unPAUSED with Dr. Mary Claire Haver - Endometriosis and Fibroids Don't Stop at Menopause with Dr. Karen Tang

Episode Date: July 7, 2026

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Karen Tang, a board certified gynecologist and minimally invasive gynecologic surgeon, and author of It's Not Hysteria: Everything You Need to Know About Your Reproductive Health But Were Never Told. This is part one of a two part conversation. Together they take on a question that most women entering perimenopause have never been given the tools to answer: what happens to the gynecologic conditions you have been managing for years when your hormones start to shift? Dr. Tang opens with endometriosis, dismantling two of the most persistent myths in gynecology: that it goes away after menopause, and that it is cured by pregnancy or hysterectomy. She explains what endometriosis actually is, why it so often goes undiagnosed for an average of seven years, why imaging studies frequently miss it, and what the full range of treatment options looks like for perimenopausal women dealing with painful periods, pelvic pain, and chronic inflammation, including when surgery is the right next step. Guest links Karen Tang, MD (Instagram) Karen Tang, MD (Facebook) Karen Tang, MD (YouTube) Karen Tang, MD (LinkedIn) Karen Tang, MD (TikTok) GynoMight with Karen Tang, MD (Substack) Thrive Gynecology Books “It's Not Hysteria: Everything You Need to Know About Your Reproductive Health (but Were Never Told),” by Dr. Karen Tang “The New Perimenopause: An Evidence-Based Guide to Surviving the Zone of Chaos and Feeling Like Yourself Again,” by Dr. Mary Claire Haver “The New Menopause"⁠ by Dr. Mary Claire Haver To learn more about listener data and our privacy practices visit: https://www.audacyinc.com/privacy-policy Learn more about your ad choices. Visit https://podcastchoices.com/adchoices

Because there was so much to cover with Dr. Karen Tang, we have broken this episode into two parts. This is part one, and we will publish part two later this week. How long do people suffer in general with endometriosis or adeno before they are diagnosed formally? It's on average seven years. And it's actually eight years in the UK because also their system, there's a longer weight period, just to see a gynecologist. Like, take a step back. And so imagine something, I would say, imagine something affected. at least 10% of men.

It's actually much higher, but it caused excruciating pain. It hurt when you had sex. Like debilitating pain when you have sex. It made you bleed through your penis. And it gave you diarrhea. And you were having, like, incredible bloating. We would, you know, like have a little bit more like awareness and research and all these things. But for women, we were just like, oh, you know, like it's just, you just kind of deal with it.

So the fact that we let people suffer like that for seven years. Like you can't even conceive of forcing men. on average to wait seven years in that much pain before they get a diagnosis. It's insanity. Like it would never stand. Nobody would be okay with that. They'd be like, this is like an international crisis. The views and opinions expressed on unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis or treatment.

Up to 90% of women experience menstrual abnormalities or pelvic issues in their lifetime. 90%. That means the vast majority of women entering perimenopause are not arriving with a clean slate. They're bringing endometriosis, fibroids, vulvar conditions, polycygoyan syndrome, and chronic pelvic pain with them. And yet, menopause care and gynecologic care are treated as if they exist in different lanes. My guest today, Dr. Karen Tang, is a medical. expert who works tirelessly to break down the stigma around reproductive health and empower women to understand their own bodies. I found her on social media and was immediately drawn to how she

educates. She's a board-certified gynecologist, a minimally invasive gynecologic surgeon, and she is an internationally recognized leader in reproductive health. She has built an enormous following on social media and uses her expertise to raise awareness on issues such as period health, pelvic pain, endometriosis, and uterine fibroids. Her book, It's Not Hysteria, was a game changer, especially for my audience. It's a comprehensive guide to common conditions and potential treatment options covering endometriosis, PCOS, fibroids, premencial dysphoric disorder, pelvic floor dysfunction, and more. Today, she and I will take the three conditions you all ask about the most, endometriosis, fibroids, and vulvar conditions, and walk through exactly how each one

collides with the menopause transition. I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. This episode of Un paused is supported by Alloie Health. Most of us know that hormonal changes can affect things like mood, sleep, and energy. But they also have a major impact on our skin, from moisture levels to collagen production and overall skin texture. That's exactly why Alloy Health created their M4 line using Estriol, a hormone that naturally declines during midlife.

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You're going to notice a visible boost in firmness, a smoother texture, and a much more radiant complexion. As hormones shift in midlife, the way we care for our skin should shift too. With alloy, you consult with the doctor, receive expert guidance, and have your treatment delivered right to your door. You can grab $20 off your initial purchase at myalloy.com when you enter the promo code MCH-20. Head to M-Y-A-L-O-Y.com and use code M-C-H-20. That's M-C-H-20 to get $20 off your first order. This episode is brought to you by Accenture. When your advertising operations fall out of sync, everything else follows. Spotify and Accenture are working together to reinvent the rhythm of ad sales, using automation, analytics, and smarter workflows to simplify campaign delivery and access better

data across the business. The result? Less time spent on operations, more time connecting brands with the moments and fandoms that matter most. Learn more at Accenture.com slash Spotify. All right, Dr. Tane, welcome to Unpaused. I'm so excited to be here. Thank you for having me. And just call me Karen. We are so happy you're here because our followers, our listeners, Some of the most requested information was on gynecologic conditions and how they intersect with menopause. You are one of the best science communicators I've ever seen. My God. Wiping a little tear away.

Thank you. That's so nice. And so your book, the title is perfection. It's not hysteria. How important was it for you to name it that? Like, how did that name come about? Yeah. So it originally had a much more boring title with something like periods and pain and empowerment.

but we wanted something that captured, yeah, right? He was like, he had alliteration, but we wanted something that captured not just like the facts of women's health, but also the experience. And the fact that so much of women's health, sadly, is characterized by people,

like not being listened to, being told, you know, you're maybe overreacting, this is all normal, like you just kind of tough it out, or maybe you're just being anxious, you need to relax. And it just really kind of captured that experience, that there's so much of women's health

that they're genuine medical, problems. It's like, you know, high blood pressure. It's like, you know, joint problems. All these things are part of women's health. But somehow when it happens to a woman, it gets turned into, well, you know, she's just complaining about like 20 different things, not that we should take it as seriously as high blood pressure and joint pain and cancer treatments and all these things. So I wanted something that made people feel seen and heard. I think so many women can understand that sensation of like, you know, this is real medical stuff. This is not just you. It's not just in your head. And we should not just kind of, you know, acknowledge that, but then take it a step further and then,

you know, give you all the answers. So the second part of the title, it's not hysteria. Everything you need to know about your reproductive health, but we're never told. So giving you those facts so that you can then advocate for yourself, seek the treatments that you need, find the right solutions for your health. I really love that your period is a vital sign language. I think a lot of women don't realize that, that your period should be predictable, painless, and never disrupt your life. Yes. And if any of those three ever happen, it's a sign that something's going on that shouldn't be going on.

Absolutely. There's such a normalization of suffering for women. That's my other big thing is that I feel like every talk I do your interview, I like to point out that we've made it so normal for people to just be like miserable. Like that, you know, for a woman to have periods, fertility issues, parmenopause, menopause, sex. Like there's some element of suffering involved with it. And we make it seem like that's a normal thing. But like you said, periods are supposed to not be ruining your life. Like you should not be in excruciating pain. You should not be bleeding so much that you have to plan your life around it. This happens a lot where people are like literally planning, you know, leaving their house or at work, you know, what they'll need to do in terms of like changing their menstrual product or like be pouring out blood. None of that is normal. And so even though it's common to have problems with these things, you know, common. does not equal normal. Yes, that's another mantra on this podcast. Absolutely. Normal means common and it does not mean it's okay. Exactly. You don't have to keep suffering with it.

