26. Surgeon Talk: Endometriosis, Neuropelveology, and Genetics with Dr. Nicholas Fogelson

Episode Transcript
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Natalie (00:00):
On today's episode, I chat with my endometriosis
surgeon, Dr.
Nicholas Fogelson, about hisperspective on Endo, a little
bit about the genetic aspect ofthe disease, and a more in-depth
look at how endometriosis canpresent itself.
He also walks us through a videoof my surgery, so if you're
squeamish and you're watchingthe video recording, I'll put

(00:20):
the timestamps in the show notesso you can skip over the
surgical video portion.
I'm Natalie and you're listeningto the Resource Doula podcast.
A place where we provideinformation to help you make
informed healthcare decisionsfor yourself and your family.
Dr.
Nicholas Fogelson is a boardcertified and fellowship trained
gynecologist and gynecologicsurgeon in Portland, Oregon, and

(00:42):
the founder of NorthwestEndometriosis and Pelvic
Surgery.
He's committed to providingabsolutely world-class surgical
care to women with complexgynecologic surgical issues,
including endometriosis, chronicpelvic pain, heavy bleeding,
fibroids, pelvic organ prolapse,and incon.
Dr.
Fogelson focuses on minimallyinvasive surgical techniques for

(01:02):
all surgeries and is able tocomplete the vast majority of
surgeries via laparoscopy, evenin cases that might be performed
open by many surgeons.
He is also one of the fewsurgeons in the country to focus
nearly exclusively in the areaof endometriosis care, including
the management of very complexcases, including bowel, urinary
tract, and thoracic disease.

(01:24):
He is also one of just a handfulin the nation to have entered
into formal training in thefield of neurobiology, a field
dedicated to a deep neurologicunderstanding of pain and
neurosensory dysfunction, andnew surgical and non-surgical
approaches to its management.

(01:53):
Dr.
Fogelson, thank you so much forbeing here today.
Welcome to the show.

Nick (01:58):
Absolutely.
Natalie, thank you so much forinviting me.

Natalie (02:00):
Yes, of course, of course.
So I wanted to start off byasking just how did you decide
that you wanted to be in women'shealth in general, and then how
did you come acrossendometriosis and become a
specialty surgeon?

Nick (02:14):
Um, well, gosh, I mean, you know, when you're in medical
school you do, you get to do alittle bit of everything.
You do like four to six weeksof, you know, about 10 or 12
different things and, um, And soyou kind of find out what you
like.
And I honestly kind of likedeverything, to be honest.
I was always a big believer inlike, this is the first six
weeks of my life as apsychiatrist, and this is the
first week, six weeks of my lifeas the internal medicine doctor.

(02:35):
And then at the end of thattime, I had, huh, do I wanna
continue this life or not?
Which I always thought it's theway I recommended to medical
students too.
I said, if you start out withyour rotation saying you're not
gonna do this, so I won't payattention, that doesn't work out
too well.
But, um, I don't know.
When I did obgyn, I alwaysreally liked it.
I, I love, I mean, the,everyone's attraction to OB in
the beginning is deliveringbabies.
I mean, that's the experienceyou get as a medical student.

(02:56):
Um, you know, no one gets to dosurgery as a medical student a
whole lot, but you can deliver,anybody can deliver a baby
because gravity delivers 95% ofbabies.
So you can put, you can put apatient, a medical student
between someone's legs and theycan enjoy that.
Everyone can enjoy thatexperience.
And a medical student feels likethey did something great when
reality just happened in frontof them.
But, uh, the, the, the raretimes that it really requires

(03:18):
expertise, it requires a lotmore expertise.
But, Uh, anyway, so I reallyenjoyed that.
I enjoyed the connection withpatients and, and, and women in
general.
Honestly, I mean, I, um, I don'tknow.
I've, I'm fairly, just alwaysenjoyed that experience.
And then, you know, over time,um, I've always very surgically
oriented though I actually spenta lot of time in plastic surgery

(03:40):
as a medical student also, and

Natalie (03:42):
Oh wow.

Nick (03:42):
learned a lot of technical skills there and, um, could
have, I don't know, anotherversion of me could have gone on
to become a plastic surgeon.
But, um, I, I got veryinterested in, in the tech
technical side of surgery.
And as I got further and furtheralong, I was a general OB b gyn
for six years in academia afterleaving residency and, um, just

(04:03):
kind of became very interestedin, in pelvic pain.
I'm always interested in thestuff that no one else is
interested in.
I, like, I, when someone elsesays, oh, that sucks, you don't
wanna do that, I was like, Hmm,that's probably what I wanna do.
So, um, I'm always kind, youknow, because I'm d I'm just
sort of different than mostpeople, like from a neurotypical
point of view, honestly.
So I, there's a lot of timesthat I enjoy the things that

(04:25):
other people won't enjoy.
I'm interested in things thatother people aren't interested
in.
I, I find, I don't, I'm notbothered by the difficulty that
pelvic pain's a, is a, somethingthat I'm interested in and very,
you know, passionate about,honestly, because there's so
many people that are reallysuffering with it, and most ob
GYNs have no interest at allbecause they're not good at it
and they have, they fail at it.

(04:47):
And I wasn't good at it at thebeginning either, and I
understood why people wouldn'twanna do it, because you
generally wanna do things thatmake you feel good.
I mean, it's an affect bias.
You, you, you know, when youdeliver a baby, Everyone's
laughing and crying and happy,and you're like, oh, wow, that
was a great experience.
The patient has pelvic pain.
You operate on'em, they don'tget better.
Like, oh, that was a shittyexperience, like a shitty
experience for both of you.

(05:07):
Not just the patient.
The patient feels bad, but thedoctor feels bad too.
So, you know, it's at a certainpoint if people aren't having
success, they, they say, I don'twant to, that's not what I wanna
be doing.
So, but I, I was also aware, um,you know, there were people that
were having success with it and,and kind of studied what they
were doing and said, oh wow,that's, that's a lot different
than what I was trained to do.

(05:28):
And, um, and so then I looked atwhat they're doing and, and
realized that, oh wow, it'sreally, really difficult too.
That's right up my alley.
And, uh, it's, uh,

Natalie (05:39):
We need people like you,

Nick (05:40):
so I'm like, oh, wow.
It's something that, that, uh, Imight not be able to succeed at.
Um, and, um, and anyway, so Ikind of got interested in it.
I, I ended up doing a, goingback and doing cancer fellowship
after six years.
I, I, I don't, I'm not a boardedgynecologic oncologist, but I, I
did a.
I did a year of fellowship in a,basically at Emory, in, in what

(06:01):
is effectively, uh, very similarto what the, a clinical year of
a G one oncology fellowshipwould be.
I mean, I operated on cancerpatients every day and did
chemotherapy and did everythingthat that cancer fellowship
would kind of entail.
But it was a, I did that for ayear and just really honed my
sort of, really, it really kindof grows you as a surgeon to do

(06:23):
that.
The, the way that you operate asa cancer surgeon is so much more
advanced than what we do ingeneral OBGYN as far as anatomy
and comfort with things that cango weird, like bowel resections
and, and, and repairing bladdersand all the kind of things that
make most general Obi GYNs verynervous.
You know, when you do that, youstart doing cancer work, you're
like, okay, this is just sort ofpart of the work and you, you

(06:44):
don't get so scared about it.
And, um, and so I did that andthen I continued to practice and
honestly it took me quite sometime to continue to get good at
it.
And, you know, we're stillgetting better at it today, but,
Kind of reached a, a point whereI felt pretty good about what we
were doing and, and we started apractice for, uh, Wei I started
a practice about four years agoon my own five, four or five

(07:05):
years ago.
And, um, it's been going great.
We've probably taken care ofwell over a thousand people in
the practice since then.
And I have a partner now, Dr.
Shanti mulling, who's fabulous.
And, um, we're, you know, we hadenough, enough demand for my
services coming in that Icouldn't meet at all.
So I fortunate to find somebodywho, you know, is really good
also, and, and she's doing agreat job.
And that's what we're doing now.

Natalie (07:27):
Amazing.
So I didn't know you did thecancer, um, you

Nick (07:31):
Well, I don't operate on cancer.
I mean, I'm not an oncologistand I wouldn't, wouldn't
represent myself as that.
Um, but I trained did thattrain, I did that, I did that
training, yeah.

Natalie (07:39):
Yeah.
Yeah.
So do you think that laid thegroundwork then for the more
extensive endosurgery that youdo?

Nick (07:45):
Oh, absolutely.
I mean, if, if, honestly, ifsomebody said, I want to be a i,
I want to be an endometriosissurgeon, how should I do?

Natalie (07:54):
Yeah.

Nick (07:55):
I would recommend my path.
Like I, I would recommendgetting cancer training more
than getting mis s gyn training.
Like, it sounds crazy, but like,if, if, if you had an unlimited
amount of time to train, I wouldgo do a GYN oncology fellowship
rather than doing like MIS s gynFellowship Fellowship.

(08:15):
But the problem is if you, GYoncology fellowships are
incredibly competitive and youwouldn't be able to go in there
and say, well, I wanna be anendometriosis surgeon.
They're like, well, that's notwhat we do.
We're not gonna give you a spot.
So, um, cuz nobody taught me howto do endometriosis surgery in
my fellowship, they taught mehow to operate.

Natalie (08:31):
Mm-hmm.

Nick (08:31):
You know, they taught me how to be comfortable with
difficult situations.
They taught me how to becomfortable with bleeding.
They taught me how to becomfortable with injured organs
that I can repair.
They, they, they taught me howto be comfortable with
adhesions.
Like, and that is whatendometriosis requires.
It's not the only path though.
I mean, you can, most people nowdo a a, a age l i s fellowship

(08:52):
and.
Those fellowships are highlyvaried.
Like I have an MIS fellow, uh,that works with me, but she
works with me like one day aweek.
And I've had now four fellowsand maybe one of them really was
significantly interested indoing endometriosis surgery,
maybe one and a half orsomething like that.
And several were not really atall.
So it's sort of like it's, I gynfellows are, the fellows are

(09:18):
varied and the fellowships arevaried also.
Like some fellowships are moreUroGen focused, more, some
fellowships have more endoexperience, some have less, some
are more robotics focused, someare more, more laparoscopy
focused.
So it's, they're kind of allover the place.
And, um, I, I think in the end,if a surgeon wants to do this,
they just have to get enoughsurgical training and then they
have to kind of trainthemselves.

(09:38):
I mean, I, I learned how tooperate in fellowship, but I
learned how to do endometriosissurgery from YouTube, like,
right.
No, totally.
So I mean,

Natalie (09:50):
area.

Nick (09:51):
Right.
I mean, but like once you getenough base skill in surgery and
you understand anatomy and youunderstand technique, you can
replicate what you, what yousee.
So if you watch and really,like, what is it, if I'm
operating with a master surgeonacross from me, I'm watching
them operate, right?
What's the difference if I'mwatching a video of them,
operator from standing in theroom with them, even if I'm in

(10:12):
the room, only one person can beholding the instrument.
So to a, and what you're doing,I always say the surgery, so
surgery is a three.
If you're gonna be a really goodsurgeon, surgery is a
three-legged stool.
That's what I tell my fellows.
It's a three-legged stool madeup of, let tell you first of
all, what bad, what I think badsurgery is.
Bad surgery is I know how to doa hysterectomy and in order to

(10:36):
do a hysterectomy, I do this andthen I do this, and then I do
this, and then I do this, andthen I do this, and then I do
this, and then I close the skinand then I go dictate.
You know, that's all great, aslong as everything goes exactly
the, as it as planned.
And it's all great as long asthe anatomy is exactly the way
it says in the book.

Natalie (10:52):
Right

Nick (10:53):
But honestly, like most general OBGYNs, and I include
myself when I was in thattraining, are trained surgery
like that.
They're trained to operate in avery stepwise way.
How do you do a cesareansection?
You open the skin, you open thefascia, you open the uterus, you
get the baby.
It's all like this sort of likecookbook

Natalie (11:10):
Mm.

Nick (11:11):
and maybe you can do C-sections that way cause
they're pretty much all thesame, but not, it's not always,
but mostly.
Um, and but when you startgetting into, you go into a
pelvis and it's like this bigmass of bowel and ovaries and
uterus all stuck together, guesswhat?
Your cookbook doesn't work.
It's like this is a differentrecipe.

