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BackTable / OBGYN / Podcast / Transcript #30

Podcast Transcript: Ambulatory Workup of Endometriosis Patients

with Dr. Ted Lee

In this episode, Dr. Mark Hoffman invites Dr. Ted Lee, an OBGYN specializing in MIGS and professor of OBGYN at University of Pittsburgh Medical Center, about the ambulatory workup of endometriosis patients. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Endometriosis Workup: Challenges and Misconceptions

(2) Pelvic Pain & The Complex Landscape of Diagnosis of Endometriosis

(3) Recognizing the Signs & Symptoms of Endometriosis

(4) Barriers to Endometriosis Workups & Diagnosis

(5) Diagnostic Examination Techniques for Suspected Endometriosis

(6) Imaging Endometriosis: From Ultrasounds to MRIs

(7) Collaborative Approaches in Advanced Endometriosis Management

(8) Diaphragmatic Endometriosis: From Symptoms to Surgical Strategy

(9) The Future of Endometriosis Diagnosis: Pros & Cons of Advanced Testing

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Ambulatory Workup of Endometriosis Patients with Dr. Ted Lee on the BackTable OBGYN Podcast)
Ep 30 Ambulatory Workup of Endometriosis Patients with Dr. Ted Lee
00:00 / 01:04

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[Dr. Mark Hoffman]
Hello, everyone, and welcome to The BackTable OBGYN Podcast; your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com. This is Mark Hoffman, and I'm here with a friend and incredible guest, Dr. Ted Lee. How are you, Dr. Lee?

[Dr. Ted Lee]
Right.

[Dr. Mark Hoffman]
Can I call you Ted for the show?

[Dr. Ted Lee]
Please, please. Thank you. Once you're not a fellow anymore, you can call me Ted.

[Dr. Mark Hoffman]
For our listeners, Ted is a legend in our field of MIGS, minimally invasive GYN surgery. He is a clinical professor of OBGYN at Magee-Womens Hospital, UPMC in Pittsburgh. He is the director of the Division of Minimally Invasive Gynecologic Surgery, a past president of AAGL, has won the Golden Laparoscope Award there, I think, six times. Is that right, Ted?

[Dr. Ted Lee]
Yes. I haven't break Tom Brady's record yet.

[Dr. Mark Hoffman]
I think if they haven't already, the award should be named after you. Is that how it works?

[Dr. Ted Lee]
No, I don't think so.

[Dr. Mark Hoffman]
I'll work on that. Also a member of the board at SGS, the Society for GYN Surgeons. Ted, thanks again for joining us on the show.

[Dr. Ted Lee]
Oh, thank you, Mark. Thank you for having me. I'm very honored to be one of your guests.

[Dr. Mark Hoffman]
Now, we're excited. This is a continuation of a conversation we had actually at SGS about things to talk about in the show. One thing you wanted to talk about, which I think is an extremely important topic, is the ambulatory workup of endometriosis for patients in whom we suspect endometriosis. Before we get started into the topic, tell us a little bit about your practice, how you got to be where you are because I think those of us who did the AAGL, MIGS fellowships, it was set up for us in ways that maybe not everybody had that. Talk to us about your current practice and how you got to be where you are.

[Dr. Ted Lee]
I think I fall into what I do currently accidentally, to be honest with you. When I was a resident, obviously, laparoscopic surgery at that time was very, very uncommon in academic OBGYN residency programs. You probably don't know this; laparoscopic surgery in our field was started in the private sector. There's virtually nobody in the academia that is teaching laparoscopic surgery, so when I was a resident my exposure was basically vaginal surgery. I had a very good mentor, Dr. Terry, who has obviously since passed, was very well-known in the vaginal surgery world.

Then I thought when I finished training, that would be something I wanted to do at that time. It was only probably a handful a year of gyna fellowship, and then I apply, I didn't get the position. I started out my job as a brand new faculty practice in a small OBGYN residency program in Baltimore called Union Memorial Hospital. It's next to the Hopkins undergrad campus. During that year, I wasn't busy. I had only about two, three patients, a half-day session sometimes. I have nobody because a brand new practice, I had nobody, I didn't know how to get patients.

[Dr. Mark Hoffman]
This was a generalist practice, obstetrics and gynecology?

[Dr. Ted Lee]
Yes, we have like two or three residents a year. Obviously, the residency no longer exists at this point, so I was kind of like, "Feel like I'm wasting my life away. I want to do surgery," and I wasn't getting any surgery. I borrowed a bunch of slides from Terry at the time, was teaching the residents about vaginal surgery, sacrospinous ligament fixation, and so on, but I wasn't doing any surgery, so I just feel like this is not going anywhere. That was the year I learned how to fly fish because I had so much time.

[Dr. Mark Hoffman]
Something good came out of that, for sure.

[Dr. Ted Lee] Yes. I had a lot of free time on my hand, I learned how to fly fish, and then I learned how to tie flies during that same year. One day I opened the OB/Gyn News. I don't know, most of the audience, the younger audience this day doesn't even know what OB/Gyn News is. It's basically an actual paper, newspaper, basically, that give you the information on what's going on in the OBGYN world. They will have summaries of different meetings. In the back of the OB/Gyn News, there's always some advertisement for some job positions.

One day I opened it up, and then there was this fellowship with Tommy Lyons and CY Liu, both of which, they're pioneers in our field. Initially, it was supposed to be a combined fellowship, but each one ended up taking their own fellows at a different timeframe. I ended up becoming fellow with Tom Lyons.

[Dr. Mark Hoffman]
He was in Atlanta. Is that right?

[Dr. Ted Lee]
Atlanta. Yes, he was in Atlanta. If you guys don't know, he used to play professional football at Denver Broncos.

[Dr. Mark Hoffman]
It's one of the most interesting biographies I've ever read in my life. I think he was a concert musician too and led the Denver Philharmonic, I think at one point, while he was a member of the Denver Broncos. Didn't he pay for med school?

[Dr. Ted Lee]
He was doing medical school at the same time too.

[Dr. Mark Hoffman]
These people are made of different stuff than I am. That's amazing.

[Dr. Ted Lee]
Yes.

[Dr. Mark Hoffman]
By the way, he's a pioneer in gynecologic surgery.

[Dr. Ted Lee]
Right, exactly. He was a big proponent of a laparoscopic supracervical hysterectomy. Back at that time, yes, he could do a total hysterectomy easily, but he really believed that if patient doesn't have any pathology in the cervix, the cervix should be kept. Then he was the first person I realized how beautiful dissection in laparoscopic surgery can happen. I also spent a lot of time with CY Liu because, back in those days, they were the big shots. They are invited to meetings all over the world, so one of them is always traveling somewhere.
Whenever Tommy traveling somewhere in Greece or Italy or somewhere, I would drive up to Chattanooga and watch CY Liu operate and vice versa. I learned a lot from both of them.

