July 17, 2024 • 47 mins
Send us a text with a question or thought on this episode
Ever wondered how a childhood dream of becoming a veterinarian could evolve into a distinguished career in urogynecology? This week, we welcome Dr. Cindy Mosbrucker, a leading expert in minimally invasive excision of endometriosis. Her journey is nothing short of extraordinary—from hands-on experiences to impactful mentorships, and even a pivotal training encounter with the renowned Dr. David Redwine. Dr. Mosbrucker’s story is a testament to the power of perseverance and passion in transforming the landscape of women's health.
We also delve into the groundbreaking work of Dr. David Redwine, a pioneer in excision surgery for endometriosis. Despite facing fierce criticism, Dr. Redwine's innovative approach and dedication to patient outcomes have revolutionized our understanding of the condition. His humor and humanity shine through, making his contributions not just scientifically significant but also deeply personal and humane. This episode highlights the emotional and professional challenges specialists face and underscores the importance of better patient education and collaboration within the medical community.
Our discussion extends to the complexities of training and identifying skilled endometriosis surgeons. We explore the limitations of MIGS fellowships and the critical need for specialized education and experience in endometriosis care. Additionally, we touch on the slow but promising advancements in endometriosis research, focusing on genetics and immunotherapy. The episode is a comprehensive look at the multifaceted journey of improving patient care, from surgical expertise to addressing the psychological aspects of chronic pain. Join us for an insightful conversation that promises to inform, challenge, and inspire.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:03):
Welcome to EndoBattery, where I share about
my endometriosis andadenomyosis story and continue
learning along the way.
This podcast is not asubstitute for professional
medical advice or diagnosis, buta place to equip you with
information and a sense ofcommunity, ensuring you never
have to face this journey alone.
Join me as I navigate the upsand downs and share stories of
(00:23):
strength, resilience and hope.
While navigating the world ofendometriosis and adenomyosis,
from personal experience toexpert insights, I'm your host,
alana, and this is EndoBatterycharging our lives when
endometriosis drains us.
Welcome back to EndoBattery,grab your cup of coffee or your
(00:44):
cup of tea and join me at thetable.
I'm joined by my guest, dr CindyMosbreker, who is a nationally
recognized expert in minimallyinvasive excision of
endometriosis and the diagnosisand treatment of pelvic pain in
women.
She completed her medicaldegree at Northwestern
University and honed her skillsin OBGYN during her residency at
the National Naval MedicalCenter.
(01:05):
Following her Navy service, shespecialized in GYN and
urogynecology surgery in Hawaii,before training under the
renowned Dr David Redwine.
Now based in Gig Harbor,washington, Dr Mossbrecher runs
a private practice focusing onpelvic pain, endometriosis and
incontinence, advocating for amultidisciplinary approach to
patient care.
Certified in female pelvicmedicine and reconstructive
(01:28):
surgery.
She is dedicated to improvingher patient's quality of life
through a collaborative andcomprehensive treatment plan.
Please help me in welcoming DrCindy Mosbricker.
Thank you, dr Mosbricker, forjoining me today and taking your
time out of your busy scheduleand allowing us to be part of
your information resource list,and that your history and
everything else.
Thank you for joining me.
Speaker 2 (01:50):
You're very welcome, and it's my pleasure.
Speaker 1 (01:52):
Thank you.
Can we start because you have ahistory that no one else does.
Your history career as far assurgery and medical career is
very different than anyone Iknow, which is true to most
people, but you have a specialhistory.
Can you explain what inspiredyou to pursue your career in
urogynecology as well asspecialize in endometriosis?
(02:14):
Well, it's a long story.
Speaker 2 (02:18):
When I was 15, I decided I want to be a
veterinarian.
Because I worked at a ranch forsummers and the vet would come
out and take care of the animalsthat got hurt.
And the vet would come out likeonce a week and he'd need
somebody to do the dressing,changes and whatever.
And so I would volunteer andI'll do it.
(02:39):
So, anyways, I came home thatsummer and I told my dad that I
figured out what I wanted to dowhen I grew up and I wanted to
be a veterinarian.
And he's like why don't you bea people doctor?
I'm like well, you got to besmart for that.
And he's like well, you got tobe smart to be a veterinarian
too.
So my neighbor was an internalmedicine doc and his best friend
(03:00):
was an orthopod.
And so I started spending timewith those guys and decided,
yeah, I kind of like orthopedics.
I was into sports when I wasyounger and sports medicine was
really interesting to me.
And so I went to med schoolthinking that I was going to do
orthopedics.
And then I did my surgeryrotation and loved the finesse
(03:23):
of belly surgery, being in theabdomen and doing bowel surgery
and all that kind of stuff.
And then I went to do my orthorotation and it was like this is
sterile carpentry.
It was just so unfinessed andhammer and chisel and stuff like
that.
And so I had a hard time in medschool deciding between general
(03:45):
surgery, urology and gynecologyand the general surgeons were
on call every other night and Iknew my body couldn't handle
that and so it came down tourology and GYN and I picked GYN
because I would rather takecare of women basically.
(04:05):
And so during my residency thisnew field of urogyne was
beginning.
That really caught my interestbecause I liked both and I
really wasn't nuts about OB.
But it kind of came along withthe package.
So you kind of had to do alittle bit of it.
And back then in the early 90sthere were only a few
(04:27):
fellowships in urogyne and thethinking was that if you wanted
to do research and be anacademic, then you needed to do
a fellowship, and if you justwanted to do it, you just did it
.
I was in the Navy.
I got the Navy to pay for medschool, so I went to Guam and
for my first three years andmade friends with urologists and
so I do bladder cases with themand learn how to do systos and
(04:51):
stents and all that kind ofstuff, and then did a lot of
slings once slings wereintroduced in the early 2000s
and prolapse repairs and allthat kind of stuff.
I wound up getting out of theNavy and moving to Hawaii and
did kind of half general OBGYNand urogyne for about eight
(05:11):
years over there and eventuallyI felt this little tap on my
shoulder like in the cartoonswhere the angel sitting on your
shoulder tapping you and it'slike there's something more
you're supposed to be doing.
And I knew I had the potentialto be a better surgeon and to do
(05:34):
more challenging cases.
And I also knew that what I'dbeen taught about endometriosis
made no sense at all.
And so we were looking to moveback from Hawaii back to the
mainland and our parents were inthe Northwest and we didn't
want to be too close to ourparents but we wanted to be
close enough that we could getthere if we had to.
And so Bend, oregon, seemedlike a great place to go.
(05:58):
And lo and behold, david Redwinehad put an ad in the Green
Journal, which is the journal ofOBGYN, looking for somebody to
come join him.
So I wrote to him and he wroteback with this like three page
long email saying everythingthat he did and all the crazy
(06:19):
surgical stuff that he did andhow he took care of these women
with endometriosis, and at firstI thought he was just making it
all up.
I'm like he's doing bowelresections and ureteral
reimplantations and all thisstuff and I'm like that's crazy.
And then, the more I wrote backand forth to him, the more I
realized no, this is really whathe does.
It's everything that I hadalways ever wanted to do.
(06:41):
So, anyways, I went out andspent a week with him in
December of I think it was 2005,and came home thinking this
this guy is an incrediblesurgeon and what he does is life
changing for these women and Ineed to do this.
(07:01):
And so we we moved in the summerto Bend Oregon and I was there
for two years and operated withDavid every day.
And it was in 2008 when the twoyears was up.
It kind of was the subprimemortgage financial crisis and it
was kind of clear that hispractice was a one person
(07:24):
practice and, you know, notreally enough volume.
People didn't have the money tobe traveling to crazy places
like Bend Oregon for surgery, soI moved back home up to Gig
Harbor, which is where I grew up.
I grew up in Fort Crest, whichis right across the Narrows
Bridge, but spent a lot of timein Gig Harbor, so I felt like
home.
Fircrest, which is right acrossthe narrows bridge, but spent a
lot of time in gig harbors, soit felt like home.
Speaker 1 (07:45):
So I've been here since 2008 doing initially it
was like 50 50 endo and urogyne,and over the years it's become
now now I do probably 90, 95percent endo and very little
urogyne that's what I mean, likethat history, because correct
me if I'm wrong, but you were DrRedwine's only fellow, correct,
(08:07):
which is something no one elseobviously can say and you have a
perspective that I think is sounique because you've seen the
conception of excision andendometriosis from a different
viewpoint with Dr Redwine, andfrom the very beginning of what
many called crazy, so to speak.
(08:28):
You know they said so manydifferent things.
Speaker 2 (08:31):
The medical staff board brought him in and was
going to sanction him because hewas removing endometriosis and
some I think it was the chief ofthe department of OBGYN thought
that he was being a cowboy anddoing all this stuff that he
(08:52):
shouldn't do.
And they brought him in infront of the board of directors
and said what are you doing andwhy are you doing this?
And he's like well, let meexplain it to you this way If a
patient had appendicitis, wouldyou take out their gallbladder?
You know, if somebody had akidney mass, would you take out
(09:15):
their bladder?
No, you would take out thedisease.
He's like I remove the diseaseand I leave normal reproductive
organs alone.
And they're like really, oh,why isn't everybody doing this?
It seems to make so much sense,right, but you know?
But yet that's the kind ofostracism that he got from the
(09:39):
community.
Speaker 1 (09:40):
Yeah.
Speaker 2 (09:41):
And he was called crazy.