(11:33):
And so, you know, if you go tocooking school, you don't learn
recipes, you learn cooking.
You know, you learn like howflavors go together or whatever.
So, so, so surgery, I think todo surgery really well.
You have to first of all knowanatomy, you know, really,
really, really well and generalob gy, and again, I include

(11:54):
myself at that time, don't knowanatomy really, really well.
It, it's just not part of whatthey do.
And they know, they know anatomyof the inside of the abdomen.
But when you start getting intolike the retroperitoneum and the
blood vessels and the nerves andstuff in the back of the pelvis,
forget it now.
There aren't that many otherpeople that know well either,
but urologists and know it, youknow, probably better, but not a

(12:15):
lot of people dunno it verywell, to be completely honest.
The people that know it well areGY oncologists, to be honest.
And, and then certain areas likeUrogyn in some parts of it in
other really experiencedgeneralists, gy, exceptional
gynecologic surgeons.
I'm not saying that therearen't, there aren't general
OBGYNs that aren't exceptionalat that, but it's not, I would
say it's the exception ratherthan the rule.
And the, so do you know anatomyreally, really well?

(12:38):
How did I learn anatomy?
I read fricking anatomy books,you know.
I, I, I drilled myself.
I made sure that I could take apiece of paper and draw out the
pathway from the heart all theway down to the terminal
branches of every artery in thepelvis, like in my sleep like
this, every day.
And I made my fellows do thesame thing.
I said, take this piece ofpaper, draw this, okay.

(12:58):
I want you to be able to do it.
You can't do it.
I want you to be able to do ittomorrow.
You know, because, okay, got thearteri, let's do the veins now.
Okay, let's do the nerves now.
Like, that's the, that's thefundamental.
Okay.
So you do that and then, andthen the next thing is, do you
know technique?
You know how to manipulatetissue.
Do you know how to tie upbleeding?
Do you how to know how to, doyou know how to sew things

(13:19):
together?
Like those are the basicbuilding blocks of good surgery.
Like, do you that manipulating.
In an effective potential way,not causing undue trauma, how to
repair things, how to, how todeal with bleeding.
That seems scary.
How to keep your sh I mean, someof it's emotional technique, how
to keep your shit together whensomething bad is happening and
realizing that, okay, I bettersolve this problem.

(13:40):
It's all on me.
I better fix, better fix it.
You know, some people are betterat that than others, you know?
And, and, and then the, thethird thing is, is, is then the
last thing is knowing what youwant to do.
You know, do you know how to, Imean, there's the knowing what
you wanna do in the operatingroom, and then there's knowing
what, what you wanna doclinically and, and oops, when

(14:01):
you, um, you know, when youspeak to a patient, I mean, this
is like how to do surgery.
There's the fourth arm of this.
This is like how to do surgeryin the operating room.
Like knowing what are you tryingto accomplish?
Like, let's just say it's assimple as you wanna do a
hysterectomy.
Like what is it supposed to looklike when you're.

Natalie (14:18):
Mm-hmm.

Nick (14:19):
the terro ligaments have been severed, partially severed.
The cardinal ligament has taken,there's a, the cervix been
separated from the vagina.
The uterine arteries have beensealed.
Like, they're just like, can youlist it?
Like, these are all the thingsthat, that should have happened
by the end of the case.
And then when you get into acase that's totally
straightforward, you can do itin a totally straightforward
way.
When you get into a case that'svery messed up with an

(14:39):
anatomical changes, you stillknow what it is that you're
trying to accomplish.
It's just gonna be different.
You're gonna have to accomplishit differently.
And you realize that even thoughnormally the ureter is kind of
like sitting a couplecentimeters below the ovary,
well this time it's gonna becompletely glued to the ovary,
you know?
But do you recognize that, okay,because of this disease state,
this anatomy's gonna bedistorted and we're gonna have

(15:01):
to deal with it.
And, you know, any, any reallygood experienced surgeon does
that.
Um, but that's, that's how youhave to approach it to be, I
think, to be a little bit betterat it.
And, and I, look, I'm not, I'mcompetent.
I, I, I feel good about what,what we do.
I'm not, I'm not.
You know, there's plenty,there's a lot of people that are
good.
You know, I, I never wanna saylike, oh, I'm the best surgeon
in the universe, or whatever.

(15:21):
It's like, no, I'm just good atwhat I do.
There's lots of people that aregood.
Um, the, but anyway, the fourth,the fourth thing though is then
the clinical part where you canyou speak to a patient, get the
information that is required tofigure out a complex issue when
it comes to pelvic pain.
So the first thing was aboutsurgery.
When it comes to pelvic pain, doyou kinda understand enough

(15:43):
about like, why people have painand what different kinds of
pains kind of present as, um,when people describe something,
how do you ask the next questionthat kind of gets you where,
where you want to go, um, sothat you can come up with a good
plan and, and it's not alwaysgonna be maybe always the right
plan, but can you come up with aplan that makes sense, that has
a good chance of getting,getting the patient where they

(16:05):
wanna go?
And that takes a lot of time.
It probably took me, at leastfrom the moment I said I wanted
to.
Do this, it probably took me atleast a decade to feel like,
okay.
I, I'm still getting slightlybetter, but I've, I've gotten
quite good at this, you know,that's a long-winded answer, but
Yeah.

Natalie (16:23):
I appreciate it too, and I, I will tell you, I am
even more glad that I hired youto do my surgery.
Now, hearing a little bit moreabout your background, so, um,
something that you talk about isneuro pathology.

Nick (16:37):
Yeah.
Neuro,

Natalie (16:38):
about that?

Nick (16:39):
yeah.
So neuro, neuro, uh, no, it'sneurobiology, but whatever.
Okay.
It, you know, I don't, it's,it's, it's a European title, so
they gotta add some extra valvesin there.
But, um, it, it's, um, you know,neurobiology is everything that
a second year medical studentwas ever taught and then went on
to forget and that you decidedto go back and relearn it.

(17:02):
Like, it's not, it's not magic,it's just, it, it is.
Starting out with the assumptionthat every single pain that in
person experiences and everysingle visceral n neurologic
phenomenon, first of all isreal.
And second, that a very detaileddescription of a patient's

(17:23):
symptoms with a limited amountof physical exam can usually
tell you exactly what's wrongwith the patient.
And it's using a little bit of amore advanced understanding of
neuroanatomy and neurophysiologyto try to add up what's wrong
with somebody.
And it's like a puzzle where youhave all these little pieces and

(17:46):
you try to gather all the littlepieces together.
And then I think neurobiologysomewhat gives you the questions
to gather a few additionalpieces, but then also helps you
to understand how they fittogether in a way that you might
not have understood before.
So I'll give you an example.
I'll just give you kinda a basicexample.
So patient has pain.
That is radiating down theinside of her right leg.

(18:07):
Every time she has a menstrualcycle.
It is worse when she's standingup and when she lies down, it
feels better.
She also gets a weird tinglingfeeling in her bladder when she
stands up and she has urgency tourinate.
But when she lies that she inthe middle of the night, she
doesn't have to get up to pee,but during the day she pees like
10 times a day.

Natalie (18:27):
Hmm

Nick (18:28):
It's only on the right side.
It gets much, much worse duringher menstrual cycle.
Like okay, put it all together.
She ha uh, she has bladdersymptoms, she has symptoms down
the S two nerve, the S two partof her sciatic nerve.
Um, she has a intra pelvicentrapment on her second cy

(18:48):
nerve rib.
And we know this because likesome people say she has got pain
down her leg.
Oh, she has sciatica.
It's like no, she can't havesciatica cause it wouldn't make
her bladder feel that way.
Her bla her.
I mean, you may not may, butlike when you look at the
innovation, it's like a tree.
It's like, no, the problem'shigher up on the tree that the
split this problem is, is beforethe, the nerve end, the SCID

(19:11):
nerve and like, and so then yougo and operate on that patient
and you expose that nerve.
And part of sort of thephilosophy of neurobiology is
like if the patient tells youthat that's where the lesion is,
you're going to find somethinglike, it doesn't make sense that
she would have those symptoms.
And then you go in there andthen it's gonna look normal and

(19:33):
it doesn't.
I, I, I have, and there's a lotof examples like that.
I mean, I'll give you one otherexample.
Probably the first neuralpologic kind of thought process
case I ever had that I thought,I, I was like, wow, I really
accomplished something that Imight not have accomplished
without this is I had a patientwho had cyclic epigastric pain,

(19:54):
that she had pain under her ribsright in the center.
Over and over and over.
And a lot of people go, oh, Ihave diaphragm endometriosis.
I'm like, no diaphragmendometriosis hurts in your
shoulder because the third,fourth, and fifth cervical nerve
root up here innervates thediaphragm.
And it also innervates here,here, and here.
That's where you feel yourdiaphragm.
You don't feel your diaphragmdown here.

(20:16):
Okay.
So, and that's just theneurologic, the neurology of it.
So this patient has thisepigastric pain.
She's been to a zillion doctors.
She, someone took out hergallbladder cause that was the
obvious thing that didn't work.
She's had an endoscopy.
She's had colonoscopy.
She's had, she's tried a milliondiets.
She's been doing naturopath, puther on a million different
things.
It didn't work, obviously.
It didn't work.

(20:37):
Uh, been to a, to achiropractor, maybe helped a
little bit.
She comes to me and says, Ievery single, I have time.
I have menstrual cycle.
I have horrible pain in rightunderneath my, my gut hair.
Um, and I have endometriosis.
I've been operated on in thepelvis for endometriosis before,
but, but everyone says itdoesn't have anything to do with
endometriosis.

(20:58):
And I said, well, it mightbecause, uh, you, I would say
that you probably, that thatarea of pain is the right colon
cuz the, the, the innervation ofthe right colon is, um, where we
feel our visceral pains is wherethose nerves enter the spinal

(21:19):
cord.
We feel somatic pains where thenerve ends.
So if you smash your UL nerve,you will feel a pain running
down your, your funny bone.
It's gonna run down your arminto your pinky and your, and
your second finger.
Your second finger.
And actually, uh, because that'swhere the ul nerve innovates.
So you hit the nerve.
It, I just did it right nowhurt.

(21:39):
It'll run right down the rightdown.
So somatic nerve goes out,nerves come in.
So if a visceral nerve isirritated, you're gonna feel the
pain where the nerve meets oneof the, the plexes between the
sympathetic and parasympatheticplexes.
So the plexus that the rightcolon will hit is the celiac and
superior mesenteric plexus.

(22:00):
Okay, so that's right here.

Natalie (22:03):
Hm.

Nick (22:04):
So when the person says, I have pain right here, I know,
first of all, she is feelingpain in that plexus.
It's a visceral pain.
It's not a very sharp pain.
It's a really dull, aching,severe cramping grabbing pain
right there.
Okay.
Neurobiology tells me she'sfeeling a visceral pain in that
plexus.

(22:24):
What organs are bringing nervesto that plexus Transverse colon,
the, the right colon, A littlebit of the ileum, uh, uh, the,
the right kidney.
Um, these are the things thatare getting there.
Okay.
At least within the bowel.
The left, left kidney, there's arenal plexus, but it kinda left

(22:45):
kidney could be too.
And so I'm like, okay, wellsomething is wrong in that.
Like it's not possible for therenot to be anything wrong in that
set of things because there'sonly so many signals that get
there.
And so rather than going like,oh, you have this pain here, I
don't know what it is, you'relike, oh no, let's just figure
it out.
Like it's gotta be something.
And so we operate on her andshe's got a huge baseball of

(23:05):
endometriosis in her secum andit wasn't, it wasn't that easy
to see, to be honest.
Like I could see how you mightnot see it because it, the secum
really is very distensible and.
And when it, when you get a masson the wall of the secum, it
doesn't look that muchdifferent.
Um, and so what I saw is thatyou could just see some unusual

(23:27):
adhesions around it and youcould see that and you touched
it with your instrument.
It felt hard, but I knew what Iwas looking for.
I was like, there's gotta besome disease in that general
vicinity, right?
So I go in there, we do a allocectomy, we take out part of her
right colon and she's cured.
It's like the surgery is not thebig deal.
I mean, any, any colorectalsurgeon can do that.
And I didn't do that part of thesurgery myself.
I kind of made the diagnosis andI coordinated for her to have a

(23:49):
right, right.
He colectomy and although not awhole just take out like the
disease piece, but anyway, youknow, and she's better.
So like that, that was somethingthat I was like, wow.
I mean, if I hadn't studiedthis, I wouldn't have solved
that problem and that, and that,you know, that, that feels good.
I'm like, oh, glad.