[Dr. Mark Hoffman]
What an amazing opportunity.

[Dr. Ted Lee]
Yes. It was very strange because apparently when the position was posted, there was over 100 application for one spot.

[Dr. Mark Hoffman]
Wow.

[Dr. Ted Lee]
I was obviously very fortunate. I don't know how I got chosen. The only thing I can think of is that I share the same birthday as Tom Lyons and we have the same initial.

[Dr. Mark Hoffman]
Whatever it takes, again, I think.

[Dr. Ted Lee]
Whatever it takes, yes.

[Dr. Mark Hoffman]
No, I think it's always fun for me to start the show with understanding how people got to be where they are. To think what a loss to MIGS it would be, had you matched into urogyn.

[Dr. Ted Lee]
Yes, it was meant to be.

[Dr. Mark Hoffman]
Yes. It wasn't your favorite day, but it was a good thing for patients with endometriosis and for the MIGS specialty as a whole. You were with Tommy Lyons and CY Liu for a year?

[Dr. Ted Lee]
One year. Back then, it was basically apprenticeship. Back in those days, it's like the people service. Those people in private practice are rock stars of our field. They were basically getting paid before service for everything. Not just for endometriosis surgeries, everything, they got to pay for service. I was fortunate he allowed me to perform some of the surgeries. I also practiced a lot on my own. I was his first fellow, so he didn't know what to do with me, to be honest. I was practice a lot on my own. He has a back room where he has a TV monitor, and so I construct my little pelvic trainer that's made of a copy paper box with a lid.

I put trocars on the lid of the paper box, and I carved out the end of the box. I used the colposcopy light as my light source, I put the camcorder that was a gift from my in-laws, and I put it on a tripod, and I connected it to the TV monitor. That was my pelvic trainer. I'll be basically getting the chicken thigh, getting all the fat off the chicken thigh, debone the chicken thigh, all laparoscopically, and then close the defect of the chicken thigh once I debone the chicken thigh. That was basically my training, my pelvic trainer, and it comes in handy. When he hand me the tools, and I was able to jump out and do a laparoscopic purge, paravaginal repairs without much prompting because I was pretty good at suturing by that point on my own with all the practice--

[Dr. Mark Hoffman]
That's something that I talk to my residents about a lot is I think when we're teaching open surgery, most of us know how to hold a pen, holding a knife and retracting. There's skill there, but I think we're used to using our hands. What I want our residents to show up to the OR with is the ability to use those instruments as extensions of their hands. That's something that you can do in the lab like you did with the cardboard box. That's something I did with a cheap trainer in a closet up by the post-op floor, just throwing stitches and just tying knots, and just doing as many of those kinds of little dexterity things, so when I got to the OR and had an opportunity to operate, I could learn how to operate, not how to hold the instruments.

[Dr. Ted Lee]
Exactly.

[Dr. Mark Hoffman]
That's a perfect example of how someone can make the most of their opportunity in that situation.

[Dr. Ted Lee]
Right.

[Dr. Mark Hoffman]
You were with Tommy Lyons. You were there for a year, and then did you go straight to Pitt after that?

[Dr. Ted Lee]
No. At that time, MIGS wasn't a thing. Most academic departments does not know what MIGS is. I was getting close to finishing my fellowship, I sent out maybe over 100 cover letters to various OBGYN chairs in the country, and I think I heard back from like three or four places. The first place that offered me a job was the Medical College of Georgia because Tom is very famous and people in Georgia respected him, so I got a job offer there. Then I interviewed at Wake Forest, and I interviewed at GW. GW was where I went. That's my first job after the fellowship.

[Dr. Mark Hoffman]
Okay. How long were you there?

[Dr. Ted Lee]
I was there for two and a half years. Two and a half years, yes. When I started there, what I do is I think most people consider me as a threat because I'm stirring up the status quo there. There's a lot of people at that time just don't want you to succeed, basically. You just have to prove them wrong, and you get better and so on, because they are always people who want to pick on you when you first start. Especially back then, laparoscopic surgery just wasn't so common. Then also when I started, I still had to do OB calls. I was doing a lot of OB calls.

[Dr. Mark Hoffman]
Yes, no, I did too. It's nice to see all these jobs that are being posted now for MIGS fellows. It would have been nice, but it's folks like you that laid the groundwork for the rest of us to follow. Then from there, it was Pitt.

[Dr. Ted Lee]
Was Pitt, right, yes. At that time, towards the last year of my tenure at GW, they were having some financial troubles. I just opened the back of the Green Journal. At that time, I had been always doing a lot of urogyn procedure laparoscopically, even when I was at Magee. When I opened the back of the OBGYN journal, they have a position posted for a urogynecologist at Magee-Womens Hospital, and I just apply. I was applying for a position at Yale at that time, but then Magee replies that "That position has been taken, but your experience is very, very different. My chairman still want to interview. Can you come in and interview you?"

[Dr. Mark Hoffman]
Who was the chair at the time?

[Dr. Ted Lee]
Rick White. He's an infectious disease expert, originally from the University of San Francisco.

[Dr. Mark Hoffman]
Amazing how much a leader with vision can make an impact and get someone like you to come and give you the space to grow and build something when most other people in that situation, in that seat did not. I love hearing the story of how you got to where you are because it's never the straight shot, it's almost never just the straight shot.

[Dr. Ted Lee]
Yes, it's very circuitous, it's not like a direct straight line.

[Dr. Mark Hoffman]
The other thing I wanted to ask you, endometriosis-related, but before we get into the workup, I think as a fellow who also went somewhere after training where I was the only mixed person, and there wasn't anyone really doing what I did, I found endometriosis surgery to be the toughest thing to learn how to do. I still feel like I have so much to learn. I watch your videos and talk to you about this and your colleagues and those who you've trained. Your interest, your skill set, your ability to take care of those complex endometriosis patients, how did that come to be? What did that look like in your early career?

[Dr. Ted Lee]
Yes, I think in the early career I was obviously still learning. To get to where I am obviously took many, many years. Also, back in those days, there wasn't YouTube, there wasn't any kind of things that you can watch online. Everything is you go to meetings and you see how the people does it. You're trying to go back and to see if you can do it and so on. That's how it was in those days. When I started, it was basically, I remember when I was in GW, anytime I get into trouble I had my good friend oncologist come in and help me.