So yeah, the statistic around, which I was not taught in residency, that 90% of women will have some form of dysfunctional uterine bleeding during perimenopause, which may or may not be related to the hormone changes or an anatomic problem like a polyp or a fibroid or growth, you know, I was like 90%, like, why were we screening the same? from the rooftops. Right. And when you talk to both doctors and patients, you're like, oh, it feels like it should be more like 100. Like 90% almost seems like it's underestimating it because it is so common for the periods to be unpredictable. And a lot of people may say, oh, it's a little unusual that you are an endometriosis specialist and talk about perimenopause and menopause so

much now. It affects like every organ system, both endo and paraminopause. It's affecting your muscles and your joints and your mood and your, you know, GI system, all of these different things. And, you know, by and large, people are not being heard and not getting the answers. And, and this is things, too, that I think just as a field of OBGYN, we are playing ketchup in both areas. Yeah. Let's start with endometriosis. Yep. What is it? So endometriosis is something that causes painful periods, pain with sex, and it's very inflammatory. So what it actually is, is think of the tissue that comes out like period blood. That's called endometrium. It's the tissue that grows inside the cavity of your uterus every month when you're having periods and then it gets flushed out with your periods.

Endometriosis looks very much like that tissue but grows outside of your uterus. And it very often grows between your uterus and your rectum and your colon. So because it's very inflammatory, it often causes bowel symptoms too. So a lot of people don't realize this. Most people will actually have the bowel problems and probably see a doctor for like GI stuff before. or they're seeing a gynecologist because they have super bad diarrhea bloating. There's something called endobelly, which people with endometriosis out there are nodding their heads because you literally look like you're pregnant. Your bowel is so inflamed.

That's very viral on social media. Yeah. These women look pregnant. The abdominal shots of someone at different times of the month. Yep. And they look like different people. They can have, you know, pain with bowel movements, pain with sex because it inflames the muscles of your pelvic floor around your vagina. You can have bladder problems.

And typically gets worse with your periods and with ovulation. So it is stimulated by hormones and it gets worsened around those phases of your cycle. It's also really associated with infertility. So something like 50% of women with infertility have endometriosis and don't realize it. It's extremely common. We think at least 10% of women have it. One of the tricky things is that the only way to 100% know if you have it is with a laparoscopic surgery where we look with the camera. And the reason for that is, is it very often doesn't show up on imaging studies.

Like, for example, an ultrasound, a cat scan. Cat scan for sure, even MRIs. And so people will go to the emergency room in excruciating pain and have an ultrasound or a cat scan that, quote unquote, look normal. So what happens is that people are told, well, everything looks fine. All the tests are normal. You are okay. We're not sure what's going on.

And then they sort of dismiss it as well. You must just have really just bad periods. Or it could be irritable bowel syndrome. It gets misdiagnosis irritable bowel syndrome because of how often people, people of the bowel problems. Where else can you find endometriosis? Is it just the pelvis? So most commonly the pelvis, it can also be inside your ovaries in the form of cysts. That's actually a sign of really bad endo. So, you know, for those of you out there who have been told, oh, you just have some small endometriosis cyst is actually usually a sign that's pretty significant inside.

And then it can be in lots of different places. Like people can get it on their diaphragm and they can have like basically pain in their upper abdomen or their chest with their periods or it may hurt to breathe when you're on your period. You can have it like in your thorax. Like actually, people can bleed into their chest cavity. Yeah, you can bleed into your chest cavity once a month. When I was in Miami, I actually had a couple of patients who literally get admitted with blood in their chest cavity when they have their periods, have to be treated by a thoracic surgeon. And other things like you can be in your nasal cavity in the brain, it's been found lots of different places. And actually, I will say, including in cisgender men, like there have been

some diagnosis in men who had higher the normal levels of estrogen because it's stimulated by estrogen. So it's a really fascinating and terrible disease that there's just definitely not enough research on. So I grew up in the school of the retrograde transmission, but I think has that been disproven by now? So in layman's terms, we were taught, so I trained probably a little bit before you, so I'm 57, that endometriosis could have three possible ways that it would form, but no one really knew how, okay? Because, you know, we don't actually see. study this stuff. It's just lady stuff. We don't know. Because the endometrium should flow through the cervix out to the world and to the vagina for you to have a period. For some women, it liked to

flow back out through the fallopian tube and then it would find a new home outside. But that didn't explain it getting into the chest. And I've heard there's a couple of cases of brain. Yeah. And we know it gets into, yeah, C-section scars and all that. So what is the thought now? So it's like a tumor. Yeah, we think it may actually be. be multiple different things. Like, the more we learn about it, the more we're like, is this actually just one disease or is it different things? The myth about what's called a retrograde menstruation was because there are certain conditions where people have a blockage of the pathway. You know, normally that develops with your uterus, like if there's like a septum that blocks off your

vagina, that those women had a higher chance of endometriosis. So the thought was like, well, if it can't get out the regular way, maybe it's flowing backwards out through your tube. and implanting into your pelvis. So I always say, we don't know anything 100%. That's the sad thing about women's health is that we just don't have enough research. But a lot of people think, well, it could be that there's something that develops when you're an embryo yourself, like when you're in utero in your mother's womb, that something about the tissue that becomes the uterus implants elsewhere and becomes the endometriosis or that maybe there's something that's traveling through the bloodstream that's implanting. There's some really good,

folks who are doing basic science research, including at Connecticut. It's called CT EndoRise. So there are some people out there who are really trying to understand the basics of it. We deserve that. Whenever I talk about endo or fibroids or any of these things, in the book, every chapter starts with, we don't know where this comes from. We're going to try and explain it, but no one actually knows. We don't know the gene. We don't know, you know, like, in utero where does this come from. So a lot of it has to do with just lack of research. And that The problem is that if we don't know what it comes from, we can't prevent it. We can't have targeted, like, therapies, like there are gene therapies. So there's so much that kind of goes back to just that

problem of not knowing, like, we don't have these basic facts. So let's talk about funding for a second. The McKenzie report from 2023 was pretty mind-blowing to me where they looked at NIH funding. It was $43 billion was the budget, and I may have the numbers off slightly. But roughly it was like 10 to 15 percent went to women's health of the entire budget. And then in that women's health pie, mostly cancer and pregnancy. Cancer and pregnancy, which are important, right? But things like endometriosis and fibroids and menopause,

PCOS received less than 1% of, you know, and they're affecting, when we add in those conditions together, well, everyone goes through menopause, by the way. Exactly. If you survive long enough, yes. You're going to be menopause. So forget that one. But these, like, very,

common, very life disrupting, you know, gynecologic conditions that affect a huge percent of the population. It is a literal drop in the bucket. Absolutely. Funding for the NIH is public information. You can Google this for yourself, like what amount goes to each different type of medical problem? And it absolutely blew my mind because, like you said, just overall, the amount of funding for women's health that has nothing to do with pregnancy or cancer is like a tiny drop in the bucket. So in 2022, they allocated $37 million for smallpox. The amount for endometriosis was $27 million, so $10 million less. Fibroates affect 70% of white women, 80% of black women, and that only had $15 million. Amazing.