Didn't help that he lived in themiddle of Central Oregon, which
was when he moved there in 78,it was kind of the middle of
nowhere, Right, but he, I reallybelieve, is the father of
excision surgery.
And when you go through and readall of his papers and you were
(10:02):
at the end of summit and Sallyasked me to speak about David's
life and I went through all ofhis papers and kind of briefly
summarized them in that talk andit really made me think again
about how the genius of that manand how he thought to create
(10:25):
this database and how he knew atthe get-go that he was doing
something that was going tochange medical practice and that
he needed to record that.
And then he needed to keeptrack of those patients and
their outcomes and in doing sohe kind of defined how well does
(10:46):
excision work?
What does endo look like?
What does it look like in ateenager versus in a 40-year-old
woman?
Does it spread?
No, 40-year-olds have as manyareas of endo as 20-year-olds do
.
And so some of the kind ofexistential questions about
(11:07):
endometriosis he answered.
Speaker 1 (11:09):
Right.
And he you know it'sinteresting because right before
he passed away he was on thepodcast and I, you know same way
I always start when I haveguests on I say, how would you
like me to refer to you, becauseI think that's important to
understand.
And he's like, well, I'd liketo be called the emperor,
because I think that's importantto understand.
And he's like, well, I'd liketo be called the emperor.
And I said, okay, you're theemperor.
(11:32):
And I think, beyond just hisfight for endometriosis and
patience with endometriosis, youknow, I think his humor really
allowed people to see the humanside of him and how much he
genuinely cared for those in theendometriosis community.
And I think that it was shownwithin his papers.
It was shown in the way that hewould teach about endometriosis
and the way that hecontinuously, until his passing,
(11:56):
would educate and fight forthose with endometriosis to get
proper care.
And that didn't happen justover one night.
It was, it was a progression.
And he fought, and he foughthard against those who
criticized, who bashed him, whomyou know wanted to defeat the
(12:17):
emperor, so to speak.
Speaker 2 (12:19):
And he didn't let them and he kept fighting.
Speaker 1 (12:21):
I think that should be a role model, beyond just the
endometriosis piece, but be arole model that we can't give up
at just the criticism of whatyou're doing when you know it's
right.
So you're saying I can't retire, you can't retire, that's it
right there.
You're not allowed to retire.
Nancy hasn't retired fromadvocacy.
(12:42):
You're not allowed to retire.
Speaker 2 (13:07):
Nancy hasn't retired from advocacy.
You're an interest in me.
I think they saw a potential,you know, and they really helped
me learn how to dissect and howto approach surgery, which I
think gave me a leg up in myresidency and allowed me to
become a better surgeon thanmost of my peers just out of
residency.
(13:28):
But I never learned how todissect out a ureter.
I never learned how to dividethe uterine artery lateral to
the ureter and basically do aradical hysterectomy, which is
what we have to do sometimes forendo, when there's really
deeply infiltrating disease onthe uterus sacral.
We have to treat it like acancer case.
(13:49):
And I had learned how to doovarian cystectomies but we
never closed the ovary and itmakes so much more sense to put
a suture in it and close it andprevent the adhesions that
happen after you don't close itand so many things that you
don't close it and so manythings that you know.
I thought I was a good surgeonand I was nothing until I spent
(14:10):
two years with David and hetaught me as far as surgical
technique goes.
He taught me 90% of what I dotoday.
Speaker 1 (14:18):
Did that also affect the way that you interact with
patients, seeing it differentfrom the fellowship perspective
and getting into endometriosis,versus not doing a fellowship
and potentially not knowinganything about endometriosis?
How do you think that shaped?
Speaker 2 (14:33):
you.
Before I spent time with him.
I did not specialize inendometriosis and you know,
occasionally we'd have somebodythat had endo and I'd operate on
them and do the ablationtechniques.
And I had one girl that hadthese recurrent cysts in her
(14:56):
pelvis despite having doneoophorectomy on her for
endometriomas, and I didn'trealize what was happening and I
didn't know what I didn't knowbecause I'd never been taught.
And now I know exactly what washappening with that girl and I
wish I could go back and say,hey, let me do your surgery the
(15:17):
correct way, because she had anovarian remnant and we never got
the disease out from aretroperitoneal approach.
And so I know now what I shouldhave done in some of those
cases before I learned what Ilearned from him.
But I will tell you the first Idon't know a couple of months
(15:38):
that I was there in Bend I wouldcry when I heard these women's
stories about surgery aftersurgery after surgery and people
not treating them right anddoctors making the patients feel
like they're crazy because thedoctors didn't know what was
wrong with them.
And initially it made me sad andmade me upset and then it just
(16:02):
made me mad.
And it still angers me when Isee 28 year olds who had normal
ovaries removed and they weren'ttold what the repercussions
were of that, they weren't toldwhat their life was going to be
like, you know, for the next 25years, until they should have
(16:26):
normally gone through menopause,and the patients who are
dismissed because they're justlooking for secondary gain, oh,
you know, nothing's really wrongwith you.
You know, why are you here?
Why are you on my doorstepasking for meds?
You must be drug seeking.
You know.
You must be crazy, you musthave been raped sometime in the
(16:47):
past and you just don't rememberit.
So you need to go dopsychotherapy.
So you, you know, so that youcan deal with this, or you're
just stressed.
That's why your pelvic floor istight.
There's really nothing wrongwith you.
Speaker 1 (16:58):
Yeah.
Speaker 2 (16:59):
So I mean, you see these things all the time and I
don't know how to deal with it,because general OBGYNs it seems
like a lot of them aren't reallyinterested in what I have to
say.
Some of them are, some of themare wonderful, and I've
developed a relationship withsome generalists who you know,
(17:20):
when they're, when they havepatients that have pain and you
know endo that they know thatthey can't deal with, they're
like you need to go see Cindy.
Yeah, I really appreciate thatand I would love to nurture
those relationships and I wouldlove to make more of them, but
it seems hard because a lot ofthem are like yeah, yeah, yeah,
fine, whatever.
Speaker 1 (17:40):
It's uncomfortable for them to be faced with that.
Yeah, absolutely.
It sounds like I mean, and Ihaven't really thought of it
this way, but I see it time andtime again with doctors who
specialize with endometriosis.
They almost go through agrieving process with their
patients, like it's not.
You go into the office, youtell your story, they find a
solution.
They kind of just grieve withyou because it impacts them and
(18:04):
impacts the way that they treatother patients down the road
when they are faced with certainsituations or circumstances.
And I think that we forget thatas a patient, that when we go
to see an endometriosisspecialist, yes, they care, yes,
they validate, but they alsogrieve because they're hearing
this time and time again.
And it's the different stagesof grief it's the sadness, it's
(18:26):
the anger, it's the how couldthey, the denial.
You know, I think they all gothrough that.
I mean that just is animpactful statement for those
that have dealt with it tounderstand that they grieve with
you.
Speaker 2 (18:37):
Yes, I think, I mean, I certainly do.
Speaker 1 (18:40):
What has changed?
What have you seen in theprogression with fellowships in
the years that you've been doingthis?
Because now you know you'vegone through your fellowship,
you've practiced, you havestarted creating a space for
other fellows to come in.
What is the biggest differenceyou're seeing in endometriosis
and fellowships?
Speaker 2 (19:00):
Well, there really aren't many.
I mean, I had a fellow from2019 to 2021, and then she went
away for two years and then shecame back last fall, dr Newville
, and she's phenomenal, she'sjust an awesome human being and
she's an amazing surgeon and sheright now is probably capable
(19:24):
of doing 90% of what I can do.
The you know, the last 10% isgoing to take a while because
it's the hardest and you knowthe frozen pelvises and the you
know digging out ureters and allthat kind of stuff.
And then last summer I had anew fellow come, dr Yagy, who
was on your podcast, and so shestarted last August and I think
(19:49):
her mind is blown on a dailybasis with what she hears from
these people and it's a honorand a pleasure and I think my
mission in life to educate thenext generation of endosurgeons,
and David's mission in life wasto define the disease and I
(20:11):
think my mission is to try totrain the next generation.
There are a lot of minimallyinvasive GYN fellowships now.
They started probably 25, 30years ago with basically
mentorships where surgeons wouldgo work with an established
gynecologist who did a lot ofminimally invasive stuff, like
(20:34):
Tom Lyons and Dan Martin andpeople like that and so
gradually over time, aagldeveloped minimally invasive
gynecologic surgery or MIGSfellowships, and now there's
probably I don't know 20, 25locations, maybe more than that,
maybe 30 across the country.
(20:55):
But some of them do a prettygood job at endo and others
don't really do much of anythingwith respect to endo, and so
there's a little bit of aproblem when it comes to who's
an endo specialist.
You know, because a lot ofthese kids that have finished a
MIGS fellowship they're like oh,I'm a specialist in endo, you
(21:17):
know I can do endo, but theyreally don't understand.
Yeah, maybe they can do acystectomy decently and maybe
they can suture laparoscopicallyso they can sew the ovary
closed, but they don'tunderstand the deep disease,
they don't understand how deepthey have to go to get around
the base of it.
There's a lot of stuff theydon't do, and they can't do
(21:38):
because they were not taughtadequately how to take care of
endopatients.
It would be wonderful if therewere true endometriosis
fellowships, if there were moreof them, but the problem is that
you have to have a mentor andyou have to have somebody who's
an expert endosurgeon in orderto be the trainer.
Speaker 1 (22:02):
Right, it's true.
