<v Speaker 1>have been a number of new mutations identified in endometrial

2:04:03.800 --> 2:04:08.480
<v Speaker 1>tissue that are associated with cancer, but never enough of them,

2:04:08.720 --> 2:04:12.800
<v Speaker 1>like only one mutation instead of three mutations that would

2:04:12.800 --> 2:04:17.280
<v Speaker 1>then cause it to be a cancer. So it is

2:04:17.320 --> 2:04:20.880
<v Speaker 1>not a cancer, and it does not metastasize the way

2:04:20.880 --> 2:04:25.680
<v Speaker 1>that a cancer does. But it's not normal tissue either.

2:04:26.920 --> 2:04:30.760
<v Speaker 1>So it's an interesting disease in that respect, and we

2:04:30.920 --> 2:04:35.520
<v Speaker 1>have a long way to go to understanding it. I

2:04:35.600 --> 2:04:37.760
<v Speaker 1>was thinking this and feeling this, and then I went

2:04:37.800 --> 2:04:40.320
<v Speaker 1>for a walk today and I was listening to an

2:04:40.320 --> 2:04:45.240
<v Speaker 1>episode of Vox's podcast Unexplainable, and they have an episode

2:04:45.280 --> 2:04:49.800
<v Speaker 1>on endometriosis. It's really great. It has stories from like

2:04:49.920 --> 2:04:54.440
<v Speaker 1>fourteen people who have been living with endometriosis. I recommend

2:04:54.480 --> 2:04:58.560
<v Speaker 1>the listen. But they also had an interview with someone

2:04:58.640 --> 2:05:04.000
<v Speaker 1>who researches endometri it's doctor Lisa Griffiths. She is at

2:05:04.080 --> 2:05:08.160
<v Speaker 1>MIT and runs the Center for Gynopathology Research. Her research

2:05:08.240 --> 2:05:12.920
<v Speaker 1>is super fascinating. Its focuses on tissue engineering, like growing

2:05:13.000 --> 2:05:16.920
<v Speaker 1>endometrial tissue on like chips, and they're trying to develop

2:05:16.960 --> 2:05:21.120
<v Speaker 1>better diagnostic markers that can be used to not only diagnose,

2:05:21.200 --> 2:05:26.600
<v Speaker 1>but then also classify endometriosis into different subtypes, which could

2:05:26.600 --> 2:05:31.080
<v Speaker 1>then theoretically lead to more personalized or targeted treatment options,

2:05:31.320 --> 2:05:35.800
<v Speaker 1>which is amazing. But she also brought up this exact

2:05:36.000 --> 2:05:39.880
<v Speaker 1>same thing that like, the language that we use surrounding

2:05:40.000 --> 2:05:43.560
<v Speaker 1>endometriosis is so important, and she was saying that, like

2:05:43.720 --> 2:05:47.040
<v Speaker 1>her collaborators kept calling it a benign condition, benign condition,

2:05:47.120 --> 2:05:50.480
<v Speaker 1>and she was like, I live with this, she has endometriosis.

2:05:50.800 --> 2:05:54.720
<v Speaker 1>She's like, there's nothing benign about it. Yeah, right, But

2:05:54.760 --> 2:06:00.600
<v Speaker 1>it's that difference between quote medical language and colloquial language, right.

2:06:00.640 --> 2:06:03.960
<v Speaker 1>But it matters, right, and it influences we are all humans,

2:06:04.040 --> 2:06:07.120
<v Speaker 1>even in the medical community. It influences the way that

2:06:07.200 --> 2:06:09.960
<v Speaker 1>we perceive it and then the way that we treat

2:06:10.000 --> 2:06:14.160
<v Speaker 1>people who are living with it. There are a lot

2:06:14.160 --> 2:06:18.080
<v Speaker 1>of people doing research on endometriosis from so many different

2:06:18.120 --> 2:06:22.120
<v Speaker 1>angles because there's so much that we don't know. So