So less than half of the budget for a disease that no one has, even though it affects 70, 80% of women. That just kind of goes to show just the amount of concern. And you can almost see behind the lines of read between the lines that, well, smallpox could be used as biological warfare. It is national defense. But quality of life for women, like, literally is given almost no consideration. They're like, well, that's not as important as, you know, fertility, biological warfare, et cetera. Let's address what I've learned as a myth and something I was absolutely told in medical school and definitely in residency med school. It was probably a whisper of nothing. That inometriosis goes away after menopause.

Yeah, not true. And also that it goes away after hysterectomies, which unfortunately is still told to women, and then they'll have a hysterectomy, and they'll be like, why do I still have all this pain? So endometriosis is stimulated by the estrogen from your ovaries. So it is true that in situations where the estrogen levels are lower, so for instance, after menopause, or when you're on things like hormonal birth control, which suppress your ovaries and kind of drop your natural ovarian estrogen, that people do feel better. it doesn't make it go away entirely. So there are definitely people out there who still have pain and inflammation despite being in menopause, despite being on birth control.

And I even, you know, I take care of transgender men as well. And so even if they're having no periods, they're on testosterone, they can still have pain. And people are like, well, that can't be like you're not having periods anymore. You know, there must be something else going on. We're like, no, it's endometriosis still. It doesn't disappear, though it might be suppressed. And another myth that's still, and I cannot believe that this is still being perpetuated, but another myth that's still going around is that pregnancy cures it.

So I, when I make videos about endo and I mention that, I will get like hundreds of comments from women who are still told that. They're like, well, you should go get pregnant to treat your endo. We would tell patients that all the time. It's bizarre to me. And the way that it works, people do feel better during pregnancy because they're not having periods. They're not ovulating. And they have high progesterone, which suppresses the activity of endo. So that's part of the reason we give the birth controls for the progesterone part that suppresses and keeps it less active.

And so when they're pregnant, they have a high progesterone. They have no periods. They do feel better. But it's not like a long-term solution. Like you can't stay pregnant for like 20 more years. And then you have a baby to take care of it. Yeah, and then you got some babies to take care. Finding the right mental health support can feel overwhelming,

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Bank, N.A., pursuant to a license from Visa USA, Inc. See Terms and Conditions for the Sutton Pre-Pay Card, Sutton Debit Flex Card, and Bank Corp Debt Flex Card. savings provided by Cash App, a block incorporated brand. Visit cash.app forward slash legal, forward slash podcast for full disclosures. So in your surgical practice, how often are you seeing postmenopausal women or perimenopausal women? Paralymenopausal women quite often. Postmenopausal women, it does go down significantly.

I do find that the postmenopausal win with endo have really bad endo. Like, they're the people who don't just have a few specs. Like they have the real deal, like big sis. Like, you know, it just never fully got suppressed or went away because their estrogen went down. But what does actually come up a lot in perimenopause is adenomyosis. And you and I were talking about this before we started recording. Adnomiosis is probably the most common thing that no one's ever heard of. Okay. So let's go there then. All right. So what is adenomyosis? How is it different than endometriosis? How does it present, et cetera? So I call them cousins. They are very similar,

except they grow up in different places. So endometriosis is out. side of the uterus. Adomiosis is the same thing. It's endometrial-like tissue that grows into the muscular wall of the uterus. So let's walk people who don't understand this, how heterogeneous the uterus is, and that there's the two, well, three different kinds of tissue between the uterine wall, the endometrium, and the cervix. Yeah. So if you picture a pair, I like to use the example of a pair. So the flesh of the pair is a muscular wall. And the inside where the seeds are is the cavity. and then in there is what's called endometrial tissue. So again, when you're having periods, that tissue builds up every month in preparation for

pregnancy. If you don't get pregnant, it gets shed as your period. So endometriosis, like I said, is outside completely, like outside of the uterus, totally. Adnomyosis is in that kind of fleshy wall of the uterus. So what it typically causes is the same things. It can cause all the same pain, bloating, bowel problems, bladder problems, but a lot more bleeding issues. So people start to bleed very, very heavily, almost like uncontrollably, and they can have really bad pain. And the classic story, and I think a lot of the listeners will recognize this

in themselves, is most of the time people are like, okay, like they're living life, doing all right, periods were not that bad. They typically, then they have kids, especially C-sections, and then afterwards, they're like, what happened? Like all the floodgates open, the periods are just insane. They're bleeding all over the place and very irregularly and having much more pain and inflammation pressure than they ever did. So C-sections and other procedures like D&Cs, like for miscarriage, increased the risk of adenomiosis. We think maybe because it's breaking the normal separation between those parts. I did not know this. Really? No. No. What? My God, I can't believe I talked to something. That's amazing. I did not know that having a surgical procedure in your

uterus would increase the risk of adenomyosis. Yeah, absolutely. C-sections is the big one. D&Cs, like I said, scraping, like if you had a miscarriage and then you need to kind of like, then, you know, take the tissue out from the cavity. And surgeries were fibroids where you cut the fibroids out of the uterus. We think because maybe it breaks that border. There's supposed to be a border between the cavity and the muscle. And if you break that border, maybe the tissue kind of starts to grow into the muscle. Okay. Yeah. But it's very classic. Classic classic. So anyone out there, if you're like, I had some C-sections, I was doing okay. And then I was miserable afterwards. Very, very likely adenomyosis. What is the bleeding profile?

for adenomyosis in general. So it's both the heaviness of the flow, so meaning you're still having your predictable cycles, but the actual amount is much more. Okay. It can be more painful. And you can have more irregular bleeding too, so meaning unpredictable bleeding.

And we were talking a little bit before about the influence of hormone replacement therapy, the menopause hormone therapy that people are given, sometimes can cause some of the worsening bleeding profile when you have these problems like adenomyosis and endometriosis, because you're giving estrogen, which sometimes can flare these problems. And then again, people are like, I was okay. And then suddenly, you know, I'm bleeding all over the place. I'm bleeding between my periods. I'm bleeding, you know, for a longer time during my period. So any or all

of those are game. What about imaging? Can we see adenomyosis on ultrasound or any of the other imaging? Yeah. So that is much easier to see on ultrasound and MRI than endometriosis. So you can see on ultrasound or MRI, like the muscle looks blotchy. The fancy medical terms, heterogeneous myometrium that the muscle looks like not just one uniform smooth look, but that there's like little blotches inside or even little kind of pockets of blood. Like it can bleed into the muscle. Like almost like a mini period is happening in the walls. And you can also see that the normal tissue border is gone. So there's sort of this border that usually looks very sharp. Now is a little bit more blurry. They're indistinct. So, and the uters can get bigger. Like we see.

sometimes we'll see the uterus is like more swollen looking. It's rounder. It's, you know, enlarged for no reason. There's things like fibroids, which are benign tumors that grow in the wall, also very common. But you don't see anything like that, but you have a big uterus. I just remember being a big boggy uterus. Big boggy. We say like soft and boggy. Like it feels kind of squishy. Yeah. So let's go back to endometorosis for a minute and we'll, you know, how does that intersect with perimenopause and menopause? would a patient expect her symptoms to get better, would she expect it to get worse? You know, in this zone of hormonal chaos, and we've lost our predictability and the trailing progesterone, what typically an endometriosis does a patient experience?