I mean, I think that that alsobrings up the next point of why
it's important to know whereyour surgeon has gotten their
education and why it's importantto know if they've done a
fellowship and where thatfellowship was done.
Because you can go to a MIGScertified doctor but doesn't
(22:22):
necessarily mean they knowenough about endometriosis to do
a good surgery forendometriosis Like, yes, they
can maybe do a good surgery forother gynecological issues
because that's what they'retrained in.
But it doesn't mean thatendometriosis is going to be the
same, because endometriosis,like many of us know, is almost
like a cancer, so it respondsdifferently for everyone, it's
(22:46):
different presentation foreveryone and it can be really
scary to go in there.
Dr Yagi was actually talkingabout that.
How, when she went in one time,she was like this is beyond my
scope.
The same can be true with aMIGS certified surgeon or a MIGS
fellow surgeon.
And so it is important, I think,to have an understanding of,
(23:08):
before you decide on surgery ortreatment, where your doctor got
their education onendometriosis Not just their
education as a whole, but theireducation on endometriosis.
Maybe a few extra pieces ofthat.
What do you think is the mostimportant part to look for when
you're looking for that, becausemost of us don't know where
(23:28):
these fellowships are, but whatcan help us identify a good
education on endometriosis?
Speaker 2 (23:35):
That is, the $100,000 question.
You know because you know.
Nancy says there's a hundred or200 people in the country who
do excision and I say, well,that may be true, but there's
probably 20 people in thecountry who do excision.
(23:55):
Well, and there are doctors atacademic institutions who write
lots and lots of papers onendometriosis, yet they are not
very good surgeons and I seetheir videos at meetings and
online and places like that.
(24:15):
And I look at these people whoclaim to be experts in
endometriosis and I'm watchingthem operate and I'm watching
them operate and I'm like youshould have done this.
You should have done that.
Why did you do that?
This makes no sense, and so,unless you know how to evaluate
somebody's videos, it makes ithard to know how good of a
(24:37):
surgeon they are, right, howgood of a surgeon they are.
And so there are gynecologistswho they write lots and lots of
articles and I've seen patientsthat they have operated on and
it's like this just this doesn'tlook like a true excision
specialist has been here.
(24:58):
I mean, I even had a patient whohad surgery by one of the top
dog people and after thatsurgery she was told well, you
have endo on your rectum andthere's nothing you can do about
it.
There's nothing anybody can doabout it.
You just have to go meditateand do Chinese herbs and, you
(25:20):
know, come to peace with it.
And she came out to see us andshe had a five centimeter mass
in her rectum and we did a bowelresection and you know she was
better.
But these are well-knownacademic centers and it's so
frustrating because it's like,well, how should a patient know,
right?
(25:40):
So we we tried to start thisthing and we're trying to put
our heads together to figure outhow do we create a way to look
at surgeons videos to say, yes,they know what they're doing, or
no, they don't know how whatthey're doing.
Speaker 1 (25:56):
Right.
Speaker 2 (25:57):
And we met this guy.
You know he's like well, I havethe platform that I can
facilitate this.
So we started working togetherand initially there were
probably 20, 25 people who werevetted, and everybody, including
me, had to submit de-identifiedvideos of our surgeries and
(26:19):
each other reviewed it and said,yes, this is good, we know what
we're doing.
And then we vetted other peopleand then the vetted people
would be able to vet otherdoctors, and so initially it was
a really good program.
Recently, I have heard that heis allowing people to pay him to
(26:42):
put them on this list, and so Ihaven't actually been to the
website to see what it lookslike.
But it's sad because it dilutesthe effectiveness of knowing
that, okay, this doctor has beenreviewed, their surgical
technique has been reviewed byall the true expert excision
(27:06):
specialists and you know they'vebeen deemed adequate to do X, y
and Z, and meaning stage one,stage two, stage three, stage
four, diaphragm, you knowwhatever.
So originally it was.
It was a great idea.
It was something that wasdrastically needed, because
patients need to know how goodis this person sitting in front
(27:29):
of me?
Because a lot of doctors arevery nice.
A lot of doctors are verypersuasive they're, they're very
sweet, they seem to care abouttheir patients, but they can't
operate their way out of a paperbag and you're not going to
know that.
Patients aren't going to knowthat, unless there's some way to
identify who they are.
Nancy keeps a list on the Nook,but her list is based on patient
(27:53):
feedback, right, which isimportant, which is definitely
important, but it's notnecessarily based on outcomes or
let's watch your surgicaltechnique and see how things
looked.
So I don't know that there is away to know other than word of
(28:14):
mouth knowing who was originallyvetted, knowing who trained
with the people who have beenvetted, knowing who trained with
the people who have been vetted.
So if somebody trained withVidali or Cenervo or somebody
with a name like that, somebodythat's known to be in a known
quantity of expertise, somebodywho came from Brazil and the
University of Sao Paulo, wherethey do amazing work, and some
(28:37):
of the Italian hospitals arepretty amazing Horace Roman in
France, but it's you know, howdo you find these people?
Speaker 1 (28:45):
Yeah, that's a challenge.
Speaker 2 (28:47):
It is.
Speaker 1 (28:47):
Absolutely, I mean, I think, as a patient, when you
are in the midst of trying tonavigate your care through pain,
through medical trauma, throughmental trauma, and years and
years of being dismissed or notunderstanding your own body.
It is hard, though, to findsomeone that you can truly trust
(29:09):
, because it is a decision thatwill affect the rest of your
life one way or the other, andit doesn't necessarily mean that
it's a drastic change all thetime, but it certainly can be,
and so it's hard for patients tounderstand who is good, who
isn't good, and it's also hardfor patients to decide who is
(29:29):
good for their care, because Ithink there is a difference
between who's just good andwho's good for what they need in
their care and who's going tobe a good fit for them.
I think that makes a hugedifference in their care, and
who's going to be a good fit forthem.
Speaker 2 (29:43):
I think that makes a huge difference, Absolutely.
I think that there's a lot ofdocs who are just fine for stage
one, stage two and probably alot of endometriomas, but they
can't really do stage four.
They're not really experts atgetting the deep disease out of
the uterus sacral or off of thesciatic nerve and things like
(30:03):
that, where you really do need atrue expert.
Speaker 1 (30:07):
Absolutely.
That's a lasting outcome rightthere, one way or the other,
yeah.
Speaker 2 (30:12):
I kind of look at surgeons like baseball players.
I love baseball, I do too.
My dad used to take me to.
You know, my, my mom lovedbaseball too, so we'd all go to
baseball games from when I was akid and you know, it's like
there's there's only so manyJustin Verlanders, there's only
(30:33):
so many doctors who are like ahousehold name and, yeah,
they're who you'd want on yourteam, no matter what.
But there's a lot of majorleaguers who are.
Nobody knows them unless youknow.
You go to the games all thetime and you follow your team.
And people like cal raleigh,the mariners catcher yeah, he's,
(30:54):
he's a great player, but nobodyknows him outside of seattle,
right, you know, that's likechar.
Speaker 1 (31:00):
Blackman here.
My husband and I were justtalking about this.
Speaker 2 (31:02):
He cut his hair.
Speaker 1 (31:03):
I bet he will when he retires.
I bet he'll retire, but it'shis luck.
You know how superstitious theyare.
Speaker 2 (31:09):
He's not going to cut his hair.
Speaker 1 (31:10):
He doesn't care.
He doesn't care, but he's gotsome of the best stats in the
league, but he's widelyunder-recognized across the
board.
I feel like that's it's true.
Now that you're saying this,this is really good, it is
similar.
Speaker 2 (31:26):
Yeah, because I mean, there are some.
There are some people who arelike you know, derek Jeter A-Rod
, you know everybody, evenpeople who don't follow sports.
They're like oh yeah, I knowwho Derek Jeter is, but you
don't need Derek Jeter if youhave stage one endometriosis,
(31:47):
you need Ty France, my favoritefirst baseman from the Mariners.
He's a great player, he's agreat guy.
And so one of my good friendshas three boys and their dad is
MIA, and so I've tried to kindof step in, not to replace their
father, but to do things withthem, like take them to sporting
(32:10):
events and teach them how toski.
And her oldest son he's my15-year-old best friend.
We ski together and we used togolf together and stuff like
that, but so, anyways, they tookthe boys to the baseball game
and it was during COVID, so wewere sitting in the front row
and Ty France came over andhanded after the warmups, handed
(32:32):
each one of those boys abaseball, and I'm like this guy
is my new favorite playeranywhere.
Yeah, is my new favorite playeranywhere.
Speaker 1 (32:39):
Yeah, and that could be said for turning it back, but
, like those doctors who listenand validate and can assess what
is right for you, you justchanged my outlook on how we
approach this.
But it is true, I mean thiscould be a whole other
discussion about staging andunderstanding and mapping out
(33:01):
the endometriosis and what thepatient needs, but I think
there's something to be saidabout finding a provider that
meets your needs where you're atin your journey.
And if it's a doctor, firstlythat validates you and can treat
where you're at.
Speaker 2 (33:18):
Yeah, it starts with listening Absolutely and
believing and saying, yes,there's something going on with
you.
I don't know what it is, butI'm not going to rest until I
figure it out.
Speaker 1 (33:28):
Stage one is not the minor leagues Stage one, in the
sense that an excisionspecialist still needs to
address that stage one Stage.
Speaker 2 (33:36):
one is like your routine everyday guy on the
Colorado Rockies or the SeattleMariners that you and I know who
they are because we follow theteams but nobody else knows.