Usually, if endometriosis is so severe, he will come in and open the patients, and he would do surgery with me. Obviously, in those early days, that's how it was, and then you learn and you get better. I think what got me interested in is not even patient with severe endometriosis, in actually patient who has actually relatively straightforward endometriosis surgery, relatively straightforward excision. Patient has seen many doctors and has have many procedures done, and they have no improvement of their pain. All of a sudden, you come in there, you find the endometriosis, you cut it out, and they are pain-free.

Then you feel special. You feel like you can do something that other people cannot do, and then you keep on doing it. I think that's how it all got started is just because just a few patients that you feel you can make an impact on, give you that motivation to continue to do more. Then as you get better known, then you get fed a lot of worse and worse cases, and then you either sink or swim. You get better and figure things out, and then that's how it works. I think a lot of times it's, I consider myself very, very fortunate that I was able to be able to take care of a lot of complicated patients early on in my career without causing too much complications and then be able to learn.

[Dr. Mark Hoffman]
It's a tight line to walk. I had that experience in many ways and actually, it was at a different hospital than our GYN oncologist. It was urology, it was colorectal for me for some of these bigger, tougher cases. I'm very, very grateful for the partners that I have that work with me. Also, yes, you get into too much trouble early on, that can be the end for your career in that place. It's a tightrope to walk, for sure.

[Dr. Ted Lee]
Yes.

(1) Endometriosis Workup: Challenges and Misconceptions

[Dr. Mark Hoffman]
For all the surgery we could talk with Ted Lee, one of the things that I was surprised that he said he was interested in talking about the ambulatory workup of endometriosis, but it's also, when I talk to our trainees about being a surgeon, I always focus on the clinic workup, the ambulatory workup, the decision for surgery. That's what I think really makes the doctor. I think you can train a lot of people to do procedures, but the decision to go to the OR-- Before we get into the steps you take, what is it about endometriosis that is such a diagnostic challenge? Because it is, right? It's years; seven, eight years before people get diagnosed. What is it about endometriosis that makes diagnosing it so difficult?

[Dr. Ted Lee]
I think it's, there's always the stigma of pelvic pain. I think a lot of people whenever they have busy practice, you have many patients waiting in the waiting room, and then you flip the chart and look at this patient's chart, and you say, "Oh, pelvic pain." Then automatically, a lot of people are just thinking that it's pelvic pain, and this will take a lot of time, and so they already have a built-in prejudice already about the patient. That's one of the obstacles that the patient face, is that the physicians themselves just don't feel comfortable asking questions and taking care of [unintelligible] patients.
In reality is once you have done this long enough, it's, a lot of the questions become very automatic. Nowadays, if you have Epic, you can have basically a smart phrase or smart text, basically, all the prompting questions that I prompt you to ask. You can do that very, very easily. Back in those days, for me, it was just automatic this is what I ask and the answers I get. Once you're comfortable with the history part of the whole encounter, it's pretty straightforward, and everything is practiced. If you do enough, then it won't take us long.

[Dr. Mark Hoffman]
My guess is most of the patients or many of the patients that you're seeing are patients that have already been diagnosed with endometriosis, and then they get referred to you. Is that true, or are you getting a lot of patients that are just coming in with pelvic pain, or--

[Dr. Ted Lee]
I have patients who has been seeing so many doctors already and who hasn't been diagnosed. Recently, I was shown a video of a patient of mine that was doing-- Basically, the video was recorded so one of the PhD students can convince the people who give out grants to give her the grants for AI diagnostics for endometriosis. There was a project that Nicole Donnellan, one of my associate, was working on with the PhD student. This was obviously after they recorded and they show it to me, and it turns out the mentor for the PhD student turned out to be the husband of this patient.

[Dr. Mark Hoffman]
Oh, wow.

[Dr. Ted Lee]
I was like, "How did Dr. Donnellan know about my patient?" It was kind of strange. Anyhow, they showed me the videos, and it was this patient who I met for the first time in her late 40s. She'd been having pelvic pain for many years and had four rounds of IVF all fail. I examined her and look at her ultrasound, and I say, "You have Stage 4 endometriosis." She has tethering and nodularities on exam. Then when I heard about the IVF that she did, the full IVF she did that fail, I feel really bad. I said, "I wish I had met you earlier." Not all my patient were diagnosed. Actually, a lot of patients are not diagnosed with endometriosis.

They've been diagnosed with many different things. They have been diagnosed with interstitial cystitis, they have diagnosed with irritable bowel syndrome, everything else, but endometriosis.

[Dr. Mark Hoffman]
For those of us that do it, those are red flags, right? Those; IBS, IC, chronic pelvic pain.

[Dr. Ted Lee]
Yes.

[Dr. Mark Hoffman]
It just jumps to the top of our list because I think we see it a lot. I guess when you're not doing this a lot, it's not something maybe that's high enough on your differential.

[Dr. Ted Lee]
A lot of our patients are given diagnosis they don't have, a lot of times. I have patient who supposedly used to have interstitial cystitis and a palpated anterior vaginal wall. She's even tender there. Typically, a patient with interstitial cystitis, you palpate anterior vaginal wall, do a compression, they would've severe pain, but a lot of those patients don't have those kind of exams. There are a lot of patient being diagnosed with all kind of problems, palpated spasms, IC, irritable bowel. I do exam and I touch their cul-de-sac and uterosacral ligament, and they jump off the table.

That's the kind of exam that they have instantaneous reaction to the exam. What I call is very like a visceral reaction to the exam, a classic visceral reaction. That's how I term it, how I describe it.

[Dr. Mark Hoffman]
Yes, you can see it in their face.

[Dr. Ted Lee]
It's something that they cannot fake. It's just what I call very authentic exam. Those are the type of patients I know I can help.

(2) Pelvic Pain & The Complex Landscape of Diagnosis of Endometriosis

[Dr. Mark Hoffman]
To begin your workup, now, we can start in clinic, but a lot of folks will have surveys and stuff they send out. Are you guys sending out packets or surveys to patients prior to them coming to clinic? Does the workup begin when they come into your office?

[Dr. Ted Lee]
Yes. I think the problem with surveys, sounds great, the problem is that nobody look at it a lot of times.

[Dr. Mark Hoffman]
No, I think that's very true.

[Dr. Ted Lee]
I think you need to have resources to have like a nurse practitioner or PA to screen or somebody to screen those surveys. I think it could be incredibly helpful. Unfortunately, most people just don't have the time to go through the surveys. I think ideally you really could use the survey, but ideally, most people don't.

