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

Natalie: 0:49

On today's episode, I chat with my endometriosis surgeon, Dr. Nicholas Fogelson, about his perspective on Endo, a little bit about the genetic aspect of the disease, and a more in-depth look at how endometriosis can present itself. He also walks us through a video of my surgery, so if you're squeamish and you're watching the video recording, I'll put the timestamps in the show notes so you can skip over the surgical video portion. I'm Natalie and you're listening to the Resource Doula podcast. A place where we provide information to help you make informed healthcare decisions for yourself and your family. Dr. Nicholas Fogelson is a board certified and fellowship trained gynecologist and gynecologic surgeon in Portland, Oregon, and the founder of Northwest Endometriosis and Pelvic Surgery. He's committed to providing absolutely world-class surgical care to women with complex gynecologic surgical issues, including endometriosis, chronic pelvic pain, heavy bleeding, fibroids, pelvic organ prolapse, and incon. Dr. Fogelson focuses on minimally invasive surgical techniques for all surgeries and is able to complete the vast majority of surgeries via laparoscopy, even in cases that might be performed open by many surgeons. He is also one of the few surgeons in the country to focus nearly exclusively in the area of endometriosis care, including the management of very complex cases, including bowel, urinary tract, and thoracic disease. He is also one of just a handful in the nation to have entered into formal training in the field of neurobiology, a field dedicated to a deep neurologic understanding of pain and neurosensory dysfunction, and new surgical and non-surgical approaches to its management. Dr. Fogelson, thank you so much for being here today. Welcome to the show.

Nick: 2:47

Absolutely. Natalie, thank you so much for inviting me.

Natalie: 2:49

Yes, of course, of course. So I wanted to start off by asking just how did you decide that you wanted to be in women's health in general, and then how did you come across endometriosis and become a specialty surgeon?

Nick: 3:03

Um, well, gosh, I mean, you know, when you're in medical school you do, you get to do a little bit of everything. You do like four to six weeks of, you know, about 10 or 12 different things and, um, And so you kind of find out what you like. And I honestly kind of liked everything, to be honest. I was always a big believer in like, this is the first six weeks of my life as a psychiatrist, and this is the first week, six weeks of my life as the internal medicine doctor. And then at the end of that time, I had, huh, do I wanna continue this life or not? Which I always thought it's the way I recommended to medical students too. I said, if you start out with your rotation saying you're not gonna do this, so I won't pay attention, that doesn't work out too well. But, um, I don't know. When I did obgyn, I always really liked it. I, I love, I mean, the, everyone's attraction to OB in the beginning is delivering babies. I mean, that's the experience you get as a medical student. Um, you know, no one gets to do surgery as a medical student a whole lot, but you can deliver, anybody can deliver a baby because gravity delivers 95% of babies. So you can put, you can put a patient, a medical student between someone's legs and they can enjoy that. Everyone can enjoy that experience. And a medical student feels like they did something great when reality just happened in front of them. But, uh, the, the, the rare times that it really requires expertise, it requires a lot more expertise. But, Uh, anyway, so I really enjoyed that. I enjoyed the connection with patients and, and, and women in general. Honestly, I mean, I, um, I don't know. I've, I'm fairly, just always enjoyed that experience. And then, you know, over time, um, I've always very surgically oriented though I actually spent a lot of time in plastic surgery as a medical student also, and

Natalie: 4:31

Oh wow.

Nick: 4:31

learned a lot of technical skills there and, um, could have, I don't know, another version of me could have gone on to become a plastic surgeon. But, um, I, I got very interested in, in the tech technical side of surgery. And as I got further and further along, I was a general OB b gyn for six years in academia after leaving residency and, um, just kind of became very interested in, in pelvic pain. I'm always interested in the stuff that no one else is interested in. I, like, I, when someone else says, 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, you know, because I'm d I'm just sort of different than most people, like from a neurotypical point of view, honestly. So I, there's a lot of times that I enjoy the things that other people won't enjoy. I'm interested in things that other people aren't interested in. I, I find, I don't, I'm not bothered by the difficulty that pelvic pain's a, is a, something that I'm interested in and very, you know, passionate about, honestly, because there's so many people that are really suffering with it, and most ob GYNs have no interest at all because they're not good at it and they have, they fail at it. And I wasn't good at it at the beginning either, and I understood why people wouldn't wanna do it, because you generally wanna do things that make you feel good. I mean, it's an affect bias. You, you, you know, when you deliver 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't get better. Like, oh, that was a shitty experience, like a shitty experience for both of you. Not just the patient. The patient feels bad, but the doctor feels bad too. So, you know, it's at a certain point if people aren't having success, they, they say, I don't want 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. And, um, and so then I looked at what they're doing and, and realized that, oh wow, it's really, really difficult too. That's right up my alley. And, uh, it's, uh,

Natalie: 6:28

We need people like you,

Nick: 6:29

so I'm like, oh, wow. It's something that, that, uh, I might not be able to succeed at. Um, and, um, and anyway, so I kind of got interested in it. I, I ended up doing a, going back and doing cancer fellowship after six years. I, I, I don't, I'm not a boarded gynecologic oncologist, but I, I did a. I did a year of fellowship in a, basically at Emory, in, in what is effectively, uh, very similar to what the, a clinical year of a G one oncology fellowship would be. I mean, I operated on cancer patients every day and did chemotherapy and did everything that that cancer fellowship would kind of entail. But it was a, I did that for a year and just really honed my sort of, really, it really kind of grows you as a surgeon to do that. The, the way that you operate as a cancer surgeon is so much more advanced than what we do in general OBGYN as far as anatomy and comfort with things that can go weird, like bowel resections and, and, and repairing bladders and all the kind of things that make most general Obi GYNs very nervous. You know, when you do that, you start doing cancer work, you're like, okay, this is just sort of part of the work and you, you don't get so scared about it. And, um, and so I did that and then I continued to practice and honestly it took me quite some time to continue to get good at it. And, you know, we're still getting better at it today, but, Kind of reached a, a point where I felt pretty good about what we were doing and, and we started a practice for, uh, Wei I started a practice about four years ago on my own five, four or five years ago. And, um, it's been going great. We've probably taken care of well 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 had enough, enough demand for my services coming in that I couldn't meet at all. So I fortunate to find somebody who, you know, is really good also, and, and she's doing a great job. And that's what we're doing now.

Natalie: 8:16

Amazing. So I didn't know you did the cancer, um, you

Nick: 8:20

Well, I don't operate on cancer. I mean, I'm not an oncologist and I wouldn't, wouldn't represent myself as that. Um, but I trained did that train, I did that, I did that training, yeah.

Natalie: 8:29

Yeah. Yeah. So do you think that laid the groundwork then for the more extensive endosurgery that you do?

Nick: 8:34

Oh, absolutely. I mean, if, if, honestly, if somebody said, I want to be a i, I want to be an endometriosis surgeon, how should I do?

Natalie: 8:43

Yeah.

Nick: 8:44

I would recommend my path. Like I, I would recommend getting 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 would go do a GYN oncology fellowship rather than doing like MIS s gyn Fellowship Fellowship. But the problem is if you, GY oncology fellowships are incredibly competitive and you wouldn't be able to go in there and say, well, I wanna be an endometriosis surgeon. They're like, well, that's not what we do. We're not gonna give you a spot. So, um, cuz nobody taught me how to do endometriosis surgery in my fellowship, they taught me how to operate.

Natalie: 9:20

Mm-hmm.

Nick: 9:20

You know, they taught me how to be comfortable with difficult situations. They taught me how to be comfortable with bleeding. They taught me how to be comfortable with injured organs that I can repair. They, they, they taught me how to be comfortable with adhesions. Like, and that is what endometriosis requires. It's not the only path though. I mean, you can, most people now do a a, a age l i s fellowship and. Those fellowships are highly varied. Like I have an MIS fellow, uh, that works with me, but she works with me like one day a week. And I've had now four fellows and maybe one of them really was significantly interested in doing endometriosis surgery, maybe one and a half or something like that. And several were not really at all. So it's sort of like it's, I gyn fellows are, the fellows are varied and the fellowships are varied also. Like some fellowships are more UroGen focused, more, some fellowships have more endo experience, some have less, some are more robotics focused, some are more, more laparoscopy focused. So it's, they're kind of all over the place. And, um, I, I think in the end, if a surgeon wants to do this, they just have to get enough surgical training and then they have to kind of train themselves. I mean, I, I learned how to operate in fellowship, but I learned how to do endometriosis surgery from YouTube, like, right. No, totally. So I mean,

Natalie: 11:43

area.

Nick: 11:44

Right. I mean, but like once you get enough base skill in surgery and you understand anatomy and you understand technique, you can replicate what you, what you see. So if you watch and really, like, what is it, if I'm operating with a master surgeon across from me, I'm watching them operate, right? What's the difference if I'm watching a video of them, operator from standing in the room with them, even if I'm in the room, only one person can be holding 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 good surgeon, surgery is a three-legged stool. That's what I tell my fellows. It's a three-legged stool made up of, let tell you first of all, what bad, what I think bad surgery is. Bad surgery is I know how to do a hysterectomy and in order to do a hysterectomy, I do this and then I do this, and then I do this, and then I do this, and then I do this, and then I do this, and then I close the skin and then I go dictate. You know, that's all great, as long as everything goes exactly the, as it as planned. And it's all great as long as the anatomy is exactly the way it says in the book.

Natalie: 12:45

Right

Nick: 12:46

But honestly, like most general OBGYNs, and I include myself when I was in that training, are trained surgery like that. They're trained to operate in a very stepwise way. How do you do a cesarean section? You open the skin, you open the fascia, you open the uterus, you get the baby. It's all like this sort of like cookbook

Natalie: 13:03

Mm.