Speaker 1 (33:48):
Yeah, but the minor leagues are the ablation
surgeons, yeah.
Speaker 2 (33:53):
Triple A, double A is general OBGYNs who make a mess
out of things, and you know.
You said your mission in lifewas to educate people on
hormones and castrations and whyto not get their ovaries out.
My mission in life is to stopaverage gynecologists from
(34:14):
taking care of endometriomas andoperating on them because they
just make a mess out of it.
Speaker 1 (34:19):
There's so much value in that and you have to start
out growing and learning alongthe way, because you're not
going to be the A-Rods first.
You can be a fantastic surgeon,but lived experience and
working with patients day in andday out is what really makes
you one of the biggest in theleague.
(34:41):
Right, like?
It is not something you learnovernight and you have to grow
into that.
What do you look forward to andwhat is your hope for the
future?
In fellowships and inendometriosis care and
endometriosis treatment?
Do you see promise and hope inthe future, and what is that for
you?
Speaker 2 (35:01):
Well, I mean there are a lot more people doing
excision now than there werewhat is it 18 years ago when I
started?
And so that's a good thing.
There are a lot of videoresources now that there didn't
used to be, and so a doctorwho's really interested in
(35:23):
learning how to do surgery cango to SurgeryU can go to.
There's a kind of a Europeansurgery video repository that
has a ton of really good videoson how to do excision and how to
do it right.
You know you can watch ArnoldWattier, you can watch, you can
watch all these Mauricio Abreu,all these kind of godfathers of
(35:47):
endosurgery, and you can watchtheir techniques.
And you know you don't have tobe in a fellowship to learn
anymore.
You can learn on your own bywatching and doing and gradually
get better.
Hopefully some of the MIGSfellowships will do more endo
and will graduate more peoplewho understand at least the
(36:10):
basics of excision.
But it's a long road and it's avery slow process and I don't
think anything is going tohappen overnight.
Working on the genetic basis ofendo and immunotherapy and
things like that I mean maybethere's some promise there.
My friend Vicky Vargas, who's Ikind of mentored her from afar,
(36:33):
she's a MIG surgeon in DC.
She had finished her MIGSfellowship and recognized that
she really didn't know as muchas she should have known about
endo, and so we got together andshared videos and, you know,
spent probably a year doingvideo reviews and coaching and,
(36:55):
you know, teaching from afar.
And she's an amazing youngsurgeon I mean, she's the hope
for the future because she'sbrilliant.
She and Dr Yege actually didtheir residencies together, and
so they went to Switzerland forsome endoconference I think it
was the WERF conference orsomething and they were plotting
(37:15):
about all the things that theyneeded to do for research and
creating a database so that wecan document how well excision
works.
And I think that's kind ofgoing a little bit off track,
but that's what we need to do inorder to convince everybody,
including insurance companies,that excision is worthwhile.
(37:37):
And I've said for a long timethat we need to collect a bunch
of data beforehand not only likestandardized pain scores, but
standardized anxiety, depression, central sensitization and
catastrophizing paincatastrophizing prior to surgery
and then follow people,stratify them out based on stage
(38:00):
and then see what theiroutcomes are and then correlate
their outcomes with theirsurgical stage and also their
degree of central sensitizationand then I think if we follow
these people out long enough, wewill get better data on how
successful excision is and thenI think we'll be able to show
(38:23):
that the people who are morelikely to fail excision surgery
have more central sensitizationand that their nerves are just
so sensitive and whether it's aprocess in their brain or
whether it's the peripheralnervous system and they have
almost like a CRPS of the pelvis.
Crps is complex regional painsyndrome and it's kind of like
(38:48):
phantom limb syndrome wherepatients have people have
traumatic amputations and theirarm is gone or their leg is gone
.
It's no longer there, but theystill feel pain in their legs or
their arm and it's because ofpartly because of the trauma, I
think, that that their brain gotso sensitized that they you
(39:13):
know these nerves are stillsending input to the brain,
whether it's the fault of theperipheral nerve that's still
sending the impulse or the brain.
That's so sure less than 5%that have something like that
going on in the pelvis and thatthat's why they have persistent
(39:42):
pain.
But if we can correlatesurgical outcomes, stratify them
, like I said, by stage, andthen look at their degree of
central sensitization and thensee if the central sensitization
reverses itself.
Because there was a study outof China, I think probably 10
years ago, where they did lookat markers of central
sensitization before they didexcision and then what they
(40:05):
found was that six to 12 monthsafter surgery people's nervous
systems the tendency was thatthey normalized and that that
central sensitization went away.
Speaker 1 (40:16):
Interesting and I resonate with that because you
know, after I had my ovaries out, I would still feel like I had
ovary pain occasionally and itwas a very and there are still
times I will say like there'stimes I'm like is that that
feels like an ovary pain?
But I know I don't have myovaries, so is it something else
?
And this is what the commonthought process is is my endo is
(40:40):
back.
That's what the patient'sthought process is right.
Speaker 2 (40:43):
Yeah, yeah, exactly.
Speaker 1 (40:44):
But the endo can't be back on my ovary.
I don't have an ovary, so thatdoesn't make sense, right?
So it's understanding how ourbrain works in conjunction with
the trauma that it's had withour bodies, and who is
heightened in that area asopposed to others, and
understanding that component ofit.
I think that's magnificent,because this is a huge part of
(41:06):
realistic expectations ofsurgery, as well as healing
expectations of surgery andunderstanding the disease from
the psychological standpoint too.
Right, like it's not just aphysical standpoint.
It does alter the way our bodyperceives pain.
Speaker 2 (41:23):
So Well, and it's hard for some people because
they've been so dismissed for solong and they've been told well
, it's all in your head.
But pain really is all in yourhead because because the pain
signals are not really painfuluntil they get to the brain and
they're processed, and so that'swhy we talk about nociceptive
(41:43):
signals, which means that it'sthe nerve transmission of
potentially painful experiences,but it's not really turned into
pain until it's processed inyour brain.
And so I've had discussionswith patients and trying to
explain the role of the brainand their history of trauma and
(42:08):
their anxiety and how that playsa role in how they perceive
pain.
And most of I will say most ofmy patients are like oh well,
that makes a lot of sense.
But a few of them are like theyget really mad and really upset
and they think that I'm tryingto dismiss them and tell them
(42:30):
that you know their pain's allin their head and there's
nothing wrong with them.
But that's not the point.
The point is to say, you know,we need to think.
When we're taking care of womenwith endo and pelvic pain, we
need to think not only of what'sgoing on in the pelvis, but how
is this affecting their brain?
How is it affecting theiremotions?
(42:51):
How are their emotionsaffecting their pain?
What can they do about it?
How can cognitive behavioraltherapy and other things like
this try to ramp down theemotion of the pain?
You know, I kind of understandwhy it's a bit of a slippery
slope, but it's also necessarybecause it's basic biology and
(43:15):
it's you know how our bodieswork.
I realized that firsthandbecause I had a labral tear in
my hip and I had surgery.
Probably 10 years ago, 12 yearsago now I'd been home for I
don't know a week and hadn'tgone anywhere and I was going
stir crazy.
I got in my car and went toCostco and went a couple other
places.
By the time I got into the backof Costco I was dying and it's
(43:39):
like where's the furnituresection?
I need to sit down for a while,and and so, anyways, I got home
and when I got home things werenot calm and I got all upset
and my hip was just killing meand my pain just went through
the roof and I laid down on thebed and I thought, oh my gosh,
(44:00):
this is what my patients arefeeling when their anxiety gets
out of control and then theirpain gets worse, because it
wasn't like this ephemeral thing, it was like boom, you know.
And as soon as I, as soon as Irecognize that, I'm like, okay,
I need to calm down, I need tonot be so upset.
(44:23):
And you know, it helped becauseI connection and the role that
anxiety and trauma play intopeople's pain perception and how
(44:45):
that affects them.
Speaker 1 (44:47):
Absolutely Well, and I think too, once you
down-regulate that system,you're able to better pinpoint
where the not the emotional painof what you've carried for so
long is, but where actual painand where your body is really
telling you what's going on.
I think it's easier to pinpointwhere things are coming from
(45:08):
better, and that's aphysiological fact, right?
Speaker 2 (45:12):
So when, when pain becomes more emotional and it
gets upregulated in the brain,it becomes less localized and
more diffuse and it's likeeverything hurts.
Speaker 1 (45:25):
Exactly, absolutely.
Oh, that's going to befascinating.
So what I'm hearing that yousay is that you're hopeful that,
with new fellows coming on andpeople getting excited about
endometriosis, we're going tosee more research, we're going
to see more change andprogression within the knowledge
and the base of the disease, aswell as the treatment of the
patients who have the disease.
(45:45):
I think that's huge becauseyou're getting, like this new
blood, so to speak.
You're getting rejuvenatedthrough these people coming on
that are excited to talk aboutit.
Speaker 2 (45:55):
And that data will allow us to change standard of
care.
And that's what needs to happen, because right now, standard of
care is people doing ablations.
It's okay for doctors to removetotally normal ovaries in a
25-year-old.
If the patient decided to takethem to court to say you took my
(46:19):
ovaries out, all they have todo is say you signed the consent
form Because it's withinstandard of care.
If somebody has persistent painand thought to be from
endometriosis, it's okay tocastrate a 25-year-old.
To me, that's not okay in anyworld and it certainly isn't
(46:42):
okay without a very longdiscussion, even in my 40 year
old patients who come in and sayyou know, I really want you to
take my ovaries out.