Any or all, like I said, all comers, basically there are some people who as the estrogen is, you know, quietly decreasing, like they can start to feel better. But as you've talked about it on the podcast before, it's almost never just like a quiet decrease to nothing. It's a roller coaster. If you picture like the ups and downs, the estrogen is really high and it's really low. And, you know, progesterone is sometimes there and sometimes not if you're ovulating or you're not. So the problem is it's totally unpredictable. Like some months you could be like absolutely miserable. You're having the heaviest bleed of your life or you're having the most painful period of your life. And then the next month you may be like there's barely anything

and you feel great. So very unpredictable. And then the important thing to know is that whatever it is, If you are starting to feel like this is bothering you, like you mentioned before, that's where it's time to maybe talk to your gynecologist. You know, the slowly peering away, periods are getting better. Like, that's great. We're like very happy. But if you're like, wow, suddenly the amount of bleeding, the painfulness, like the associate stuff, like the bowel stuff, is all over the place. Like, that's where you should go and see your gynecologist and maybe ask for an ultrasound, see if there's something else like adenomyosis or fibroids that are popping up. So now you go to your clinician and you get the diagnosis, this looks like without surgery yet. Okay. For endometriosis, what are our treatment options? So anything with a progestin. And progestin is sort of like that category of medicine like progester, which are made by your ovaries when you ovulate. So like I said, there are things like birth controls. That's what oftentimes gets suggested. And so people in parameda pause obviously can still get pregnant. So if they need birth control, then that's great. It kind of kills the multiple birds with one stone. But there's a lot of

a lot of people who don't need birth control, they're not sexually active, they've had a tubal ligation or their partner had a vasectomy, and they're like, you know, I just really don't want to do birth control. We have lots of other things that we can give as well. So there are separate progestin medicines that are not birth controls, but are given, you know, I say in a bottle rather than a pill pack like a birth control is. There's something called Northendrone. The brand name's Agestin. And then there's modroxyprogesterone or provera. And the nice thing about those is you can take more than one. So sometimes if people are having a particularly heavy period, you can take more than one tablet to suppress it. A lot of your listeners probably know literal progesterone, micronized progesterone,

which is again, yeah, permatrium, exactly. That's actually very weak progestin. It's great for perimenopause symptoms and sleep and calming. It's wonderful. It's actually not usually enough for endometriosis adenomyosis suppression. It's sort of like a drop in the bucket. It's great for the perimenopause stuff is probably not enough for these really bad period things. So what happens a lot is, you know, very well-meaning, very, you know, excellent and skilled, menopause specialists may just give progesterone, give estrogen too, which then sometimes makes the endo and the adeno worse. It's like throwing fuel on the fire. And then they're like, wow, why is my patient suddenly just bleeding all over the place? It's oftentimes there's these

hidden things like the adeno, the endometriosis, polyps too, like little fleshy balls of tissue inside the cavity that are being stimulated. And you actually have to counteract that by doing a stronger progestin. Or a marina IUD. Progesterone IUDs are very good. Put them in the uterus if somebody doesn't want to take as much stuff, you know, by mouth. Yeah, it helps to control bleeding and inflammation and pain a little bit more locally to the pelvis. Does the type of formulation matter? You talked about the pharmacology of progesterone. What people don't understand are these progestions were developed really to suppress pregnancy. So they bind super tight to the receptors, way higher affinity, typically than our natural hormones.

Exactly. The bioidentical ones, quote, quote. So it may not be your best option if symptom control is for you. Exactly. Yeah. So we always have to see, like, what are people's concerns? So if some, I have some people on two types. I was going to ask, do you ever like stack your progester?

I do. I do have people on micronized progesterone or permetrium for the sleep and the calming. And it helps with things like the hot flashes and night sweats as well. And I have them on a stronger kind of synthetic. one for the bleeding control. So I'll pop an IUD in for the bleeding control or I'll have them take an oral like a Justin for anometriosis suppression. So, and, you know, we always have to talk through, there's not one size fits all for everybody, but we can do different, I call it the Chinese menu, like you can kind of pick and choose of the different things that you need based on the person's

symptoms and what they're looking for. I love having options. I know, right? Awesome. All right. So let's take a woman like she's who's listening and she had endometriosis in her 30s. She maybe had had the laparoscopy, gotten a biops. he got the diagnosis. And then she was on hormonal suppression and she did great. Now she's 47 and she's starting to have hot flashes during her breakthrough week, you know, during her placebo pills. What should she expect? So some people do great. I always tell people I don't want to scare them and think, oh, if you take HRT, there's going to be problems. I always just want to make people aware because I don't want them to be surprised if they're the ones who, as soon as they start that, you know,

wonderful transdermal esteratol patch, which is definitely necessary in so many cases, that, I don't want them to be like shocked. Oh my God. Afterwards, oh my gosh, why am I bleeding more? What's going on? So we just want to make people aware. And I always tell people it's about having a game plan, like to know what could happen, to make people aware if you are having any more issues, come back so we can talk about different things. And then sometimes, too, if people have been through the ringer with endometriosis, like they're pros. Like they know, like what they need to do and if they need to come back. There are sometimes that, you know, and we didn't get into this before with the management, but, you know, some people do need another surgery. Like there

When a surgery an option. Yeah, exactly. So laparoscopic surgery to excise or remove the endometriosis if someone is not having good enough symptom control with just medications. So they try the medications, it's not working, or say some people have side effects from the stronger progestins, like they get mood symptoms, they feel like they can't tolerate it. So either if it's not doing the job or if the medications are causing more problems and they're helping with, then we move to the surgery. when people are younger kind of in reproductive age, the surgery question gets pushed a little bit more for fertility purposes. Like obviously, like, you know, if you are wanting to get pregnant, you can't be on birth control or these hormones or have an IUD. So like I said, that sort of like kind of funnels people into the surgery path a little bit more often when you're a perimenopausal menopausal and you obviously don't care about like getting pregnant, then it's not as much of a kind of a pressing issue.

But it's more of a quality of life. Okay. So if we can't get your quality of life where it needs to be with just medications, then the surgery is there. How long do people suffer in general with endometriosis or adenone before they are diagnosed formally? It's on average seven years. And it's actually eight years in the UK because also their system, there's a longer weight period just to see a gynecologist. Like take a step back. And so imagine something, I would say, imagine something affected at least 10% of men. It's actually much higher. But it caused excruciating pain. It hurt when you

had sex, like debilitating pain when you have sex. It made you bleed through your penis and it gave you diarrhea and you were having like incredible bloating. We would, you know, like have a little bit more like awareness and research and all these things. But for women, we were just like, oh, you know, like it's just, you just kind of deal with it. So the fact that we let people suffer like that for seven years, like you can't even conceive of forcing men on average to wait seven years in that much pain before they get a diagnosis. It's insanity. Like it would never stand. Nobody would be okay with that. They'd be like, this is like an international, like, crisis. If you're complaining of fertility that will speed up your diagnosis, like this country worships the ability

to get pregnant and the ability to be a mother, which is very important to me, very important to you, and I don't want to make light of this. But you'll get a quicker diagnosis if you layer infertility on rather than just pain. I was about to say the quality of life angle is so underappreciated. Like it's obviously fertility is extremely important and, you know, it's important for me. It's important for so many listeners. But the fact that it is that much more important than just your ability to function or work or like live your day-to-day life is insane. But it is true. Like it will kind of fast track you a little bit rather than saying, oh, I just am having a really hard time pain-wise. If you're like, well, I need to try and get pregnant, I'm trying to conceive

and nothing's happening and I'm worried about my fertility being affected, it does sort of kind of speed you through to kind of the laparoscopy and things like that. Yes or no. This is, I'm seeing it's on the internet. I'm getting so many questions about this. A woman with endometriosis or adenomyosis are being told they cannot take HRT because it will make their disease worse. Yeah. And it's funny because one, I feel like so few people are talking about endo and menopause, but of the people I'm seeing talk about it, a lot of times it's phrased that negative way because of the concern about estrogen. Like so much of endometriosis medical management is based on dropping estrogen and, keeping it low. We luckily don't do this as much, but like, you know, back when I first started

training, and this is probably the case with you too, we did so many, like, surgical menopause, like, ovary removals for endometriosis. We were, like, taken out everyone's ovaries to, like, plunge them into surgical menopause to treat endometriosis because, again, if your estrogen's low, it, you know, helps with the disease, but then you get completely miserable. The thought process is, well, we work so hard to get your estrogen low, like, why would you then give estrogen back and make it flare again? So the good news is that those of us who do know endo and parimenopause know that you can take HRT. Of course you would. I give it all the time for my patients. What are the nuances here? A patient needs to understand. Yeah. So the nuances are you have to kind of go into it planning that you might need to go stronger on progestions than you normally would.

