00:00 – Dr. khazali: Tells you about the womb, Tells you it is normal. I was like that, my mother was like that, you know.
00:05 – If it’s affecting you, and if it’s bothering you then it’s time for you to talk to someone
00:12 – about the possibility of endometriosis. Hi, welcome to the channel. My name’s Melissa,
00:18 – and today we’ll be talking about endometriosis and UTI. We have another fantastic guess with us,
00:24 – Dr Shaheen khazali. In the first part of the interview we’ll be discussing what endometriosis is and its symptoms.
00:31 – If you’re new to the channel, check out the description below, as we’ve linked some resources that might be helpful.
00:37 – And lastly, if you enjoy these videos, think they’re important, and wanna support what we do be sure to hit subscribe
00:43 – and check the bell so you’ll be notified of our new videos. Other than that, thanks again for joinin us on this journey to making change in women’s health
01:05 – Melissa: I’m here today with Dr. Shaheen khazali and we have collected a lot of questions from our community. so thank you so much for taking the time
01:12 – to share your expertise about endometriosis with us. Dr. Khazali: Thank you for having me. Melissa: I’d like to start with a little bit about your background,
01:20 – so you could tell us some more about how you came to specialize in endometriosis Dr. khazali: Oh, hum… I…
01:28 – I’ve always found endometriosis fascinating. Mostly because of
01:33 – how much we don’t know about it. I remember when I was training as a junior gynecologist
01:41 – I always taught my trainers and my teachers
01:46 – sweat and struggle whenever they had to deal with endometriosis. And not just with surgery,
01:53 – with finding the right solution for the right patient.
01:58 – And I always like a challenge, I guess that that was the start. And then, I came across some er…
02:06 – some people who I admired the works of, and it just got me interested in the field.
02:14 – The rest is History. Melissa: Haha, yeah. Also, I think it would be helpful to start
02:20 – with some basic information about endometriosis. So the first one is: What is endometriosis according to the current understanding?
02:28 – Dr. Khazali: Hum, so… The definition of endoùetriosis is when the tissue similar to
02:35 – the tissue that is supposed to line the inside of the womb, that’s the endometrium,
02:40 – grows outside the uterus. That is called endometriosis.
02:47 – And…hum… endometriosis can cause lots of different symptoms
02:53 – that I’m sure we’re going to cover But… Generally speaking the essence of endometriosis
03:01 – is the growth of this tissue outside the uterus and it can be anywhere and it can do lots of
03:08 – And cause lots of different types of problems. Melissa: How does endometriosis tissue differ
03:13 – from the endometrium in the uterus? Dr. Khazali: So, there are lots of…
03:19 – basics science research around that and a lot of it I don’t understand.
03:25 – But basically it is… not exactly the same tissue,
03:30 – it doesn’t appear to its surrounding structures with the same In the same way.
03:36 – It doesn’t have the exact genetic structure it doesn’t have the exact receptors on it.
03:43 – But it’s similar, it’s too similar to be called anything else. And it shares a lot of…
03:50 – features with the endometrium tissue with the gland-like tissue that grows inside the uterus.
03:58 – Melissa: Ok. Can you explain what endometriomas are? Dr. Khazali: Endometriomas are…
04:04 – any collection of endometriosis in a cyst-like fashion,
04:10 – it’s called endometrioma. In… most of those cases, endometriomas are inside the ovaries.
04:18 – So, endometriomas are also called chocolate cyst. And these are collections of…
04:26 – just to simplify, old blood that is usually found in ovaries
04:32 – And… “oma” basically is a collection of er…
04:39 – is a mass basically. Endometrioma is a mass of endometriosis which is often filled with…
04:48 – dark thick chocolate colour material. And almost always we see it in in the ovaries
04:55 – but they can be found elsewhere as well. Melissa: Ok. What is the current theory about why endometriosis occurs in the first place?
05:04 – Dr. Khazali: The currency is we don’t know. Err…But…
05:09 – Our best guess is that it’s… It’s a combination of different factors.
05:16 – Hum, and… What complicates the matter even more is…
05:24 – We don’t even know for sure whether what we call endometriosis is one disease or…
05:31 – different diseases that we just clump together and call endometriosis.
05:36 – Hum, so… the reason I say it complicates matters is that therefore
05:42 – these different diseases may have completely different particusiology.