[Dr. Mark Hoffman]
It starts with an H&P for you. It starts with-

[Dr. Ted Lee]
Yes, exactly.

[Dr. Mark Hoffman]
-just get a thorough history. I think that's something about what we do that is extremely valuable. Like you said, I think it's the first thing we learned as med students. I don't think it's gotten less important even with all the technology that we have. In your history, what are the types of things you're asking that maybe not everybody is asking? Obviously, Gs and Ps and other health history, but what are the things you're looking for in patients in whom you suspect endometriosis?

[Dr. Ted Lee]
Obviously, the age is extremely important. If you have patient coming at age 50 and have pelvic pain for the first time, you're not going to think endometriosis. Age, when the patient present it to you. Obviously, they can tell you, older patient in their 40s, they will tell me, "I have severe pain with my period since my teenage years." Those patients, even though they present late, they can still have endometriosis because they understand the symptoms was many, many, many years ago. I think gravidity parity, it's important too, because a lot of times, for example, if you are doing hysterectomy for fibroid and the patient G0, P0, it should not be assumed that just the way it is because most people are going to be pregnant unless they purposely try to avoid pregnancies.
If they come in G0, P0, you have to ask, "You just don't want to have kids, or you have you tried using birth control?" If they tell you, "I just never used birth control, and I never got pregnant," that should be a red flag.

[Dr. Mark Hoffman]
That's a good one. Yes, that's interesting.

[Dr. Ted Lee]
Yes. It's something that you need to keep at the back of your mind. In terms of the Gs and Ps, I think C-sections, vaginal delivery, and stuff like that, it's important, especially with C-sections. A lot of patients with C-section end up with endometriosis. The other thing that can happen with C-section is abdominal wall endometriosis.

[Dr. Mark Hoffman]
I see a lot of that. I think my threshold to think about that's pretty low if they're having pain at the scar apices, and it gets missed a lot.

[Dr. Ted Lee]
A lot of times abdominal endometriosis, actually, are not even near the C-section scar. Sometimes they could be maybe a few inches or even removed from the actual C-section scar. Then the ones that usually get missed a lot, the subcutaneous ones that people can pick up because sometimes you'll feel that in patients, the one that gets missed a lot is rectus muscle endometriosis.

[Dr. Mark Hoffman]
Subfascial.

[Dr. Ted Lee]
Subfascial endometriosis, right?

[Dr. Mark Hoffman]
Yes.

[Dr. Ted Lee]
Those you don't feel a lump. Top of the area, they would have tenderness there, but it don't actually feel a lot because it's the fascial. In those patient, they'll frequently tell you the symptoms of pain with coughing, pain doing situps, that's worse with their period, stuff like that. In those patients, I would just order MRI, and a lot of times they would show up with the rectus muscle endometriosis.

[Dr. Mark Hoffman]
Yes. I want go through your imaging modalities to work up here in just a minute because I think there's a lot of variability, but I have a pretty low threshold for that as well.

[Dr. Ted Lee]
In history, I think your typical things are 3Ds; dysmenorrhea, dyspareunia, dyschezia. Very, very typical symptoms that you ask. I think if patients does not have dysmenorrhea, and stopped having menses, then I think dysmenorrhea is the most common, the most basic symptoms of endometriosis unless they have become amenorrhea for different reasons. They're on some kind of hormonal medication make them amenorrhea. Most patient with endometriosis, like I said, almost all of them have dysmenorrhea. Dyspareunia and dyschezia are much more-- What do they call it? It's, a patient can go without it.

(3) Recognizing the Signs & Symptoms of Endometriosis

[Dr. Mark Hoffman]
I tend to think, and I don't know that I have the evidence at the tip of my tongue to support it, but I think about endometriosis in terms of progression. Like you said, starting off when they started having periods, a lot of times they had painful periods with menarche, or shortly thereafter, they got put on birth control pills, whether it's because they were becoming sexually active, or because their doctor said, "Ah, you're having painful periods. Let's see if we can't improve that." They do better for a number of years, and then sometime in their 20s, they're like, "I'm tired of being on birth control pills." Or they're taken off birth control pills because they're going to try to start a family and all the symptoms return.

That to me is like a telltale sign. Like, okay, when you were being treated, symptoms went away, and then it got a whole lot worse. The longer they're off treatment, the worse it gets and the more difficult it is to put them back on hormonal suppression to treat it. That's oftentimes when they get put back on, they fail, that's when they get sent to me. Yes, I agree. I feel like it starts cyclic, all the other stuff down the road, the daily pelvic pain worse throughout the day with activity, the musculoskeletal component, IC, IBS, kind of the three-headed monster with endometriosis, that seems to be a later progression. Do you feel like that's what you're seeing as well in your patients?

[Dr. Ted Lee]
Yes, I think so. I think a lot of times, initially, the pain may be just during their periods, and over time, they would have pain also in their periods and typically still worse with period. Usually, worse also during this cycle too. That's a very common report.

[Dr. Mark Hoffman]
Ovulation pain.

[Dr. Ted Lee]
Exactly, yes. Also, one of the things, and I tell other people, is that I say if patient have lateralized pain during their period, that is a very important piece of history because that--

[Dr. Mark Hoffman]
Explain what you mean by that lateralized pain. Like it radiates?

[Dr. Ted Lee]
No, if they say, "I have right-sided pain during my period," or, "I have left-side pain during my period."

[Dr. Mark Hoffman]
Oh, specific. I got you.

[Dr. Ted Lee]
Yes. Not just pelvic pain. If they can say, "I have right-side pain or left-sided pain," of course, a lot of patient with endometriosis have midline pain too, but if they tell you that they have right-side pain or left-sided pain during their period, that is very, very indicative of endometriosis.

[Dr. Mark Hoffman]
You have a patient that you are suspicious of. I use the term in whom a patient with suspected endometriosis or presumed endometriosis because I think we talked a little bit about the delay in diagnosis. I think part of that is undoubtedly, we got to believe women, we got to believe patients. It's chronic pelvic pain. It's a challenging condition that it can overlap. I do think part of it is also the fact that this is a disease that is diagnosed, at least currently it's a disease that is diagnosed surgically. We'll have patients that I presume have it, or in whom I'm highly suspicious that they have endometriosis.

(4) Barriers to Endometriosis Workups & Diagnosis

[Dr. Mark Hoffman]
If they're doing well on birth control pills or we find some other non-surgical management that works for them, we don't necessarily have to diagnose, or at least that's how I've been practicing. Are you always starting treatment with hormonal suppression of some kind prior to surgery, or how quick are you to go to the OR?