Nick: 13:04

and maybe you can do C-sections that way cause they're pretty much all the same, but not, it's not always, but mostly. Um, and but when you start getting into, you go into a pelvis and it's like this big mass of bowel and ovaries and uterus all stuck together, guess what? Your cookbook doesn't work. It's like this is a different recipe. And so, you know, if you go to cooking school, you don't learn recipes, you learn cooking. You know, you learn like how flavors go together or whatever. So, so, so surgery, I think to do surgery really well. You have to first of all know anatomy, you know, really, really, really well and general ob gy, and again, I include myself at that time, don't know anatomy really, really well. It, it's just not part of what they do. And they know, they know anatomy of the inside of the abdomen. But when you start getting into like the retroperitoneum and the blood vessels and the nerves and stuff in the back of the pelvis, forget it now. There aren't that many other people that know well either, but urologists and know it, you know, probably better, but not a lot of people dunno it very well, to be completely honest. The people that know it well are GY oncologists, to be honest. And, and then certain areas like Urogyn in some parts of it in other really experienced generalists, gy, exceptional gynecologic surgeons. I'm not saying that there aren't, there aren't general OBGYNs that aren't exceptional at that, but it's not, I would say it's the exception rather than the rule. And the, so do you know anatomy really, really well? How did I learn anatomy? I read fricking anatomy books, you know. I, I, I drilled myself. I made sure that I could take a piece of paper and draw out the pathway from the heart all the way down to the terminal branches of every artery in the pelvis, like in my sleep like this, every day. And I made my fellows do the same thing. I said, take this piece of paper, draw this, okay. I want you to be able to do it. You can't do it. I want you to be able to do it tomorrow. You know, because, okay, got the arteri, let's do the veins now. Okay, let's do the nerves now. Like, that's the, that's the fundamental. Okay. So you do that and then, and then the next thing is, do you know technique? You know how to manipulate tissue. Do you know how to tie up bleeding? Do you how to know how to, do you know how to sew things together? Like those are the basic building 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 to deal with bleeding. That seems scary. How to keep your sh I mean, some of it's emotional technique, how to keep your shit together when something bad is happening and realizing that, okay, I better solve this problem. It's all on me. I better fix, better fix it. You know, some people are better at that than others, you know? And, and, and then the, the third thing is, is, is then the last thing is knowing what you want to do. You know, do you know how to, I mean, there's the knowing what you wanna do in the operating room, and then there's knowing what, what you wanna do clinically and, and oops, when you, um, you know, when you speak 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 surgery in the operating room. Like knowing what are you trying to accomplish? Like, let's just say it's as simple as you wanna do a hysterectomy. Like what is it supposed to look like when you're.

Natalie: 16:11

Mm-hmm.

Nick: 16:11

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 been sealed. Like, they're just like, can you list it? Like, these are all the things that, that should have happened by the end of the case. And then when you get into a case that's totally straightforward, you can do it in a totally straightforward way. When you get into a case that's very messed up with an anatomical changes, you still know what it is that you're trying to accomplish. It's just gonna be different. You're gonna have to accomplish it differently. And you realize that even though normally the ureter is kind of like sitting a couple centimeters below the ovary, well this time it's gonna be completely glued to the ovary, you know? But do you recognize that, okay, because of this disease state, this anatomy's gonna be distorted and we're gonna have to deal with it. And, you know, any, any really good experienced surgeon does that. Um, but that's, that's how you have to approach it to be, I think, to be a little bit better at it. And, and I, look, I'm not, I'm competent. 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 say like, oh, I'm the best surgeon in the universe, or whatever. It's like, no, I'm just good at what I do. There's lots of people that are good. Um, the, but anyway, the fourth, the fourth thing though is then the clinical part where you can you speak to a patient, get the information that is required to figure out a complex issue when it comes to pelvic pain. So the first thing was about surgery. When it comes to pelvic pain, do you kinda understand enough about like, why people have pain and what different kinds of pains kind of present as, um, when people describe something, how do you ask the next question that kind of gets you where, where you want to go, um, so that you can come up with a good plan and, and it's not always gonna be maybe always the right plan, but can you come up with a plan that makes sense, that has a good chance of getting, getting the patient where they wanna go? And that takes a lot of time. It probably took me, at least from the moment I said I wanted to. Do this, it probably took me at least a decade to feel like, okay. I, I'm still getting slightly better, but I've, I've gotten quite good at this, you know, that's a long-winded answer, but Yeah.

Natalie: 18:16

I appreciate it too, and I, I will tell you, I am even more glad that I hired you to do my surgery. Now, hearing a little bit more about your background, so, um, something that you talk about is neuro pathology.

Nick: 18:30

Yeah. Neuro,

Natalie: 18:31

about that?

Nick: 18:32

yeah. So neuro, neuro, uh, no, it's neurobiology, but whatever. Okay. It, you know, I don't, it's, it's, it's a European title, so they gotta add some extra valves in there. But, um, it, it's, um, you know, neurobiology is everything that a second year medical student was ever taught and then went on to forget and that you decided to go back and relearn it. Like, it's not, it's not magic, it's just, it, it is. Starting out with the assumption that every single pain that in person experiences and every single visceral n neurologic phenomenon, first of all is real. And second, that a very detailed description of a patient's symptoms with a limited amount of physical exam can usually tell you exactly what's wrong with the patient. And it's using a little bit of a more advanced understanding of neuroanatomy and neurophysiology to try to add up what's wrong with somebody. And it's like a puzzle where you have all these little pieces and you try to gather all the little pieces together. And then I think neurobiology somewhat gives you the questions to gather a few additional pieces, but then also helps you to understand how they fit together in a way that you might not have understood before. So I'll give you an example. I'll just give you kinda a basic example. So patient has pain. That is radiating down the inside of her right leg. Every time she has a menstrual cycle. It is worse when she's standing up and when she lies down, it feels better. She also gets a weird tingling feeling in her bladder when she stands up and she has urgency to urinate. But when she lies that she in the 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: 20:19

Hmm

Nick: 20:20

It's only on the right side. It gets much, much worse during her menstrual cycle. Like okay, put it all together. She ha uh, she has bladder symptoms, she has symptoms down the S two nerve, the S two part of her sciatic nerve. Um, she has a intra pelvic entrapment on her second cy nerve rib. And we know this because like some people say she has got pain down her leg. Oh, she has sciatica. It's like no, she can't have sciatica cause it wouldn't make her bladder feel that way. Her bla her. I mean, you may not may, but like when you look at the innovation, it's like a tree. It's like, no, the problem's higher up on the tree that the split this problem is, is before the, the nerve end, the SCID nerve and like, and so then you go and operate on that patient and you expose that nerve. And part of sort of the philosophy of neurobiology is like if the patient tells you that that's where the lesion is, you're going to find something like, it doesn't make sense that she would have those symptoms. And then you go in there and then it's gonna look normal and it doesn't. I, I, I have, and there's a lot of examples like that. I mean, I'll give you one other example. Probably the first neural pologic kind of thought process case I ever had that I thought, I, I was like, wow, I really accomplished something that I might not have accomplished without this is I had a patient who had cyclic epigastric pain, that she had pain under her ribs right in the center. Over and over and over. And a lot of people go, oh, I have diaphragm endometriosis. I'm like, no diaphragm endometriosis hurts in your shoulder because the third, fourth, and fifth cervical nerve root up here innervates the diaphragm. And it also innervates here, here, and here. That's where you feel your diaphragm. You don't feel your diaphragm down here. Okay. So, and that's just the neurologic, the neurology of it. So this patient has this epigastric pain. She's been to a zillion doctors. She, someone took out her gallbladder 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 million diets. She's been doing naturopath, put her on a million different things. It didn't work, obviously. It didn't work. Uh, been to a, to a chiropractor, maybe helped a little bit. She comes to me and says, I every single, I have time. I have menstrual cycle. I have horrible pain in right underneath my, my gut hair. Um, and I have endometriosis. I've been operated on in the pelvis for endometriosis before, but, but everyone says it doesn't have anything to do with endometriosis. And I said, well, it might because, uh, you, I would say that you probably, that that area of pain is the right colon cuz the, the, the innervation of the right colon is, um, where we feel our visceral pains is where those nerves enter the spinal cord. We feel somatic pains where the nerve 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 arm into your pinky and your, and your second finger. Your second finger. And actually, uh, because that's where the ul nerve innovates. So you hit the nerve. It, I just did it right now hurt. It'll run right down the right down. So somatic nerve goes out, nerves come in. So if a visceral nerve is irritated, you're gonna feel the pain where the nerve meets one of the, the plexes between the sympathetic and parasympathetic plexes. So the plexus that the right colon will hit is the celiac and superior mesenteric plexus. Okay, so that's right here.

Natalie: 23:56

Hm.

Nick: 23:57

So when the person says, I have pain right here, I know, first of all, she is feeling pain 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's feeling a visceral pain in that plexus. What organs are bringing nerves to that plexus Transverse colon, the, the right colon, A little bit of the ileum, uh, uh, the, the right kidney. Um, these are the things that are getting there. Okay. At least within the bowel. The left, left kidney, there's a renal plexus, but it kinda left kidney could be too. And so I'm like, okay, well something is wrong in that. Like it's not possible for there not to be anything wrong in that set of things because there's only 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're like, oh no, let's just figure it out. Like it's gotta be something. And so we operate on her and she's got a huge baseball of endometriosis in her secum and it wasn't, it wasn't that easy to see, to be honest. Like I could see how you might not see it because it, the secum really is very distensible and. And when it, when you get a mass on the wall of the secum, it doesn't look that much different. Um, and so what I saw is that you could just see some unusual adhesions around it and you could see that and you touched it with your instrument. It felt hard, but I knew what I was looking for. I was like, there's gotta be some disease in that general vicinity, right? So I go in there, we do a alloc ectomy, we take out part of her right colon and she's cured. It's like the surgery is not the big deal. I mean, any, any colorectal surgeon can do that. And I didn't do that part of the surgery myself. I kind of made the diagnosis and I coordinated for her to have a right, right. He colectomy and although not a whole just take out like the disease piece, but anyway, you know, and she's better. So like that, that was something that I was like, wow. I mean, if I hadn't studied this, I wouldn't have solved that problem and that, and that, you know, that, that feels good. I'm like, oh, glad. So that's so neuro pub. But, but what's really important about neuro pulmonology is that it's not like the panacea to everything. Like it, it definitely leads to. Some diagnoses that we might not otherwise have made. Sometimes it leads to some different surgical plans. Sometimes it leads to some, a few different kind of surgical techniques, but it's not the solution to everything. I do have some patients contact me who have had, you know, recurrent pain after un unfortunately, like recurrent issues after endometriosis surgery, um, and who have had surgery by good surgeons. It's not like they had bad surgery. They just, like, for whatever reason, their disease state has not responded as well to surgeries they would like, and some of those patients we can figure out like, oh, well maybe there is some nerve compression or something that we can address. But some of them, you know, I can't solve everything. I, I, there are mysteries to everyone and, but I, I think that it's a, it, it, that field of study does reveal some of the mysteries. And so like you have this whole chunk of patients where you're like, you're not quite sure how to fix them. And you're like, okay, now we can whack off a slice of that chunk and go, oh, I know how to fix this part now. There's still other parts that you don't always know, but, but it's definitely led to some good things. So, um, and again, it's a, I mean, it, everything that is new starts out as being blasphemy. I mean, David Red Wine's theory of Excision was completely derided 20 years ago. People thought he was insane. Now he's like, everyone knows that, you know, everyone thinks very highly of him for starting it. And he and a few other guys are sort of the first few people to excise endometriosis. So Neuropsychology was started by Mark Paso about, you know, in his own la in his own like mad scientist laboratory, like 20 years ago. And he kind of kept it to himself for 10 years while he was sort of developing this whole set of theories and then eventually started telling people about it. And, and now 20 years later, he just got the, the, it's a, I can't remember what it's, what, it's a European award. It's effectively like the Nobel Prize for Medicine in Europe that he was just awarded this year. So,