I talked to them for a long,long, long time about what are
you going to feel?
You're going to be menopausal.
Your bones are going to getbrittle, your brain is going to
(47:02):
get old, your vagina is going todry up, your bladder is going
to be irritable, you're going tohave to pee all the time.
You're going to be incontinent.
You're going to you know allthese things are going to happen
to your body, not right away,but over time.
And going to happen to yourbody not right away, but over
time, and your aging process isgoing to be accelerated.
Speaker 1 (47:21):
Thank you for joining us for part one of this
fascinating discussion.
If you found this thoughtprovoking and intriguing, make
sure that you tune in for parttwo of this discussion with Dr
Mossbrucker, and until next time, everybody continue advocating
for you and for those that youlove.
Welcome to EndoBattery, where I share about
my endometriosis andadenomyosis story and continue
learning along the way.
This podcast is not asubstitute for professional
medical advice or diagnosis, buta place to equip you with
information and a sense ofcommunity, ensuring you never
have to face this journey alone.
Join me as I navigate the upsand downs and share stories of
(00:23):
strength, resilience and hope.
While navigating the world ofendometriosis and adenomyosis,
from personal experience toexpert insights, I'm your host,
alana, and this is EndoBatterycharging our lives when
endometriosis drains us.
Welcome back to EndoBattery,grab your cup of coffee or your
(00:44):
cup of tea and join me at thetable.
I'm joined by my guest, dr CindyMosbreker, who is a nationally
recognized expert in minimallyinvasive excision of
endometriosis and the diagnosisand treatment of pelvic pain in
women.
She completed her medicaldegree at Northwestern
University and honed her skillsin OBGYN during her residency at
the National Naval MedicalCenter.
(01:05):
Following her Navy service, shespecialized in GYN and
urogynecology surgery in Hawaii,before training under the
renowned Dr David Redwine.
Now based in Gig Harbor,washington, Dr Mossbrecher runs
a private practice focusing onpelvic pain, endometriosis and
incontinence, advocating for amultidisciplinary approach to
patient care.
Certified in female pelvicmedicine and reconstructive
(01:28):
surgery.
She is dedicated to improvingher patient's quality of life
through a collaborative andcomprehensive treatment plan.
Please help me in welcoming DrCindy Mosbricker.
Thank you, dr Mosbricker, forjoining me today and taking your
time out of your busy scheduleand allowing us to be part of
your information resource list,and that your history and
everything else.
Thank you for joining me.
Speaker 2 (01:50):
You're very welcome, and it's my pleasure.
Speaker 1 (01:52):
Thank you.
Can we start because you have ahistory that no one else does.
Your history career as far assurgery and medical career is
very different than anyone Iknow, which is true to most
people, but you have a specialhistory.
Can you explain what inspiredyou to pursue your career in
urogynecology as well asspecialize in endometriosis?
(02:14):
Well, it's a long story.
Speaker 2 (02:18):
When I was 15, I decided I want to be a
veterinarian.
Because I worked at a ranch forsummers and the vet would come
out and take care of the animalsthat got hurt.
And the vet would come out likeonce a week and he'd need
somebody to do the dressing,changes and whatever.
And so I would volunteer andI'll do it.
(02:39):
So, anyways, I came home thatsummer and I told my dad that I
figured out what I wanted to dowhen I grew up and I wanted to
be a veterinarian.
And he's like why don't you bea people doctor?
I'm like well, you got to besmart for that.
And he's like well, you got tobe smart to be a veterinarian
too.
So my neighbor was an internalmedicine doc and his best friend
(03:00):
was an orthopod.
And so I started spending timewith those guys and decided,
yeah, I kind of like orthopedics.
I was into sports when I wasyounger and sports medicine was
really interesting to me.
And so I went to med schoolthinking that I was going to do
orthopedics.
And then I did my surgeryrotation and loved the finesse
(03:23):
of belly surgery, being in theabdomen and doing bowel surgery
and all that kind of stuff.
And then I went to do my orthorotation and it was like this is
sterile carpentry.
It was just so unfinessed andhammer and chisel and stuff like
that.
And so I had a hard time in medschool deciding between general
(03:45):
surgery, urology and gynecologyand the general surgeons were
on call every other night and Iknew my body couldn't handle
that and so it came down tourology and GYN and I picked GYN
because I would rather takecare of women basically.
(04:05):
And so during my residency thisnew field of urogyne was
beginning.
That really caught my interestbecause I liked both and I
really wasn't nuts about OB.
But it kind of came along withthe package.
So you kind of had to do alittle bit of it.
And back then in the early 90sthere were only a few
(04:27):
fellowships in urogyne and thethinking was that if you wanted
to do research and be anacademic, then you needed to do
a fellowship, and if you justwanted to do it, you just did it
.
I was in the Navy.
I got the Navy to pay for medschool, so I went to Guam and
for my first three years andmade friends with urologists and
so I do bladder cases with themand learn how to do systos and
(04:51):
stents and all that kind ofstuff, and then did a lot of
slings once slings wereintroduced in the early 2000s
and prolapse repairs and allthat kind of stuff.
I wound up getting out of theNavy and moving to Hawaii and
did kind of half general OBGYNand urogyne for about eight
(05:11):
years over there and eventuallyI felt this little tap on my
shoulder like in the cartoonswhere the angel sitting on your
shoulder tapping you and it'slike there's something more
you're supposed to be doing.
And I knew I had the potentialto be a better surgeon and to do
(05:34):
more challenging cases.
And I also knew that what I'dbeen taught about endometriosis
made no sense at all.
And so we were looking to moveback from Hawaii back to the
mainland and our parents were inthe Northwest and we didn't
want to be too close to ourparents but we wanted to be
close enough that we could getthere if we had to.
And so Bend, oregon, seemedlike a great place to go.
(05:58):
And lo and behold, david Redwinehad put an ad in the Green
Journal, which is the journal ofOBGYN, looking for somebody to
come join him.
So I wrote to him and he wroteback with this like three page
long email saying everythingthat he did and all the crazy
(06:19):
surgical stuff that he did andhow he took care of these women
with endometriosis, and at firstI thought he was just making it
all up.
I'm like he's doing bowelresections and ureteral
reimplantations and all thisstuff and I'm like that's crazy.
And then, the more I wrote backand forth to him, the more I
realized no, this is really whathe does.
It's everything that I hadalways ever wanted to do.
(06:41):
So, anyways, I went out andspent a week with him in
December of I think it was 2005,and came home thinking this
this guy is an incrediblesurgeon and what he does is life
changing for these women and Ineed to do this.
(07:01):
And so we we moved in the summerto Bend Oregon and I was there
for two years and operated withDavid every day.
And it was in 2008 when the twoyears was up.
It kind of was the subprimemortgage financial crisis and it
was kind of clear that hispractice was a one person
(07:24):
practice and, you know, notreally enough volume.
People didn't have the money tobe traveling to crazy places
like Bend Oregon for surgery, soI moved back home up to Gig
Harbor, which is where I grew up.
I grew up in Fort Crest, whichis right across the Narrows
Bridge, but spent a lot of timein Gig Harbor, so I felt like
home.
Fircrest, which is right acrossthe narrows bridge, but spent a
lot of time in gig harbors, soit felt like home.
Speaker 1 (07:45):
So I've been here since 2008 doing initially it
was like 50 50 endo and urogyne,and over the years it's become
now now I do probably 90, 95percent endo and very little
urogyne that's what I mean, likethat history, because correct
me if I'm wrong, but you were DrRedwine's only fellow, correct,
(08:07):
which is something no one elseobviously can say and you have a
perspective that I think is sounique because you've seen the
conception of excision andendometriosis from a different
viewpoint with Dr Redwine, andfrom the very beginning of what
many called crazy, so to speak.
(08:28):
You know they said so manydifferent things.
Speaker 2 (08:31):
The medical staff board brought him in and was
going to sanction him because hewas removing endometriosis and
some I think it was the chief ofthe department of OBGYN thought
that he was being a cowboy anddoing all this stuff that he
(08:52):
shouldn't do.
And they brought him in infront of the board of directors
and said what are you doing andwhy are you doing this?
And he's like well, let meexplain it to you this way If a
patient had appendicitis, wouldyou take out their gallbladder?
You know, if somebody had akidney mass, would you take out
(09:15):
their bladder?
No, you would take out thedisease.
He's like I remove the diseaseand I leave normal reproductive
organs alone.
And they're like really, oh,why isn't everybody doing this?
It seems to make so much sense,right, but you know?
But yet that's the kind ofostracism that he got from the
(09:39):
community.
Speaker 1 (09:40):
Yeah.
Speaker 2 (09:41):
And he was called crazy.
Didn't help that he lived in themiddle of Central Oregon, which
was when he moved there in 78,it was kind of the middle of
nowhere, Right, but he, I reallybelieve, is the father of
excision surgery.
And when you go through and readall of his papers and you were
(10:02):
at the end of summit and Sallyasked me to speak about David's
life and I went through all ofhis papers and kind of briefly
summarized them in that talk andit really made me think again
about how the genius of that manand how he thought to create
(10:25):
this database and how he knew atthe get-go that he was doing
something that was going tochange medical practice and that
he needed to record that.
And then he needed to keeptrack of those patients and
their outcomes and in doing sohe kind of defined how well does
(10:46):
excision work?
What does endo look like?
What does it look like in ateenager versus in a 40-year-old
woman?
Does it spread?
No, 40-year-olds have as manyareas of endo as 20-year-olds do
.