(24:09):
So that's so neuro pub.
But, but what's really importantabout neuro pulmonology is that
it's not like the panacea toeverything.
Like it, it definitely leads to.
Some diagnoses that we might nototherwise have made.
Sometimes it leads to somedifferent surgical plans.
Sometimes it leads to some, afew different kind of surgical
techniques, but it's not thesolution to everything.
I do have some patients contactme who have had, you know,

(24:32):
recurrent pain after ununfortunately, like recurrent
issues after endometriosissurgery, um, and who have had
surgery by good surgeons.
It's not like they had badsurgery.
They just, like, for whateverreason, their disease state has
not responded as well tosurgeries they would like, and
some of those patients we canfigure out like, oh, well maybe
there is some nerve compressionor something that we can
address.
But some of them, you know, Ican't solve everything.

(24:54):
I, I, there are mysteries toeveryone and, but I, I think
that it's a, it, it, that fieldof study does reveal some of the
mysteries.
And so like you have this wholechunk of patients where you're
like, you're not quite sure howto fix them.
And you're like, okay, now wecan whack off a slice of that
chunk and go, oh, I know how tofix this part now.

(25:14):
There's still other parts thatyou don't always know, but, but
it's definitely led to some goodthings.
So, um, and again, it's a, Imean, it, everything that is new
starts out as being blasphemy.
I mean, David Red Wine's theoryof Excision was completely
derided 20 years ago.
People thought he was insane.
Now he's like, everyone knowsthat, you know, everyone thinks

(25:34):
very highly of him for startingit.
And he and a few other guys aresort of the first few people to
excise endometriosis.
So Neuropsychology was startedby Mark Paso about, you know, in
his own la in his own like madscientist laboratory, like 20
years ago.
And he kind of kept it tohimself for 10 years while he
was sort of developing thiswhole set of theories and then

(25:57):
eventually started tellingpeople about it.
And, and now 20 years later, hejust got the, the, it's a, I
can't remember what it's, what,it's a European award.
It's effectively like the NobelPrize for Medicine in Europe
that he was just awarded thisyear.
So,

Natalie (26:13):
How cool?

Nick (26:14):
it's, it's like it took 20 years in the first 10 years.
People thought he was insane,you know?
And they thought that he wasalso using that technology to,
uh, help paraplegic people towalk, which has nothing to do
with pelvic pain and still doestoday.
And it's something that I'mactually interested in
developing the United States,but it's, it's a little easier
to do the stuff in Europe, butusing a better understanding of

(26:38):
the electrical, the electricalissues of the nerves to get
around the fact that people'sspinal cords are broken.
And, you know, he has madepeople who are paraplegic able
to get up.
I mean, they're not running amarathon, but he has made them
able to get up and walk and get,you know, get something out of
the, out of the, get cereal, outof the cabinet and have a better

(26:59):
life.
You know, and they, it's not,and there were neurosurgeons
that said that you're lying,that these people are actors.
This is a scam.

Natalie (27:10):
Wow.

Nick (27:12):
There's no way this is true.
And they, they would ratherbelieve that this doctor is
literally hiring actors topretend they're paraplegic and
get up than to believe thatmaybe they don't entirely
understand this stuff as well asthey think.

Natalie (27:27):
Hmm.

Nick (27:29):
And that happens throughout medicine.
People are very, very sure thatthey're right about everything,
because that's what they weretaught.
And doctors are taught to,should be sure.
Doctors are taught to kind oflike project confidence about
what they know and to, they'resupposed to be the, the, the
source of knowledge forpatients.
And that, you know, youshouldn't tell a patient, I

(27:50):
don't know.
Although, I mean, a lot ofpeople do, but some people are
like that, that when you'rechallenged by something that is
completely different than whatyou thought was reality, your
first thought is it's bullshit.
It's, it's fake.
It's made up.
there's a lot of people thatthought that about endometriosis
surgery.
There's people that still do,there's people that still
believe that what I do is likeCharlatan re or something.

(28:12):
And I'm like, I don't care ifyou believe that.
That's fine.
I, I, it's like I have, we'renot a hundred percent success.
And what they do is they pointto the few patients that haven't
done as well as we would likeand say it, look at this thing
doesn't work.
I'm like, yeah, well look at thepatient who's like so much
better.
You know?
So, and most people aresignificantly better.

(28:32):
I, I, and I never sell, I neversell endometriosis surgeries,
the cure of endometriosis.
I, it's the best thing that wehave.
It's, and if I tell a patientthat if I can make you 75%
better from your symptoms,that's successful surgery.
You know?
And, and, um, and hopefully wecan achieve that.
And, and, and I, so it's, again,a long-winded answer that goes

(28:54):
in a million directions, but.

Natalie (28:56):
Well, the approach is so vastly different than what
you generally get going to, youknow, a regular, I guess, reg
quote unquote regular ob.
And I think for me, and a lot ofother patients I've talked to
who have been through excisionsurgery, just the fact that you
can say your pain is real and Ican see it and I can remove

(29:16):
that.
is so validating and I thinkthat.
I mean, it's a huge component,if not one of the biggest
components of having, you know,hiring a specialty surgeon for
endometriosis.

Nick (29:31):
Yeah.
I mean, it's, it's veryimportant.
It's always real.
All pain is real.
Okay.
I, I honestly am not sure in thehistory of time that anyone has
ever made up the fact thatthey're hurting.
I mean, I'm just like, I don'tunderstand it.
I really don't, I don'tunderstand it.
There's, there's people that areso caught up in the fact that

(29:52):
they can't fix someone.
That their own inability to fixsomeone is so goddamn painful to
them, that they would ratherbelieve that the patient is
fabricating it than that.
They were just incapable offixing it.
There's things I'm incapable offixing.
There's lots of things I'mincapable of fixing, and it
feels bad and I'm sorry aboutit, but that doesn't mean I'm

(30:13):
gonna tell the patient thatyou're making it up because I'm
infallible.
I'm infallible.
I can fix everything.
So if I can't fix it, you mustbe making it up.
No, it's horses shit.
It's like you can't fixeverything and you try, you try
to do your best to fix things asbest we can and, and the, but
there's a lot of people thatfeel that way.

(30:34):
Like I, you know, or the, theidea that there's this large
population of patients who arefabricating pain in order to get
narcotics because they'readdicted to narcotics.
And I'm like, I think it's real.
I think there are people thathave developed dependencies on
narcotics.
but I think it started out withpain.

(30:54):
And I think that they areexperiencing pain.
Again, I think they've continuedto experience pain and the only
way that they're having anysuccess at having addressing it
is through the taking of potentanti pain medications.
I mean, it does create a lot ofproblems and I really try to
avoid making that solutionbecause it's a difficult, it's a
difficult path to get outta.
Um, but I, I don't reallybelieve that there's this large

(31:17):
population of people who justmake things up, like, why would
you bother?
You know, like, that seems likea lot of effort,

Natalie (31:25):
Yeah,

Nick (31:25):
But, uh, nonetheless, some people, some people tend to
think that,

Natalie (31:29):
I think especially in women's health, because we've
been, we collectively as womenhave been dismissed for so many
years saying, oh, you know,you're, I, for whatever reason,
what, whatever bias the provideris coming from, or just assuming
that you're complaining aboutpain for whatever reason, that I
think many women either like,just suck it up and say, well,

(31:53):
this is what I have to dealwith.
Or they go beyond that andexaggerate potentially, or, or
they have to make it appearworse to actually get some help,
which is really sad because thatshouldn't, it shouldn't be that.

Nick (32:10):
No, no, it shouldn't.
And I, but I, I will also be indefense of, you're, you're the
person who isn't very good atthis.
A little bit like I wasn't verygood at this.
When I started, you know, earlyon, I mean, I was terrible at it
as a general ob b gyn, I mean, Ibelieve lots of things that I
now think are ridiculous backthen.
And, um, you know, asking ageneral ob gyn to be really good

(32:33):
at pelvic pain is like askingthem to be good at neurosurgery
or something.
It's like you don't get muchtraining in it.
Like I have zero training inneurosurgery.
I have almost, well, I actually,I guess that's not true anymore.
I have zero training in, youknow, whatever podiatry, and I
have, you know, almost zerotraining.
As a general obgyn, I had almostzero training in pelvic pain and

(32:54):
endometriosis.
I mean, like, it could fit intoa thin, what I was trained, it
was like, take birth controlpills.

Natalie (33:00):
Right.

Nick (33:01):
If that doesn't work, try Lupron.
If that doesn't work, crysurgery.
But surgery won't work anyway.
But you can, at least you cantry it and then you can say you
did it.

Natalie (33:07):
Oh man.

Nick (33:08):
You know, and I'm not joking, like that's what I was
trained by.
Intelligent, thoughtful, caringpeople who really thought that's
all they had to offer, you know?
Yes, these people are miserable,but don't get too caught up in
it cuz you'll make you miserabletoo.
You know?

Natalie (33:23):
Wow.

Nick (33:24):
And, and to some extent it's true.
Like if you really get involvedin taking care of a lot of
patients with public pain andall you do is fail at it,
they'll make you miserable, makeyou wanna go kill yourself, you
know?
And it's like doctors want tofeel good about what they do and
that, that doesn't I get that.
I totally get that.
And so, um, uh, so they're notgood.

(33:47):
I don't really train that.
And they didn't spend a lot oftime.
And second, if you were to takeme what I know now and ask me to
see 30 patients in a day, Iwould fail.
Like I cannot do what I do in 15minutes.
And the industrial machine ofmedicine these days asks doctors

(34:07):
to see 20 to 30 patients in aday.
It is like, so in the morningyou start at like eight 30 until
noon, you're gonna see a patientevery.
15 to 30 minutes at most.
You're gonna get 30 minutes witha new patient, 15 minutes for a
return patient.
You're gonna do it again in theafternoon.
You're probably gonna have totry to dictate during lunch, and
then you're probably gonna bedoing charts after you go home,

(34:28):
after your kids go to bed.
So ask that person to reallydedicate themselves to doing
something that A, is gonna take'em a lot of time to master, and
B, they're not gonna get paid todo.

Natalie (34:40):
Hmm.

Nick (34:41):
It's like, forget it.
Of course not.
And, and, and it, no.
And, and, and again, if you wereto put me in that position, I
would not be able to do what Ido.
I, I spend an hour to two,sometimes even two hours with a
new patient.
I frequently see them back foran hour for a follow-up visit.
Sometimes I see people for anhour for an unpaid post-op

(35:02):
visit.
Like most people have theirnurse do a post-op visit and the
doctor that comes in and goes,Hey, how you doing?
Okay, bye.
Because it's like, no, you'renot paid.
Like they gotta like, churn,churn, churn.
And.
You know, I spend an hour with apost-op patient.
I can't remember how long youand I spent together, but we,
we, you know, we'll, we'll checkthe incisions and stuff, but
mostly we'll talk, we'll talkabout what, what did we find,

(35:23):
how does that correlate to whattheir symptoms were?
And then we'll go over a videoof the surgery and we'll say,
this is what you sh this is whatwas there, and let's, let's kind
go through all the highlights ofthe video and then I'll give
you, copy the video so you canlook at it, you can take it
home.
And not paid.
I mean, to me it's like all partof the, what I do, you know,
that's just part of, part of theservices I want to provide.
But I mean, that would beimpossible to do in a, kind of

(35:45):
like a traditional medicalpractice.
So, you know, and the vastmajority of people are in
traditional medical practices.
So it's, it's not, it's not justthat, like all these are just
ignorant, bad doctors.
Like the system does notpossibly allow them to succeed.

Natalie (35:57):
Hmm hmm.
Yeah.
Interesting.
I will tell you the video that'sone of my favorite things that I
received.
I mean, besides having surgeryobviously, but I have been able
to show a lot of my friends, myvideo, I'm kind of the nerd
like, Hey, you wanna see myinsides

Nick (36:15):
You gonna see my endometriosis?

Natalie (36:16):
But it has been eye-opening to a lot of people
and other providers that I'mfriends with who I can show and
say like, look at this.
Would you have assumed that thiswas a problem?
But look at how extensive itgets once he goes in there and
starts to excise it.
So, um, yeah, I think it's, it's

Nick (36:33):
it can be,

Natalie (36:34):
interesting teaching tool.