Natalie: 28:06

How cool?

Nick: 28:07

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 was also using that technology to, uh, help paraplegic people to walk, which has nothing to do with pelvic pain and still does today. And it's something that I'm actually interested in developing the United States, but it's, it's a little easier to do the stuff in Europe, but using a better understanding of the electrical, the electrical issues of the nerves to get around the fact that people's spinal cords are broken. And, you know, he has made people who are paraplegic able to get up. I mean, they're not running a marathon, 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, out of the cabinet and have a better 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: 29:03

Wow.

Nick: 29:05

There's no way this is true. And they, they would rather believe that this doctor is literally hiring actors to pretend they're paraplegic and get up than to believe that maybe they don't entirely understand this stuff as well as they think.

Natalie: 29:20

Hmm.

Nick: 29:22

And that happens throughout medicine. People are very, very sure that they're right about everything, because that's what they were taught. And doctors are taught to, should be sure. Doctors are taught to kind of like project confidence about what they know and to, they're supposed to be the, the, the source of knowledge for patients. And that, you know, you shouldn't tell a patient, I don't know. Although, I mean, a lot of people do, but some people are like that, that when you're challenged by something that is completely different than what you 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 that thought that about endometriosis surgery. There's people that still do, there's people that still believe that what I do is like Charlatan re or something. And I'm like, I don't care if you believe that. That's fine. I, I, it's like I have, we're not a hundred percent success. And what they do is they point to the few patients that haven't done as well as we would like and say it, look at this thing doesn't work. I'm like, yeah, well look at the patient who's like so much better. You know? So, and most people are significantly better. I, I, and I never sell, I never sell endometriosis surgeries, the cure of endometriosis. I, it's the best thing that we have. It's, and if I tell a patient that if I can make you 75% better from your symptoms, that's successful surgery. You know? And, and, um, and hopefully we can achieve that. And, and, and I, so it's, again, a long-winded answer that goes in a million directions, but.

Natalie: 30:49

Well, the approach is so vastly different than what you generally get going to, you know, a regular, I guess, reg quote unquote regular ob. And I think for me, and a lot of other patients I've talked to who have been through excision surgery, just the fact that you can say your pain is real and I can see it and I can remove that. is so validating and I think that. 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: 31:24

Yeah. I mean, it's, it's very important. It's always real. All pain is real. Okay. I, I honestly am not sure in the history of time that anyone has ever made up the fact that they're hurting. I mean, I'm just like, I don't understand it. I really don't, I don't understand it. There's, there's people that are so caught up in the fact that they can't fix someone. That their own inability to fix someone is so goddamn painful to them, that they would rather believe that the patient is fabricating it than that. They were just incapable of fixing it. There's things I'm incapable of fixing. There's lots of things I'm incapable of fixing, and it feels bad and I'm sorry about it, but that doesn't mean I'm gonna tell the patient that you're making it up because I'm infallible. I'm infallible. I can fix everything. So if I can't fix it, you must be making it up. No, it's horses shit. It's like you can't fix everything and you try, you try to do your best to fix things as best we can and, and the, but there's a lot of people that feel that way. Like I, you know, or the, the idea that there's this large population of patients who are fabricating pain in order to get narcotics because they're addicted to narcotics. And I'm like, I think it's real. I think there are people that have developed dependencies on narcotics. but I think it started out with pain. And I think that they are experiencing pain. Again, I think they've continued to experience pain and the only way that they're having any success at having addressing it is through the taking of potent anti pain medications. I mean, it does create a lot of problems and I really try to avoid making that solution because it's a difficult, it's a difficult path to get outta. Um, but I, I don't really believe that there's this large population of people who just make things up, like, why would you bother? You know, like, that seems like a lot of effort,

Natalie: 33:17

Yeah,

Nick: 33:18

But, uh, nonetheless, some people, some people tend to think that,

Natalie: 33:22

I think especially in women's health, because we've been, we collectively as women have been dismissed for so many years saying, oh, you know, you're, I, for whatever reason, what, whatever bias the provider is coming from, or just assuming that you're complaining about pain for whatever reason, that I think many women either like, just suck it up and say, well, this is what I have to deal with. Or they go beyond that and exaggerate potentially, or, or they have to make it appear worse to actually get some help, which is really sad because that shouldn't, it shouldn't be that.

Nick: 34:03

No, no, it shouldn't. And I, but I, I will also be in defense of, you're, you're the person who isn't very good at this. A little bit like I wasn't very good at this. When I started, you know, early on, I mean, I was terrible at it as a general ob b gyn, I mean, I believe lots of things that I now think are ridiculous back then. And, um, you know, asking a general ob gyn to be really good at pelvic pain is like asking them to be good at neurosurgery or something. It's like you don't get much training in it. Like I have zero training in neurosurgery. I have almost, well, I actually, I guess that's not true anymore. I have zero training in, you know, whatever podiatry, and I have, you know, almost zero training. As a general obgyn, I had almost zero training in pelvic pain and endometriosis. I mean, like, it could fit into a thin, what I was trained, it was like, take birth control pills.

Natalie: 34:53

Right.

Nick: 34:54

If that doesn't work, try Lupron. If that doesn't work, cry surgery. But surgery won't work anyway. But you can, at least you can try it and then you can say you did it.

Natalie: 35:00

Oh man.

Nick: 35:01

You know, and I'm not joking, like that's what I was trained by. Intelligent, thoughtful, caring people 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 miserable too. You know?

Natalie: 35:16

Wow.

Nick: 35:17

And, and to some extent it's true. Like if you really get involved in taking care of a lot of patients with public pain and all you do is fail at it, they'll make you miserable, make you wanna go kill yourself, you know? And it's like doctors want to feel good about what they do and that, that doesn't I get that. I totally get that. And so, um, uh, so they're not good. I don't really train that. And they didn't spend a lot of time. And second, if you were to take me what I know now and ask me to see 30 patients in a day, I would fail. Like I cannot do what I do in 15 minutes. And the industrial machine of medicine these days asks doctors to see 20 to 30 patients in a day. It is like, so in the morning you start at like eight 30 until noon, you're gonna see a patient every. 15 to 30 minutes at most. You're gonna get 30 minutes with a new patient, 15 minutes for a return patient. You're gonna do it again in the afternoon. You're probably gonna have to try to dictate during lunch, and then you're probably gonna be doing charts after you go home, after your kids go to bed. So ask that person to really dedicate themselves to doing something that A, is gonna take'em a lot of time to master, and B, they're not gonna get paid to do.

Natalie: 36:33

Hmm.

Nick: 36:33

It's like, forget it. Of course not. And, and, and it, no. And, and, and again, if you were to put me in that position, I would not be able to do what I do. I, I spend an hour to two, sometimes even two hours with a new patient. I frequently see them back for an hour for a follow-up visit. Sometimes I see people for an hour for an unpaid post-op visit. Like most people have their nurse 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're not paid. Like they gotta like, churn, churn, churn. And. You know, I spend an hour with a post-op patient. I can't remember how long you and I spent together, but we, we, you know, we'll, we'll check the incisions and stuff, but mostly we'll talk, we'll talk about what, what did we find, how does that correlate to what their symptoms were? And then we'll go over a video of the surgery and we'll say, this is what you sh this is what was there, and let's, let's kind go through all the highlights of the video and then I'll give you, copy the video so you can look at it, you can take it home. And not paid. I mean, to me it's like all part of the, what I do, you know, that's just part of, part of the services I want to provide. But I mean, that would be impossible to do in a, kind of like a traditional medical practice. So, you know, and the vast majority of people are in traditional medical practices. So it's, it's not, it's not just that, like all these are just ignorant, bad doctors. Like the system does not possibly allow them to succeed.

Natalie: 37:50

Hmm hmm. Yeah. Interesting. I will tell you the video that's one of my favorite things that I received. I mean, besides having surgery obviously, but I have been able to show a lot of my friends, my video, I'm kind of the nerd like, Hey, you wanna see my insides

Nick: 38:07

You gonna see my endometriosis?

Natalie: 38:09

But it has been eye-opening to a lot of people and other providers that I'm friends with who I can show and say like, look at this. Would you have assumed that this was a problem? But look at how extensive it gets once he goes in there and starts to excise it. So, um, yeah, I think it's, it's

Nick: 38:26

it can be,

Natalie: 38:27

interesting teaching tool.