So I'm sure you've gone over a million times on your podcast, normally the progesterone's there to protect your uterus. It's sort of like forgotten. It's a non-negotiable. Right. I was about to say you got to take progesterone, micronized progesterone usually to protect your. uterus from the estrogen causing problems, you know, with cancer. But we sometimes need to, again, think stronger if you have endometriosis because we want to counteract potential stimulation. So this is where I'll tell patients in advance, like, okay, like right off the bat, do you want me to give you a stronger progestin like a noret, just so we don't take the chance that it will flare your endo? Or do you want to see how things go? Like, we'll try with just marginalized progesterone. If you feel like your endo is flaring, we could.

pretty quickly jump in with like an agestin or Provera to suppress it or add an IUD for bleeding control, et cetera, if you've had no myosis. So as long as you kind of have that plan in place and you talk it through, people do great. Like people do very, very well. And they have all of the quality of life stuff handled. They aren't having the pain anymore. They are having all their menopause, paramedopause symptoms taken care of. So there's definitely ways to do it. It's just you have to go into it with that, you know, that foresight. I always tell people it's like playing chess. Like, if you like, if I move this, it could cause this move next, but then I'll do this. You think multiple chest steps ahead and it'll all be fine.

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So yes, I'm glad menopause is finally getting attention, but don't settle for noise. Get care from clinicians who are in this with you for the long haul. Book your virtual visit today at join midi.com. That's join midI.com. What about the patient who had surgical menopause? So we were also quite often removing ovaries in my training program. This was before Miggs was really minimally evasive gynaecologic surgery. Fellowships where you were doing a lot of that kind of surgery were robust.

They were just starting. So that's an age thing between the two of us. And there was zero discussion. Maybe there was a whisper, a hint of, oh, we got to watch your bones, but not like in an early bone scan or anything like that. No discussion of cardiovascular disease risk. You know, in modern endometriosis practice, how often are we recommending over-removal? And then if we are, which I'm sure is still needed on a case-by-case basis, are we being aggressive enough about the downstream effects of early menopause?

Yeah. And so this is one of the good things that has changed since I trained. So I did my fellowship 2009 to 10. And it was sort of the early years of this formal field. So again, for listeners, like, you know, it's not like endometriosis as a specialty or this, you know, specialized surgery has been around for a really long time. No, I was one of the first kind of, you know, fellows. When I applied, I think there was like 10 programs or maybe like 15 programs in the whole country training women in these women, training GYN surgeons in these like advanced surgeries and also management of pain. So back then, again, we were so much more aggressive. We're like, okay, you have really bad endovers are coming out. Like you're done with fertility. They're gone. Now we, because we know about the dangers of

surgical menopause, both in terms of, you know, the longevity aspect, the cardiovascular disease, bone thinning, increased diabetes risk, quality of life issues. We know we don't want to trade one quality of life problem with pain for another, potentially much worse one. So we really try and avoid taking out the ovaries unless there's some other pressing issues. say if there's like a really strong family history of ovarian cancer or if someone's had just surgery after surgery with really good surgeons who know what they're doing. It's not like end as being left behind so that it's like not like an optimal surgery. So if somebody really is getting good surgery and removal and it's still recurring and there are some of these cases, it's almost like a

cancer. I would say it's not cancer and that's going to, you know, like potentially like end your life, but it is sometimes so tenacious. It can grow into other organs. And there are versions that are very aggressive and they come back no matter what you do. There are some situations that we do remove the ovaries because we're like, look, you've had like four surgeries and it may continue to come back unless we do this. But we always now, at least most people I know, we'll have that conversation. We'll be like, we may do this, but we're going to want to talk about HRT if you're young to avoid the quality of life issues and the bone thinning, et cetera. As long as again, we're careful with the progestin part. And this happens to, I think you probably have gone over

the whole, you know, you've had a hysterectomy, you don't need progesterone, that gets told all the time, which is so wild, because again, there's so many good things about progesterone. It's not that you have to have a uterus to benefit from it, but especially in then metriosis, there's times that people will get the whole shebang surgery. They're going to get the hysterectomy for adenomyosis. They're going to get the ovaries removed. And then they will just get an estrogen patch because they're like, well, we want to give you estrogen. You quote-unquote don't need progesterone. That's like the worst thing you could do because now you've done all this. Because there is usually microscopic disease left behind that you couldn't see.

You can only remove what you can see with your eyeballs. There could definitely be, I always say this to my patients, you can always have microscopic disease and you give just estrogen, no progester, like you're just going to flare it again and you've done all this work for nothing. So that's another mistake that people do. If they give HRT, they sometimes only give estrogen without a progestin because there's no uterus. And then they're like, wow, patients still having pain, what's going on. And then sometimes the patient gets blamed.

You know, like, well, I guess it's just in your head. Like, no, it's me flared your endometriosis. There's some emerging data that women, when I was doing the research for this, women with endometriosis may experience accelerated ovarian aging. You want to talk about that a little bit? Yeah. So, again, most of this is known in the context of fertility, because, again, that's what a lot of the research has been on. Enimitriosis, because it's inflammatory, can inflame everything. And that includes your ovaries.

So this is where people with endometriosis, we know, have a higher likelihood of problems with like egg quality and like, you know, kind of premature, like you said, ovarian kind of dysfunction stuff just because it just doesn't function as well as it normally does. And again, we think of it mostly in terms of the getting pregnant, but yeah, it can, you know, we're learning more and more that it could just, you know, in terms of hormone production, maybe affecting things. So let's talk about something that's rare, but is there, the malignant transformation of endometriotic foci. So I've seen it a couple times in residency, but it is something I were worth talking about? Yeah, there's a very slight increased risk of ovarian cancer with enometriosis. I will say in my whole

career, so, you know, 15 plus years of practice, I've only seen it three times and every time was in a big endometriosis cyst of the ovary. So it was never just sort of microscopic and what we found it. There was a huge cystic thing on the ovary that when we did the surgery, it ended up being an ovarian cancer. So I get a lot of patients who are worried about that because they've heard this. And so I want to, you know, put people's minds at ease that, one, it's quite rare. It's, it is a tiny increased risk, but it's not common. And so me as somebody who sees us, you know, endometriosis all the time, I've seen very few cases of the cancer. And it's usually in the context of a pretty large ovarian cyst. So it is something that we do take seriously. We always

make sure we're getting imaging studies. We're checking those ovaries. You know, when we do a surgery to do a cyst removal, we send the specimen to a pathologist so they can make sure that it's just a benign cyst. It's not something else. So we have it kind of in the back of our minds, but it's not something I tell people that they need to like live in fear about. Okay. You were ready to talk about fibroids? Let's do it. Yeah. What is a fibroid? Yay. So, fibroids are benign tumors. And again, I always kind of, because people hear the word tumor and they get kind of scared. It's not a cancerous tumor. It's basically a mass that grows out of the muscles in the wall of uterus. And here's a fun fact. They are clones of each other. So all of the cells in a fibroid are identical cells. They kind of all are cell clones of each other. It's kind of a neat little fact. And we don't know again where it comes from. It's shocking.