And so some of the kind ofexistential questions about
(11:07):
endometriosis he answered.
Speaker 1 (11:09):
Right.
And he you know it'sinteresting because right before
he passed away he was on thepodcast and I, you know same way
I always start when I haveguests on I say, how would you
like me to refer to you, becauseI think that's important to
understand.
And he's like, well, I'd liketo be called the emperor,
because I think that's importantto understand.
And he's like, well, I'd liketo be called the emperor.
And I said, okay, you're theemperor.
(11:32):
And I think, beyond just hisfight for endometriosis and
patience with endometriosis, youknow, I think his humor really
allowed people to see the humanside of him and how much he
genuinely cared for those in theendometriosis community.
And I think that it was shownwithin his papers.
It was shown in the way that hewould teach about endometriosis
and the way that hecontinuously, until his passing,
(11:56):
would educate and fight forthose with endometriosis to get
proper care.
And that didn't happen justover one night.
It was, it was a progression.
And he fought, and he foughthard against those who
criticized, who bashed him, whomyou know wanted to defeat the
(12:17):
emperor, so to speak.
Speaker 2 (12:19):
And he didn't let them and he kept fighting.
Speaker 1 (12:21):
I think that should be a role model, beyond just the
endometriosis piece, but be arole model that we can't give up
at just the criticism of whatyou're doing when you know it's
right.
So you're saying I can't retire, you can't retire, that's it
right there.
You're not allowed to retire.
Nancy hasn't retired fromadvocacy.
(12:42):
You're not allowed to retire.
Speaker 2 (13:07):
Nancy hasn't retired from advocacy.
You're an interest in me.
I think they saw a potential,you know, and they really helped
me learn how to dissect and howto approach surgery, which I
think gave me a leg up in myresidency and allowed me to
become a better surgeon thanmost of my peers just out of
residency.
(13:28):
But I never learned how todissect out a ureter.
I never learned how to dividethe uterine artery lateral to
the ureter and basically do aradical hysterectomy, which is
what we have to do sometimes forendo, when there's really
deeply infiltrating disease onthe uterus sacral.
We have to treat it like acancer case.
(13:49):
And I had learned how to doovarian cystectomies but we
never closed the ovary and itmakes so much more sense to put
a suture in it and close it andprevent the adhesions that
happen after you don't close itand so many things that you
don't close it and so manythings that you know.
I thought I was a good surgeonand I was nothing until I spent
(14:10):
two years with David and hetaught me as far as surgical
technique goes.
He taught me 90% of what I dotoday.
Speaker 1 (14:18):
Did that also affect the way that you interact with
patients, seeing it differentfrom the fellowship perspective
and getting into endometriosis,versus not doing a fellowship
and potentially not knowinganything about endometriosis?
How do you think that shaped?
Speaker 2 (14:33):
you.
Before I spent time with him.
I did not specialize inendometriosis and you know,
occasionally we'd have somebodythat had endo and I'd operate on
them and do the ablationtechniques.
And I had one girl that hadthese recurrent cysts in her
(14:56):
pelvis despite having doneoophorectomy on her for
endometriomas, and I didn'trealize what was happening and I
didn't know what I didn't knowbecause I'd never been taught.
And now I know exactly what washappening with that girl and I
wish I could go back and say,hey, let me do your surgery the
(15:17):
correct way, because she had anovarian remnant and we never got
the disease out from aretroperitoneal approach.
And so I know now what I shouldhave done in some of those
cases before I learned what Ilearned from him.
But I will tell you the first Idon't know a couple of months
(15:38):
that I was there in Bend I wouldcry when I heard these women's
stories about surgery aftersurgery after surgery and people
not treating them right anddoctors making the patients feel
like they're crazy because thedoctors didn't know what was
wrong with them.
And initially it made me sad andmade me upset and then it just
(16:02):
made me mad.
And it still angers me when Isee 28 year olds who had normal
ovaries removed and they weren'ttold what the repercussions
were of that, they weren't toldwhat their life was going to be
like, you know, for the next 25years, until they should have
(16:26):
normally gone through menopause,and the patients who are
dismissed because they're justlooking for secondary gain, oh,
you know, nothing's really wrongwith you.
You know, why are you here?
Why are you on my doorstepasking for meds?
You must be drug seeking.
You know.
You must be crazy, you musthave been raped sometime in the
(16:47):
past and you just don't rememberit.
So you need to go dopsychotherapy.
So you, you know, so that youcan deal with this, or you're
just stressed.
That's why your pelvic floor istight.
There's really nothing wrongwith you.
Speaker 1 (16:58):
Yeah.
Speaker 2 (16:59):
So I mean, you see these things all the time and I
don't know how to deal with it,because general OBGYNs it seems
like a lot of them aren't reallyinterested in what I have to
say.
Some of them are, some of themare wonderful, and I've
developed a relationship withsome generalists who you know,
(17:20):
when they're, when they havepatients that have pain and you
know endo that they know thatthey can't deal with, they're
like you need to go see Cindy.
Yeah, I really appreciate thatand I would love to nurture
those relationships and I wouldlove to make more of them, but
it seems hard because a lot ofthem are like yeah, yeah, yeah,
fine, whatever.
Speaker 1 (17:40):
It's uncomfortable for them to be faced with that.
Yeah, absolutely.
It sounds like I mean, and Ihaven't really thought of it
this way, but I see it time andtime again with doctors who
specialize with endometriosis.
They almost go through agrieving process with their
patients, like it's not.
You go into the office, youtell your story, they find a
solution.
They kind of just grieve withyou because it impacts them and
(18:04):
impacts the way that they treatother patients down the road
when they are faced with certainsituations or circumstances.
And I think that we forget thatas a patient, that when we go
to see an endometriosisspecialist, yes, they care, yes,
they validate, but they alsogrieve because they're hearing
this time and time again.
And it's the different stagesof grief it's the sadness, it's
(18:26):
the anger, it's the how couldthey, the denial.
You know, I think they all gothrough that.
I mean that just is animpactful statement for those
that have dealt with it tounderstand that they grieve with
you.
Speaker 2 (18:37):
Yes, I think, I mean, I certainly do.
Speaker 1 (18:40):
What has changed?
What have you seen in theprogression with fellowships in
the years that you've been doingthis?
Because now you know you'vegone through your fellowship,
you've practiced, you havestarted creating a space for
other fellows to come in.
What is the biggest differenceyou're seeing in endometriosis
and fellowships?
Speaker 2 (19:00):
Well, there really aren't many.
I mean, I had a fellow from2019 to 2021, and then she went
away for two years and then shecame back last fall, dr Newville
, and she's phenomenal, she'sjust an awesome human being and
she's an amazing surgeon and sheright now is probably capable
(19:24):
of doing 90% of what I can do.
The you know, the last 10% isgoing to take a while because
it's the hardest and you knowthe frozen pelvises and the you
know digging out ureters and allthat kind of stuff.
And then last summer I had anew fellow come, dr Yagy, who
was on your podcast, and so shestarted last August and I think
(19:49):
her mind is blown on a dailybasis with what she hears from
these people and it's a honorand a pleasure and I think my
mission in life to educate thenext generation of endosurgeons,
and David's mission in life wasto define the disease and I
(20:11):
think my mission is to try totrain the next generation.
There are a lot of minimallyinvasive GYN fellowships now.
They started probably 25, 30years ago with basically
mentorships where surgeons wouldgo work with an established
gynecologist who did a lot ofminimally invasive stuff, like
(20:34):
Tom Lyons and Dan Martin andpeople like that and so
gradually over time, aagldeveloped minimally invasive
gynecologic surgery or MIGSfellowships, and now there's
probably I don't know 20, 25locations, maybe more than that,
maybe 30 across the country.
(20:55):
But some of them do a prettygood job at endo and others
don't really do much of anythingwith respect to endo, and so
there's a little bit of aproblem when it comes to who's
an endo specialist.
You know, because a lot ofthese kids that have finished a
MIGS fellowship they're like oh,I'm a specialist in endo, you
(21:17):
know I can do endo, but theyreally don't understand.
Yeah, maybe they can do acystectomy decently and maybe
they can suture laparoscopicallyso they can sew the ovary
closed, but they don'tunderstand the deep disease,
they don't understand how deepthey have to go to get around
the base of it.
There's a lot of stuff theydon't do, and they can't do
(21:38):
because they were not taughtadequately how to take care of
endopatients.
It would be wonderful if therewere true endometriosis
fellowships, if there were moreof them, but the problem is that
you have to have a mentor andyou have to have somebody who's
an expert endosurgeon in orderto be the trainer.
Speaker 1 (22:02):
Right, it's true.
I mean, I think that that alsobrings up the next point of why
it's important to know whereyour surgeon has gotten their
education and why it's importantto know if they've done a
fellowship and where thatfellowship was done.
Because you can go to a MIGScertified doctor but doesn't
(22:22):
necessarily mean they knowenough about endometriosis to do
a good surgery forendometriosis Like, yes, they
can maybe do a good surgery forother gynecological issues
because that's what they'retrained in.
But it doesn't mean thatendometriosis is going to be the
same, because endometriosis,like many of us know, is almost
like a cancer, so it respondsdifferently for everyone, it's
(22:46):
different presentation foreveryone and it can be really
scary to go in there.
Dr Yagi was actually talkingabout that.
How, when she went in one time,she was like this is beyond my
scope.
The same can be true with aMIGS certified surgeon or a MIGS
fellow surgeon.