[Dr. Ted Lee]
I think it depends. Actually, one of the barriers for diagnosis is, frequently, physician are now comfortable of taking patient to the surgery. One of the reason, the barrier is they are not sure if the surgery is going to help or if they're going to find anything. I think one of the ways for me is I'm very confident with my history and the exams that allow me to offer that as surgery as an option to the patient, a lot more frequently than other people. I think if you are not sure of whether the patients is having the choices or you're not even sure if you're going to be able to help the patient surgically, you're less likely to offer that as an option.

[Dr. Mark Hoffman]
Right. Physician comfort in managing a problem is definitely going to push you one way or another in terms of what you're going to recommend.

[Dr. Ted Lee]
Right, exactly. Of course, always do no harm, right? That you don't want to do something that you don't have the training or the skill set to perform and hurt the patient. I totally understand that, but I think one of the barriers is that people, in general, just don't feel comfortable performing surgery. That's one of the reason. Actually, one of the other reason that I think most people don't think about is the patient themself as part of the delay for the diagnosis because they write things off. They think it's normal.

[Dr. Mark Hoffman]
People get busy, people have lives. Yes, they don't know, that's right.

[Dr. Ted Lee]
They think it normal and say, "Oh, yes. I miss work all the time. I miss school whenever I have my period. Then I just thought that was normal." Then I tell them, "No, that's not normal."

[Dr. Mark Hoffman]
Sadly, a lot of patients that I see, their doctor said, "Well, that's just the way it is," or their mom or family or somebody has just told them this is the way it's going to be, or it's supposed to be, and it's sad to hear that. Yes, so listening is a huge part of diagnosis. Trust patients, believe them. When they tell you something is wrong, believe them. They oftentimes have been through many, many things.

(5) Diagnostic Examination Techniques for Suspected Endometriosis

[Dr. Mark Hoffman]
Okay, so you've got a patient. You're suspicious that they have endometriosis based on history, touched on it a little bit. What are the exam findings that make you think a patient is more likely to have endometriosis, less likely to have endometriosis?

[Dr. Ted Lee]
I do, obviously, see the patients. Obviously, see how their general behavior is and everything before I even start the exams. I usually tell the patient exactly what I'm going to do and the reason, the purpose behind my exams.

[Dr. Mark Hoffman]
So important.

[Dr. Ted Lee]
Yes, I tell the patients that, "I'm going to palpate different regions in your pelvis. I want you to tell me whether I reproduce your pain or produce a different kind of pain altogether. The better I can reproduce your pain, the more likely I can help you. I also tell them about, I perform a rectovaginal exam on all my patients with pelvic pain, essentially. It's not something that everybody does. For them, it's the first time for them to have rectovaginal exams. I tell them exactly the reason behind that I do the rectovaginal exam. I tell them that the most common site of endometriosis is going to be the cul-de-sac or uterosacral ligament, and it's a lot easier for me to access that area with the finger in the rectum.

[Dr. Mark Hoffman]
Are you feeling for big nodules or are you feeling for nodularity? Is it pretty subtle sometimes, the findings on the--

[Dr. Ted Lee]
Most of patient don't have nodules. Most patient with endometriosis are not going to have nodules. Nodule is a sign of late disease. It's, obviously, when you feel nodules you know that deep infiltrating endometriosis. Majority of the patients just going to have localized tenderness in the area. Usually, most people don't know how to do rectovaginal exam. Obviously, this is a podcast. People have to use their imagination to see how I do the exam. I have one finger, my index finger in the vagina, my middle finger in the rectum.

I have my middle rectal finger palpate anteriorly, and then I feel the cervix. Cervix is a very reliable landmark you can feel on the recto exam because it's firm. We all know that uterosacral ligament is there behind the cervix, so on either side of the cervix would be the uterosacral ligament. If you sweep it laterally and posteriorly, that would be your uterosacral ligament. Whatever is in between, it's the cul-de-sac. If you touch that part of the pelvis and you reproduce the pain, the reaction that I describe as a visceral reaction to the exam, I feel pretty confident that those patients very, very likely would have endometriosis.

That visceral reaction is something that it's, you cannot fake that part of the exam. Obviously, with pelvic pain, there's always a lot of drug-seeking patients who want to get medication from you. With this exam, it's very specific. If everything hurts, typically, I don't feel confident the surgery is going to help them. This is something beyond surgery if everything hurts. They may have vaginismus.

[Dr. Mark Hoffman]
You're looking for more localized pain at the uterosacral ligaments, at posterior lower uterine segment is a place I feel like we feel it all the time.

[Dr. Ted Lee]
Yes, most of the posterior cul-de-sac uterosacral. I can also feel tethering. If there's scar tissues, then I feel some tethering. If they have very small, what I say, granular nodularities, like little rice grains in the area, I can feel that sometimes as well. Obviously, the big nodules I can feel. Those are what I do; rectovaginal exam. Before I even get to that part, I usually tap in the anterior vaginal wall. That would be the first thing I do unless I know the patient have interstitial cystitis. They're very strongly suspicious, patient might have interstitial cystitis.

I do one digit or two-finger exam on the anterior vaginal wall. You just start on that first unless I strongly suspect that patient might have IC because if you have a patient with IC, you touch that part first, then the exam is done basically. Those patient, I don't start anteriorly, but in general, for most of the patients, I start anterior vaginal wall, palpate that area, I then palpate levator, coccygeus muscles, just for focal tenderness. Patient might develop myofascial pain. I used to do lot of injections in the muscles, but a lot of times, in my experience is that the muscle spasms and pain tend to be reactionary to the disease. If you treat a disease that you would treat a patient, a lot of injections that you may get some temporary relief, but the pain will come back.

[Dr. Mark Hoffman]
The analogy I use for that, I did the same thing, if you hold a gallon of water for a week, I can take the gallon of water away, but your muscle is still going to be hurting for a while. Occasionally, we can address the initial insult. At times, though, the muscle pain that was associated with may continue, and there may be opportunities for improvement with PT. I agree, starting with the insult, the initial nitis of pain that led to that musculoskeletal pain, you address that first, and then see what's left over. I think that's a common thing.

[Dr. Ted Lee]
Yes.

[Dr. Mark Hoffman]
Are you starting your exam with the back and the belly, or are you going straight to the pelvic exam first?