Nick: 38:29

I had a patient just last week that was 25 years old who I have, she had a lot of pain and I'm, I'm, I'm glad I found what I found. But I looked in there and I'm like, wow, I got a lot of endometriosis and. She's 25 years old, like extensive and it, but it was the perfect time to operate because it was very developed and not yet horrible. Like she, I would say that she was five years from having a Bower section, but she was, or 10 years from maybe five or 10 years from needing a Bower section. But, but it was early enough that we're able to get it before it kind of got into there, but it was really right on the edge. I mean, it's like the creeping ooze of some, you know, whatever fantasy movie Marvel you want of like, it, it's like kind of growing and growing and growing and you can see that it was just starting to tack onto the, and the was just starting to get stuck in the back of the vagina. It's like, huh, this is 10 years before 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 lot better for it. Um, and it's a crazy disease. Like, I, I don't like, I'll be the first to say like, I don't understand the disease and I don't think anybody does. I'm a little bit put off. By the certainty that some people will talk about, about why they think people have endometriosis. Because I've read plenty of articles, I've read a lot of articles written by the people that seem so sure about it, and I have yet to be convinced of anything, to be honest. I mean, I don't find any particular explanation for endometriosis to be explanatory of everything I've ever seen. And, and I also don't find the level of proof required to prove some claims to have been met personally. Uh, you know, I'm very open minded about what is this disease all about. And I, I actually, the one thing that I truly firmly believe is that it's not one disease, and that to call endometriosis one disease is, is just kind of foolish. I mean, you typically, when you have a disease, it looks a certain. Endometriosis doesn't look a certain way, that there's markedly different cases of endometriosis. There's some people that have this explosion of superficial endometriosis everywhere. There's some people that have very focal deep legions that are like invading all the way down to their pelvic floor, but it's in one place. Everything else looks totally normal. There's some people that have adenomyosis that they were born with. Clearly they never had children, but they've got it. Okay. How did that get there? They had some people that have endometriosis. There's some people that have a disease in their diaphragm and other people that don't. Like when you look genetically at the disease, it's very diverse. Um, I used to work with a genetics lab in Utah. Um, and we sequence the DNA of our patients, and there's over a hundred genes that have been identified that are really tightly bound in the disease state. Meaning that if you have that genetic mutation, you're very, very likely to have endometriosis. And some of those genes are very, very high value mutations that you've, you've endometriosis percent practical. And if it were one disease, you would see one group of genes in one locust that all do pretty much the same thing. You'd either find one dis, you'd either find one, one gene, or you'd find like a bunch of genes that pretty much do the same thing. But that's not what endometriosis is like. Like there's a whole bunch of genes that clearly quote, cause endometriosis that do totally different things. Like you look at what do they do in the body. Some of them are cell cell interaction defects, some of them are angiogenesis defects, some of them are neurogenesis issues. Some of them are just pain sensitivity issues where people. Their primary defect is they seem to have an outward, an an exaggerated, and I don't mean that they're exaggerating it, but like their neurologic system is, is perceiving an exaggerated sense of pain. And that's really the one thing you can identify about them. That's not normal. And so when you see these things that are so genetically diverse, what it says is that it's not one disease. It's, it's just like cancer's not one disease. You know, nobody would say that cancer is one disease. It sounds crazy to say that, cause obviously lung cancer is not leukemia and that's not, you know, skin cancer. Like anybody can, any reasonable person would say that. And I think that from a genetic background point of view, endometriosis is very much like cancer. And yet as surgeons and doctors we're kind of taught that, okay, it's all the same, but it's not. I mean, you, you will see some patients who will have excisional surgery and they will have be cured. They will dance the jig and they'll scream to the world about how they were cured. And I'm glad I was a part of that. That's awesome. And then you'll see some patients that'll have excisional surgery and they'll recur a year later. And some of the internet would like to say that patient didn't get good enough surgery. And I'm here to tell you that's not true. Um, it's true sometimes. I mean, clearly if you have endometriosis surgery, that doesn't effectively remove the disease. Yeah. That, that, that's the problem. But there are plenty of patients who have had surgery by very good surgeons, including myself, including you name it, any name you wanna come up with who have recurrence and, and you can go back and look at the surgical video and you're like, good. I mean, you did it as good as anybody can do it. You're like, I wouldn't have changed that surgery at all. And yet the patient recurred. And, and that's part of why I like recording all my videos. I always go back if I have a patient that comes back a year later and they're having some issues, well, let's go back and look at the video. Where are you in pain? Is it, oh, was there something there 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 learn from. And, and sometimes it helps us make clinical decisions. Um, Of course, teaching of course, is very important too, but, but it just goes to show you that like you can do the best surgery in the universe and some people are gonna not do as well as others, and it has to do with their own genetic background. I mean, I, I was, I was taught this as a, my first academic position. I worked with a guy named Ken Ward, who actually is the, the PI of the lab that I worked with in Utah for a while. He's a geneticist, he was an obgyn, and he's a quadruple boarded, literally the smartest human being I've ever met in my life. I mean, you, like, you, you talk with 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. Genius level intelligence beyond like, hi and, and ob gyn, maternal fetal medicine, clinical genetics and molecular genetics, these are all fellowships. He did'em all and he, he said, you know, Nick, when you see one person that has the same, you have two different people that have the same disease. They have the same disease and they behave differently. It's because they're genetically different. It's not random. The patient that has diabetes and one person has, one person has type one diabetes and they have extraordinarily difficult to control blood, blood sugars and it's very hard to, to figure out how much insulin they should be on. And, and no matter what you do, they just seem to be gyrating all over the place. Another person has type one DI diabetes. You give them a normal regimen and it just works. You know, the one person will be like, ah, that person doesn't check their sugars often enough. They're not following the regimen. Right. You must not be following the regimen now. Bullshit. They're genetically different. They, they don't have the same disease. One of them has some disease that seems to work pretty well when you just sort of replace some insulin. The other one doesn't, and it's, they are genetically different and the patient. I mean, you can't take away that maybe one person isn't following instructions, but they can follow the instructions and it cannot go well. You know? And, um, a patient with, so a patient with Endo can, can have a fabulous response to surgery. And I'll also say a patient with Endo can have a fabulous response to medical therapy. And that's why I hate this sort of like, like medical therapy is the dragon that is being promoted by these ignorant gynecologists. It's like, no, it's bullshit. Like there are patients that will, there is a reason why medical therapy's on the market. It's because it works for a lot of people. Okay. And the people that it worked for probably never went to Nancy's snuck because they're fine. Okay. So, you know, you always gotta look at kind of this sort of selection bias of the groups of people that you're talking to. It's like people that did well with taking birth have endometriosis and took birth control pills and they're doing well. they don't, they don't seek more answers, 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 a minority of patients that have had, had really bad side effects to Lupron, but there's a lot of people that have been well on it too. You know, it's, it's, it's, again, it's on the market for a reason. It, it has effectiveness. Um, now does it address the fundamental reason why people have endometriosis? Absolutely not. But does it make a subset of people have an improved quality of life? Yes, absolutely It does. So does Oris. And so either one of these, any one of these drugs are okay, so surgery is not perfect. Drugs are not perfect. These, uh, all of these things are on the table as things that can potentially be used. Now, by the time a patient gets to my office, they've probably tried a lot of that stuff and it hasn't worked, you know, because other doctors have already tried those things. But that doesn't mean that those things are fundamentally evil or fundamentally wrong, in fact, that they're effective for a lot of people. And, and if, if they are effective, then great. Now, do those things prevent recurrence or prevent progression? That's a big question. So does the patient that I have who's 25 years old, that looked like she had horrible disease and was 10 years from bowel section, she'd been on birth control for at least some of that time. So if she had continued suppression that wasn't really working, would she have gotten worse? Worse, worse? Probably so. But she wasn't getting better on birth control either. So the question is, is does the Pearson that has good control of their symptoms on hormonal suppression, are they having progression or not? It's very hard to answer that. We've certainly seen people that were on hormonal suppression that went on to have surgery that had a horrible disease. So clearly it wasn't suppressing them, but it also wasn't controlling their symptoms because they went on to have surgery. So did the pe, did the person who did have control of their symptoms, in fact have non progression of their disease? These are questions you can't answer cause you don't operate on all of them. But I tend to think that you don't have pain because you don't have inflammation. Again, you get back to neurobiology, like, why do you have pain? You have pain. Cause nerves are irritated. They're sending signals to your brain saying that you're injured. So if you're not having pain, then your nerves aren't irritated. So that must mean that there's not very much inflammation. Well, what's, what's causing scarring? Why does the pelvis get scarred? It gets scarred because of inflammation, because your immune system is going in and trying to address this inflammation that is going on. And part of the process of doing that is sort of waging this immune war that creates scarring. And so it's sort of my assumption, my, again, I don't, I cannot proof, but if I'm gonna go from a functional medicine point of view where I kind of think about how does a system work, what is the most rational explanation that if someone is not having pain from endometriosis, they're probably not having progression? I don't know for true. I don't know that for, I mean, I don'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 the disease can be different. They've not been on suppression. They've, they've never had pain, they've never had a problem. They just can't get pregnant.

Natalie: 50:05

Hmm.

Nick: 50:06

And when you operate on them, they have endometriosis and there's a patient that got scarring and so forth, and they never had pain. So it's like no one answer is satisfactory to explain it all. And, and why does that patient not have pain, but maybe she has a neurologic or, or, you know, people get upset if you just say she, the person with endometriosis. They, they, they, they, um, maybe they have a genetic, uh, absent sensation for pain. Maybe they just don't feel pain very much. And there are people like that. I'm kinda like that actually. I mean, like my wife says, I'm like that, that like, I don't seem to care. I can get injured. And I'm like, yeah, whatever.

Natalie: 50:44

tolerance or.