05:49 – They may have different ways of forming. The…
05:54 – The oldest theory is what Samson came up with in 1921
06:00 – so that’s a hundred and one years ago. And it was… to say that’s when you have
06:08 – retrograde menstruation meaning blood coming out from the fallopian tubes, instead of going out to the uterus
06:16 – or at least some of it coming out to the fallopian tubes. Some of this can implant and can then grow into endometriosis.
06:25 – We don’t think that can explain Endometriosis and we think that’s probably too simplistic theory.
06:35 – But since then lots of different theories have… Err… Have been proposed.
06:42 – So, hum… Some theories talk about
06:47 – the fact that Endometriosis is just a deviation
06:52 – in the way that embryonic tissue Has has evolved, has changed.
07:00 – So, for example you have a type of embryonic tissue that is supposed to become skin,
07:06 – another type that is supposed to become endometriom. And if some of these are frozen in their parts
07:15 – their target organ, in later life they can grow to become Endometriosis.
07:21 – There are genetic theories, there are the logical theories And the bottom line is…
07:29 – The answer to most of your questions today could be “we don’t know”.
07:34 – And I ‘d be right in saying that because although we have lots of different ideas,
07:41 – and there’s lots of good research that shows that some of these theories may
07:48 – be more… Err…er… A more suitable explanation.
07:55 – We still haven’t got the final answer. And, hum…
08:00 – I think it’s safe to say that the right answer maybe a combination of all of these wrong answers.
08:07 – And… Who knows who’ll find out one day? Melissa: Hopefully!
08:13 – Is there any known association between endometriosis and the microbiome?
08:18 – Dr. Khazali: There are some suggestions. Again microbiome,
08:24 – environmental factors, and some other factors have been proposed
08:31 – and they are very interesting… Suggestions. Again, same,
08:38 – we haven’t got the final answer, but there are there is some evidence to suggest, er…
08:44 – Relationship. Melissa: Ok. Can endometriosis only occur in people with female anatomy?
08:51 – Dr Khazali: As far as I’m aware, hum, so you need to have xx chromosome.
09:00 – Or endometria sister care There may be reports that I’m not aware of,
09:08 – but as far as I’m aware, yes. Certainly all of the patients I’ve seen and treated
09:13 – have had an xx chromosome. And you mentioned it can occur anywhere, in what parts of the body have you found endometriosis in your patients?
09:22 – Dr. Khazali: So, I think this is worth, hum… exploring it a bit more,
09:27 – because… Two people who don’t… Endometriosis that well,
09:34 – or to patients who are worried about having Endometriosis, this may sound really scary,
09:40 – maybe too scary, maybe unduly scary, that…
09:45 – it can go everywhere, it can grow in brain or in… the eyering, in the nose.
09:54 – For that reason I think it’s important to step back and look at numbers.
09:59 – The reality is ninty-nine per cent of endometriosis
10:05 – is seen in its usual places.
10:12 – And that is on the ovaries, in the pelvis, in the uterus sacral ligaments, on the bowel.
10:18 – Hum, and on the appendix. These are the most common places for endometriosis.
10:25 – And then we have slightly left common areas, and that would be the diaphragm,
10:32 – or in the skin or in the rectus sheath, that’s the body in the abdomen.
10:37 – And then we have very rare places for endometriosis. Some of them I’ve never seen,
10:44 – so for example Endometriosis of the brain. I’ve heard about, I’ve seen reports of it,
10:50 – but I’ve not treated one or seen one. Keep in mind that…
10:56 – I don’t do anything other than endometriosis and I was looking at my numbers
11:01 – I believe I’ve done close to four thousand surgeries for endometriosis.
11:06 – So multiply that by I don’t know maybe…five or ten, that’s the number of patients I’ve seen with Endometriosis.
11:14 – So, They are very rare. And therefore… If you’re diagnosed with Endometriosis and also had headaches,
11:24 – or have chest pain, the first thing that comes to mind shouldn’t be… Oh, it may be endometriosis of that organ.
11:33 – But with that in mind, Endometriosis has been found in…
11:39 – Almost every! But the most common areas that Endometriosis grows
11:46 – are the ones that I mentioned in the first group. Ovaries. Hum, bladder.
11:52 – Peritonum in general. So that’s the lining of the inside of the abdomen.