And so it is important, I think,to have an understanding of,
(23:08):
before you decide on surgery ortreatment, where your doctor got
their education onendometriosis Not just their
education as a whole, but theireducation on endometriosis.
Maybe a few extra pieces ofthat.
What do you think is the mostimportant part to look for when
you're looking for that, becausemost of us don't know where
(23:28):
these fellowships are, but whatcan help us identify a good
education on endometriosis?
Speaker 2 (23:35):
That is, the $100,000 question.
You know because you know.
Nancy says there's a hundred or200 people in the country who
do excision and I say, well,that may be true, but there's
probably 20 people in thecountry who do excision.
(23:55):
Well, and there are doctors atacademic institutions who write
lots and lots of papers onendometriosis, yet they are not
very good surgeons and I seetheir videos at meetings and
online and places like that.
(24:15):
And I look at these people whoclaim to be experts in
endometriosis and I'm watchingthem operate and I'm watching
them operate and I'm like youshould have done this.
You should have done that.
Why did you do that?
This makes no sense, and so,unless you know how to evaluate
somebody's videos, it makes ithard to know how good of a
(24:37):
surgeon they are, right, howgood of a surgeon they are.
And so there are gynecologistswho they write lots and lots of
articles and I've seen patientsthat they have operated on and
it's like this just this doesn'tlook like a true excision
specialist has been here.
(24:58):
I mean, I even had a patient whohad surgery by one of the top
dog people and after thatsurgery she was told well, you
have endo on your rectum andthere's nothing you can do about
it.
There's nothing anybody can doabout it.
You just have to go meditateand do Chinese herbs and, you
(25:20):
know, come to peace with it.
And she came out to see us andshe had a five centimeter mass
in her rectum and we did a bowelresection and you know she was
better.
But these are well-knownacademic centers and it's so
frustrating because it's like,well, how should a patient know,
right?
(25:40):
So we we tried to start thisthing and we're trying to put
our heads together to figure outhow do we create a way to look
at surgeons videos to say, yes,they know what they're doing, or
no, they don't know how whatthey're doing.
Speaker 1 (25:56):
Right.
Speaker 2 (25:57):
And we met this guy.
You know he's like well, I havethe platform that I can
facilitate this.
So we started working togetherand initially there were
probably 20, 25 people who werevetted, and everybody, including
me, had to submit de-identifiedvideos of our surgeries and
(26:19):
each other reviewed it and said,yes, this is good, we know what
we're doing.
And then we vetted other peopleand then the vetted people
would be able to vet otherdoctors, and so initially it was
a really good program.
Recently, I have heard that heis allowing people to pay him to
(26:42):
put them on this list, and so Ihaven't actually been to the
website to see what it lookslike.
But it's sad because it dilutesthe effectiveness of knowing
that, okay, this doctor has beenreviewed, their surgical
technique has been reviewed byall the true expert excision
(27:06):
specialists and you know they'vebeen deemed adequate to do X, y
and Z, and meaning stage one,stage two, stage three, stage
four, diaphragm, you knowwhatever.
So originally it was.
It was a great idea.
It was something that wasdrastically needed, because
patients need to know how goodis this person sitting in front
(27:29):
of me?
Because a lot of doctors arevery nice.
A lot of doctors are verypersuasive they're, they're very
sweet, they seem to care abouttheir patients, but they can't
operate their way out of a paperbag and you're not going to
know that.
Patients aren't going to knowthat, unless there's some way to
identify who they are.
Nancy keeps a list on the Nook,but her list is based on patient
(27:53):
feedback, right, which isimportant, which is definitely
important, but it's notnecessarily based on outcomes or
let's watch your surgicaltechnique and see how things
looked.
So I don't know that there is away to know other than word of
(28:14):
mouth knowing who was originallyvetted, knowing who trained
with the people who have beenvetted, knowing who trained with
the people who have been vetted.
So if somebody trained withVidali or Cenervo or somebody
with a name like that, somebodythat's known to be in a known
quantity of expertise, somebodywho came from Brazil and the
University of Sao Paulo, wherethey do amazing work, and some
(28:37):
of the Italian hospitals arepretty amazing Horace Roman in
France, but it's you know, howdo you find these people?
Speaker 1 (28:45):
Yeah, that's a challenge.
Speaker 2 (28:47):
It is.
Speaker 1 (28:47):
Absolutely, I mean, I think, as a patient, when you
are in the midst of trying tonavigate your care through pain,
through medical trauma, throughmental trauma, and years and
years of being dismissed or notunderstanding your own body.
It is hard, though, to findsomeone that you can truly trust
(29:09):
, because it is a decision thatwill affect the rest of your
life one way or the other, andit doesn't necessarily mean that
it's a drastic change all thetime, but it certainly can be,
and so it's hard for patients tounderstand who is good, who
isn't good, and it's also hardfor patients to decide who is
(29:29):
good for their care, because Ithink there is a difference
between who's just good andwho's good for what they need in
their care and who's going tobe a good fit for them.
I think that makes a hugedifference in their care, and
who's going to be a good fit forthem.
Speaker 2 (29:43):
I think that makes a huge difference, Absolutely.
I think that there's a lot ofdocs who are just fine for stage
one, stage two and probably alot of endometriomas, but they
can't really do stage four.
They're not really experts atgetting the deep disease out of
the uterus sacral or off of thesciatic nerve and things like
(30:03):
that, where you really do need atrue expert.
Speaker 1 (30:07):
Absolutely.
That's a lasting outcome rightthere, one way or the other,
yeah.
Speaker 2 (30:12):
I kind of look at surgeons like baseball players.
I love baseball, I do too.
My dad used to take me to.
You know, my, my mom lovedbaseball too, so we'd all go to
baseball games from when I was akid and you know, it's like
there's there's only so manyJustin Verlanders, there's only
(30:33):
so many doctors who are like ahousehold name and, yeah,
they're who you'd want on yourteam, no matter what.
But there's a lot of majorleaguers who are.
Nobody knows them unless youknow.
You go to the games all thetime and you follow your team.
And people like cal raleigh,the mariners catcher yeah, he's,
(30:54):
he's a great player, but nobodyknows him outside of seattle,
right, you know, that's likechar.
Speaker 1 (31:00):
Blackman here.
My husband and I were justtalking about this.
Speaker 2 (31:02):
He cut his hair.
Speaker 1 (31:03):
I bet he will when he retires.
I bet he'll retire, but it'shis luck.
You know how superstitious theyare.
Speaker 2 (31:09):
He's not going to cut his hair.
Speaker 1 (31:10):
He doesn't care.
He doesn't care, but he's gotsome of the best stats in the
league, but he's widelyunder-recognized across the
board.
I feel like that's it's true.
Now that you're saying this,this is really good, it is
similar.
Speaker 2 (31:26):
Yeah, because I mean, there are some.
There are some people who arelike you know, derek Jeter A-Rod
, you know everybody, evenpeople who don't follow sports.
They're like oh yeah, I knowwho Derek Jeter is, but you
don't need Derek Jeter if youhave stage one endometriosis,
(31:47):
you need Ty France, my favoritefirst baseman from the Mariners.
He's a great player, he's agreat guy.
And so one of my good friendshas three boys and their dad is
MIA, and so I've tried to kindof step in, not to replace their
father, but to do things withthem, like take them to sporting
(32:10):
events and teach them how toski.
And her oldest son he's my15-year-old best friend.
We ski together and we used togolf together and stuff like
that, but so, anyways, they tookthe boys to the baseball game
and it was during COVID, so wewere sitting in the front row
and Ty France came over andhanded after the warmups, handed
(32:32):
each one of those boys abaseball, and I'm like this guy
is my new favorite playeranywhere.
Yeah, is my new favorite playeranywhere.
Speaker 1 (32:39):
Yeah, and that could be said for turning it back, but
, like those doctors who listenand validate and can assess what
is right for you, you justchanged my outlook on how we
approach this.
But it is true, I mean thiscould be a whole other
discussion about staging andunderstanding and mapping out
(33:01):
the endometriosis and what thepatient needs, but I think
there's something to be saidabout finding a provider that
meets your needs where you're atin your journey.
And if it's a doctor, firstlythat validates you and can treat
where you're at.
Speaker 2 (33:18):
Yeah, it starts with listening Absolutely and
believing and saying, yes,there's something going on with
you.
I don't know what it is, butI'm not going to rest until I
figure it out.
Speaker 1 (33:28):
Stage one is not the minor leagues Stage one, in the
sense that an excisionspecialist still needs to
address that stage one Stage.
Speaker 2 (33:36):
one is like your routine everyday guy on the
Colorado Rockies or the SeattleMariners that you and I know who
they are because we follow theteams but nobody else knows.
Speaker 1 (33:48):
Yeah, but the minor leagues are the ablation
surgeons, yeah.
Speaker 2 (33:53):
Triple A, double A is general OBGYNs who make a mess
out of things, and you know.
You said your mission in lifewas to educate people on
hormones and castrations and whyto not get their ovaries out.
My mission in life is to stopaverage gynecologists from
(34:14):
taking care of endometriomas andoperating on them because they
just make a mess out of it.
Speaker 1 (34:19):
There's so much value in that and you have to start
out growing and learning alongthe way, because you're not
going to be the A-Rods first.
You can be a fantastic surgeon,but lived experience and
working with patients day in andday out is what really makes
you one of the biggest in theleague.
(34:41):
Right, like?
It is not something you learnovernight and you have to grow
into that.