Nick: 50:46

Yeah. Sort of, yeah, sort of. I mean, I, I sort of like, Okay. I feel this, but it's not that upsetting to me. And, um, and the, I I think that there are some people like that. I, I have one patient who literally came to see me back when I was more doing more, a little bit more general work. She came to see me for just annual exam and pap smear. She's a competitive tennis player. In fact, kind of a low level pro, uh, not quite at the high highest level tour, but she was kind of trying to play professional tennis or she was a professional tennis player and, um, she had stage four endometriosis and it was invading into her bowel. She didn't come into me with complaints about that. She came to me with needing a pap smear and I examined her and she had a knot of endometriosis in the back of her vagina and I did a rectal exam. It's like, wow. I mean, this is invading your bowel. Do you have any bowel problems? Uh, a little bit. Yeah. I've got kind of constipated one in my period. You know, do you have pain? Also she was, uh, had female partners, so she wasn't having a lot of penetrative intercourse. That might have been more of a problem for her if she was, um, but in the end, like she didn't have a problem. And, and like did I recommend, like if I had operated on her, I would've taken out six or eight inches of her colon and probably her uterus, you know, maybe her uterus. Um, is that worthwhile? Like she's out playing tennis on the professional tour, like obviously she's doing okay. So, uh, I didn't tell her she should have surgery. I told her just check in, see in six months or a year and see, it may change. Maybe over time it changes. And it, and it very well may be that when she stops being so active at tennis, she gets into pain. And it may be that the fact that she is being highly athletic six or eight hours a day is such an endorphin rush all the time that she just doesn't have pain. Maybe that's what it's,

Natalie: 52:32

Yeah. Okay. This is giving me a lot of questions. So and I have two that maybe you could kind of combo put them together. So the genetic aspect, if we know that certain genes are markers for yes, you will have endo or you might be more likely to have pain, whatever that might be. Is there any research in, I mean there probably is into like how can we prevent such extreme cases of endo in the future, or can we like let these people know that they're going to have issues? And then also there's also a lot of talk about endo being in autoimmune condition. Does that play into the genetic aspect of it as well? How would you approach

Nick: 53:18

Yeah. So, yeah, two different very interesting questions. So the first question is, is that, can we do any, can we prevent people from getting end up at this point? No. Um, I would say that most of the genetic information is still, is still kind of in development. A lot of it's proprietary within. You know, for-profit genetics labs, um, uh, there's a certain amount of public information and, you know, like the NIH funding for this stuff is not very much the, the most of the funding is in for-profit genetics labs that are looking for novel therapeutics that they can cap, that they can, you know, commercialize. And, and a lot of advancement in medicine is made that way. I mean, that's the capitalistic world. There's a reason why a lot of advancement comes outta the US cuz it's, there's a incentive to do it. Um, and so a lot of the genetics is still in proprietary situations. Um, but I think right now there's tests you can order that will tell you if you have these genes that are gonna predispose you for endometriosis, like you can order that test. Uh, there's a company called Predictive Laboratories that will order that will, that will do that. Um, it's not very helpful right now. Like there's not any treatments we can do. We're not really. Humanity right now is not really very excited about changing the genes of of, of people. We're not very excited about changing the genes of embryos either. Um, we're okay with selection, which means that if you do IVF and you get 20, you get 10 embryos. We're okay with genotyping each one of them and then growing the one that has the least bad genes. Like we're everyone's, okay, these are all these interesting ethical, moral questions, right? As society, we're generally okay with that, that if you've got 10 embryos and one of them's gonna have cystic fibrosis, why would we implant that one? Let's implant the one that doesn't, you know? So we're a little bit okay with saying that, uh, what's implant the boy instead of the girl. Some people are upset about that. Um, you know, and that's an interesting ethical question, but we're, we're, we're, we're generally okay with kind of selecting that kind of stuff, but we start getting into these questions about like, do we want to mold the future of humanity by kind of like selecting what our genetic future will be? So these are the things that ethicists get all bound up about. Um, so as far, that's all we can do right now is potentially select embryos in ivf Right now, there is not any traction at this moment, at least that I am aware of, that you could treat genetically someone within endometriosis. It will happen. I suspect it will happen. I suspect it will happen for all diseases. I think that there will, there will come a time when we look at what we're doing right now as being antiquated, not just in, not just in surgery, but not just in endometriosis, but in everything. Like there will come a time that, that we will address the defect that caused someone to get cancer. You know, rather than just trying to cut it out and give'em chemotherapy, but we're not there right now. Or maybe you have to cut it out and then address the defect. I don't know. But then the question becomes like, what, okay, what does that do to our humanity? Do we. We're supposed to die from something, 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 to cure everyone of everything? But anyway, that obviously people, that's a off question that you could talk about a lot that I have no more authority and then the garbage man. But the, um, so right now, not really your, your, your second question. Sorry. Say what was your second question again?

Natalie: 56:51

are calling Endo an autoimmune

Nick: 56:55

Oh, yeah. Okay. So interesting. In any textbook, it's not on autoimmune disease, but we all know that there's lots of things in textbooks that are incomplete. Um, it doesn't quite behave like an auto. So I'm gonna give you a two-sided answer to this, which is gonna sound a wishy-washy, but it doesn't behave like an autoimmune disease. And by that I mean that you don't have any. Um, autoimmune fundamentally means that your immune system is attacking your own tissues, and it's not like attacking something else and then creating a byproduct of damage. It's literally attacking the tissues you've got. So if you have a lupus, you're attacking 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, rheumatoid arthritis, you're attacking your synovium in your joints. For some reason. Your, your immune system has identified your own native tissue as being an enemy and is trying to kill it. It's not good, but that's what it's, and so the general treatment of those diseases is to try to suppress the immune system in one way or another. And those have changed over time. We have developed a lot of these new biologics. Any, any, uh, Drug you see on that has an ab at the end of it, it says a adalimumab. Uh, it's on tv. You know, those are all biologics. They're all lab made, uh, antibodies that are going to shut down some part of your immune system. They're extraordinarily profitable. By the way, you, you'll notice now that the only drugs that are direct to consumer advertising on television these days are all biologics because they're expensive. It's, it's not worth it to advertise 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's not anymore. All the, all the research is going into new biologics, and that's where all the ads are. So, um, endometriosis, as far as we can tell, it's not attacking the tissue. Your immune system's attacking the endometriosis. It's not attacking. The tissue, the damage that's happening to the tissue is the byproduct of the, of the attacking of the endometriosis. I think. I think that's what's going on. I don't think it's all the scar tissue is being created by the fact that the endometriosis is creating inflammation and then the immune system is,

Natalie: 59:30

Responding

Nick: 59:31

thing. The immune system is responding to it, and in turn, that's creating scarring. If you have a splinter in your foot, your immune system will create, it'll be inflamed and inflamed and inflamed, and if the body never gets rid of it, eventually you'll get like a capsule of scar tissue around it and it won't hurt anymore because it'll just be like a dead scar tissue around it. Um, and I think that's what's happening with endometriosis. So that, so that's where I, where I would say that it doesn't really behave like an autoimmune disease. That being said, there is a clear genetic connection between autoimmune diseases and endometriosis. Um, they co-locate, meaning people that tend to have autoimmune diseases also tend to have auto endometriosis, and I will. Also tell you, and it may mean that some of the genes are just close to each other on the chromosome. So if I have a, let's say I have a eight 18th chromosome and I have a gene that's, uh, 60% down the, one of the arms of the chromosome, that's where it's supposed to exist. And now I have another disease and it's 70% down the arm. Just the fact that they're close to each other on the chromosome is gonna make them tend to be together because the way that we assort our chromosomes when we go through myosis, which is how we jumble up our chromosomes when we make our gammy, so when, when women make eggs and when men make sperm, we, we mix up our chromosomes. That's why we don't create clones of ourselves. We create, we create children that carry our genes, but they carry a random assortment of our genes. They don't just create a copy of ourselves, nor are they a 50% copy of mom and a 50% copy of dad. They're a jumble of the two and the. Well, they are 50% mom and 50% dad, but it's not like copies of half and half. It's literally like a jumble of mom and a jumble of dad. So what happens in that jumbling process is the chromosomes get cut and then they switch and they mix. And so if two genes are very close to each other on a chromosome, when you cut the chromosome and mix it with another arm of another chromosome, those genes are gonna tend to come together unless the cut just happens to happen right between them. And so the closer the genes are together, the more likely they are to associate in the person because it's pure randomness. Where's the cut gonna happen? So if the gene is really far, if the genes are very far apart on the same chromosome, you could easily cut between them and send and send one gene to one egg and send one gene to the other. But if the genes are really close together, You're much more likely to cut the chromosome in a way that sends the two genes to the same egg. And so then you say these diseases are together. Were they causing each other? No, but they were close to each other on the chromosome and so they just tend to go together. And so the, there is definitely a over association of autoimmune diseases and endometriosis. I think there's an over association with s dental syndrome also. I think there's an over association with, uh, leaky gut kind of, uh, IBS or some bowel issues it seems like. Um, and the other weird thing I would tell you is that men who carry the genes for endometriosis have overrepresentation of autoimmune diseases.

Natalie: 1:02:43

That's

Nick: 1:02:44

And well, I mean, it it, it, it is. So they, if you look at men who, whose mothers had endometriosis, whose daughters have endometriosis, cuz the genes went through them and just didn't give'em endometriosis cause they didn't have the. They didn't have what was required to give them mendo. In most cases, these, these super edge cases of the men getting endometriosis. I kinda, yes. Some people get, get one to point 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 get hung up on that mostly endometriosis as people are born with two X chromosomes and you know, and if they go on to become men later in their life, then that's fine. But they generally are, it's generally a disease of people that are borning X two X chromosomes. So the men who carry the genes of endometriosis from their mothers who may have daughters that have endometriosis, those genes do not leave them unscathed. They have an overrepresentation of having autoimmune diseases and they have overrepresentation of diabetes, they have overrepresent representation of thyroid disease. They so did, do those endometriosis genes carry some. Additional risk of autoimmune diseases themselves, or are they just co-located with those other genes and they're close to each other and therefore they tend to distribute together? I'm not really sure. I'm not a geneticist. Like I'm kind of giving you a high level answer to this that makes me sound smarter than I am. I feel like, because the, like you could ask a, a geneticist who studies this stuff and they would, they would say, okay, I just said like 0.5% about what we know about this. You know, but that phenomenon, if anything, I'm just explaining that phenomenon that, that a phenomenon 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, there will come a time where I think that we treat most diseases this way. We will figure out what are the genetic things that are causing the disease and just fix that. Um, I, the ethical issues about whether we edit people's genes, I, I wish we would get over it personally. I, I actually think that humanity. Is in a post evolutionary phase. I think that modern medicine has ended evolution for humanity because the whole idea of evolution would be that you don't reproduce because you have some defect. And so we are going to, humanity will slowly evolve because, because, or any animal or any, any beast or plant or whatever, it's gonna slowly evolved because there will be selective advantages that will allow one mutation to win over another. Well, guess what? It's really, really hard to die these days. Like

Natalie: 1:05:27

It's

Nick: 1:05:28

keep almost anybody alive. There's not a lot of diseases these days that will keep you from reproducing. Like Endo is like almost one of the few cystic fibrosis. Another one like, and still many women with endometriosis are able to reproduce and. It's very, very hard, I feel like, for humanity to change genetically anymore via evolution because of modern medicine. And so I kind of think like, if humanity is going to change over time, it's because we're gonna edit our own genes. And that's why I say bring it on. I'm like, great, you know, but I'm a futurist, you know, I'm not quite Elon Musk. He's crazy. But, but I mean, I, when someone says, oh, we could edit our own gene. Great. Let's figure out the ethical issues later. Let's just figure out how to do it first. You know? And I, that's my own feeling. That's my own feeling. Not everyone agrees with me about that. But I, you know, if you could edit endometriosis out of our gene pool, would you do it? Sure. I would think so.