11:59 – On the pelvic side walls, uterus sacral ligaments, and then it can involve the surface of the bladder
12:05 – or it can go deep in the bladder it can be involved with surface of the bowel, or go deep in the bowel.
12:11 – And then we have extra pelvic areas that I mentioned. Melissa: You just mentioned the deep in the bladder,
12:17 – does that mean forming on the inside of the bladder or growing through from the outside?
12:22 – Dr. Khazali: It always grows from the outside. It applies to bladder,
12:28 – ureter, and all these hollow structures. And the bowel.
12:33 – That’s, Endometriosis grows from their… at the outside surface of the hollow organ.
12:40 – And grows inwards. Not the other way around, never the other way round.
12:46 – Melissa: That’s good to know. There was also a question about adenomyosis and fibroids, and what those are,
12:52 – and whether they have an association with Endometriosis. Dr. khazali: Yes, hum…
12:57 – Adenomyosis is when endometriosis grows inside the muscle of the uterus.
13:03 – So, and that is very much associated with Endometriosis. in fact, in around fifty percent
13:11 – of patient with deep Endometriosis who also have adenomyosis.
13:17 – Fibroid is not directly associated with Endometriosis.
13:23 – But it does have a common feature and that is, like Endometriosis,
13:29 – it is oestrogen dependant, it’s fed by oestrogen. And therefore,
13:35 – in some circumstances, we see that the growth of one is associated with the growth of the other.
13:43 – Melissa: Ok. Someone also asked about endometritis, and whether there’s an increased risk of this
13:48 – with the presence of Endometriosis. Dr. Khazali: Not that I’m aware of. Endometritis,
13:53 – anything in medicine that has “itis” in the end means “inflammation of”.
13:58 – So Endometritis is inflammation of the lining of the womb. And that usually happen for
14:05 – completely different reasons, not Endometriosis-related. I think perhaps I should take this opportunity to…
14:14 – Maybe explain something else that would be useful in all areas of medecine, but particularly in this area.
14:23 – There are associations, and there are cause and effect relationship.
14:28 – These are very different things. So, hum, we know smoking
14:34 – causes lung cancer. That’s a cause and effect, we have proven that…
14:40 – It’s much more likely for you to to get lung cancer I think it’s twenty times, maybe more, I can’t remember now,
14:48 – if you’re a smoker, to have lung cancer. It doesn’t mean that everyone with lung cancer is a smoker.
14:57 – And it doesn’t mean that everyone who smokes gets lung cancer. Ok, but they have a cause and effect relationship.
15:05 – With endometriosis there are lots of different conditions that have been suggested to have
15:12 – some correlation some association with it. It doesn’t mean that
15:18 – for example, if you have an autoimmune disease, you’re going to have endometriosis.
15:24 – We have an interesting… Saying in research
15:32 – that if you torture data, data will confess! And that is appointed to…
15:41 – Sometimes these associations Or simply the result of
15:46 – although torturing a set of big data. That we’ve looked at thousands of endometriosis patients
15:54 – and then we’ve looked at different conditions that are a bit more prevalent. And then when you analyse this
16:01 – sometimes it can be statistically significantly different to the general population.
16:07 – And this kind of association needs to be interpreted with caution.
16:13 – So, we need to, sometimes, in some of the situations, take it with a pinch of salt.
16:19 – Melissa: Yeah, that makes sense. Let’s move on to some of the symptoms, what are the most common symptoms of endometriosis?
16:27 – So, the three big ones are painful periods,
16:32 – painful sex, and painful defecation. These are the ones that are typically and classically
16:38 – mentioned with Endometriosis but there are lots and lots of other symptoms
16:44 – that are typical for endometriosis.
16:50 – Bloating is one. Urinary symptoms is another one. all sorts of different urinary symptoms.
16:59 – Extreme tiredness is another one. Abnormal bleeding is another symptom that we see from time to time.
17:07 – Problem getting pregnant is another one and it again comes in different shapes and forms.
17:16 – These are the main ones. These are the ones that are we focus on, but of course, there are lots of different ones
17:22 – and there are different types of endometriosis growing in different organs. And those will have their own specific symptoms.
17:30 – Melissa: Ok. Do symptoms tend to differ depending on a patient’s age? Dr. Khazali: Hum, we used to think that.