2:06:22.160 --> 2:06:25.240
<v Speaker 1>I already mentioned some fascinating research by the Center for

2:06:25.320 --> 2:06:29.600
<v Speaker 1>Gynopathology Research. There's also other groups like Citizen Endo, which

2:06:29.640 --> 2:06:34.400
<v Speaker 1>is led by doctor Noemi Elhadad at Columbia University and

2:06:34.520 --> 2:06:39.400
<v Speaker 1>their team. Super fascinating are using like citizen science y

2:06:39.640 --> 2:06:43.400
<v Speaker 1>based tools to try and better characterize the symptoms of

2:06:43.560 --> 2:06:48.400
<v Speaker 1>endometriosis to try and bridge the gaps between what clinicians

2:06:48.520 --> 2:06:52.480
<v Speaker 1>know or think they know or think about endometriosis and

2:06:52.600 --> 2:06:56.720
<v Speaker 1>how people who are living with it actually experience endometriosis,

2:06:56.800 --> 2:06:58.360
<v Speaker 1>which I love so much.

2:06:58.400 --> 2:07:00.640
<v Speaker 3>I know, I love I love that so much.

2:07:00.640 --> 2:07:04.920
<v Speaker 1>It's so cool, I think, honestly, in so many ways,

2:07:04.960 --> 2:07:08.080
<v Speaker 1>we're still at the phase. I think we've talked about

2:07:08.120 --> 2:07:11.200
<v Speaker 1>this in a number of different episodes, arin but we're

2:07:11.200 --> 2:07:13.480
<v Speaker 1>at the phase in endometriosis right now where we still

2:07:13.520 --> 2:07:17.920
<v Speaker 1>are trying to just like Garner awareness about this condition. Yeah,

2:07:18.600 --> 2:07:22.800
<v Speaker 1>you know, so I have a feeling after this episode

2:07:23.160 --> 2:07:24.880
<v Speaker 1>maybe a lot of our listeners are going to be

2:07:25.320 --> 2:07:28.400
<v Speaker 1>going to their doctor's offices, like, so, can I ask

2:07:28.440 --> 2:07:29.960
<v Speaker 1>you about endometriosis?

2:07:30.040 --> 2:07:33.480
<v Speaker 3>So I shouldn't be laying in bed all day and

2:07:33.560 --> 2:07:35.720
<v Speaker 3>not able to go to work because of my period?

2:07:36.000 --> 2:07:38.480
<v Speaker 1>Yeah, I mean I didn't even get into like the

2:07:38.520 --> 2:07:42.080
<v Speaker 1>statistics on the number of missed school days, the number

2:07:42.120 --> 2:07:46.120
<v Speaker 1>of missed work days, like the economic and financial is

2:07:46.360 --> 2:07:52.080
<v Speaker 1>in the billions of dollars every year. Yeah, so that

2:07:53.120 --> 2:07:55.800
<v Speaker 1>is endometriosis there, it is.

2:07:57.640 --> 2:07:58.240
<v Speaker 3>Sources.

2:07:58.400 --> 2:08:01.440
<v Speaker 1>Sources.

2:08:01.520 --> 2:08:04.880
<v Speaker 3>I mentioned. I have some papers, but I mentioned the

2:08:04.920 --> 2:08:07.720
<v Speaker 3>four books that I read all great, love them, And

2:08:07.800 --> 2:08:10.560
<v Speaker 3>if you do want to know more about like the

2:08:10.640 --> 2:08:14.080
<v Speaker 3>medical history of endometriosis, who found it, who made this

2:08:14.160 --> 2:08:16.640
<v Speaker 3>development and that development sort of the argument over who

2:08:16.720 --> 2:08:19.280
<v Speaker 3>was the first one to describe it. There is a

2:08:19.640 --> 2:08:23.160
<v Speaker 3>very extensive I'm talking like fifth over fifty pages paper

2:08:23.280 --> 2:08:25.840
<v Speaker 3>by Neshat at All from twenty twelve that goes into

2:08:25.920 --> 2:08:29.480
<v Speaker 3>all of that found that very interesting and in terms

2:08:29.480 --> 2:08:33.280
<v Speaker 3>of the evolutionary biology. Those papers that I mentioned are

2:08:33.280 --> 2:08:37.000
<v Speaker 3>both by Dinsdale at All from twenty twenty one.