[Dr. Ted Lee]
Obviously, I just inspect the abdominal wall initially. Especially in patients with C-sections, I'll palpate the anterior vaginal wall. Most patients with endometriosis, unless they have abdominal wall endometriosis, typically abdominal proportion exam are quite non-tender. I suspect something is not quite right when patient, you barely put your hands on their abdomen, they are having so much pain. Those patients, sometimes you're not sure if it's endometriosis-related or something else. After anterior vaginal wall, levator ani muscles, and then I touch posterior fornix.

In patient with endometriosis, if you lift the cervix, stretch cervical motion tenderness, you can stretch the uterosacral ligaments. They're going to have pain with that as well. Then I do the rectovaginal exam at the last part because that's the most difficult part of the exam that you don't want to do that first because you may not be able to do any of the exam after that.

[Dr. Mark Hoffman]
Right, the exam enders, or you've found something that's extremely painful.

(6) Imaging Endometriosis: From Ultrasounds to MRIs

[Dr. Mark Hoffman]
You have a patient that you suspect disease or maybe in someone you anticipate finding advanced disease. Now, I imagine you are someone who operates on the bowel frequently. I've got a colorectal surgeon, a colleague I work with regularly for patients in whom we suspect bowel involvement. What are additional tests you're ordering? Are all your patients getting ultrasounds? How frequently are you getting MRIs? What's your threshold for referring to colorectal surgery or urology for patients? What are next steps you take from clinic between your initial eval and then the operating room?

[Dr. Ted Lee]
Right. I would say majority of my patient don't end up with any further imaging. By the way, your typical OBGYN ultrasound are very, very insensitive when with diagnosis of endometriosis because most patients are going to have Stage 1, 2 disease, and that's not visible on ultrasound. Then so, usually, if the patients have evidence of endometrioma, the patient have debris-filled cysts, for example, you've taken somebody out to do history for fibroid and you notice that she had the debris-filled cysts on her recent ultrasound, and you look five years back and that debris-filled cyst was there already, guess what that cyst could be?

That could be endometrioma. The worst thing that you want to do is going to do you think a simple fibroid history for endometriosis and you go in there and you have frozen pelvis. Presence of endometrioma is basically a factor, basically increase the risk of obliteration of cul-de-sac for some pelvis and bowel invasions by as much as five times based on some of the earliest study by Ray White. If I had a patient who had endometrioma, I would order MRI because my finger can only reach up so far on my exams. If their nodularity is beyond the reach of my finger, I would miss it. Those patients with endometrioma, I would definitely order MRI.

[Dr. Mark Hoffman]
You said you're not getting ultrasound though on most patients or you are?

[Dr. Ted Lee]
No, most patient already have ultrasound by the time they come to see me. Then most of them would say, "No more ultrasound." Right?

[Dr. Mark Hoffman]
Right.

[Dr. Ted Lee]
Obviously, if they come in with the [unintelligible] or suspicious for endometrioma, regardless of my exams, those patients get a MRI just because the risk of having severe disease is so high.

[Dr. Mark Hoffman]
I order quite a few MRIs at a lot of them. We've got to a radiologist who we work with closely here as well who-- I think it's important to have surgeons who operate on endometriosis a lot. I think having radiology teams that are used to looking at pathology is important. Do you have specific radiologists you work with regularly at UPMC that are reading your scans?

[Dr. Ted Lee]
Sure. The other indication for MRI would be if I feel nodules on exams. Then those patient get an MRI. There are basically two type of people get MRI. Patient with endometrioma or patient with nodularities on exams. They get MRIs.

(7) Collaborative Approaches in Advanced Endometriosis Management

[Dr. Mark Hoffman]
Would the third be the abdominal wall endometrioma [crosstalk]?

[Dr. Ted Lee]
Yes. If I suspect abdominal wall endometriosis, I want to see the front layers of the abdominal wall, this endometriosis involving because some of those patient might require resection of a segment of the rectus muscles and might have a piece of fascia removed that may require you to place a mesh. I have placed a mesh myself for a lot of those patients. I've been doing it for so many years. Those kind of things you need to know. Then frequently, a lot of times, because if you don't know the depth of the invasions and you think that the endometriosis is just subcutaneous and you begin digging and digging and you hit a fascia, most people just back out and just say, "Stop right there. I don't want to do anymore." Then you end up with patients who still have endometriosis on the rectus muscle. It's important to know that information ahead of time. Just like you want to know if patient have bowel endometriosis or bladder endometriosis. Usually, even in patients that I think that I can just do a discoid resections without doing the whole segmental resections, they will see my general surgeons regardless, ahead of time.

[Dr. Mark Hoffman]
Yes, I do the same. I think those of us that are out there doing this without senior partners like you, as we develop these practice plans, it's always so reassuring to me. I was watching a video of one of our other colleagues when I was first out and we were operating on a bladder nodule, and I thought, "Man, I'm just so far from being in that level." Then I hear the person say, "Oh, and now is my urology colleague is going to take over." It's like, "Okay, good. I'm not the only person who's using other people in the OR to help these patients get what they need."

I think, especially in academic centers when you've got a colorectal surgeon next door and then urology on the other side, if you're doing that stuff as a gynecologist, you have to be pretty careful about whether you're going to be doing those surgeries when you've got the experts next door. I've got a colorectal surgeon who I work very closely with,on our advanced endo cases. If I suspect bowel endometriosis for the reasons you're talking about, I always have them go see them first. They oftentimes get a colonoscopy if there's concern about transmural disease.

In that way, they're able to be counseled about what bowel surgery is going to look like. It's nice to hear that you also are referring to general surgery colleagues as well. I think it helps when they know the surgeons who are going to be involved on their team at that time.

[Dr. Ted Lee]
Right, yes. I do my discoid resection myself and that's because I work very well with my general surgeons. Typically if the patient's disease is a minimal to discoid resection, I do it myself. Then if the nodules is very large or it's multifocal, then they will come in to do segmental resection. Fortunately for me, I operate three days a week. Mondays, I operate with one general surgeon, and Thursday, I operate with different general surgeons. They all have cases going on at the same time, and so they don't come in to do the surgery unless I tell them that, "You need to come in to do the segmental resection." The discoid resection, I just take care of myself. That's what I do. For bladder endometriosis, I do it myself, and then for uterine endometriosis, I usually do it myself with them watching me doing it for the most part.

[Dr. Mark Hoffman]
What was the last part? For the?

[Dr. Ted Lee]
Ureteral reimplantations. Ureteral reconstructive surgery.

[Dr. Mark Hoffman]
Yes, because you're doing it on a straight stick, a lot of the urologists are robot only.

[Dr. Ted Lee]
Yes, I'm their Da Vinci basically.