17:38 – But newer research shows that actually the type of symptoms people get
17:45 – are more or less steady over the course of twenty thirty years which is very surprising.
17:53 – But… From personal experience, Yes, it can do. The type of Endometriosis
18:01 – that presents in later er…
18:06 – Side of reproductive age tends to be slightly different to the earlier age.
18:12 – You see more dyspareunia, at least, it’s my personal experience, that more dyspareunia
18:18 – In…as the first complaint Maybe in a younger population and we see in the older population
18:27 – and women who had children, we see a different type of issue. The bleeding apnormalities tend to be a little bit more prominent
18:35 – in the latter of end of the world Melissa: Is it possible that endometriosis symptoms
18:42 – won’t come on at all until you’re in your 30s, 40s, or 50s? Dr. Khazali: I just saw a patient with that…
18:49 – Exact description, no problem at all until forty-four,
18:56 – And then suddenly, significant symptoms. See, that’s the issue with Endometriosis, that…
19:06 – It can do anything. It can behave in any way. There is always that…
19:13 – That core group that will present in a typical way
19:18 – and they behave the way that textbooks and tell them to behave. But there are lots of outliers
19:25 – that would present in a strange way. One example is
19:31 – the severity of endometriosis doesn’t really correspond with with severity of symptoms that march.
19:39 – Again… just… the risk of confusing your andience
19:46 – That’s also not completely true, because in most patients there is a correlation
19:53 – but then, there are lots of outliers where we have very…
19:58 – Superficial or very mild endometriosis and very significant pain.
20:03 – And then there is the other group where we have very Severe endometriosis
20:08 – but actually no pain. This latter group is the dangerous one because Endometriosis can grow to
20:16 – affect the kidneys, affect the ureters. And because they have no symptoms at all
20:23 – they may not seek help. Melissa: And you mentioned that it can often appear on the bowel,
20:28 – you mentioned that means many people are diagnosed with things like IBS or other conditions. Are there conditions that are known
20:35 – to be kind of miss diagnosis of endometriosis? Dr. Khazali: Yes and that’s…
20:41 – Another challenge, because… A lot of Endometriosis symptoms
20:48 – are… the same or very similar to the symptoms of other common conditions
20:54 – IBS is a good example, that in fact there was a research… a few years ago that
21:02 – looked at people who have attended… a gastrointestinal
21:09 – with the diagnosis of IBS and then looked at all the patients who are attending
21:14 – Endometriosis clinic, and then, looked at how many of those have both diagnosis
21:20 – or interchangable diagnosis. Hum, but that’s a good reason.
21:28 – Some of the symptoms are exactly the same. And even in patients
21:34 – who have confirmed diagnosis of Endometriosis, we can’t be a hundred per cent sure that
21:39 – that particular bowel symptom was endometriosis. Because…
21:44 – Both IBS and endometriosis are very common. And…
21:51 – and therefore there are lots of patience who would have both or would have combination of them.
21:58 – Melissa: Is a diagnosis of IBS a indication that you maybe should… check for endometriosis?
22:05 – Dr. Khazali: Not on its own, I would say. So if there are
22:11 – typical IBS symptoms that would then respond to technical IBS treatments,
22:18 – not necessarily. As a general rule you should seek help for Endometriosis
22:24 – if your symptoms are not responding to simple treatments, and if you are affected,
22:31 – your quality of life is affected by those symptoms. Melissa: Ok. You touched on this next question briefly
22:37 – but it’s worth highlighting, and the question is: Is it possible to experience symptoms of endometriosis
22:43 – outside of the time that you’re menstruating? Dr. Khazali: Absolutely. Your, hum…
22:49 – that period pain is only one presentation of endometriosis. You can have constant pain.
22:57 – Dis there are types of endometriosis pain that are actually not fluxuating
23:02 – with the cycle. Sometimes, there are pains that…
23:09 – start being cyclical and then become constant.
23:15 – And that’s also the case and there are some pains that are
23:20 – that are cyclical but don’t… occur during the cycle.
23:25 – They can occur before the start of the period for example. Bloating being one of them,
23:31 – that is worsened in that part of the cycle. So yes, answering your question, yes,
23:36 – you can experience symptoms of endometriosis outside your periods. Melissa: Ok. And is it possible to experience
23:44 – Endometriosis symptoms pre puberty or post menopause? Dr. Khazali: Hum, post menopause, definitely.