Natalie: 1:06:28

Hmm. That's a very thought provoking question. Um, I wanted to ask kind of an interesting question. If somebody doesn't have a problem getting pregnant, but they definitely have endo, have not had surgery, is there any risk to carrying a pregnancy to term with endometriosis lesions? Is there any studies on that? Okay. Okay.

Nick: 1:06:53

I mean, I don't know there studies on it, it's just not, I, I've operated a million, I don't a million C-sections for people with endometriosis. I mean, if, if, if the baby got in there and it didn't and it survived, then I think everything's gonna be fine. I mean, there's lots of things that can go wrong in pregnancy, but the, there's, there's no reason to operate on someone to prevent adverse pregnancy outcome unless the outcome is, is recurrent pregnancy loss. Then there may be reason to operate for that, and even that's controversial. But, but in general, I don't think that endometriosis supposes a risk in a pregnancy anymore than other random, weird things that can happen in pregnancy.

Natalie: 1:07:27

does it predispose you to having a cesarean ver versus a vaginal birth, do you think?

Nick: 1:07:32

No, I don't think so.

Natalie: 1:07:33

Okay. That was an aside question that I, that I

Nick: 1:07:36

No, that's a good question. I mean, if anything, maybe they're more likely to have eeds then they're more likely to do over vaginal. But I don't, in any event, I don't, I I, I would say no. I, I would not be worried about the outcome of a pregnancy cause of endometriosis.

Natalie: 1:07:52

Okay. That's encouraging. That's good. Um, so if somebody is thinking about having surgery, what are your hard and fast rules? Like what are your next steps for them?

Nick: 1:08:04

Well, I would just say that like, if you can access someone who's really experienced with endometriosis, you should, I, if you have surgery with someone who's a general ob gyn, and again, not, I never mean this to disparage other doctors. That's not my point. I'm just saying like, if you're gonna have neurosurgery, go see a neurosurgeon. You know, if, if you probably will not have very good outcomes if you have surgery with a general OBGYN for endometriosis. They're just not trained in how to do surgery well. and includes me when I was a general obgyn. My outcome sucked because I didn'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's like a perception that excision surgery is so inaccessible and rare. And I understand I'm in my own practices out of network. I decided to charge for my services cause I really specialize in this. But there, there are people that have mis gyn practices that have a reasonable experience in excision that will do a pretty good job in most cases. And, and they're generally accessible. So I would try to, at the very least, see a surgeon who does a 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 be a good place to start. Um, if you can access someone like myself who really makes an entire career out of endometriosis, you should I understand that. That's not accessible for everyone. There are some barriers and I, and that's that. It is what it is. But, um, if you can access that, you should, um, your long-term outcomes I think are gonna be better. Um, but if, if, if the only option 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's there. And then you're gonna have a, and then even if you talk to someone else who's a little more experienced 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 really far away and doesn't really show things very closely and it's like, okay, these pictures are not that helpful. And then someone asked me, do you see? I know. I'm like, I dunno, it's not, the pictures are not, not adequate. So, That's what I, but I mean, in general, I would say, you know, access the best position you can. And I'm not saying that's necessarily me. I mean, I, I, I'm very good at what I do, but I'm not, I'm not like the only doctor in the universe. You know, there's, anybody could call me from any state in this country and I could tell you the closest person that I know of who's really good at endometriosis, like we all kind of know each other. We, we all go to the meetings, a g l meetings together. And like, if you ever wondered, ever thought that endometriosis surgery is so rare, you go to the A A G L meeting and it's like the endometriosis show, like every damn videos endometriosis. And it wasn't like that a decade ago. Like I think endometriosis, I think Nancy Snuck honestly grew a lot of demand. Like I think that there weren't that many real good endometriosis surgeons 15 years ago, just a handful. And I think that the growth of Nancy's no really raised the awareness of excision. And I think that in time the market responded and, and more doctors started to see this as something that they wanted to do. and also more trainees saw it during their fellowship. They saw videos at a g L and so forth. And I've been going to a G now for 15 years and it's totally different. It used to be like endometriosis was like a one video session, a few videos. Now it's like you could watch for four day meeting, you could watch endometriosis from the beginning of the day to the end of the day. All meeting long if you want to. I mean, there's lots of sort of breakouts. You can't watch it all at once, but there's enough endometriosis you could never stop watching it if you want to. Um, uh, and so clearly the interest in endometriosis is there. Um, but you know, see somebody who does a fair bit of it. Um,

Natalie: 1:12:04

Solid

Nick: 1:12:05

I would say.

Natalie: 1:12:07

That's what I would also recommend. I know I am very, very thankful we were able to fly, cuz in Alaska we don't have any end neurosurgeons any, unless you know of anybody who has started. Yeah.

Nick: 1:12:20

I don't think so. It's difficult in Alaska, I think. I think that it's a small medical community. It's not really that supportive. It's not really enough of a population to support a full-time kind of endometriosis surgeon. It's hard to, it's hard to do part-time endometriosis surgeon. Well, to be honest, I mean, it just takes a lot of doing to be really good at it. But it's all a big spectrum, you know, and we're all getting, we're all getting better at it. The more you do it, the better you get at it too.

Natalie: 1:12:47

So if somebody wants to do more research, um, what are your favorite books, websites, people, accounts that you would recommend?

Nick: 1:12:59

I mean, I think that a lot of, you know, my honest answer, if you were to give me my answer would be to find a doctor who's really experienced with it and then go work with them and trust them and let, let them tell you what they've learned about this disease state. I, it's not to say that you shouldn't do research. I, I. you should, but anything you get online and it's gonna be like in Facebook or something, it's always gonna be somewhat true and somewhat incomplete. I think that there's a lot of very, very kind of monolithic truths that are spun around online 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 one truth is going to be true for all of them. And, and so getting a lay of the land, I mean, if there's one 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 do some work online and look at, look in various different things, but take it all with a grain of salt also, that if anything is being presented as being the monolithic truth of everything, realize that, no, it's probably a little bit more complicated than. And that's why it's helpful to really see someone who's really experienced, because they've seen a lot of different cases, I mean hundreds if not thousands of people. And they kind of see different kinds of cases, how they tend to go, how they tend to respond to different things. And that's probably going to kind of lead you down the road most likely to help. Um, I think if you're interested in the disease state, there's tons and tons to read. If what you wanna know is how to fix yourself, go see somebody who works with a lot of endometriosis patients and take their advice. Um, what I always say is, um, find a doctor you trust and then trust them, which means do lots and lots of research to figure out who you wanna work with. And then once you decide to work with them, let them give you their best advice and, and do your best to take it because they ultimately have your best interest at heart. You know, doesn't mean that they'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 best judgment about what would be a good path. At least. At least kind of lay it out there and let you make a decision. Um, there's tons of books out there though. I mean, a lot of the, a lot of the kind of big name endometriosis surgeons have written books. I haven't, um, if I ever did, it would just be like, everything we know about the deceased state, it wouldn't be about me. It'd be like, okay, what do we know? The problem is it would be outta date in like two minutes, but, um, but, um, there are a bunch of books out there. Uh, Iris Orbs book is excellent. Uh, Dr. Seskin wrote a book. Uh, there's, there's a bunch of books by, by some surgeons. I, they're all gonna have good information. They're all gonna be fairly similar, which is basically to say excision surgeon is, is excision, surgery is helpful, PT is helpful. A lot of things, um, in, in many ways, a, a good way to, to, to research per se is talk to a lot of other people who have a disease state and see how, how things went for them. Um, and. While being aware that you are unique and that you will not necessarily follow the path of any other particular person. But if you talk to a lot of different people, um, you will get a sense of different paths that have been have, there have been for different people, but also being aware of like, depending on where you find the people, you're gonna get a certain bias. So if, if, I would say that people that are really, really successful with their endometriosis treatment are less represented online than people ha haven't done as well. And I think that's because, um, if you're really successful, you probably get on with the other important things in your life a little more. And if you're not doing as well, you may be a little bit more occupied with it and wanna spend more time. And I don't know that for sure, but I think that's probably true. So I, I think there's a little bit more of an overrepresentation of problems in some of the online spaces than if you take the entire population of people that have gotten treatment for endometriosis. So it's all good. Just realize it's all. It all has certain biases to it and, and even what your physician tells you has certain biases to it and try to make the best decisions you can.

Natalie: 1:17:06

Yeah, I would say that echoes my experience because originally when I didn't know anything about surgery, I was like, absolutely not. Why would I, why would I get surgery

Nick: 1:17:17

Why would you do

Natalie: 1:17:18

do that? Until I talk to people who had excision and they explained to me the benefits. And I, I'm one who likes to know the why behind every single thing that I do. don't just tell me to do something. Tell me exactly why I'm gonna do it. Um, and so that was really helpful for me to learn, um, prior to actually having surgery. And, and I, that was an empowering decision to make for sure.

Nick: 1:17:42

Mm-hmm. Hmm.