Nick (36:36):
I had a patient just last week that was 25 years old who I
have, she had a lot of pain andI'm, I'm, I'm glad I found what
I found.
But I looked in there and I'mlike, wow, I got a lot of
endometriosis and.
She's 25 years old, likeextensive and it, but it was the
perfect time to operate becauseit was very developed and not
yet horrible.
Like she, I would say that shewas five years from having a

(36:58):
Bower section, but she was, or10 years from maybe five or 10
years from needing a Bowersection.
But, but it was early enoughthat we're able to get it before
it kind of got into there, butit was really right on the edge.
I mean, it's like the creepingooze of some, you know, whatever
fantasy movie Marvel you want oflike, it, it's like kind of
growing and growing and growingand you can see that it was just

(37:18):
starting to tack onto the, andthe was just starting to get
stuck in the back of the vagina.
It's like, huh, this is 10 yearsbefore this other horrible case
I did last week was, you know,and, and I was like, wow, that
was, and, and, and I, I think,you know, we did a good surgery
and I'm sure she'll be a lotbetter for it.
Um, and it's a crazy disease.

(37:38):
Like, I, I don't like, I'll bethe first to say like, I don't
understand the disease and Idon't think anybody does.
I'm a little bit put off.
By the certainty that somepeople will talk about, about
why they think people haveendometriosis.
Because I've read plenty ofarticles, I've read a lot of
articles written by the peoplethat seem so sure about it, and

(38:02):
I have yet to be convinced ofanything, to be honest.
I mean, I don't find anyparticular explanation for
endometriosis to be explanatoryof everything I've ever seen.
And, and I also don't find thelevel of proof required to prove
some claims to have been metpersonally.
Uh, you know, I'm very openminded about what is this

(38:24):
disease all about.
And I, I actually, the one thingthat I truly firmly believe is
that it's not one disease, andthat to call endometriosis one
disease is, is just kind offoolish.
I mean, you typically, when youhave a disease, it looks a
certain.
Endometriosis doesn't look acertain way, that there's
markedly different cases ofendometriosis.

(38:45):
There's some people that havethis explosion of superficial
endometriosis everywhere.
There's some people that havevery focal deep legions that are
like invading all the way downto their pelvic floor, but it's
in one place.
Everything else looks totallynormal.
There's some people that haveadenomyosis that they were born
with.
Clearly they never had children,but they've got it.
Okay.
How did that get there?

(39:05):
They had some people that haveendometriosis.
There's some people that have adisease in their diaphragm and
other people that don't.
Like when you look geneticallyat the disease, it's very
diverse.
Um, I used to work with agenetics lab in Utah.
Um, and we sequence the DNA ofour patients, and there's over a

(39:26):
hundred genes that have beenidentified that are really
tightly bound in the diseasestate.
Meaning that if you have thatgenetic mutation, you're very,
very likely to haveendometriosis.
And some of those genes arevery, very high value mutations
that you've, you'veendometriosis percent practical.
And if it were one disease, youwould see one group of genes in

(39:47):
one locust that all do prettymuch the same thing.
You'd either find one dis, you'deither find one, one gene, or
you'd find like a bunch of genesthat pretty much do the same
thing.
But that's not whatendometriosis is like.
Like there's a whole bunch ofgenes that clearly quote, cause
endometriosis that do totallydifferent things.
Like you look at what do they doin the body.

(40:07):
Some of them are cell cellinteraction defects, some of
them are angiogenesis defects,some of them are neurogenesis
issues.
Some of them are just painsensitivity issues where people.
Their primary defect is theyseem to have an outward, an an
exaggerated, and I don't meanthat they're exaggerating it,
but like their neurologic systemis, is perceiving an exaggerated

(40:27):
sense of pain.
And that's really the one thingyou can identify about them.
That's not normal.
And so when you see these thingsthat are so genetically diverse,
what it says is that it's notone disease.
It's, it's just like cancer'snot one disease.
You know, nobody would say thatcancer is one disease.
It sounds crazy to say that,cause obviously lung cancer is
not leukemia and that's not, youknow, skin cancer.

(40:49):
Like anybody can, any reasonableperson would say that.
And I think that from a geneticbackground point of view,
endometriosis is very much likecancer.
And yet as surgeons and doctorswe're kind of taught that, okay,
it's all the same, but it's not.
I mean, you, you will see somepatients who will have
excisional surgery and they willhave be cured.

(41:10):
They will dance the jig andthey'll scream to the world
about how they were cured.
And I'm glad I was a part ofthat.
That's awesome.
And then you'll see somepatients that'll have excisional
surgery and they'll recur a yearlater.
And some of the internet wouldlike to say that patient didn't
get good enough surgery.
And I'm here to tell you that'snot true.
Um, it's true sometimes.

(41:31):
I mean, clearly if you haveendometriosis surgery, that
doesn't effectively remove thedisease.
Yeah.
That, that, that's the problem.
But there are plenty of patientswho have had surgery by very
good surgeons, including myself,including you name it, any name
you wanna come up with who haverecurrence and, and you can go
back and look at the surgicalvideo and you're like, good.

(41:52):
I mean, you did it as good asanybody can do it.
You're like, I wouldn't havechanged that surgery at all.
And yet the patient recurred.
And, and that's part of why Ilike recording all my videos.
I always go back if I have apatient that comes back a year
later and they're having someissues, well, let's go back and
look at the video.
Where are you in pain?
Is it, oh, was there somethingthere that maybe I should have
done differently?
I don't, I don't know.
You can always go back and look,but at the very least, we can

(42:12):
learn from.
And, and sometimes it helps usmake clinical decisions.
Um, Of course, teaching ofcourse, is very important too,
but, but it just goes to showyou that like you can do the
best surgery in the universe andsome people are gonna not do as
well as others, and it has to dowith their own genetic
background.
I mean, I, I was, I was taughtthis as a, my first academic

(42:33):
position.
I worked with a guy named KenWard, who actually is the, the
PI of the lab that I worked within Utah for a while.
He's a geneticist, he was anobgyn, and he's a quadruple
boarded, literally the smartesthuman being I've ever met in my
life.
I mean, you, like, you, you talkwith this guy and you're like,
oh shit, this guy's smart.
Like really smart.
Like, like, like you're like,this is on a different level.

(42:55):
Genius level intelligence beyondlike, hi and, and ob gyn,
maternal fetal medicine,clinical genetics and molecular
genetics, these are allfellowships.
He did'em all and he, he said,you know, Nick, when you see one
person that has the same, youhave two different people that
have the same disease.

(43:15):
They have the same disease andthey behave differently.
It's because they're geneticallydifferent.
It's not random.
The patient that has diabetesand one person has, one person
has type one diabetes and theyhave extraordinarily difficult
to control blood, blood sugarsand it's very hard to, to figure
out how much insulin they shouldbe on.
And, and no matter what you do,they just seem to be gyrating

(43:36):
all over the place.
Another person has type one DIdiabetes.
You give them a normal regimenand it just works.
You know, the one person will belike, ah, that person doesn't
check their sugars often enough.
They're not following theregimen.
Right.
You must not be following theregimen now.
Bullshit.
They're genetically different.
They, they don't have the samedisease.
One of them has some diseasethat seems to work pretty well

(43:57):
when you just sort of replacesome insulin.
The other one doesn't, and it's,they are genetically different
and the patient.
I mean, you can't take away thatmaybe one person isn't following
instructions, but they canfollow the instructions and it
cannot go well.
You know?
And, um, a patient with, so apatient with Endo can, can have

(44:21):
a fabulous response to surgery.
And I'll also say a patient withEndo can have a fabulous
response to medical therapy.
And that's why I hate this sortof like, like medical therapy is
the dragon that is beingpromoted by these ignorant
gynecologists.
It's like, no, it's bullshit.
Like there are patients thatwill, there is a reason why
medical therapy's on the market.

(44:41):
It's because it works for a lotof people.
Okay.
And the people that it workedfor probably never went to
Nancy's snuck because they'refine.
Okay.
So, you know, you always gottalook at kind of this sort of
selection bias of the groups ofpeople that you're talking to.
It's like people that did wellwith taking birth have
endometriosis and took birthcontrol pills and they're doing

(45:02):
well.
they don't, they don't seek moreanswers, you know, they're doing
fine.
And so by the time a patient,and there's people that do well
on Lupron too, yes, there's aminority of patients that have
had, had really bad side effectsto Lupron, but there's a lot of
people that have been well on ittoo.
You know, it's, it's, it's,again, it's on the market for a
reason.
It, it has effectiveness.

(45:22):
Um, now does it address thefundamental reason why people
have endometriosis?
Absolutely not.
But does it make a subset ofpeople have an improved quality
of life?
Yes, absolutely It does.
So does Oris.
And so either one of these, anyone of these drugs are okay, so
surgery is not perfect.
Drugs are not perfect.
These, uh, all of these thingsare on the table as things that

(45:43):
can potentially be used.
Now, by the time a patient getsto my office, they've probably
tried a lot of that stuff and ithasn't worked, you know, because
other doctors have already triedthose things.
But that doesn't mean that thosethings are fundamentally evil or
fundamentally wrong, in fact,that they're effective for a lot
of people.
And, and if, if they areeffective, then great.
Now, do those things preventrecurrence or prevent

(46:06):
progression?
That's a big question.
So does the patient that I havewho's 25 years old, that looked
like she had horrible diseaseand was 10 years from bowel
section, she'd been on birthcontrol for at least some of
that time.
So if she had continuedsuppression that wasn't really
working, would she have gottenworse?
Worse, worse?
Probably so.

(46:26):
But she wasn't getting better onbirth control either.
So the question is, is does thePearson that has good control of
their symptoms on hormonalsuppression, are they having
progression or not?
It's very hard to answer that.
We've certainly seen people thatwere on hormonal suppression
that went on to have surgerythat had a horrible disease.
So clearly it wasn't suppressingthem, but it also wasn't

(46:48):
controlling their symptomsbecause they went on to have
surgery.
So did the pe, did the personwho did have control of their
symptoms, in fact have nonprogression of their disease?
These are questions you can'tanswer cause you don't operate
on all of them.
But I tend to think that youdon't have pain because you
don't have inflammation.
Again, you get back toneurobiology, like, why do you
have pain?

(47:08):
You have pain.
Cause nerves are irritated.
They're sending signals to yourbrain saying that you're
injured.
So if you're not having pain,then your nerves aren't
irritated.
So that must mean that there'snot very much inflammation.
Well, what's, what's causingscarring?
Why does the pelvis get scarred?
It gets scarred because ofinflammation, because your
immune system is going in andtrying to address this
inflammation that is going on.

(47:29):
And part of the process of doingthat is sort of waging this
immune war that createsscarring.
And so it's sort of myassumption, my, again, I don't,
I cannot proof, but if I'm gonnago from a functional medicine
point of view where I kind ofthink about how does a system
work, what is the most rationalexplanation that if someone is
not having pain fromendometriosis, they're probably

(47:49):
not having progression?
I don't know for true.
I don't know that for, I mean, Idon't know, but none that
everything's true.
Like I have some patients.
who don't have any pain.
They've never had pain.
They've not been on suppression.
We're talking about how thedisease can be different.
They've not been on suppression.
They've, they've never had pain,they've never had a problem.

(48:10):
They just can't get pregnant.

Natalie (48:12):
Hmm.

Nick (48:14):
And when you operate on them, they have endometriosis
and there's a patient that gotscarring and so forth, and they
never had pain.
So it's like no one answer issatisfactory to explain it all.
And, and why does that patientnot have pain, but maybe she has
a neurologic or, or, you know,people get upset if you just say
she, the person withendometriosis.

(48:34):
They, they, they, they, um,maybe they have a genetic, uh,
absent sensation for pain.
Maybe they just don't feel painvery much.
And there are people like that.
I'm kinda like that actually.
I mean, like my wife says, I'mlike that, that like, I don't
seem to care.
I can get injured.
And I'm like, yeah, whatever.

Natalie (48:52):
tolerance or.

Nick (48:53):
Yeah.
Sort of, yeah, sort of.
I mean, I, I sort of like, Okay.
I feel this, but it's not thatupsetting to me.
And, um, and the, I I think thatthere are some people like that.
I, I have one patient wholiterally came to see me back
when I was more doing more, alittle bit more general work.
She came to see me for justannual exam and pap smear.

(49:15):
She's a competitive tennisplayer.
In fact, kind of a low levelpro, uh, not quite at the high
highest level tour, but she waskind of trying to play
professional tennis or she was aprofessional tennis player and,
um, she had stage fourendometriosis and it was
invading into her bowel.
She didn't come into me withcomplaints about that.
She came to me with needing apap smear and I examined her and

(49:37):
she had a knot of endometriosisin the back of her vagina and I
did a rectal exam.
It's like, wow.
I mean, this is invading yourbowel.
Do you have any bowel problems?
Uh, a little bit.
Yeah.
I've got kind of constipated onein my period.
You know, do you have pain?
Also she was, uh, had femalepartners, so she wasn't having a
lot of penetrative intercourse.
That might have been more of aproblem for her if she was, um,

(49:59):
but in the end, like she didn'thave a problem.
And, and like did I recommend,like if I had operated on her, I
would've taken out six or eightinches of her colon and probably
her uterus, you know, maybe heruterus.
Um, is that worthwhile?
Like she's out playing tennis onthe professional tour, like
obviously she's doing okay.
So, uh, I didn't tell her sheshould have surgery.