2:08:37.200 --> 2:08:40.680
<v Speaker 1>I had a number of papers I already said the

2:08:40.720 --> 2:08:45.400
<v Speaker 1>title of one the epidemiology of Endometriosis is poorly understood,

2:08:45.800 --> 2:08:50.040
<v Speaker 1>No is poorly known as the pathophysiology and diagnosis are unclear.

2:08:50.400 --> 2:08:53.480
<v Speaker 1>That was from Best Practice and Research Clinical of Stetrics

2:08:53.520 --> 2:08:56.760
<v Speaker 1>and Gynecology from twenty twenty one. There was a number

2:08:56.800 --> 2:09:00.200
<v Speaker 1>of other really interesting papers that dig deeper into what

2:09:00.280 --> 2:09:04.160
<v Speaker 1>we know about the mechanisms of endometriosis. I think my

2:09:04.320 --> 2:09:09.720
<v Speaker 1>favorite one was from Nature Reviews Enderchronology in twenty nineteen,

2:09:09.920 --> 2:09:12.680
<v Speaker 1>as well as another one in the Annual Review of

2:09:12.720 --> 2:09:17.080
<v Speaker 1>Pathology Mechanisms of Disease from twenty twenty. We'll post all

2:09:17.160 --> 2:09:20.640
<v Speaker 1>of these sources from this episode and every one of

2:09:20.640 --> 2:09:25.400
<v Speaker 1>our now eighty eight episodes.

2:09:25.200 --> 2:09:27.120
<v Speaker 3>Eighty eight normal season episode.

2:09:26.840 --> 2:09:30.520
<v Speaker 1>Right not including COVID on our website, this podcast will

2:09:30.600 --> 2:09:31.400
<v Speaker 1>kill you dot com.

2:09:31.680 --> 2:09:35.840
<v Speaker 3>We will ye. Thank you again so much, Susie for

2:09:35.920 --> 2:09:38.600
<v Speaker 3>sharing your story with us. I love chatting with you,

2:09:38.880 --> 2:09:41.280
<v Speaker 3>and yeah, we just really appreciate it.

2:09:41.400 --> 2:09:44.640
<v Speaker 1>Yeah, thank you. Thank you also to Blowdmobile for providing

2:09:44.680 --> 2:09:47.840
<v Speaker 1>the music for this episode and all of our one

2:09:47.960 --> 2:09:50.360
<v Speaker 1>hundred plus episodes.

2:09:51.120 --> 2:09:54.240
<v Speaker 3>Thank you to exactly Right Media. We are so proud

2:09:54.280 --> 2:09:55.480
<v Speaker 3>to be a part of this stut work.

2:09:56.200 --> 2:09:59.160
<v Speaker 1>And thank you to you listeners. We make this podcast

2:09:59.200 --> 2:10:03.040
<v Speaker 1>for you, and thanks for sticking through this really long episode.

2:10:03.040 --> 2:10:04.240
<v Speaker 1>I hope you learned something new.

2:10:04.760 --> 2:10:08.080
<v Speaker 3>I hope so too. And a special thank you also

2:10:08.280 --> 2:10:13.480
<v Speaker 3>to our wonderful, incredible, beautiful patrons on Patreon.

2:10:13.160 --> 2:10:14.800
<v Speaker 1>On Patreon, love you so much.

2:10:16.040 --> 2:10:20.000
<v Speaker 3>Well, until next time, wash your hands

2:10:20.160 --> 2:10:21.200
<v Speaker 1>You feelthy animals