Shockingly, we don't know because it's a women's thing. And when like say those stats again because I think people don't realize this. Isn't it crazy? So it's 70% of white women, 80% of black women have fibroids. And the fact that we just don't know where they come from is just ridiculous. It's just like this mystery of life. They show up. We don't know.

And so they do tend to run in families. So this is actually both endo and fibroids run in families. So this becomes important because all the women in the family have bad periods. So I have a lot of patients, especially black women who say, my mom, my grandmother, my sisters, everybody's periods was miserable. Like they were bleeding super crazily. They're always in pain. They're always bloated.

But every woman had that. So they didn't have a frame of reference that was different. So sometimes it takes where they're like literally hemorrhaging with their fibroids like in the ER getting a blood transfusion before someone's like, wow, you have fibroids. Have you heard of this? And they're like, no, I don't know what that is. I didn't know I had anything. So the main symptoms, like we kind of mentioned, number one is really. really bad bleeding. So both heaviness of the bleeding, a regular bleeding, pain, especially with

your periods. And then we would call bulk symptoms, which is almost like pregnancy symptoms, because fibers can be enormous. They can be tiny, like one centimeter, or they can take up your entire abdomen as if you're a full term pregnant, like the size of a watermelon. So they can cause things like bloating or they push on your bladder make you need to urinate a lot or on your dyspronia. Yeah, dyspronia pain with sex because you feel like you're hitting something. Or it can push on your rectum make you feel like you can't poop, like you have constipation. And it can also cause infertility. If it's blocking the cavity of your uterus, it can cause miscarriages if there's no room for a fetus to grow or to implants on a fibroid. Conventional wisdom is that they shrink after menopause. Is that true?

They do shrink a little bit. I always tell people, if you have pretty big fibroids, they may not necessarily go away. So maybe like, you know, a three centimeter fibroid may shrink enough that you can't find it anymore. But if you have like a 10 centimeter fibroid, it's probably still going to be there in some way. So it also tends to prolong periods. I've had women with fibroids who are still having regular periods when they're 59. So it does kind of just keep things going longer in terms of periods. And also you can have bleeding after menopause too because the fibroids can just bleed. So fun fact, I had a C-section 22 years ago with my daughter.

And no one told me I had fibroids. And I never got imaged again, okay? really didn't have any gynecologic issues other than my polycycobarian syndrome, you know, which was managed. And then I went into menopause. I was imaged for another reason. I have a big family history of cancer.

So I got an image and the radiologist called me because I'm a doctor and was like, hey, you've got a seven centimeter fibroid. Oh my gosh. And I'm like 55 years old going... Seven centimeters, yeah. What kind of gynecologist am I

that I did not know? My gosh. I had a significant size fibroid just sitting in the back of my uterus and it never caused me a problem. I knew my mother had them as supposedly her hysterectomy after eight children. So in South Louisiana, there were a lot of hysterectomies done for birth control in the Catholic hospitals. So I always kind of assume mammas was, but now I know maybe she did have fibroids because I certainly had one. But it never really caused me a problem, but I thought, you're like, I'm a whole gynecologist.

How did this happen? No, but it's never really caused me problem. I feel like I probably should get imaged at some point to see what it's doing. Yeah, keep watching it. You know. The running and the family thing, again, people may not necessarily be talking about this. Like, sometimes like women's health stuff and periods especially, people don't feel comfortable sharing with their, even their family members. So a lot of times people say, well, I actually don't even know what was going on with my mother, my grandmother, but everyone had mystery hysterectomies. So a lot of the listeners are probably thinking, oh, yeah, like there's every woman in my family has had a hysterectomy. No one knows why. There's sometimes like a history of miscarriage or infertility. All the time. Almost certainly there's probably either endometriosis or fibroids. And it's just that's the clue is every woman, quote unquote, had a hysterectomy. In my family.

Yes, we don't know why. They all needed them. They all had trouble. We used to call it family history of hysterectomy. Absolutely. Yes. So I would say today in 2026, when I'm taking a medical and surgical history, 20% of my patients cannot tell me why they had the surgery.

Yeah. I used to practice in Miami. Doctors said it was time. Exactly. Yes. I think I didn't need it anymore. Yep. I practiced in Miami.

It was only going to cause me problems. Literally every woman who was postmanipausal had had to hystract me. They're just like, doctor told me I needed one. I don't know what it was for. But yeah, just if you're not having pregnancies anymore, if there's like a whisper of a problem with your periods, they're like, it's gone. Take it out.

But then they don't tell them what it was for. And then no one knows. So the children, the daughters, granddaughters have no idea. And then everyone goes to the same cycle again. I always point out to people, I get these sometimes. And the patient is miserable. They're like literally pouring blood out. I'm like, there's something wrong with that uterus, even if pathologists can't see it under the microscope.

So I've definitely had patients where I'm like, you've got to have adenomyosis. There is no way you don't. And it comes back with a quote unquote normal uterus. I'm like, lies. Go back and look again. Go back and look again. Not that I don't believe the pathologist, but just to say that there's definitely times that a uterus will act up, we say. And it may not necessarily show up on the slides that they're looking at under the microscope.

But there's something going on with it. So let's talk about fibroid types and location mostly. A fibroid's a fibroid, but location matters. Absolutely. And this is where we say, you know, if somebody is coming in, they're like, I have fibroids. We always have to look at the images because fibroid size and where they are in your uterus makes all the difference in what symptoms they cause you, in the options you have for removing them or treating them. So for instance, if you have a fibroid that's in the cavity, so there's pushing into the cavity, that's where the tissue is coming out like period blood, it could be teeny tiny, it could be one centimeter and you could be like just literally. pouring out blood. I had a patient once who was literally, I had never seen a blood count this low. Like her hemoglobin was like two. Like it was, you should be dead. Like you should not be alive right now. We've all seen that in the hour. Absolutely. And she had, I think, like a two centimeter fiberoid, but it was just right smack in the middle of her cavity and just bled like crazy, like a gunshot wound. And you can have like a huge fibroid that is outside of the uterus, like almost like a mushroom.

And you could have no bleeding at all because it's, you know, it's not touching the cavity. But that can cause a lot of pain. can cause lots of pressure, almost as if you're pregnant. So the treatment options also vary because the ones that are in the cavity, we can actually reach through the vagina. We can put a camera called a hystroscope through the vagina into the uterus and shave away fibroids that are inside. If it's obviously on the outside surface, then you have to go through your abdomen. There's, you know, different treatments where you can destroy the fibroids. You can, you know, cut them out. You can take the whole uterus out. That's the hysterectomy where you remove the entire uterus. So we always kind of have to look at the exact number, location, how big they are,

in order to give someone their options. Does it matter where it is and how it's going to respond or flare to hormones at all? Not necessarily. Like I said, the ones that are in the cavity probably more likely to have the bleeding problem. So those, if we know that someone has a fibroid right in the middle, that might be something you want to have removed before starting like an estrogen just so that it doesn't end up with like lots of bleeding. Not that you have to do it, just, again, to be aware that it could cause a bleeding problems. Does HRT make a fibroid grow? We're seeing, I'm seeing some of that on social media.