[Dr. Mark Hoffman]
I was closing a cuff one time because the urologist came in to look at something. I was like, "Oh, let me just close it real quick so they can get in and do their part." I hear the urology attending turn to his fellow and go, [whispers] "He's making it look really easy. Yes, very easy," because they're not doing a ton of straight stick stuff in urology. Again, I think it's not necessarily should or shouldn't you be doing things yourself. Also, if there's a bladder issue, I'll have the urologist come in but I'll close it myself. I think the key is understanding what your comfort level is.

Getting to a point that you got to where you are now, I'm guessing, took working with these other surgeons for years and years to get to where they know that you can handle these things on your own. You're not doing this fresh out.

[Dr. Ted Lee]
Right. I think it's, no, I just feel very fortunate that I have all these people to rely on when things gets beyond what I can offer them. Also, too, is my general surgeons really trusts me. If they are stuck in their own case and want me to get started with their dissection for their segmental resections, I do all the dissections for them. I lift the rectum, open the retro rectal space, tunnel between the [unintelligible] and the ureter, get out all that space. That's enough for them, so when they come in, they can just do a segmental resection with the staplers.

[Dr. Mark Hoffman]
How important it is for your patients and for those of us to do this, to develop those relationships. That's something that I don't know that I thought about ahead of time, but over the years, I've got colleagues that I consider friends who I've operated with countless times, and who, like you said, there's times when they pop in, and they go, "Looks like you got it", and we do those parts or whatever. Over time, it's, surgery is a team sport. As we get further and further along, there's more and more people that are responsible for my training and my growth and those things. It's such an important part of this job is to have good colleagues.

[Dr. Ted Lee]
Right. On the flip side of the coin, for the endometriosis surgery, the gynecologist should be the captain-

[Dr. Mark Hoffman]
For sure.

[Dr. Ted Lee]
-in terms of what needs to be removed because the general surgeon doesn't know what needs to be removed.

[Dr. Mark Hoffman]
Important point.

[Dr. Ted Lee]
It's important for you to be able to-- For example, if you just have the general surgeon coming in to do the bowel endometriosis and you leave all the endometriosis on the rectovaginal septum, recto-cervical region, which is in the same patient with bowel endometriosis, they have lot of endometriosis behind the cervix, causing the uterus to rip onto itself. The uterus can rip onto a bowel and it stuck to the cervix. When you unravel that between the uterus and the cervix, is all this disease that needs to be removed. The general surgeons are not going to do that.

You are the one who is going to recognize that and take care of those endometrioses. You are responsible for separating the bowel from the posterior vagina, and you say, "Okay, here is a huge nodule," or, "This is a multifocal nodule," or, "This is a patient with a stricture. You need to come in do the segmental resections." You're the one who should decide that this should be a segmental or discoid. That's my take on that.

(8) Diaphragmatic Endometriosis: From Symptoms to Surgical Strategy

[Dr. Mark Hoffman]
We'll have to have you back on the show to talk through the surgical side of things too. It's so tempting for me to just keep going with this thread. I want to make sure for the purposes of this show that we make sure we touch on all the ambulatory stuff too. The other thing I was thinking about in the ambulatory workup is the non-pelvic endometriosis. I think we see occasional videos in our societies about diaphragmatic stripping and those things. What's your threshold for referring to or getting CT surgery involved for these particular cases? How often are you finding diaphragmatic disease?

[Dr. Ted Lee]
The people who I worked with, the two general surgeon I worked with, they also are surgical gynecologists.

[Dr. Mark Hoffman]
Wow. They're comfortable in that space.

[Dr. Ted Lee]
Yes. Both of them are surgical gynecologists and the bariatric surgery, they do two fellowships, both of them. For diaphragmatic endometriosis, I work with them and then they'll help me position the patients. Then frequently, a lot of diaphragmatic endometriosis, the best position would be left lateral decubitus position because you use gravity to get to retreat the liver all the way and give you a good exposure to the posterior diaphragm.

[Dr. Mark Hoffman]
Are you repositioning them interop?

[Dr. Ted Lee]
No, usually, I don't like to do them in the same settings.

[Dr. Mark Hoffman]
Oh, so separate. surgery?

[Dr. Ted Lee]
Yes, because a lot of times you don't really know how bad the diaphragmatic endometriosis, and the imaging is not always that great for diaphragmatic endometriosis. I tell the patients that usually it's just better to do a staged procedure if you have diaphragmatic endometriosis just to know exactly where the disease is and everything because not all diaphragmatic endometriosis is the same because if you have diaphragmatic endometriosis near the central tendon, that's much more dangerous because that's where all-

[Dr. Mark Hoffman]
It all sounds dangerous to me.

[Dr. Ted Lee]
No, it's because, near the central tendon, that's where all the vena cava, the aorta, the portal vein, and all the phrenic nerve is in the central portion of the diaphragm.

[Dr. Mark Hoffman]
What's the clinical findings where you're suspecting that? What gets you to the point in the clinic, in the office to where you suspect endometriosis in those spaces?

[Dr. Ted Lee]
Yes, the cyclic chest pain or shoulder pain, they will tell you that and there's not many things that can cause that. The problem is that when I tell a patient I'll put additional pore under the rib for me to reach that area, do a bit of visual, I put my scope, my camera underneath the rib to look around the liver.

[Dr. Mark Hoffman]
I see.

[Dr. Ted Lee]
If you keep your umbilical trochar as your primary visual port for diaphragmatic endometriosis, you'll miss a lot.

[Dr. Mark Hoffman]
You'll see it, you'll diagnose it, and then you'll wake him up and talk to him about it, and then come back another day to manage if you do find it.

[Dr. Ted Lee]
Exactly, yes. Actually, a lot of patients don't have it.

[Dr. Mark Hoffman]
Right, but you won't know if you don't look.

[Dr. Ted Lee]
Exactly, yes. If you just say, "Okay, I look at it from my umbilical port," you may miss it.

[Dr. Mark Hoffman]
Interesting.

[Dr. Ted Lee]
If you really want to know, you have to put a subcostal port there.

[Dr. Mark Hoffman]
I do a lot of palmar splint entry as well.

[Dr. Ted Lee]
On the right side, if you do that on the right side and use the angle scope to look around the liver, then you'll find it.

[Dr. Mark Hoffman]
Excellent.

[Dr. Ted Lee]
Most of posterior diaphragmatic endometriosis, you're not going to find it with umbilical port, so that's important.