Natalie: 1:17:44

and to put it on the record for you, I know I've talked about this online and another podcast episode, but I'm doing better. My constipation is better, my pain is better. I'm really, really happy that I

Nick: 1:17:55

Yeah, I wanted to ask, I mean, it's not really your pod, my podcast to direct, but you know, 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, you know?

Natalie: 1:18:08

I would say it was an 11 before 11 or 12 If I can go beyond the scale and, um, I probably, I was trying to calculate, I think I had pelvic pain more than half the month prior to surgery, which when I sat down and looked at it, I was like, this is more than half my life. That is significant to time to be in pain. And after surgery, I still get, I still get pretty significant cramps on like day one or two of my period, but way less bleeding, way shorter periods, way less pain overall. And I'm not, I'm not having pain half the month and I can do. Life I can do real things cuz I was calling out of work, um, when I worked for somebody else and I was staying home and now I can actually live my life even if I'm having some cramps. So, yeah.

Nick: 1:18:58

that's good. And that's, and that's a realistic success, you know, and I think that that's what we wanna accomplish. I mean, I, I, endometriosis is a, it's a shitty disease state. It causes inflammation and scarring. And like, you cannot take someone who had endometriosis and make'em into someone who never did. Like, you can remove the inflamma, you can remove the sort of ennis of inflammation and, and then remove the tissue that is sort of inflaming everything. And then the body has to heal it, and your body will heal scars over a long time. But as we know, like if you have surgery and you get your belly cut open, it never looks like normal skin again. You know, it's. it will be really inflamed and then over time it will be less and less scarred, but it never looks quite normal and you can't really make the pelvis normal. What you can do is you can try to make it a lot better, and I think in turn, people's symptoms are generally a lot better. And that's exactly your outcome. Exactly what I hope patients will have, which is that their life is better. Not that they have no pain whatsoever, but that they have a notable increase in their quality of life and that they're able to be more productive or better with their family or their kids or whatever. And that's what I can potentially offer. You know, I can't offer cure of this disease state, like the disease state is in their genes. It's not something I can cure,

Natalie: 1:20:17

brain.

Nick: 1:20:18

I can make things better. We could even show your video if you want, but you want to

Natalie: 1:20:23

do it.

Nick: 1:20:25

Okay, you see that?

Natalie: 1:20:27

Uh, yes I can.

Nick: 1:20:30

All right.

Natalie: 1:20:30

is very exciting, I haven't watched it in a few months, so

Nick: 1:20:36

Okay. So this is the beginning of how we start any surgeries. We look at the diaphragms. This is the gallbladder. We always look behind the liver here. This is something that I started doing a couple years ago where we get, you can get endometriosis behind the liver. This is all the way behind the livers is posterior diaphragm. The vast majority of people that look at the diaphragm don't look back here. I think. Um, and I've seen disease back here. This is a left diaphragm up there. This is us pulling the camera in and out to clean it. But, um, Okay, so this is now in the pelvis, but let's, let's, we'll stop. This is the pelvic brim. So this is kind of where you're dipping from being your lumbar spine into your sacral part here. So your sacral vertebrae are kind of underneath all of this. This is fat that's attached to your colon that's now attached to the pelvic brim. These white spots here are endometriosis for sure. Um, notably, this is about over the area of your first sac nerve root. It's not that deep, so I don't know whether or not this would've inflamed that nerve root because there's a quite a bit of tissue between this spot and the nerve root, which is like a couple centimeters down from there. So if it were enough to inflamm it, you might get some pain down your left leg, but it may not be quite enough. Um, endo here. This white spot here. And as far as in general for people like this is a case of 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 back here, which would be more of a stage four case. But there's also deep infiltrating endometriosis. You see this black stuff in the back of the vagina that's deep infiltrating endometriosis. These are the uter cycle ligaments, that's endometriosis. Um, and so we're kind of just starting and then we're gonna dock our surgical robot, which we have now, this is robotic. You notice that the screen is really stable now. Cause the, the, the, uh, the, the robot is holding the camera instead of a human. Humans are always jickling their hands around, where's a human? The robot is just dead stable.

Natalie: 1:22:40

Got.

Nick: 1:22:41

this, these areas here we're taking down, we're gonna remove some of that stuff. And now this is this area of endometriosis that's on the left uter sac ligament. You see this black. This blacks up. This would cause pain into your back on the left side. This might cause urinary symptoms. Um, it would cause pain potentially into your, probably into your back left side of the pelvis, maybe, maybe into your butt, uh, maybe into your pelvic floor. Um, and it's also gonna create uterine pain effectively because the nerves that are carrying sensation from the uterus are running right underneath here. It's called the inferior hypogastric nerve plexus, and it's running right underneath here. So this area of endometriosis is inherently gonna inflame the nerves for the uter from the uterus. It's gonna give you the sense that the uterus is in pain, even though the uterus itself is not necessarily the source of the pain. It's the, it's the nerves that are just are, that are, that are coming from the uterus that are getting inflamed. And so we're using our instruments here to remove this endo. There's the fallopian tube getting in the way, and now I'm gonna use an instrument to get it outta the way. Probably. Um,

Natalie: 1:23:50

It's kind of floppy

Nick: 1:23:51

So, um, yeah, and you know, surgery's not perfect. Like, like if you see an edited video, you're always gonna see like this beautiful thing cause they cut out all the garbage, but weird things happen all the time. Like right there, the Flo tube kind of fell in the way and got in their way. So we had to get it outta the way. And sometimes the bowel falls down in the pelvis cuz it's, it's attached down there. So sometimes it, we want to kind of pull it outta the way, but sometimes it kind of just fall. All the small bell falls down and you gotta get it up outta there. So this is excision. Ablation would be where you just effectively would just try to burn the lesion away, whereas in this case, I'm trying to cut, cut the tissue out. That is, um, that is inflamed. Um,

Natalie: 1:24:32

So cool. It's

Nick: 1:24:34

and on the right side, this is the lesion on the right side here, right side of the pelvis. Ureter, this tube right here. Do you see my pointer by the way?

Natalie: 1:24:42

Um, yeah, it's very small for me, but I think in the

Nick: 1:24:45

You can see it. So this, this area right here is the ureter. Um, this particular case, not very involving the ureter, but the, the ureter is running right over here, and this is endometriosis here on the right side 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 of the mountain and everything is growing from it. And so the, the actual biggest lesion is right under here, right here where I'm, where I'm marking it. But you can see this whole kind of area here from the other side. You see this lesion right here. And in fact, my partner, Dr. Molan, just made a really nice Instagram video showing something like this, like the lesion is right on the other side here. And the, um, you can see we're kind of just getting all that tissue off. Um,

Natalie: 1:25:34

Yeah. It's amazing to me how deep it goes,

Nick: 1:25:37

yep, it does. Right. And part of the key for doing decision is to get deep enough, and again, what we were talking about before about knowing anatomy that. You gotta know the anatomy of what's underneath there to feel comfortable going deep because you got, there's stuff under there that you don't want to injure, so you better understand where it is.

Natalie: 1:25:55

Mm-hmm.

Nick: 1:25:56

Um, and if you don't, it's difficult to proceed because you, you're afraid you're gonna cause damage. And I've heard lots of times you'll hear people say, oh, I didn't wanna remove that disease cause I was worried I was gonna hurt the, it's not that it's not removable, it's that that person doesn't understand the anatomy of the situation very well and they don't understand the technique very well. It's not like it's fundamentally not removable. It's just like that person doesn't quite have the skillset required. And so here now we're just removing all that. So that's that whole bit of endo. And then this is endo that was right behind the vagina. I'm sure this would've caused pain with sex. Um, this, this, this is right behind the vagina. So if someone was, if you or someone's having intercourse, and it's gonna be pushing right up into this space. And so this is endometriosis is right behind the vagina that we're removing and. I think, you know what's funny is I watched this video, I think I even remember that there was like a plume of brown endo as I cut through this. Like I, it's weird. I have like this flashback, I'm like, oh yeah, I remember this. Um,

Natalie: 1:26:54

That's amazing with how many patients you see every year,

Nick: 1:26:59

uh, well now I wouldn't have remembered that this is your video, to be honest. I mean, I I you, I looked it up cause I had your name on

Natalie: 1:27:05

Oh, I

Nick: 1:27:06

but I, but, but I kind of, but I kind of remember this moment in time. I was like, oh yeah, I think I remember that Legion But the, uh, the, so you can see that brown is that brown right there. That's the infiltrating endometriosis is that little plume of brown stuff. That's what I was remembering. Uh, um, and so what we're seeing here, this is the back of the vagina that looks healthy and this is this endometriotic nodule here that's in the back of the vagina.

Natalie: 1:27:38

and I think

Nick: 1:27:39

And.

Natalie: 1:27:39

to feel that on a manual exam prior to

Nick: 1:27:42

Yes, I'm sure I could. Yeah, with a finger in the, in the, in the vagina. And then if you do a rectal exam too, you can, you should be able to feel that. You can kind of feel it in the vagina, but you probably could feel that it's not quite in the wall, the rectum. So this back here is the vagina, but this here is the rectum, like this tissue here is the actual anterior wall, the rectum, and then appears the posterior wall of the vagina. And then this space is called the rect space. So you can imagine if this lesion 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, then it'll invade the rectum and that's where you end up getting into it, power section situation. But you know, you were early enough that that really wasn't ever a concern for you, but it could have been maybe eventually. Um, so I think we're gonna clean up a little bit. Looks like there's a little bit more. 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 of Nick does get it and I go like, oh, good. Good job. Um, th there was some other stuff. This was the stuff early in the case that we were looking at, up on the left pelvic side wall that I now I'm getting rid of too. Or it's on the pelvic brim.

Natalie: 1:28:53

Right cuz

Nick: 1:28:54

rid of that.

Natalie: 1:28:54

colon was attached to my pelvic side wall. I

Nick: 1:28:57

Yep. That's, that's, that's right there.

Natalie: 1:28:59

that's right there. Okay. Yeah.

Nick: 1:29:00

Yep.