You know, we just don't have enough data. Like, I don't know if you've seen. Again, I hate to always be coming back to like, we don't know. HRT since day one with a seven centimeter of fiber rate at 57. And I'm like, it's okay. You know what? She can stay there. She's not bothering me.

She's doing fine. We already didn't know enough about fibroids as is. And now we're adding in this layer of there are so many more women going on HRT, which is fantastic. We love it. Just like the problems with people not being able to get patches because suddenly we're like, oh, a lot of people are using this. We definitely are playing catch up with the research. You know, what's the additional layer of HRT and fibroids? Hormones in general can stimulate fibroids. Obviously, that's why they... Oh, I mean, a lot of women are scared off from seeing a report or doctors telling them,

someone well-meaning but not educated. Like, you can't have HRT because you have fibroids. It will make them grow. Right. No. And now, and they're having hot flashes and osteoporosis and all the things. Yeah. Yeah. It's not a myth. Because when someone say pregnant and they are getting lots of hormones, fibroids can grow really big under the influence of hormones. So again, everyone who has taken care of pregnant patients with fibroids knows that they can get larger. What's interesting is because the HRT is not like those gangbusters huge, huge levels of hormone like you get in pregnancy. Like I actually, like you said, I haven't personally seen people coming back with like significant enlargement of the fibroids with HRT. Like postmenopausal. Postmenopausal, right. You've already gone through

menopause. So it is something, again, we kind of make people aware. We're like, let us know if you're having any pain. You feel like something's getting bigger. You're bleeding it all in a strange way so that we can kind of jump in, get an ultrasound early or keep an eye on it. What we don't want to do is just sort of like, you know, fling hormones and then be like, never come back again. We don't want that. But again, it's definitely not something I'm withholding at all. Like I think that women with fibroids need hormones just like any. other woman does, but just as long as they're aware. And it's just like the endometriosis, we just have to have that plan. Because like if, say, something were to happen, you know, talk

through what your treatments are for the fibroids. I've had a lot of women who end up being like, I need my hormones. Maybe I am having more pain and we're bleeding, endometriosis fibroids, whatever. And they end up needing a surgical procedure so that they can then enjoy their hormones without the problems that it's causing with, say, like, the fibroids and stuff. But the good news is, In my experience, I'm not having people come back with major problems. Like you said, you yourself have a pretty big fibroid and you're on hormones. And it's almost basically- It was an incidental finding.

Yeah. I mean, I was like, show me that, please. Yeah. We, in our minds, think of it. We're just trying to get you back to where you were when you were, like, you know, like kind of right in your main reproductive years. We're not, like, going super high like when you're pregnant. Let's talk about perimenopause and fibroids because we do have, most of us will have periods where

we have these loop ovulation cycles and we'll have very high estrogen level. So I try to warn patients with who are going to cycle, try to go through perimenopause without the aid of hormone therapy. You know, your fibroids might grow. They might get worse. You may have bleeding. Like, you need to be prepared for this. And then we'll talk about treatment options or I'll get you over to gynecology because I'm not doing surgery anymore. Are you in your clinical practice seeing kind of like a little bit of a jump, a surge in fibroid symptomatology through perimenopause?

I actually diagnose new fibroids a lot in paraminopause. Yes, all the time. And this actually happens a lot after someone starts HRT because they were like doing okay, like where they kind of just gotten used to a certain level of periods. And then again, we start the hormones and the estrogen kind of flare something and then they're like, oh, it kind of hurts. Like I'm feeling a little bit more bloated or like my period was really heavy this time. I'm not sure what happens. I have a very low threshold to get an ultrasound because I've diagnosed so many fibroids and polyps. And I've actually started telling my patients

is because it comes up so often. Or I inherit patients from other doctors who have started them on HRT and the patient's like, whoa, what's going on? And then just want a second opinion. I'm like, let's get an ultrasound. And we find the fibroids. We find the polyps. We find the adenomyosis that someone may have gone their whole life, didn't know that they had. Like you said, it's not often, if you're doing well, like we aren't getting ultrasounds all the time. We would never know. We would never know. So a lot of people just quietly had their fibroids and polyps and just didn't realize it. And only kind of, I quote the, you know, we wake up the fibroids with the estrogen that we're giving them, which is, again, not a problem.

Now we know, and now we can address them. Is a progestin containing IUD like a moraine or is scyla ever a good option for a patient with fibroids? It can be, yeah. It depends on the fibroid. So there are sometimes that the fibroid is so big that it actually pushes on your cavity and makes it either impossible to get an IUD in or if someone's already bleeding like crazy. I've had a few patients would they bleed the IUD out. So before it's had a chance to kind of kick in.

enlighten everything, they actually pour out blood or a huge clot comes out and the IUD just washes out right with the clot. So it is something that we do have to be aware of, but it can be a good option. And so, especially for the women who have, you know, side effects, like they don't love the stronger progestin because of side effect potential. Or they just don't want to have to remember something. A lot of people, you know, like the IUD for both uterus control and then also for the HRT, if they don't want to take the progesterone orally. So it's kind of a nice option to. to kind of kill two birds with one stone, too. Okay. When is a surgery an option for these women?

I always tell people, you know, if the medications aren't doing what they need to do. We always, I'm somebody who likes to go through all the options right off the bat so someone can choose for themselves. So there's a lot of people who end up just being like, I've heard all this. Like, I know medications are not for me, which is great. Like, you know, we just jump right over medications. In general, we always kind of in medicine in general go from less aggressive, less risk to more aggressive, more risk. And obviously surgery is kind of on the upper end of those things. But if somebody's like, look, you know, I tried X, Y, and Z didn't work.

It's not for me. I had side effects. I don't want to take something every day. Then we can pretty quickly jump to surgeries. And there are quite a few surgeries for fibroids now. For somebody who's not trying to get pregnant, we skip over the like just cut, you know, like a big. Mymectomy. Yeah, exactly.

Let's talk about surgical options. I think our audience is really interested. And there's probably new one since I've stopped doing. Yeah, there's one new one. Yeah. let's go from the most mentally invasive, like all the way up. Yeah, so starting like less invasive, like we said, if there are fibroids that are not that big and they are in the cavity, we can do what's called a hystereoscopy, which is, I say it's our

version of a colonoscopy. It's a thin camera that you can operate through, and we put it through the vagina into your uterus, and we can use like a spinning blade or a little wire loop with electricity to basically shave away the fibroids. And then there are, as you kind of go up the ladder, this is the new one, which there's very few breakthroughs in women's health, which is very sad, but this is one of them, which is what called radiofrequency ablation of fibrate. So there's two different ways. One is done through the hystroscope, like through the vagina, and one is done through a laparoscopy through the abdomen. So

the one through the vagina is called sonata through the abdomen. It's called assessa. And basically, you do an ultrasound or you look with a camera at the same time and you put these little needles into the fibroid that pass electricity into the fibroid and heat it to destroy it. So decrease. is bleeding, it shrinks the fibroid. It doesn't make it completely disappear, but it makes it smaller, softer, less painful, less bloody. And so it's a great way to treat the fibroids without being as invasive as like cutting the whole thing out or taking the whole uterus out. So it's a really nice, I actually have been following this technology for like 15 years before it was a little bit more widely available. So now we have it at least, you know, in not everywhere, like only certain