(50:20):
I told her just check in, see insix months or a year and see, it
may change.
Maybe over time it changes.
And it, and it very well may bethat when she stops being so
active at tennis, she gets intopain.
And it may be that the fact thatshe is being highly athletic six
or eight hours a day is such anendorphin rush all the time that
she just doesn't have pain.
Maybe that's what it's,

Natalie (50:39):
Yeah.
Okay.
This is giving me a lot ofquestions.
So and I have two that maybe youcould kind of combo put them
together.
So the genetic aspect, if weknow that certain genes are
markers for yes, you will haveendo or you might be more likely
to have pain, whatever thatmight be.
Is there any research in, I meanthere probably is into like how

(51:03):
can we prevent such extremecases of endo in the future, or
can we like let these peopleknow that they're going to have
issues?
And then also there's also a lotof talk about endo being in
autoimmune condition.
Does that play into the geneticaspect of it as well?

(51:24):
How would you approach

Nick (51:25):
Yeah.
So, yeah, two different veryinteresting questions.
So the first question is, isthat, can we do any, can we
prevent people from getting endup at this point?
No.
Um, I would say that most of thegenetic information is still, is
still kind of in development.
A lot of it's proprietarywithin.
You know, for-profit geneticslabs, um, uh, there's a certain

(51:46):
amount of public informationand, you know, like the NIH
funding for this stuff is notvery much the, the most of the
funding is in for-profitgenetics labs that are looking
for novel therapeutics that theycan cap, that they can, you
know, commercialize.
And, and a lot of advancement inmedicine is made that way.
I mean, that's the capitalisticworld.
There's a reason why a lot ofadvancement comes outta the US

(52:07):
cuz it's, there's a incentive todo it.
Um, and so a lot of the geneticsis still in proprietary
situations.
Um, but I think right nowthere's tests you can order that
will tell you if you have thesegenes that are gonna predispose
you for endometriosis, like youcan order that test.
Uh, there's a company calledPredictive Laboratories that
will order that will, that willdo that.

(52:28):
Um, it's not very helpful rightnow.
Like there's not any treatmentswe can do.
We're not really.
Humanity right now is not reallyvery excited about changing the
genes of of, of people.
We're not very excited aboutchanging the genes of embryos
either.
Um, we're okay with selection,which means that if you do IVF
and you get 20, you get 10embryos.

(52:50):
We're okay with genotyping eachone of them and then growing the
one that has the least badgenes.
Like we're everyone's, okay,these are all these interesting
ethical, moral questions, right?
As society, we're generally okaywith that, that if you've got 10
embryos and one of them's gonnahave cystic fibrosis, why would
we implant that one?
Let's implant the one thatdoesn't, you know?

(53:12):
So we're a little bit okay withsaying that, uh, what's implant
the boy instead of the girl.
Some people are upset aboutthat.
Um, you know, and that's aninteresting ethical question,
but we're, we're, we're, we'regenerally okay with kind of
selecting that kind of stuff,but we start getting into these
questions about like, do we wantto mold the future of humanity
by kind of like selecting whatour genetic future will be?

(53:34):
So these are the things thatethicists get all bound up
about.
Um, so as far, that's all we cando right now is potentially
select embryos in ivf Right now,there is not any traction at
this moment, at least that I amaware of, that you could treat
genetically someone withinendometriosis.

(53:56):
It will happen.
I suspect it will happen.
I suspect it will happen for alldiseases.
I think that there will, therewill come a time when we look at
what we're doing right now asbeing antiquated, not just in,
not just in surgery, but notjust in endometriosis, but in
everything.
Like there will come a timethat, that we will address the
defect that caused someone toget cancer.

(54:16):
You know, rather than justtrying to cut it out and give'em
chemotherapy, but we're notthere right now.
Or maybe you have to cut it outand then address the defect.
I don't know.
But then the question becomeslike, what, okay, what does that
do to our humanity?
Do we.
We're supposed to die fromsomething, you know?
And when, when is it?
Okay?
These are all these, you know,those really ethicist
philosophical questions.
You know, do you, do you want tocure everyone of everything?

(54:38):
But anyway, that obviouslypeople, that's a off question
that you could talk about a lotthat I have no more authority
and then the garbage man.
But the, um, so right now, notreally your, your, your second
question.
Sorry.
Say what was your secondquestion again?

Natalie (54:58):
are calling Endo an autoimmune

Nick (55:02):
Oh, yeah.
Okay.
So interesting.
In any textbook, it's not onautoimmune disease, but we all
know that there's lots of thingsin textbooks that are
incomplete.
Um, it doesn't quite behave likean auto.
So I'm gonna give you atwo-sided answer to this, which
is gonna sound a wishy-washy,but it doesn't behave like an
autoimmune disease.

(55:22):
And by that I mean that youdon't have any.
Um, autoimmune fundamentallymeans that your immune system is
attacking your own tissues, andit's not like attacking
something else and then creatinga byproduct of damage.

(55:43):
It's literally attacking thetissues you've got.
So if you have a lupus, you'reattacking your own dna.
Believe it or not.
If you have type one diabetes,you're attacking your eyelet
cells and your pancreas.
If you have, um, rheumatoidarthritis, you're attacking your
synovium in your joints.
For some reason.
Your, your immune system hasidentified your own native

(56:06):
tissue as being an enemy and istrying to kill it.
It's not good, but that's whatit's, and so the general
treatment of those diseases isto try to suppress the immune
system in one way or another.
And those have changed overtime.
We have developed a lot of thesenew biologics.
Any, any, uh, Drug you see onthat has an ab at the end of it,

(56:28):
it says a adalimumab.
Uh, it's on tv.
You know, those are allbiologics.
They're all lab made, uh,antibodies that are going to
shut down some part of yourimmune system.
They're extraordinarilyprofitable.
By the way, you, you'll noticenow that the only drugs that are
direct to consumer advertisingon television these days are all

(56:51):
biologics because they'reexpensive.
It's, it's not worth it toadvertise a hypertensive
medication.
Just don't make, it's just not,it's just, it's economics aren't
there?
It used to be, I think, but it'snot anymore.
All the, all the research isgoing into new biologics, and
that's where all the ads are.
So, um, endometriosis, as far aswe can tell, it's not attacking

(57:18):
the tissue.
Your immune system's attackingthe endometriosis.
It's not attacking.
The tissue, the damage that'shappening to the tissue is the
byproduct of the, of theattacking of the endometriosis.
I think.
I think that's what's going on.
I don't think it's all the scartissue is being created by the
fact that the endometriosis iscreating inflammation and then
the immune system is,

Natalie (57:37):
Responding

Nick (57:38):
thing.
The immune system is respondingto it, and in turn, that's
creating scarring.
If you have a splinter in yourfoot, your immune system will
create, it'll be inflamed andinflamed and inflamed, and if
the body never gets rid of it,eventually you'll get like a
capsule of scar tissue around itand it won't hurt anymore
because it'll just be like adead scar tissue around it.

(57:59):
Um, and I think that's what'shappening with endometriosis.
So that, so that's where I,where I would say that it
doesn't really behave like anautoimmune disease.
That being said, there is aclear genetic connection between
autoimmune diseases andendometriosis.
Um, they co-locate, meaningpeople that tend to have
autoimmune diseases also tend tohave auto endometriosis, and I
will.
Also tell you, and it may meanthat some of the genes are just

(58:21):
close to each other on thechromosome.
So if I have a, let's say I havea eight 18th chromosome and I
have a gene that's, uh, 60% downthe, one of the arms of the
chromosome, that's where it'ssupposed to exist.
And now I have another diseaseand it's 70% down the arm.
Just the fact that they're closeto each other on the chromosome

(58:42):
is gonna make them tend to betogether because the way that we
assort our chromosomes when wego through myosis, which is how
we jumble up our chromosomeswhen we make our gammy, so when,
when women make eggs and whenmen make sperm, we, we mix up
our chromosomes.
That's why we don't createclones of ourselves.
We create, we create childrenthat carry our genes, but they

(59:03):
carry a random assortment of ourgenes.
They don't just create a copy ofourselves, nor are they a 50%
copy of mom and a 50% copy ofdad.
They're a jumble of the two andthe.
Well, they are 50% mom and 50%dad, but it's not like copies of
half and half.
It's literally like a jumble ofmom and a jumble of dad.

(59:24):
So what happens in that jumblingprocess is the chromosomes get
cut and then they switch andthey mix.
And so if two genes are veryclose to each other on a
chromosome, when you cut thechromosome and mix it with
another arm of anotherchromosome, those genes are
gonna tend to come togetherunless the cut just happens to

(59:44):
happen right between them.
And so the closer the genes aretogether, the more likely they
are to associate in the personbecause it's pure randomness.
Where's the cut gonna happen?
So if the gene is really far, ifthe genes are very far apart on
the same chromosome, you couldeasily cut between them and send
and send one gene to one egg andsend one gene to the other.
But if the genes are reallyclose together, You're much more

(01:00:07):
likely to cut the chromosome ina way that sends the two genes
to the same egg.
And so then you say thesediseases are together.
Were they causing each other?
No, but they were close to eachother on the chromosome and so
they just tend to go together.
And so the, there is definitelya over association of autoimmune
diseases and endometriosis.
I think there's an overassociation with s dental

(01:00:28):
syndrome also.
I think there's an overassociation with, uh, leaky gut
kind of, uh, IBS or some bowelissues it seems like.
Um, and the other weird thing Iwould tell you is that men who
carry the genes forendometriosis have
overrepresentation of autoimmunediseases.

Natalie (01:00:51):
That's

Nick (01:00:51):
And well, I mean, it it, it, it is.
So they, if you look at men who,whose mothers had endometriosis,
whose daughters haveendometriosis, cuz the genes
went through them and justdidn't give'em endometriosis
cause they didn't have the.
They didn't have what wasrequired to give them mendo.
In most cases, these, thesesuper edge cases of the men
getting endometriosis.
I kinda, yes.

(01:01:12):
Some people get, get one topoint that stuff out.
It's very rare.
It's so rare.
I've certainly never seen it.
It's extraordinarily rare.
I've heard of it.
I don't even know if it's real.
If it's real.
Okay.
But it's, it, it, you'll gethung up on that mostly
endometriosis as people are bornwith two X chromosomes and you
know, and if they go on tobecome men later in their life,
then that's fine.

(01:01:32):
But they generally are, it'sgenerally a disease of people
that are borning X two Xchromosomes.
So the men who carry the genesof endometriosis from their
mothers who may have daughtersthat have endometriosis, those
genes do not leave themunscathed.
They have an overrepresentationof having autoimmune diseases

(01:01:53):
and they have overrepresentationof diabetes, they have
overrepresent representation ofthyroid disease.
They so did, do thoseendometriosis genes carry some.
Additional risk of autoimmunediseases themselves, or are they
just co-located with those othergenes and they're close to each
other and therefore they tend todistribute together?
I'm not really sure.

(01:02:14):
I'm not a geneticist.
Like I'm kind of giving you ahigh level answer to this that
makes me sound smarter than Iam.
I feel like, because the, likeyou could ask a, a geneticist
who studies this stuff and theywould, they would say, okay, I
just said like 0.5% about whatwe know about this.
You know, but that phenomenon,if anything, I'm just explaining

(01:02:34):
that phenomenon that, that aphenomenon exists.
And so it's very interesting.
You know, I mean, if I, maybe I,maybe I could have been a
geneticist in another life,cause I find it fascinating.
But, but, um, you know, therewill come a time where I think
that we treat most diseases thisway.
We will figure out what are thegenetic things that are causing
the disease and just fix that.
Um, I, the ethical issues aboutwhether we edit people's genes,

(01:02:58):
I, I wish we would get over itpersonally.
I, I actually think thathumanity.
Is in a post evolutionary phase.
I think that modern medicine hasended evolution for humanity
because the whole idea ofevolution would be that you
don't reproduce because you havesome defect.
And so we are going to, humanitywill slowly evolve because,

(01:03:18):
because, or any animal or any,any beast or plant or whatever,
it's gonna slowly evolvedbecause there will be selective
advantages that will allow onemutation to win over another.
Well, guess what?
It's really, really hard to diethese days.
Like

Natalie (01:03:34):
It's

Nick (01:03:35):
keep almost anybody alive.
There's not a lot of diseasesthese days that will keep you
from reproducing.
Like Endo is like almost one ofthe few cystic fibrosis.
Another one like, and still manywomen with endometriosis are
able to reproduce and.
It's very, very hard, I feellike, for humanity to change
genetically anymore viaevolution because of modern

(01:03:58):
medicine.
And so I kind of think like, ifhumanity is going to change over
time, it's because we're gonnaedit our own genes.
And that's why I say bring iton.
I'm like, great, you know, butI'm a futurist, you know, I'm
not quite Elon Musk.
He's crazy.
But, but I mean, I, when someonesays, oh, we could edit our own
gene.
Great.