Natalie: 1:29:01

Which I think was a like mechanically why I was constipated all the time or part of the

Nick: 1:29:06

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 stripes right here. These are hypogastric nerves. These are all curing sensation to bladder bowel. See this little white stripes right here? These little pine right behind the instrument on the left. This right. This is all part of the hypo nerve plexus. So there's endometriosis directly over the top of all that. And that's what was inflaming that I'm not sure what I'm looking at right now. I, I think I may be demonstrating some anatomy to my fellow. It looks like, it kind of looks like that's what I'm doing. The, this right here is the uterine artery. This is, yeah. I'm almost certain that's what I'm doing. I, I probably just did a little anatomy lesson to my fellow right there. Um,

Natalie: 1:29:46

glad to be of service.

Nick: 1:29:47

yeah. Um, so, and there you go. That's all that endos removed. We may have put some adhesion barrier. It looks really clean, so I may not have, so, oh, this is a great view of the hypogastric plexus. You can see all these nerves right here. These little stripes nerves are very small. This is a big nerve here. Yep. Very small little fibers. You can see these little fibers here. In fact, I think I must be anatomy lifting. Again, these are showing this, these tissues. This is a hypo inferior hypogastric nerve flexes right here. So you can see how if you had endo, there's like a big ball here, you could involve these nerves.

Natalie: 1:30:21

Mm-hmm.

Nick: 1:30:22

In your case, I'm sure it involved them in an inflammatory way, but it didn't directly invade them, which is why, um, surgery worked well too. Like if it had already invaded the nerves, I'd have to remove whatever nerves are invaded and then you left with some certain amount of autonomic nerve damage. But it's all you can do. Like, you can't, you, you hope that what happened is that the endo kind of grew slow enough that the nervous system has already started to reroute around that damaged part. Because we can do that. Like if our nerves start to get slowly damaged, we will, A lot of it's redundant, so we'll start to use other nerves to do the same thing. Um, but

Natalie: 1:30:57

That's fascinating.

Nick: 1:30:58

that's, that's your surgery.

Natalie: 1:31:00

Amazing. Thank you for sharing it and, and walking through it too.

Nick: 1:31:05

Yeah, absolutely. Lemme see if I can get out of this. Um, there we go. So, um, yeah. So obviously that was helpful for you. I'm glad it was.

Natalie: 1:31:14

Yeah. Yeah. Thank you. Okay. I have two final questions that I ask every single guest on my show. Number one, what is your number one piece of advice for anyone listening? What do you want every single person to know?

Nick: 1:31:30

Well, trust yourself. I mean, if you're having pain, you're having pain. If somebody, if somebody's telling you that what you're experiencing isn't real, they're not a good person to work with, there's not really that, it's not really that important to get angry at them and be like, go fist at the universe. They're just not the right person to work with. And, and find somebody that's gonna believe you and then take 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 implies that 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 that have their own their own issues and stuff. So, um, just try to find somebody who's really experienced. I mean, if everybody could see somebody with, everyone with pelvic pain, could see someone who's really experienced with this stuff, it would be better. It's hard cause it's not scalable. Like it took me a long time to get good at this stuff, and it's not, it's not that scalable to make a thousand or 10,000 people who are really good at it, but try 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: 1:32:45

Awesome. Okay, second question. What is your current favorite daily wellness habit that you incorporate into your own life?

Nick: 1:32:54

Hmm. Well, I wish I could say try to get enough sleep, but I don't, um, I'm not very good at daily wellness habits. Natalie, I, I

Natalie: 1:33:07

why I asked this question. It's a little bit of a challenge.

Nick: 1:33:10

I don't, uh, my wife is a health coach. She's good at daily wellness habits. I, um, am a functional medicine physician as well, but I, um, you know, I try to do some things I enjoy. I try to, I, I like to do artistic things. I build, I build Legos sometimes. I, I, I'm a total geek Natalie, like ridiculously so, okay. I'm the, I'm the one guy at the Magic the Gathering tournament who's like, has a job. Okay, well that's not really fair, but that, that, that, that's not quite fair. But, but, but, um, I'm, I'm the odd man out at that situation. Um, no, that's not fair at all. Plenty of them have, plenty of people have chat, but, but I'm definitely the odd man out of sort of like a straightforward, like career. Um, I, uh, I'm a, I'm a super geek, 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 at it.

Natalie: 1:34:12

Yeah, I would imagine. I mean, you're good at

Nick: 1:34:14

I get my, I get my, my daughter's kind of my daughter's into that. You know, you find hobbies, you find 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 or that have problems, and it's my own wellness habit, but also as a wellness habit, I would encourage to anybody, seek help for your problems, but don't, please don't make it your life. That, and this is not just like patronizing bullshit. This is neurologic. Your brain will will get good at whatever you pay attention to. And if you make your entire existence about the fact that you have some pain, your brain's gonna get really good at feeling pain if you make your existence. You know, your dog or your family 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 that to the point of well, distract yourself from your pain. I'm telling literally, get your brain to pay attention to something else. It's a neurologic effect. And I, I worry a little bit about people that have gone down the rabbit hole of making this the only thing they think about because I, I, I, it sounds very patronizing cuz if you have a lot of pain, I understand how it would be hard to be distracted, but I, I think from a neurologic point of view, you're actually going down the wrong road. If you want this to be the only thing you think about that actually it'll be hard to get better. So from a wellness point of view, make sure there is stuff that, that you got in your life. other than just this while also trying to get good care.

Natalie: 1:36:02

Well said. Well said. I will tell you, when my husband and 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: 1:36:11

There's some, there's some behind me too. There's R two is not quite, R two 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 things too. There's a, a wing. Oh, there's a wing up there.

Natalie: 1:36:24

amazing

Nick: 1:36:25

then, uh, here's a space station. That's not Star Wars, but, um, I have, I have a three foot tall k2 so that I'm gonna build one day and I'm gonna put it here on the floor. Um, my, my camera wants to follow me so it screws it up. But like, basically on the floor there, um, next R two, so it'll be tall enough that while was gonna put R two on the lower shelf, so there could be a K twoo that fills that whole space. It's literally that tall. That's not a, it's not like an official Lego set. It's a. A custom build, but I have all the pieces for it. The problem is I have, I only have like small aliquots of time to devote to building Lego and I, and I have like all 4,000 pieces that will be required to build that thing, but it's not like separated, so I need to break it into like 200 piece bags in order such that I could actually build it a small part at a time.

Natalie: 1:37:17

Well,

Nick: 1:37:18

one day,

Natalie: 1:37:19

build it, post it on

Nick: 1:37:20

day, oh, I'm sure I will. It's actually, I'm almost saying it's a little creepy cuz it's literally like a very accurate, very tall droid,

Natalie: 1:37:28

it might be a little bit disconcerting

Nick: 1:37:30

it, it I don't know. No, it's pretty cool. Um, alright,

Natalie: 1:37:35

yeah. Can you just tell listeners where they can find you online and what they need to do if they're wanting to book with.

Nick: 1:37:44

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 our website. Um, the website is not always that updated. It, it's funny, like, well, it's, it's fine, but we get so many calls. It's really crazy. Like we get like 20 calls a day. So the idea of doing like additional marketing seems insane. I, I, um, um, but contact our website. There's an opportunity to put in your information. Um, you can get a free phone consult if you want, if you, if you live locally here in Portland. We'd rather just, the best thing is to see you in person. But if you're out of town and you want to have just kind of a free phone call to go over your case 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 this stuff. And you can see that one of us can get great care. Um, the. you can also, sometimes people contact me on Facebook and so forth. I get a lot of messages that way and I don't always respond to them. Cause there's just, it can be difficult, but I respond to a fair number to be honest. But, um, the best thing is to contact the, the office. Um, I, I would, I would tell you that right now we're having like a real staffing issue. There's a whole, the whole world is having trouble employing people and we're bringing on some new people. We're supposed to have someone starting next week, but we're really backed up at getting calls back to people. And it's unfortunate. I know there's some people that have contacted us and we haven't gotten back to them and it's been a week or more and it's like, I, I'm sorry, I'm very sorry. It's not, it's not what we want. We don't, that's not the level of service we want, but it's, it's, we're kind of struggling to keep up right now. And to some extent, the demand greatly outstrips the supply. The supply isn't just me and my staff's time. The supply is operating room time. The supply is, and actually right now we're in a weird situation where this, the, the biggest supply defect is anesthesiologists. There's a, there's a big shortage of anesthesiologists right now, and it, it was in effect 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 with their lives. And, and, and then that created a weird situation where anesthesiologists started flying all over the country to these temporary jobs that were gonna pay them a lot of money. And, and so a lot of the employed contracted anesthesiology positions have sort of vacated. And so the hospitals, a lot of hospitals are having trouble. So we're, we're struggling to post as many cases as we li as we like. And I have a lot of patients that really wanna get in and I'm like, I don't have an operating room. Like I can't operate on my desk, so it's gonna. It'll change, it'll get fixed over time, but it, it'll get fixed slowly. So it's right now, like at this very moment, we're in this weird sort of vacuum of not quite enough operating room time,

Natalie: 1:40:31

Wow.

Nick: 1:40:32

but we're working on it.

Natalie: 1:40:33

Yeah. Well,

Nick: 1:40:34

We still operate a bunch.

Natalie: 1:40:35

Oh, good. Good. Thank you so, so much for being here and having this conversation with me. I learned a lot of new things, so thank you, and I'm sure our listeners will really appreciate it as

Nick: 1:40:46

Well now it's great podcast. Thank you for, uh, for having me on and um, thanks a lot. I'm glad that you're doing well and best wishes.

Natalie: 1:40:54

Awesome. Thank you. My top takeaway from my conversation with Dr. Fogelson is that Endo is still so misunderstood, but we're doing the best we can with the information that we have, and as I've emphasized before, it's crucial that you find someone who's. Skilled and knowledgeable about the disease before undergoing surgery. If you're interested in hearing more about my journey with endometriosis and the decision process that led me to surgery in 2021, I did a whole podcast episode on it. It's episode number 17 of the Resource Doula Podcast. I'll put a link to that as well as the other resources mentioned in this episode. Please remember that what you hear on this podcast is not medical advice, but remember to always do your own research and talk to your provider before making important decisions about your health. If you found this podcast helpful, please consider leaving a five star review in your favorite podcast app. Thanks so much for listening. I'll catch you next time.