What do you look forward to andwhat is your hope for the
future?
In fellowships and inendometriosis care and
endometriosis treatment?
Do you see promise and hope inthe future, and what is that for
you?
Speaker 2 (35:01):
Well, I mean there are a lot more people doing
excision now than there werewhat is it 18 years ago when I
started?
And so that's a good thing.
There are a lot of videoresources now that there didn't
used to be, and so a doctorwho's really interested in
(35:23):
learning how to do surgery cango to SurgeryU can go to.
There's a kind of a Europeansurgery video repository that
has a ton of really good videoson how to do excision and how to
do it right.
You know you can watch ArnoldWattier, you can watch, you can
watch all these Mauricio Abreu,all these kind of godfathers of
(35:47):
endosurgery, and you can watchtheir techniques.
And you know you don't have tobe in a fellowship to learn
anymore.
You can learn on your own bywatching and doing and gradually
get better.
Hopefully some of the MIGSfellowships will do more endo
and will graduate more peoplewho understand at least the
(36:10):
basics of excision.
But it's a long road and it's avery slow process and I don't
think anything is going tohappen overnight.
Working on the genetic basis ofendo and immunotherapy and
things like that I mean maybethere's some promise there.
My friend Vicky Vargas, who's Ikind of mentored her from afar,
(36:33):
she's a MIG surgeon in DC.
She had finished her MIGSfellowship and recognized that
she really didn't know as muchas she should have known about
endo, and so we got together andshared videos and, you know,
spent probably a year doingvideo reviews and coaching and,
(36:55):
you know, teaching from afar.
And she's an amazing youngsurgeon I mean, she's the hope
for the future because she'sbrilliant.
She and Dr Yege actually didtheir residencies together, and
so they went to Switzerland forsome endoconference I think it
was the WERF conference orsomething and they were plotting
(37:15):
about all the things that theyneeded to do for research and
creating a database so that wecan document how well excision
works.
And I think that's kind ofgoing a little bit off track,
but that's what we need to do inorder to convince everybody,
including insurance companies,that excision is worthwhile.
(37:37):
And I've said for a long timethat we need to collect a bunch
of data beforehand not only likestandardized pain scores, but
standardized anxiety, depression, central sensitization and
catastrophizing paincatastrophizing prior to surgery
and then follow people,stratify them out based on stage
(38:00):
and then see what theiroutcomes are and then correlate
their outcomes with theirsurgical stage and also their
degree of central sensitizationand then I think if we follow
these people out long enough, wewill get better data on how
successful excision is and thenI think we'll be able to show
(38:23):
that the people who are morelikely to fail excision surgery
have more central sensitizationand that their nerves are just
so sensitive and whether it's aprocess in their brain or
whether it's the peripheralnervous system and they have
almost like a CRPS of the pelvis.
Crps is complex regional painsyndrome and it's kind of like
(38:48):
phantom limb syndrome wherepatients have people have
traumatic amputations and theirarm is gone or their leg is gone
.
It's no longer there, but theystill feel pain in their legs or
their arm and it's because ofpartly because of the trauma, I
think, that that their brain gotso sensitized that they you
(39:13):
know these nerves are stillsending input to the brain,
whether it's the fault of theperipheral nerve that's still
sending the impulse or the brain.
That's so sure less than 5%that have something like that
going on in the pelvis and thatthat's why they have persistent
(39:42):
pain.
But if we can correlatesurgical outcomes, stratify them
, like I said, by stage, andthen look at their degree of
central sensitization and thensee if the central sensitization
reverses itself.
Because there was a study outof China, I think probably 10
years ago, where they did lookat markers of central
sensitization before they didexcision and then what they
(40:05):
found was that six to 12 monthsafter surgery people's nervous
systems the tendency was thatthey normalized and that that
central sensitization went away.
Speaker 1 (40:16):
Interesting and I resonate with that because you
know, after I had my ovaries out, I would still feel like I had
ovary pain occasionally and itwas a very and there are still
times I will say like there'stimes I'm like is that that
feels like an ovary pain?
But I know I don't have myovaries, so is it something else
?
And this is what the commonthought process is is my endo is
(40:40):
back.
That's what the patient'sthought process is right.
Speaker 2 (40:43):
Yeah, yeah, exactly.
Speaker 1 (40:44):
But the endo can't be back on my ovary.
I don't have an ovary, so thatdoesn't make sense, right?
So it's understanding how ourbrain works in conjunction with
the trauma that it's had withour bodies, and who is
heightened in that area asopposed to others, and
understanding that component ofit.
I think that's magnificent,because this is a huge part of
(41:06):
realistic expectations ofsurgery, as well as healing
expectations of surgery andunderstanding the disease from
the psychological standpoint too.
Right, like it's not just aphysical standpoint.
It does alter the way our bodyperceives pain.
Speaker 2 (41:23):
So Well, and it's hard for some people because
they've been so dismissed for solong and they've been told well
, it's all in your head.
But pain really is all in yourhead because because the pain
signals are not really painfuluntil they get to the brain and
they're processed, and so that'swhy we talk about nociceptive
(41:43):
signals, which means that it'sthe nerve transmission of
potentially painful experiences,but it's not really turned into
pain until it's processed inyour brain.
And so I've had discussionswith patients and trying to
explain the role of the brainand their history of trauma and
(42:08):
their anxiety and how that playsa role in how they perceive
pain.
And most of I will say most ofmy patients are like oh well,
that makes a lot of sense.
But a few of them are like theyget really mad and really upset
and they think that I'm tryingto dismiss them and tell them
(42:30):
that you know their pain's allin their head and there's
nothing wrong with them.
But that's not the point.
The point is to say, you know,we need to think.
When we're taking care of womenwith endo and pelvic pain, we
need to think not only of what'sgoing on in the pelvis, but how
is this affecting their brain?
How is it affecting theiremotions?
(42:51):
How are their emotionsaffecting their pain?
What can they do about it?
How can cognitive behavioraltherapy and other things like
this try to ramp down theemotion of the pain?
You know, I kind of understandwhy it's a bit of a slippery
slope, but it's also necessarybecause it's basic biology and
(43:15):
it's you know how our bodieswork.
I realized that firsthandbecause I had a labral tear in
my hip and I had surgery.
Probably 10 years ago, 12 yearsago now I'd been home for I
don't know a week and hadn'tgone anywhere and I was going
stir crazy.
I got in my car and went toCostco and went a couple other
places.
By the time I got into the backof Costco I was dying and it's
(43:39):
like where's the furnituresection?
I need to sit down for a while,and and so, anyways, I got home
and when I got home things werenot calm and I got all upset
and my hip was just killing meand my pain just went through
the roof and I laid down on thebed and I thought, oh my gosh,
(44:00):
this is what my patients arefeeling when their anxiety gets
out of control and then theirpain gets worse, because it
wasn't like this ephemeral thing, it was like boom, you know.
And as soon as I, as soon as Irecognize that, I'm like, okay,
I need to calm down, I need tonot be so upset.
(44:23):
And you know, it helped becauseI connection and the role that
anxiety and trauma play intopeople's pain perception and how
(44:45):
that affects them.
Speaker 1 (44:47):
Absolutely Well, and I think too, once you
down-regulate that system,you're able to better pinpoint
where the not the emotional painof what you've carried for so
long is, but where actual painand where your body is really
telling you what's going on.
I think it's easier to pinpointwhere things are coming from
(45:08):
better, and that's aphysiological fact, right?
Speaker 2 (45:12):
So when, when pain becomes more emotional and it
gets upregulated in the brain,it becomes less localized and
more diffuse and it's likeeverything hurts.
Speaker 1 (45:25):
Exactly, absolutely.
Oh, that's going to befascinating.
So what I'm hearing that yousay is that you're hopeful that,
with new fellows coming on andpeople getting excited about
endometriosis, we're going tosee more research, we're going
to see more change andprogression within the knowledge
and the base of the disease, aswell as the treatment of the
patients who have the disease.
(45:45):
I think that's huge becauseyou're getting, like this new
blood, so to speak.
You're getting rejuvenatedthrough these people coming on
that are excited to talk aboutit.
Speaker 2 (45:55):
And that data will allow us to change standard of
care.
And that's what needs to happen, because right now, standard of
care is people doing ablations.
It's okay for doctors to removetotally normal ovaries in a
25-year-old.
If the patient decided to takethem to court to say you took my
(46:19):
ovaries out, all they have todo is say you signed the consent
form Because it's withinstandard of care.
If somebody has persistent painand thought to be from
endometriosis, it's okay tocastrate a 25-year-old.
To me, that's not okay in anyworld and it certainly isn't
(46:42):
okay without a very longdiscussion, even in my 40 year
old patients who come in and sayyou know, I really want you to
take my ovaries out.
I talked to them for a long,long, long time about what are
you going to feel?
You're going to be menopausal.
Your bones are going to getbrittle, your brain is going to
(47:02):
get old, your vagina is going todry up, your bladder is going
to be irritable, you're going tohave to pee all the time.
You're going to be incontinent.
You're going to you know allthese things are going to happen
to your body, not right away,but over time.
And going to happen to yourbody not right away, but over
time, and your aging process isgoing to be accelerated.
Speaker 1 (47:21):
Thank you for joining us for part one of this
fascinating discussion.
If you found this thoughtprovoking and intriguing, make
sure that you tune in for parttwo of this discussion with Dr
Mossbrucker, and until next time, everybody continue advocating
for you and for those that youlove.
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