23:51 – Pre puberty, we know that you can find Endometriosis symptoms in new borns.
23:59 – But symptoms tend not to occur before puberty. Again, with Endometriosis there are exception.
24:08 – But it shouldn’t be the top of the different diagnoses so you have
24:13 – So if you have pain in a 8-year old Endometriosis wouldn’t be…
24:22 – top of my differential diagnosis. I have never seen one before puberty.
24:27 – Melissa: Ok. And going back to the pain during menstruation question at what level of pain
24:34 – should you see a clinician, at what level is the pain not normal? Dr. Khazali: Yes, when it’s not normal for you.
24:41 – So different people have different pain thresholds. Hum, the…
24:47 – bottom line is… Is this normal for you, is this affecting your quality of life?
24:54 – Is this pain stopping you from doing your normal activities?
24:59 – Is this pain stopping you from having sex? Is this paint stopping you
25:04 – from going to uni or turning up to your work? And if the answer is yes, then it’s not normal.
25:11 – It’s not er… You know, it doesn’t matter who tells you it is normal, “I was like that.”
25:17 – “My mother was like that.” You know. Grow up and get on with it.
25:24 – We hear that all the time. But, if it’s affecting you, and if it’s bothering you, then,
25:32 – then it’s time for you to talk to someone about the possibility of Endometriosis. Melissa: Ok.
25:38 – In what percentage of those with endometriosis known fertility issues?
25:44 – So we know the answer To the opposite question. We seem to think that around 50 to 60
25:53 – of women with fertility issues huh, have some Endometriosis.
25:59 – Again, that’s not necessarily a proof of cause and effect
26:05 – in those patients because they may habe other factors for their fertility.
26:11 – But I think again, it’s very important to stress that having endometriosis doesn’t equal fertility problems.
26:20 – Again, today I saw a lady who was…
26:25 – really upset about the possibility of not being able to have children, even though
26:32 – there was even no diagnosis. She had pain and she was worried about not having children.
26:39 – And I explained to her that, look, first, we don’t have a diagnosis, we’re going to do one two three to get to the diagnosis,
26:47 – But even if we did have a diagnosis, it doesn’t mean you can’t have children.
26:52 – Most women with endometriosis will be able to have a completely normal fertility, reproductive life.
27:03 – but, it is true that endometriosis does affect fertility in different ways, and in some patients,
27:11 – in very severe Endometriosis in particular, it can mean that having children would not be possible.
27:18 – Melissa: Ok. and on the topic of hormones, Is a hormonal imbalance likely to influence Endometriosis
27:26 – or vice versa, can endometriosis cause a hormonal inbalance? Dr. Khazali: Hum. So,
27:32 – This is a very… challenging topic because it is full of things that we don’t even have…
27:42 – good understanding of their definition. What is hormonal inbalance?
27:47 – We…er…. Female physiology
27:53 – is much more complex than male physiology. And we
27:59 – probably have not probably, definitely have not done
28:06 – as much as we should have to understand female physiology in the last two hundred years.
28:14 – And therefore you have a one hand more complex physiology and on theother hand, you know
28:22 – ignoring that physiology for 200 years, and therefore, we talk about hormonal imbalance,
28:28 – we don’t even know what’s normal for hormone levels at particular type of time of month.
28:35 – And almost fluctuating all the time so on an hourly basis your hormone levels may be different.
28:43 – So that’s the first… complication. the second complication is
28:49 – we’re understanding more and more about the fact that again, Endometriosis could be
28:55 – all sorts of different kind of tissues. For example, there was a recent paper on
29:04 – how some parts of endometriosis are resistant progesterone for example,
29:10 – they don’t have the right receptors. And therefore, when we use oestrogen and progesterone at the same time,
29:18 – hoping that the progesterone componant will subside will supress the endometriosis,
29:26 – and counter the effect of the oestrogen. We are just giving oestrogen
29:33 – without being able to counter its effects All of that means that
29:40 – we need to hesitate before… before coming up with…
29:47 – with a definitive answer about hormones and endometriosis and how the imbalance may affect
29:55 – Endometriosis, and how, as you said, the other way round, Endometriosis could either generate its hormones or affect the
30:04 – levels of hormones in your body. Melissa: Ok. When it comes to endometriosis on the urinary tract,
30:10 – kind of symptoms might that cause? Dr. Khazali: That’s another problem.