(9) The Future of Endometriosis Diagnosis: Pros & Cons of Advanced Testing

[Dr. Mark Hoffman]
Right, that's interesting, it's helpful. In the clinic setting, anything else? We're getting close to time here, I know you're a busy guy. Any other imaging studies, lab tests, anything else you're getting in these folks? That's what I think of in terms of my workup, but anything else we're missing that our listeners should think about when evaluating patients for endometriosis?

[Dr. Ted Lee]
Yes, I think a lot of your listeners are general OBGYN in the community. One of the worst thing you could do is order a CO125, and then it's elevated, refers to oncologist. You're guaranteed it's--

[Dr. Mark Hoffman]
It's always going to be mildly elevated with endo, and it's just going to be a--

[Dr. Ted Lee]
Or it can be also pretty high too. What's going to happen is that oncologist is going to remove that patient's ovary, and that's what's going to happen. You are basically-

[Dr. Mark Hoffman]
Interesting.

[Dr. Ted Lee]
-asking the oncologist to remove the ovary when you do that. In the young patients, I don't typically order any tests. Obviously, it can be elevated in the patient with severe endometriosis, but there are a lot of the newer tests that's coming in the horizon.

[Dr. Mark Hoffman]
Yes, so let's talk about the future of diagnosis of endometriosis. It's actually, there's a study in the lay press about a Japanese study, which I'm sure you heard about with the Fusobacterium, I think, was found more commonly in the uterine microbiome in patients that had endometriosis compared to those that don't. Again, very, very early. It's one study, not a huge number of patients, but what do you think the future of endometriosis diagnosis looks like?

[Dr. Ted Lee]
I think it's already here. I don't know if you have heard about it, but there is a company from France using the same technology that was used to discover the COVID vaccinations, the micro RNA. They were able to find a little bit over 100 signature micro RNAs for endometriosis and they're able to achieve close to 97% sensitivity and close to 100% specificity. Basically, a perfect test.

[Dr. Mark Hoffman]
This is just a blood test?

[Dr. Ted Lee]
No, saliva.

[Dr. Mark Hoffman]
Oh, come on. Really?

[Dr. Ted Lee]
Yes.

[Dr. Mark Hoffman]
Is this to market in Europe or this is early?

[Dr. Ted Lee]
I think they are pretty far. I first heard about this when I attended the ESG in Lisbon last October.

[Dr. Mark Hoffman]
Oh, so a while back, like eight months ago, not a while, not years, but within the last 12 months?

[Dr. Ted Lee]
Yes. You can google it you'll find those studies.

[Dr. Mark Hoffman]
Yes.

[Dr. Ted Lee]
It's pretty amazing. The problem with that, I actually was playing around with ChatGPT the other day, and I asked what would be the pitfall of extremely sensitive and accurate diagnostic tests for endometriosis, and ChatGPT gave me incredible answers.

[Dr. Mark Hoffman]
Better than any student, resident, fellow, or faculty member, probably.

[Dr. Ted Lee]
Yes.

[Dr. Mark Hoffman]
What did ChatGPT have to say?

[Dr. Ted Lee]
ChatGPT says that you're going to have a lot of patients who are overdiagnosed and over-treated.

[Dr. Mark Hoffman]
Because you're going to have asymptomatic patients that are going to have it, right?

[Dr. Ted Lee]
Yes. For example, we all know we have patients who have incidental endometriosis, very small superficial endometriosis. You're not even sure if that's the reason for their pain, but you excise it and you diagnose it. Sometimes the endometriosis can be incidental, have nothing to do with the patient's pain, but it's very hard to persuade a patient that the endometriosis may not be the reason for their pain because they have a diagnosis and nobody give any reason for their pain for the past 10 years. Now they say, "Oh, I have biopsy-proven endometriosis," even though it was just a little bit.

[Dr. Mark Hoffman]
Or mRNA-diagnosed endometriosis, not even biopsy-proven, yes.

[Dr. Ted Lee]
Exactly, because it's so, so accurate. Now you're going to have this easy test of saliva, and then you have all the patients diagnosed with endometriosis, and they all think that the reason for their pain is endometriosis. What you do with the information is going to also be the challenge, and the ChatGPT predicted that, by the way. I asked the questions.

[Dr. Mark Hoffman]
That's amazing.

[Dr. Ted Lee]
Access. ChatGPT talking about access too because the test may be very expensive. If you don't have money, you don't have the right insurance, you may not be diagnosed. There could be some inequities.

[Dr. Mark Hoffman]
Unnecessary surgeries for diagnosis.

[Dr. Ted Lee]
Unnecessary surgeries. Over-surgery, over-treatment, or over-medications, right?

[Dr. Mark Hoffman]
Over-medicated, that's right.

[Dr. Ted Lee]
Even though you have the most perfect test, it creates new problems.

[Dr. Mark Hoffman]
Be careful what you look for, yes, [crosstalk]

[Dr. Ted Lee]
Be careful what you wish for, right, exactly.

[Dr. Mark Hoffman]
Be careful what you look for because you just might find it and then now what do we do with that information? Okay, we have this thing. You know what I mean? You can worry about it forever or we can expose you to a new risk from a different intervention. Yes, it's exciting. I think there is more interest in endometriosis than there's been in our lifetime. A lot of that has to do with you both in your work as president of AAGL and your video work, and your work with-- We didn't even talk about your work with the health economics stuff with the ICD-9 codes and all those things. Your contribution to medicine, to women's health, to endometriosis is massive, Ted.

[Dr. Ted Lee]
Oh, thank you. You're too kind.

[Dr. Mark Hoffman]
It's, you make a lot of us feel like we're not doing anything compared to how much you've contributed, but it is great to call you a colleague and a friend, and a mentor or someone who I look up to very much. All your fellows you've trained, you put out unbelievably well-trained fellows and you've really done an amazing job in your career. Not that you're done, but just to see what you've done so far is incredible. It means a great deal that you've taken the time to join us on The BackTable. We'll definitely have to have you back on at some point to really get down to the nitty-gritty in the operating room and the surgical side of all this stuff.

Podcast Contributors

Dr. Ted Lee discusses Ambulatory Workup of Endometriosis Patients on the BackTable 30 Podcast

Dr. Ted Lee

Dr. Ted Lee is the director of the Division of Minimally Invasive Gynecologic Surgery at NYU Langone Health and he is chief of surgical innovation for gynecology in NYU Grossman School of Medicine's Department of Obstetrics and Gynevology.

Dr. Mark Hoffman discusses Ambulatory Workup of Endometriosis Patients on the BackTable 30 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, August 17). Ep. 30 – Ambulatory Workup of Endometriosis Patients [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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