(01:04:18):
Let's figure out the ethicalissues later.
Let's just figure out how to doit first.
You know?
And I, that's my own feeling.
That's my own feeling.
Not everyone agrees with meabout that.
But I, you know, if you couldedit endometriosis out of our
gene pool, would you do it?
Sure.
I would think so.

Natalie (01:04:35):
Hmm.
That's a very thought provokingquestion.
Um, I wanted to ask kind of aninteresting question.
If somebody doesn't have aproblem getting pregnant, but
they definitely have endo, havenot had surgery, is there any
risk to carrying a pregnancy toterm with endometriosis lesions?

(01:04:57):
Is there any studies on that?
Okay.
Okay.

Nick (01:05:00):
I mean, I don't know there studies on it, it's just not, I,
I've operated a million, I don'ta million C-sections for people
with endometriosis.
I mean, if, if, if the baby gotin there and it didn't and it
survived, then I thinkeverything's gonna be fine.
I mean, there's lots of thingsthat can go wrong in pregnancy,
but the, there's, there's noreason to operate on someone to
prevent adverse pregnancyoutcome unless the outcome is,

(01:05:20):
is recurrent pregnancy loss.
Then there may be reason tooperate for that, and even
that's controversial.
But, but in general, I don'tthink that endometriosis
supposes a risk in a pregnancyanymore than other random, weird
things that can happen inpregnancy.

Natalie (01:05:34):
does it predispose you to having a cesarean ver versus
a vaginal birth, do you think?

Nick (01:05:39):
No, I don't think so.

Natalie (01:05:41):
Okay.
That was an aside question thatI, that I

Nick (01:05:43):
No, that's a good question.
I mean, if anything, maybethey're more likely to have eeds
then they're more likely to doover vaginal.
But I don't, in any event, Idon't, I I, I would say no.
I, I would not be worried aboutthe outcome of a pregnancy cause
of endometriosis.

Natalie (01:05:59):
Okay.
That's encouraging.
That's good.
Um, so if somebody is thinkingabout having surgery, what are
your hard and fast rules?
Like what are your next stepsfor them?

Nick (01:06:11):
Well, I would just say that like, if you can access
someone who's really experiencedwith endometriosis, you should,
I, if you have surgery withsomeone who's a general ob gyn,
and again, not, I never meanthis to disparage other doctors.
That's not my point.
I'm just saying like, if you'regonna have neurosurgery, go see
a neurosurgeon.
You know, if, if you probablywill not have very good outcomes

(01:06:35):
if you have surgery with ageneral OBGYN for endometriosis.
They're just not trained in howto do surgery well.
and includes me when I was ageneral obgyn.
My outcome sucked because Ididn't know how to do the
surgery.
Well.
Um, there are doctors that do,you know, excision surgeons are
not so rare.
I think sometimes online there'slike a perception that excision

(01:06:59):
surgery is so inaccessible andrare.
And I understand I'm in my ownpractices out of network.
I decided to charge for myservices cause I really
specialize in this.
But there, there are people thathave mis gyn practices that have
a reasonable experience inexcision that will do a pretty
good job in most cases.
And, and they're generallyaccessible.
So I would try to, at the veryleast, see a surgeon who does a

(01:07:22):
lot of endometriosis surgery,does many endometriosis
surgeries a month.
If you can, if you can get that,anybody that's done a fellowship
in a G L fellowship is gonna bea good place to start.
Um, if you can access someonelike myself who really makes an
entire career out ofendometriosis, you should I
understand that.
That's not accessible foreveryone.
There are some barriers and I,and that's that.

(01:07:45):
It is what it is.
But, um, if you can access that,you should, um, your long-term
outcomes I think are gonna bebetter.
Um, but if, if, if the onlyoption is to get a scope by your
general ob gyn, that's okay too.
Ask them to take good pictures,really see what, you know,
really, really document what'sthere.

(01:08:07):
And then you're gonna have a,and then even if you talk to
someone else who's a little moreexperienced down the road, if
you have really good pictures,like I frequently get pictures
from other surgeries.
I'm like, well this is useless.
I mean, it's just like reallyfar away and doesn't really show
things very closely and it'slike, okay, these pictures are
not that helpful.
And then someone asked me, doyou see?
I know.
I'm like, I dunno, it's not, thepictures are not, not adequate.

(01:08:28):
So, That's what I, but I mean,in general, I would say, you
know, access the best positionyou can.
And I'm not saying that'snecessarily me.
I mean, I, I, I'm very good atwhat I do, but I'm not, I'm not
like the only doctor in theuniverse.
You know, there's, anybody couldcall me from any state in this
country and I could tell you theclosest person that I know of

(01:08:49):
who's really good atendometriosis, like we all kind
of know each other.
We, we all go to the meetings, ag l meetings together.
And like, if you ever wondered,ever thought that endometriosis
surgery is so rare, you go tothe A A G L meeting and it's
like the endometriosis show,like every damn videos
endometriosis.
And it wasn't like that a decadeago.
Like I think endometriosis, Ithink Nancy Snuck honestly grew

(01:09:10):
a lot of demand.
Like I think that there weren'tthat many real good
endometriosis surgeons 15 yearsago, just a handful.
And I think that the growth ofNancy's no really raised the
awareness of excision.
And I think that in time themarket responded and, and more
doctors started to see this assomething that they wanted to
do.
and also more trainees saw itduring their fellowship.

(01:09:32):
They saw videos at a g L and soforth.
And I've been going to a G nowfor 15 years and it's totally
different.
It used to be like endometriosiswas like a one video session, a
few videos.
Now it's like you could watchfor four day meeting, you could
watch endometriosis from thebeginning of the day to the end
of the day.
All meeting long if you want to.
I mean, there's lots of sort ofbreakouts.

(01:09:53):
You can't watch it all at once,but there's enough endometriosis
you could never stop watching itif you want to.
Um, uh, and so clearly theinterest in endometriosis is
there.
Um, but you know, see somebodywho does a fair bit of it.
Um,

Natalie (01:10:12):
Solid

Nick (01:10:12):
I would say.

Natalie (01:10:14):
That's what I would also recommend.
I know I am very, very thankfulwe were able to fly, cuz in
Alaska we don't have any endneurosurgeons any, unless you
know of anybody who has started.
Yeah.

Nick (01:10:27):
I don't think so.
It's difficult in Alaska, Ithink.
I think that it's a smallmedical community.
It's not really that supportive.
It's not really enough of apopulation to support a
full-time kind of endometriosissurgeon.
It's hard to, it's hard to dopart-time endometriosis surgeon.
Well, to be honest, I mean, itjust takes a lot of doing to be
really good at it.
But it's all a big spectrum, youknow, and we're all getting,

(01:10:51):
we're all getting better at it.
The more you do it, the betteryou get at it too.

Natalie (01:10:54):
So if somebody wants to do more research, um, what are
your favorite books, websites,people, accounts that you would
recommend?

Nick (01:11:07):
I mean, I think that a lot of, you know, my honest answer,
if you were to give me my answerwould be to find a doctor who's
really experienced with it andthen go work with them and trust
them and let, let them tell youwhat they've learned about this
disease state.
I, it's not to say that youshouldn't do research.
I, I.
you should, but anything you getonline and it's gonna be like in

(01:11:31):
Facebook or something, it'salways gonna be somewhat true
and somewhat incomplete.
I think that there's a lot ofvery, very kind of monolithic
truths that are spun aroundonline that just aren't
complete.
It's not that they're wrong,it's that it's that if you've
seen enough patients, no onetruth is going to be true for
all of them.
And, and so getting a lay of theland, I mean, if there's one

(01:11:55):
thing to learn, it's that, yeah,you probably should excise
endometriosis and not ablate it,and you can learn that pretty
quickly.
Uh, if you, if you decide to dosome work online and look at,
look in various differentthings, but take it all with a
grain of salt also, that ifanything is being presented as
being the monolithic truth ofeverything, realize that, no,
it's probably a little bit morecomplicated than.

(01:12:18):
And that's why it's helpful toreally see someone who's really
experienced, because they'veseen a lot of different cases, I
mean hundreds if not thousandsof people.
And they kind of see differentkinds of cases, how they tend to
go, how they tend to respond todifferent things.
And that's probably going tokind of lead you down the road
most likely to help.
Um, I think if you're interestedin the disease state, there's

(01:12:40):
tons and tons to read.
If what you wanna know is how tofix yourself, go see somebody
who works with a lot ofendometriosis patients and take
their advice.
Um, what I always say is, um,find a doctor you trust and then
trust them, which means do lotsand lots of research to figure
out who you wanna work with.

(01:13:01):
And then once you decide to workwith them, let them give you
their best advice and, and doyour best to take it because
they ultimately have your bestinterest at heart.
You know, doesn't mean thatthey're infallible, but, but it
means that.
they've seen a lot of things,and so hopefully they're gonna
be able to make the bestjudgment about what would be a
good path.
At least.
At least kind of lay it outthere and let you make a

(01:13:22):
decision.
Um, there's tons of books outthere though.
I mean, a lot of the, a lot ofthe kind of big name
endometriosis surgeons havewritten books.
I haven't, um, if I ever did, itwould just be like, everything
we know about the deceasedstate, it wouldn't be about me.
It'd be like, okay, what do weknow?
The problem is it would be outtadate in like two minutes, but,
um, but, um, there are a bunchof books out there.

(01:13:44):
Uh, Iris Orbs book is excellent.
Uh, Dr.
Seskin wrote a book.
Uh, there's, there's a bunch ofbooks by, by some surgeons.
I, they're all gonna have goodinformation.
They're all gonna be fairlysimilar, which is basically to
say excision surgeon is, isexcision, surgery is helpful, PT
is helpful.
A lot of things, um, in, in manyways, a, a good way to, to, to
research per se is talk to a lotof other people who have a

(01:14:05):
disease state and see how, howthings went for them.
Um, and.
While being aware that you areunique and that you will not
necessarily follow the path ofany other particular person.
But if you talk to a lot ofdifferent people, um, you will
get a sense of different pathsthat have been have, there have
been for different people, butalso being aware of like,
depending on where you find thepeople, you're gonna get a

(01:14:27):
certain bias.
So if, if, I would say thatpeople that are really, really
successful with theirendometriosis treatment are less
represented online than peopleha haven't done as well.
And I think that's because, um,if you're really successful, you
probably get on with the otherimportant things in your life a
little more.
And if you're not doing as well,you may be a little bit more

(01:14:48):
occupied with it and wanna spendmore time.
And I don't know that for sure,but I think that's probably
true.
So I, I think there's a littlebit more of an
overrepresentation of problemsin some of the online spaces
than if you take the entirepopulation of people that have
gotten treatment forendometriosis.
So it's all good.
Just realize it's all.
It all has certain biases to itand, and even what your

(01:15:10):
physician tells you has certainbiases to it and try to make the
best decisions you can.

Natalie (01:15:14):
Yeah, I would say that echoes my experience because
originally when I didn't knowanything about surgery, I was
like, absolutely not.
Why would I, why would I getsurgery

Nick (01:15:24):
Why would you do

Natalie (01:15:25):
do that?
Until I talk to people who hadexcision and they explained to
me the benefits.
And I, I'm one who likes to knowthe why behind every single
thing that I do.
don't just tell me to dosomething.
Tell me exactly why I'm gonna doit.
Um, and so that was reallyhelpful for me to learn, um,
prior to actually havingsurgery.

(01:15:46):
And, and I, that was anempowering decision to make for
sure.

Nick (01:15:50):
Mm-hmm.
Hmm.