pockets of the country. But we're starting to kind of have that a little bit more available for people. And then for people who are wanting to get pregnant, like they want to keep the uterus for pregnancy, there is my mechmi, which is a way of saying just cutting the fibroids out of the wall of the uterus and basically like stitching it back up, putting the uterus back together. It is actually the most invasive and takes the longest and the most risk because you basically have more bleeding. You're basically cutting into something that's already very vascular. Very vascular. It has a lot of blood flow to it. That's why people bleed so much normally. And it takes longer because you're getting all these things out, you're repairing and putting the uterus back together. So if someone's

like, look, I don't want to have kids anymore. I'm like 49. Like I'm over it. This is not what I need to do. We would skip right over that to hysterect me, which is take the whole uterus out. And that is for somebody who's like over it, over it. Like there, we are done. I want no more periods. I want these fibroids gone forever. I don't want them to come back. Anything else where we're leaving a uterus behind, the fibroids can return. So you can grow new ones. The ones that you're shaving down, like maybe leave a piece of bit, it could grow again. So the downside of all those other options is you might be coming back another day. So we always say there's always a chance you're going to need something else, including maybe a hysterectomy. Historectomy is obviously the biggest thing. You're taking out the whole organ, but it's definitive, meaning that you're not going to have any more fibroids or periods, and a lot of people are like, I'm all for that. It's a whole big discussion because even if you leave your ovaries, when we say hysterectomy, by the way,

this is a big myth. People think that there's like you're somehow talking about the ovaries and hormones. it's only referring to your uterus, which is just holds a pregnancy. The ovaries removal is something called ophrectomy. And so when we say the word hysterectomy, like you'll hear people say the word partial hysterectomy. And total. And it means different things to surgeons. Exactly. We got oncologists don't use that term. When people say partial hysterectomy, they usually mean I want to leave my ovaries behind. We just assume that. Like we're not even talk about the ovaries. So we're leaving the ovaries unless we specifically say, yes, let's take the ovaries out. But even if you leave the ovaries, the hysterectomy, are associated with a little bit of an earlier age of full-blown menopause. And then people can even temporarily feel more menopausal symptoms like hot flashes or mood fluctuations because you're breaking a connection between the ovaries and the uterus, which can, you know, temporarily affect ovarian function. So not uncommon people after history of me be like, oh, God, I kind of feel like really hot flashier. I'm really sweaty or my mood's all over the place. A lot of times that gets better after a few weeks. But there are some people who are already parimenopausal and it sort of just like

launches them into full bone menopause, even if you keep your ovaries. So I read in it, and the earlier you have a hysterectomy, the more years you'll lose. But on average, a woman with a hysterectomy and has her ovaries left behind, we'll lose four years off of her shelf life of her ovaries. So she'll go through menopause four years sooner than she would have had she not. And I was never taught to counsel that when we were, you know. And so I think it's really important for our listeners to understand, like, we need hysterectomies. It's an important surgery.

but we really have to pay attention to your symptoms and blood work because we're not going to have a period to guide us anymore as to when your menopause starts so we can counsel you appropriately. Exactly. So it's all about awareness. Like you said, we never, like, and I went to a very good residency. I feel like we were very well taught. I can deliver a baby like, nobody's business. And I was kind of just like to pause and say, I know a lot of the discussions here are like, well, here are like the things where we're doing wrong is a field of medicine. The people who go into OBGYN are so dedicated. Like they are just truly devoting their whole life to this. The fact that we do this wrong is not because someone just like doesn't care enough. It's just because like we just,

as a field, we don't have enough resources. Like we don't have research. We don't have data. So a lot of stuff is sort of based on we were told this by our attendings. And that was taken as fact. And so we get perpetuating all these sort of myths. So just to kind of take step back and say like, you know, when we, when we say we were never taught to do this, it's not that we went to a bad program. We went to great programs. We were, you know, really well-meaning attendings. But we never were taught to tell people with hysterectomy. That's lower and for lack of data. Yeah, exactly. And so I always kind of also say with the whole earlier age of menopause, we don't actually know if the hysterectomy is necessarily causing that. It could be a correlation causation thing.

Right. That whatever inflammatory process caused her to have her uterus removed. Could also affect the ovaries. Exactly. So that's exactly right. We think maybe the inflammation of the chronic fibroids or the endometriosis may also have affected the ovaries leading to more tendency to, you know, have an earlier menopause. But just the fact is, the phenomenon still exists. So we do need to tell people when they're making these decisions like, hey, just you know, like these are things to keep in mind. You know, that may make the difference between someone choosing a hysterectomy and not. What do you think about there's a push right now and it's getting popular in social media in the doctor world that we should not have OBGYN as a residency.

It should be. Oh, to split it. Obstetrics or gynecologic surgery. And I'm like, whoa, whoa, whoa, we need three. So we need the health of women outside of delivering babies and doing surgery. Absolutely. We need gynecologic surgery as its own standalone, you know, and then we need OB. Yeah.

So what do you feel about that? There's a lot of people who trained traditionally who are like, uh-uh. Yeah. I can do it all. And I'm like, can you though? Yeah. In an ideal world, yeah, of course they would be separate. There's no way to cram this much information into a four-year residency. Like either you'd have to make it much longer to do it really well. Or you split it up so that everyone can have their lane. They really focus. They know all the data. They do it every single day. You know, they're not sort of like occasionally doing surgery or occasionally talking about menopause, occasionally delivering a baby.

we serve people best by having like really concentrated training practice. And that's just the way it should be. Now, the reality is that OBGYN as a field is in trouble. Like we are, I think a third of counties in America have no OBGYN at all. Zero. Like no labor and delivery unit. So where a lot of the night, I understand this because obviously logistically it makes sense. A lot of the people who work in rural areas are like, look, we can barely get someone to come here.

Anyway, like we are, even under the best of current circumstances, have no one willing to come here because of liability, because of abortion laws, because of poor reimbursement. They just can't keep the doors open. So they're like, well, that would be great if we could have like these ultra kind of specialized things. But right now, we're just like, we can't even get a single OBGYN of any sort of any training to come to our county. So like I said, in an ideal world, I think a lot of us, especially in the GYN laparoscopic surgery world, have always sort of thought it would make sense. because there are no other surgical specialties that try to do as much as we do. Like, urology or, you know, neurosurgery are not trying to do, well, I guess urology a little bit, but like they're not trying to do preventative care.

They're not trying to do some other specialty. Like, O.B is like its own thing. Like, this is like critical care. I mean, it's everything. It's a lot of stuff. So it's very hard to kind of be the master of all those things. So I think for those of the surgical people, we've always sort of said it makes sense for people to be high-volume surgeons to do the best that they can for people. But I understand the realities

of especially in rural areas. They're just like, we just want anyone who is trained, who's qualified of any sort. Just to be here. She has a uterus next. Yeah. They're saying like we're not going to get like ultra specialized person who wants to live in the city to come to, you know, the middle of nowhere. It's going to be hard to attract somebody. So you can follow Dr. Tang on Instagram and YouTube at Karen Tang MD. And you can find her through her website, Karen Tangmd.com. Her book, It's Not Hysteria. Everything you need to know about your reproductive health, but we're never told, is available wherever you buy your books. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get

honest and accurate information on health, fitness, and navigating midlife at thepawslife.com. My new book, the new perimenopause, is available now everywhere and anywhere you buy books and through our website. If you're loving this podcast, be sure to click follow on your favorite podcast apps you never miss an episode. While you're there, leave us to review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with pod people. I'm your host, Dr. Mary Claire Haver.