30:15 – See, all of this conversation is is being about lots of problems and complexities that
30:21 – that endometriosis has. Which is fascinating about it.
30:27 – So, a lot of patients with endometriosis of the urinary tract
30:33 – may have no symptoms at all. At least no symptom of urinary tract.
30:39 – So for example, you can have endometriosis that affects your kidney,
30:45 – not directly the kidney, the ureter and therefore the kidney. Without any symptoms at all. Zero.
30:52 – You have no blood in your urine, you have no flank pain, You have no difficulty urinating
30:59 – everything can be completely normal. But, in those who are symptomatic,
31:05 – You can get a range of different urinary symptoms. So you can get…
31:10 – you can get hematuria, blood in the urine, you can get frequency, meaning to go and empty your bladder…
31:19 – all the time. And you can get dysuria you can get pain when urinating, and you can get that pain…
31:28 – particularly when you are on your periods. Now at some
31:34 – level when endometriosis affects the ureters, You could start getting flank pains
31:41 – and kidney pains as well. But that actually is a very uncommon…
31:47 – presentation of urinary tract and Endometriosis. Melissa: Ok. And then the pain after sex,
31:53 – or pain during sex that you might get with endometriosis, could that be mistaken for UTI symptoms
31:59 – for people that have those kind of symptoms after sex? Dr. Khazali: Yes. And they often are.
32:05 – So, pain, hum… the sort of pain you get after sex
32:11 – With endometriosis, and more commonly with adenomyosis it has a different character. Usually it’s a
32:18 – it’s a central pain which is hum, huh…
32:24 – like a like a spasm. Urinary tract infection pain is different,
32:30 – you get burning sensation you can get sensation of having, huhhh…
32:37 – glass shot in your urine, that kind of thing. So the type of character of pain
32:44 – is different and that would come out in the history taking.
32:49 – But because common things are common, so getting UTI after sex is very common.
32:58 – Hum, it’s… easier to, er…
33:03 – to put that at the top of the differential diagnosis. And it’s not actually wrong to put that at the top of the differencial
33:10 – Sometimes, sometimes, you know, it’s just a simple explanation. And it’s important to rule those things out.
33:18 – Melissa: Could the general inflammation caused by endometriosis make someone more susceptible to urinary tract infection?
33:24 – Dr. Khazali: That’s a possibility. And that’s something
33:30 – we don’t understand… as well as we should. There is some kind of
33:38 – relationship between the immune system,
33:43 – the inflammation, and Endometriosis. And…
33:49 – they can sometimes have a very complex relationship with each other.
33:54 – So, in some situations, we know that if you
33:59 – reduce the inflammation in the pelvic area, you can reduce the pain.
34:05 – But we haven’t proven whether that reduces the pain because the inflammation was the cause of the pain
34:11 – or does that reduce the pain because reducing the inflammation reduces Endometriosis?
34:18 – And then, add to the mix The immune system in general and the relay
34:25 – and the relationship Endometriosis has with immune system. And then when you go look at the bigger picture,
34:32 – You have the issue of how nerves, which are responsible for carrying the pain signal,
34:40 – interact with all of these, is it possible that our pain threshold changes
34:46 – because of presence of inflammation? Is it possible that the nerves spire
34:53 – in a different way during the periods? Is it possible, because we know for example that even if you have a toothache
35:00 – it will get worse during your periods. And that, it has nothing to do with Endometriosis
35:07 – but it is just the way that pain is received and the signals are transmitted to the brain
35:14 – with the change of hormones. Thanks so much for watching. I hope you found this video helpful.
35:19 – and paid particular attention to the section about Endometriosis symptoms and diagnosis, particularly if you suspect you may have endometriosis.
35:28 – If you’d like to learn more about this or related topics, check out our videos or head over to leave UTI free.com
35:34 – for other resources. One really important article you’ll find another site is about lower urinary tract symptoms and how common certain conditions are
35:41 – We’ve also linked to this article in the description below. Of course if you like this channel, be sure to help subscribe and check the bells so you’ll be notified our future videos.
35:50 – And until next time keep asking questions and keep looking for better solutions