Natalie (01:15:51):
and to put it on the record for you, I know I've
talked about this online andanother podcast episode, but I'm
doing better.
My constipation is better, mypain is better.
I'm really, really happy that I

Nick (01:16:02):
Yeah, I wanted to ask, I mean, it's not really your pod,
my podcast to direct, but youknow, you had surgery a year and
a half ago or something.
I mean, on a scale of one to 10,how much if, how bad was it
before and how is it now, youknow?

Natalie (01:16:15):
I would say it was an 11 before 11 or 12 If I can go
beyond the scale and, um, Iprobably, I was trying to
calculate, I think I had pelvicpain more than half the month
prior to surgery, which when Isat down and looked at it, I was
like, this is more than half mylife.
That is significant to time tobe in pain.

(01:16:37):
And after surgery, I still get,I still get pretty significant
cramps on like day one or two ofmy period, but way less
bleeding, way shorter periods,way less pain overall.
And I'm not, I'm not having painhalf the month and I can do.
Life I can do real things cuz Iwas calling out of work, um,
when I worked for somebody elseand I was staying home and now I

(01:17:00):
can actually live my life evenif I'm having some cramps.
So, yeah.

Nick (01:17:06):
that's good.
And that's, and that's arealistic success, you know, and
I think that that's what wewanna accomplish.
I mean, I, I, endometriosis isa, it's a shitty disease state.
It causes inflammation andscarring.
And like, you cannot takesomeone who had endometriosis
and make'em into someone whonever did.
Like, you can remove theinflamma, you can remove the

(01:17:27):
sort of ennis of inflammationand, and then remove the tissue
that is sort of inflamingeverything.
And then the body has to healit, and your body will heal
scars over a long time.
But as we know, like if you havesurgery and you get your belly
cut open, it never looks likenormal skin again.
You know, it's.
it will be really inflamed andthen over time it will be less

(01:17:49):
and less scarred, but it neverlooks quite normal and you can't
really make the pelvis normal.
What you can do is you can tryto make it a lot better, and I
think in turn, people's symptomsare generally a lot better.
And that's exactly your outcome.
Exactly what I hope patientswill have, which is that their
life is better.
Not that they have no painwhatsoever, but that they have a

(01:18:09):
notable increase in theirquality of life and that they're
able to be more productive orbetter with their family or
their kids or whatever.
And that's what I canpotentially offer.
You know, I can't offer cure ofthis disease state, like the
disease state is in their genes.
It's not something I can cure,

Natalie (01:18:24):
brain.

Nick (01:18:25):
I can make things better.
We could even show your video ifyou want, but you want to

Natalie (01:18:31):
do it.

Nick (01:18:32):
Okay, you see that?

Natalie (01:18:34):
Uh, yes I can.

Nick (01:18:37):
All right.

Natalie (01:18:37):
is very exciting, I haven't watched it in a few
months, so

Nick (01:18:44):
Okay.
So this is the beginning of howwe start any surgeries.
We look at the diaphragms.
This is the gallbladder.
We always look behind the liverhere.
This is something that I starteddoing a couple years ago where
we get, you can getendometriosis behind the liver.
This is all the way behind thelivers is posterior diaphragm.
The vast majority of people thatlook at the diaphragm don't look
back here.
I think.

(01:19:04):
Um, and I've seen disease backhere.
This is a left diaphragm upthere.
This is us pulling the camera inand out to clean it.
But, um, Okay, so this is now inthe pelvis, but let's, let's,
we'll stop.
This is the pelvic brim.
So this is kind of where you'redipping from being your lumbar
spine into your sacral parthere.
So your sacral vertebrae arekind of underneath all of this.

(01:19:27):
This is fat that's attached toyour colon that's now attached
to the pelvic brim.
These white spots here areendometriosis for sure.
Um, notably, this is about overthe area of your first sac nerve
root.
It's not that deep, so I don'tknow whether or not this
would've inflamed that nerveroot because there's a quite a

(01:19:48):
bit of tissue between this spotand the nerve root, which is
like a couple centimeters downfrom there.
So if it were enough to inflammit, you might get some pain down
your left leg, but it may not bequite enough.
Um, endo here.
This white spot here.
And as far as in general forpeople like this is a case of

(01:20:08):
like stage two endometriosis.
We have an open cul-de-sac here,the bowel, this is a colon, this
is the back of the uterus.
It's not completely fused backhere, which would be more of a
stage four case.
But there's also deepinfiltrating endometriosis.
You see this black stuff in theback of the vagina that's deep
infiltrating endometriosis.
These are the uter cycleligaments, that's endometriosis.

(01:20:28):
Um, and so we're kind of juststarting and then we're gonna
dock our surgical robot, whichwe have now, this is robotic.
You notice that the screen isreally stable now.
Cause the, the, the, uh, the,the robot is holding the camera
instead of a human.
Humans are always jickling theirhands around, where's a human?
The robot is just dead stable.

Natalie (01:20:47):
Got.

Nick (01:20:48):
this, these areas here we're taking down, we're gonna
remove some of that stuff.
And now this is this area ofendometriosis that's on the left
uter sac ligament.
You see this black.
This blacks up.
This would cause pain into yourback on the left side.
This might cause urinarysymptoms.
Um, it would cause painpotentially into your, probably
into your back left side of thepelvis, maybe, maybe into your

(01:21:11):
butt, uh, maybe into your pelvicfloor.
Um, and it's also gonna createuterine pain effectively because
the nerves that are carryingsensation from the uterus are
running right underneath here.
It's called the inferiorhypogastric nerve plexus, and
it's running right underneathhere.
So this area of endometriosis isinherently gonna inflame the

(01:21:33):
nerves for the uter from theuterus.
It's gonna give you the sensethat the uterus is in pain, even
though the uterus itself is notnecessarily the source of the
pain.
It's the, it's the nerves thatare just are, that are, that are
coming from the uterus that aregetting inflamed.
And so we're using ourinstruments here to remove this
endo.
There's the fallopian tubegetting in the way, and now I'm

(01:21:53):
gonna use an instrument to getit outta the way.
Probably.
Um,

Natalie (01:21:57):
It's kind of floppy

Nick (01:21:58):
So, um, yeah, and you know, surgery's not perfect.
Like, like if you see an editedvideo, you're always gonna see
like this beautiful thing causethey cut out all the garbage,
but weird things happen all thetime.
Like right there, the Flo tubekind of fell in the way and got
in their way.
So we had to get it outta theway.
And sometimes the bowel fallsdown in the pelvis cuz it's,
it's attached down there.
So sometimes it, we want to kindof pull it outta the way, but

(01:22:21):
sometimes it kind of just fall.
All the small bell falls downand you gotta get it up outta
there.
So this is excision.
Ablation would be where you justeffectively would just try to
burn the lesion away, whereas inthis case, I'm trying to cut,
cut the tissue out.
That is, um, that is inflamed.
Um,

Natalie (01:22:40):
So cool.
It's

Nick (01:22:41):
and on the right side, this is the lesion on the right
side here, right side of thepelvis.
Ureter, this tube right here.
Do you see my pointer by theway?

Natalie (01:22:49):
Um, yeah, it's very small for me, but I think in the

Nick (01:22:52):
You can see it.
So this, this area right here isthe ureter.
Um, this particular case, notvery involving the ureter, but
the, the ureter is running rightover here, and this is
endometriosis here on the rightside of the pelvis, this red
inflamed area.
And then you can see, right,endometriosis is like a, it's
kind of like there's a top ofthe mountain and everything is

(01:23:13):
growing from it.
And so the, the actual biggestlesion is right under here,
right here where I'm, where I'mmarking it.
But you can see this whole kindof area here from the other
side.
You see this lesion right here.
And in fact, my partner, Dr.
Molan, just made a really niceInstagram video showing
something like this, like thelesion is right on the other
side here.
And the, um, you can see we'rekind of just getting all that

(01:23:37):
tissue off.
Um,

Natalie (01:23:41):
Yeah.
It's amazing to me how deep itgoes,

Nick (01:23:44):
yep, it does.
Right.
And part of the key for doingdecision is to get deep enough,
and again, what we were talkingabout before about knowing
anatomy that.
You gotta know the anatomy ofwhat's underneath there to feel
comfortable going deep becauseyou got, there's stuff under
there that you don't want toinjure, so you better understand
where it is.

Natalie (01:24:02):
Mm-hmm.

Nick (01:24:03):
Um, and if you don't, it's difficult to proceed because
you, you're afraid you're gonnacause damage.
And I've heard lots of timesyou'll hear people say, oh, I
didn't wanna remove that diseasecause I was worried I was gonna
hurt the, it's not that it's notremovable, it's that that person
doesn't understand the anatomyof the situation very well and
they don't understand thetechnique very well.
It's not like it's fundamentallynot removable.
It's just like that persondoesn't quite have the skillset

(01:24:25):
required.
And so here now we're justremoving all that.
So that's that whole bit ofendo.
And then this is endo that wasright behind the vagina.
I'm sure this would've causedpain with sex.
Um, this, this, this is rightbehind the vagina.
So if someone was, if you orsomeone's having intercourse,
and it's gonna be pushing rightup into this space.
And so this is endometriosis isright behind the vagina that

(01:24:46):
we're removing and.
I think, you know what's funnyis I watched this video, I think
I even remember that there waslike a plume of brown endo as I
cut through this.
Like I, it's weird.
I have like this flashback, I'mlike, oh yeah, I remember this.
Um,

Natalie (01:25:01):
That's amazing with how many patients you see every
year,

Nick (01:25:06):
uh, well now I wouldn't have remembered that this is
your video, to be honest.
I mean, I I you, I looked it upcause I had your name on

Natalie (01:25:12):
Oh, I

Nick (01:25:13):
but I, but, but I kind of, but I kind of remember this
moment in time.
I was like, oh yeah, I think Iremember that Legion But the,
uh, the, so you can see thatbrown is that brown right there.
That's the infiltratingendometriosis is that little
plume of brown stuff.
That's what I was remembering.

(01:25:34):
Uh, um, and so what we're seeinghere, this is the back of the
vagina that looks healthy andthis is this endometriotic
nodule here that's in the backof the vagina.

Natalie (01:25:45):
and I think

Nick (01:25:46):
And.

Natalie (01:25:46):
to feel that on a manual exam prior to

Nick (01:25:49):
Yes, I'm sure I could.
Yeah, with a finger in the, inthe, in the vagina.
And then if you do a rectal examtoo, you can, you should be able
to feel that.
You can kind of feel it in thevagina, but you probably could
feel that it's not quite in thewall, the rectum.
So this back here is the vagina,but this here is the rectum,
like this tissue here is theactual anterior wall, the
rectum, and then appears theposterior wall of the vagina.

(01:26:11):
And then this space is calledthe rect space.
So you can imagine if thislesion were to get bigger and
bigger and bigger and bigger,eventually this rectum would be
fused to the back of the vagina.
And if it gets bad enough, thenit'll invade the rectum and
that's where you end up gettinginto it, power section
situation.
But you know, you were earlyenough that that really wasn't
ever a concern for you, but itcould have been maybe

(01:26:31):
eventually.
Um, so I think we're gonna cleanup a little bit.
Looks like there's a little bitmore.
We might cleanup.
Yeah, I'm kind of getting, I'm,I'm glad I did that.
See, I look at that and I go,Nick, make sure you get that
last little edge.
And then my, the past version ofNick does get it and I go like,
oh, good.
Good job.
Um, th there was some otherstuff.

(01:26:52):
This was the stuff early in thecase that we were looking at, up
on the left pelvic side wallthat I now I'm getting rid of
too.
Or it's on the pelvic brim.

Natalie (01:27:00):
Right cuz

Nick (01:27:01):
rid of that.

Natalie (01:27:02):
colon was attached to my pelvic side wall.
I

Nick (01:27:04):
Yep.
That's, that's, that's rightthere.

Natalie (01:27:06):
that's right there.
Okay.
Yeah.

Nick (01:27:08):
Yep.

Natalie (01:27:08):
Which I think was a like mechanically why I was
constipated all the time or partof the

Nick (01:27:13):
Could be, uh, probably, honestly it may be more neuro
neurologic.
So you can even see here,here's, here's some nerves.
The, the, these little stripesright here.
These are hypogastric nerves.
These are all curing sensationto bladder bowel.
See this little white stripesright here?
These little pine right behindthe instrument on the left.
This right.
This is all part of the hyponerve plexus.

(01:27:34):
So there's endometriosisdirectly over the top of all
that.
And that's what was inflamingthat I'm not sure what I'm
looking at right now.
I, I think I may bedemonstrating some anatomy to my
fellow.
It looks like, it kind of lookslike that's what I'm doing.
The, this right here is theuterine artery.
This is, yeah.
I'm almost certain that's whatI'm doing.
I, I probably just did a littleanatomy lesson to my fellow
right there.
Um,

Natalie (01:27:53):
glad to be of service.

Nick (01:27:54):
yeah.
Um, so, and there you go.
That's all that endos removed.
We may have put some adhesionbarrier.
It looks really clean, so I maynot have, so, oh, this is a
great view of the hypogastricplexus.
You can see all these nervesright here.
These little stripes nerves arevery small.
This is a big nerve here.
Yep.
Very small little fibers.
You can see these little fibershere.

(01:28:15):
In fact, I think I must beanatomy lifting.
Again, these are showing this,these tissues.
This is a hypo inferiorhypogastric nerve flexes right
here.
So you can see how if you hadendo, there's like a big ball
here, you could involve thesenerves.

Natalie (01:28:29):
Mm-hmm.

Nick (01:28:29):
In your case, I'm sure it involved them in an inflammatory
way, but it didn't directlyinvade them, which is why, um,
surgery worked well too.
Like if it had already invadedthe nerves, I'd have to remove
whatever nerves are invaded andthen you left with some certain
amount of autonomic nervedamage.
But it's all you can do.
Like, you can't, you, you hopethat what happened is that the
endo kind of grew slow enoughthat the nervous system has

(01:28:52):
already started to reroutearound that damaged part.
Because we can do that.
Like if our nerves start to getslowly damaged, we will, A lot
of it's redundant, so we'llstart to use other nerves to do
the same thing.
Um, but

Natalie (01:29:04):
That's fascinating.

Nick (01:29:05):
that's, that's your surgery.

Natalie (01:29:07):
Amazing.
Thank you for sharing it and,and walking through it too.

Nick (01:29:12):
Yeah, absolutely.
Lemme see if I can get out ofthis.
Um, there we go.
So, um, yeah.
So obviously that was helpfulfor you.
I'm glad it was.

Natalie (01:29:21):
Yeah.
Yeah.
Thank you.
Okay.
I have two final questions thatI ask every single guest on my
show.
Number one, what is your numberone piece of advice for anyone
listening?
What do you want every singleperson to know?

Nick (01:29:37):
Well, trust yourself.
I mean, if you're having pain,you're having pain.
If somebody, if somebody'stelling you that what you're
experiencing isn't real, they'renot a good person to work with,
there's not really that, it'snot really that important to get
angry at them and be like, gofist at the universe.
They're just not the rightperson to work with.
And, and find somebody that'sgonna believe you and then take

(01:30:00):
it seriously.
I mean, it's a serious issue.
It can be addressed.
And, um, don't doubt yourself.
You know, there's no reason to,to doubt yourself.
That the, if somebody impliesthat what's going on isn't real,
it, it doesn't, it's just them.
It's.
And everyone's human, you know,it's not like they're all people

(01:30:22):
that have their own their ownissues and stuff.
So, um, just try to findsomebody who's really
experienced.
I mean, if everybody could seesomebody with, everyone with
pelvic pain, could see someonewho's really experienced with
this stuff, it would be better.
It's hard cause it's notscalable.
Like it took me a long time toget good at this stuff, and it's
not, it's not that scalable tomake a thousand or 10,000 people

(01:30:45):
who are really good at it, buttry to, try to find the best
person that you can access and,and then go and trust them and
hopefully they can help you.

Natalie (01:30:52):
Awesome.
Okay, second question.
What is your current favoritedaily wellness habit that you
incorporate into your own life?

Nick (01:31:01):
Hmm.
Well, I wish I could say try toget enough sleep, but I don't,
um, I'm not very good at dailywellness habits.
Natalie, I, I

Natalie (01:31:14):
why I asked this question.
It's a little bit of achallenge.

Nick (01:31:18):
I don't, uh, my wife is a health coach.
She's good at daily wellnesshabits.
I, um, am a functional medicinephysician as well, but I, um,
you know, I try to do somethings I enjoy.
I try to, I, I like to doartistic things.
I build, I build Legossometimes.

(01:31:38):
I, I, I'm a total geek Natalie,like ridiculously so, okay.
I'm the, I'm the one guy at theMagic the Gathering tournament
who's like, has a job.
Okay, well that's not reallyfair, but that, that, that,
that's not quite fair.
But, but, but, um, I'm, I'm theodd man out at that situation.
Um, no, that's not fair at all.

(01:32:00):
Plenty of them have, plenty ofpeople have chat, but, but I'm
definitely the odd man out ofsort of like a straightforward,
like career.
Um, I, uh, I'm a, I'm a supergeek, so I do, um, Uh, you know,
I do artistic things.
I paint miniatures at home,which is like, oh my God, how
geeky is that?
Right?
But I'm actually quite good atit.

Natalie (01:32:20):
Yeah, I would imagine.
I mean, you're good at

Nick (01:32:21):
I get my, I get my, my daughter's kind of my daughter's
into that.
You know, you find hobbies, youfind things to interest
yourself.
I, I guess I would say that too,as a wellness, I'm gonna say
this to people that have pain orthat have problems, and it's my
own wellness habit, but also asa wellness habit, I would
encourage to anybody, seek helpfor your problems, but don't,

(01:32:43):
please don't make it your life.
That, and this is not just likepatronizing bullshit.
This is neurologic.
Your brain will will get good atwhatever you pay attention to.
And if you make your entireexistence about the fact that
you have some pain, your brain'sgonna get really good at feeling
pain if you make your existence.

(01:33:08):
You know, your dog or yourfamily or whatever it is that
you love, uh, what, you know,whatever it is that fascinates
you get into that.
And I'm really not saying thatto the point of well, distract
yourself from your pain.
I'm telling literally, get yourbrain to pay attention to
something else.
It's a neurologic effect.

(01:33:30):
And I, I worry a little bitabout people that have gone down
the rabbit hole of making thisthe only thing they think about
because I, I, I, it sounds verypatronizing cuz if you have a
lot of pain, I understand how itwould be hard to be distracted,
but I, I think from a neurologicpoint of view, you're actually

(01:33:51):
going down the wrong road.
If you want this to be the onlything you think about that
actually it'll be hard to getbetter.
So from a wellness point ofview, make sure there is stuff
that, that you got in your life.
other than just this while alsotrying to get good care.

Natalie (01:34:09):
Well said.
Well said.
I will tell you, when my husbandand I stepped into your office
and we saw the Star Wars Legos,we were like, okay, this is all
right.
We made the right decision.

Nick (01:34:18):
There's some, there's some behind me too.
There's R two is not quite, Rtwo is not, uh, done.
And, uh, let's see.
There's, there's V V eight,there's a probe droid too.
I have a bunch of other thingstoo.
There's a, a wing.
Oh, there's a wing up there.

Natalie (01:34:31):
amazing

Nick (01:34:32):
then, uh, here's a space station.
That's not Star Wars, but, um, Ihave, I have a three foot tall
k2 so that I'm gonna build oneday and I'm gonna put it here on
the floor.
Um, my, my camera wants tofollow me so it screws it up.
But like, basically on the floorthere, um, next R two, so it'll

(01:34:53):
be tall enough that while wasgonna put R two on the lower
shelf, so there could be a Ktwoo that fills that whole
space.
It's literally that tall.
That's not a, it's not like anofficial Lego set.
It's a.
A custom build, but I have allthe pieces for it.
The problem is I have, I onlyhave like small aliquots of time
to devote to building Lego andI, and I have like all 4,000

(01:35:14):
pieces that will be required tobuild that thing, but it's not
like separated, so I need tobreak it into like 200 piece
bags in order such that I couldactually build it a small part
at a time.

Natalie (01:35:25):
Well,

Nick (01:35:25):
one day,

Natalie (01:35:26):
build it, post it on

Nick (01:35:27):
day, oh, I'm sure I will.
It's actually, I'm almost sayingit's a little creepy cuz it's
literally like a very accurate,very tall droid,

Natalie (01:35:35):
it might be a little bit disconcerting

Nick (01:35:37):
it, it I don't know.
No, it's pretty cool.
Um, alright,

Natalie (01:35:42):
yeah.
Can you just tell listenerswhere they can find you online
and what they need to do ifthey're wanting to book with.

Nick (01:35:51):
first of all, call me three months before you'd like
to see me.
But, um, yeah, you can call, uh,our phone number is(503)
715-1377.
Uh, nw endometriosis.com is ourwebsite.
Um, the website is not alwaysthat updated.
It, it's funny, like, well,it's, it's fine, but we get so

(01:36:11):
many calls.
It's really crazy.
Like we get like 20 calls a day.
So the idea of doing likeadditional marketing seems
insane.
I, I, um, um, but contact ourwebsite.
There's an opportunity to put inyour information.
Um, you can get a free phoneconsult if you want, if you, if
you live locally here inPortland.
We'd rather just, the best thingis to see you in person.

(01:36:32):
But if you're out of town andyou want to have just kind of a
free phone call to go over yourcase and decide if you're
interested in working with us,and we're happy to do that,
either myself or Dr.
Mulling.
We're both very good at thisstuff.
And you can see that one of uscan get great care.
Um, the.
you can also, sometimes peoplecontact me on Facebook and so
forth.
I get a lot of messages that wayand I don't always respond to

(01:36:54):
them.
Cause there's just, it can bedifficult, but I respond to a
fair number to be honest.
But, um, the best thing is tocontact the, the office.
Um, I, I would, I would tell youthat right now we're having like
a real staffing issue.
There's a whole, the whole worldis having trouble employing
people and we're bringing onsome new people.
We're supposed to have someonestarting next week, but we're
really backed up at gettingcalls back to people.

(01:37:15):
And it's unfortunate.
I know there's some people thathave contacted us and we haven't
gotten back to them and it'sbeen a week or more and it's
like, I, I'm sorry, I'm verysorry.
It's not, it's not what we want.
We don't, that's not the levelof service we want, but it's,
it's, we're kind of strugglingto keep up right now.
And to some extent, the demandgreatly outstrips the supply.
The supply isn't just me and mystaff's time.

(01:37:37):
The supply is operating roomtime.
The supply is, and actuallyright now we're in a weird
situation where this, the, thebiggest supply defect is
anesthesiologists.
There's a, there's a bigshortage of anesthesiologists
right now, and it, it was ineffect after Covid that a bunch
of people quit.
Their jobs are retired earlier,or went to go bake or paint or
whatever they decided to do withtheir lives.

(01:37:58):
And, and, and then that createda weird situation where
anesthesiologists started flyingall over the country to these
temporary jobs that were gonnapay them a lot of money.
And, and so a lot of theemployed contracted
anesthesiology positions havesort of vacated.
And so the hospitals, a lot ofhospitals are having trouble.
So we're, we're struggling topost as many cases as we li as

(01:38:19):
we like.
And I have a lot of patientsthat really wanna get in and I'm
like, I don't have an operatingroom.
Like I can't operate on my desk,so it's gonna.
It'll change, it'll get fixedover time, but it, it'll get
fixed slowly.
So it's right now, like at thisvery moment, we're in this weird
sort of vacuum of not quiteenough operating room time,

Natalie (01:38:39):
Wow.

Nick (01:38:39):
but we're working on it.

Natalie (01:38:40):
Yeah.
Well,

Nick (01:38:41):
We still operate a bunch.

Natalie (01:38:42):
Oh, good.
Good.
Thank you so, so much for beinghere and having this
conversation with me.
I learned a lot of new things,so thank you, and I'm sure our
listeners will really appreciateit as

Nick (01:38:53):
Well now it's great podcast.
Thank you for, uh, for having meon and um, thanks a lot.
I'm glad that you're doing welland best wishes.

Natalie (01:39:01):
Awesome.
Thank you.
My top takeaway from myconversation with Dr.
Fogelson is that Endo is stillso misunderstood, but we're
doing the best we can with theinformation that we have, and as
I've emphasized before, it'scrucial that you find someone
who's.
Skilled and knowledgeable aboutthe disease before undergoing
surgery.
If you're interested in hearingmore about my journey with

(01:39:24):
endometriosis and the decisionprocess that led me to surgery
in 2021, I did a whole podcastepisode on it.
It's episode number 17 of theResource Doula Podcast.
I'll put a link to that as wellas the other resources mentioned
in this episode.
Please remember that what youhear on this podcast is not
medical advice, but remember toalways do your own research and

(01:39:45):
talk to your provider beforemaking important decisions about
your health.
If you found this podcasthelpful, please consider leaving
a five star review in yourfavorite podcast app.
Thanks so much for listening.
I'll catch you next time.

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