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Endometriosis Q and A with Tamer Seckin, MD

Endometriosis Q and A with  Tamer Seckin, MD

Endometriosis Foundation of America
Virtual Patient Conference, October 16-18, 2020

Diana Falzone:

Dr. Seckin, we received many questions from the patient conference, actually, so many we couldn't get to them during the weekend. So we have some today leftover, plenty leftover, that we want to discuss with you because you are one of the foremost experts and pioneers in this very complicated illness. And to start off, we have a very complicated question. Can endometriosis come back after excision surgery?

Tamer Seckin, MD:

Well, thank you, Diana, for having me on. The disease is complicated and the answers are complex. There's no clear cut answer. And even in the best hands, most experienced hands, and for people who are challenged with this disease, the unfortunate answer is yes. Endometriosis do come back for two reasons. One, it depends first, the extensiveness of the disease plays a lot of importance in this because it involves multiple organs. And at times, these organs may be affected severely at the same time. And it's difficult to do more than two organ, three organ, four organ radical surgery on one shot. May not be the best ethical way of handling the disease because complications would rise with every organ that is touched.

Therefore, that's for advanced disease. That means if you have a pulmonary endometriosis, and your main symptom is that, and someone is having an emergency with a collapsed lung, it is difficult to treat the other myosis, or some degree of bowel disease at its full impact, which may need bowel resection, and so you may get away with a little shaving and defer the main surgery, because if you do the bowel surgery and there's infection, then there's an infection possibly in the lungs, or the main repair in the diaphragm. That could be more too. So it's very, very difficult. In that way, patients do need to understand the disease well and have a great trust built between the doctor and the patient.

In early disease, in less involved, less organ involved disease, where the disease could be profuse and diffuse on certain areas, like say peritoneum, which could be the cause of over 90% of the infertility cases, which you do not see anything on the sonogram, on your MRI, cat scan, but the patient may have all the symptoms. People may think this is rather simple disease than compared to the first advanced disease. It's not. It's probably as difficult as the other disease because in this one, you may not see the endometriosis and recognize them easily unless you do certain things.

I like to say that what I use as contrast techniques to bring the lesions otherwise not visible in classic laparoscopic view is very helpful diseases that is in areas that's easily missed. So the idea with these type of patients, called peritoneal endometriosis is to recognize the disease every corner, and to remove the disease everywhere that is possible. You may remove 99% of the disease, and you leave one area that is untouched. That single area will cause the same impact of pain in the way individual perceives, and she may very well perceive that her endo is not removed at all. You have to understand this disease does not correlate with the amount of pathology in pelvis does not correlate with the amount of symptoms and pain.

So in other words, disease have stages or classes, pain does not. In other words, there's no class one pain, class three pain, class five pain. Pain is pain. And pain is created by ... Imagine the risk, it's a little micro circuit from pelvis to the brain, micro circuit. I mean, every lesion is connected with one little wire of nerve can stimulate the whole electrical fire up here. So that's the better explanation for people to understand. Go ahead, I'm sorry.

Diana Falzone:

No, no. I was going to say, "Why is that?" And you just answered it, because it's about the nerve endings, where the lesion could be hitting that could be causing that level of pain. It might be the smallest amount [crosstalk 00:05:32] a lot of pain.

Tamer Seckin, MD:

It's the smallest, [inaudible 00:05:34] potential of evoke potential of pain can put the fire up here because the brain has only recognizes that file that was represented as pain before. It doesn't say less, more, or this region, that region. It brings the whole file of pain is reactivated. So the patient feels the same way. More importantly, as you know, the disease has not only pain, the disease have systemic molecular signature, which is fatigue, tiredness, and along with aches around the extremities and stuff. These cannot be explained with simple mechanism that we're trying to talk. These are all molecular, all the inflammatory molecules that comes to the blood system that makes us feel like you have slight inflammation going on. And you feel that, body feels that. You don't have a temperature, but you may get all the symptoms of aches and things that goes with flu. And monthly, it happens.

Diana Falzone:

And that's the chronic inflammatory aspect of endometriosis.

Tamer Seckin, MD:

Yeah, along with endo belly, for example. I mean, why do whole bowels swell? Because of these high inflammatory molecules that gets reactivated. And the guts become confused and stops, and diarrhea versus constipation, it depends where the lesions are. For example, the lesions that are unique to upper gut system causes frequent gas, bloating, diarrhea, up to appendix, as far, appendix and that area because if there are lesions in that area, the absorption of the fluid material is not complete, and there's prominent diarrhea in the complaint.

However, it is less more into the bowel to left side and down, there's more constipation, alternating with diarrhea, painful bowel movement and things like that. So the symptoms are very much, like a detective, the doctor should be extremely methodical, and they're questions should be unique and targeting the symptoms into possible areas, those symptoms may correlate. This all comes with experience. I mean, the patients really teach this to you. There's no medical books, no endo website will write this. Trust me, this is something that we find out over years. Yeah.

Diana Falzone:

Well, that's important that you said that too because a lot of times a patient will walk in, even myself as someone who has endometriosis, you walk into a doctor's office. You get nervous. You don't want to take too much of their time. You do the Cliff Notes version of what's going on. But what you just said is explain. Do you have gas, bloating, constipation? Or are you having cyclical diarrhea? All of that can be inklings and hints for a doctor to figure out where the endo could be affecting you.

So more detailed is better for the patient. So we have a question from Regina. Endo symptoms in menopausal women was her subject. She said, "I was diagnosed with endo 25 years ago, and I'm currently perimenopausal, and still having unexplained intermitted mild to moderate pain every month. I'm told to wait until I'm fully menopausal to know what's going on. But it's hard for me to tell what's going on. What symptoms do we know about perimenopause and endometriosis?"

Tamer Seckin, MD:

That is a very, very exciting area to talk about endometriosis from the point of perimenopause and post menopause. And that says about the disease. The disease has two elements. One element is classical glands that is activated by hormones. Then the other element of the disease is scar tissue. In perimenopause and into menopause, the gland portion aspect of the disease basically goes down. But what type of damage does damage? In other words, when you have scar tissue, scar tissue remains. And it's already there. Scar tissue is the tissue that glues the organs together or causes restriction on bowel movements, or causing restriction on the nerve, and traps the nerve, or vascularity. It stays there. And that kind of symptoms persist, never goes away.

I just operated last week on a 71 year old lady, who complained by endo symptoms all her life. This is within a year, you don't see these often. I have another one, 66 years old, 65 years old then. Similarly, she had 40 endoscopes. She went to the best doctors, all the big names all over the country, or in New York City area. Never knew, even though she had hysterectomy, she did not ... She had major ovarian removes and everything, she did not know she didn't have endometriosis.

This 71 year old had removed 26 lesions. Almost all of them were positive. What is significant about them, exactly. In other words, the gland stays there and the fibrosis stays there. And she never thought, but she knew there was something wrong because-

Diana Falzone:

She felt it.

Tamer Seckin, MD:

Also, the interesting thing was she was encouraged because her daughter had surgery too a month ago. She had terrible endometriosis. And she said, "Oh, my God. I have this too, and I never paid attention." And she came to us, that's how we diagnosed her. I mean, post menopausal endometriosis is a reality, and many women continue to suffer in their menopause years because the fibrosis has settled down, and already was ... There's no way to get rid of it.

Diana Falzone:

Except surgery.

Tamer Seckin, MD:

Except going there and removing it. All right? So I hope that answer your patient's questions to a degree. So it is true, if their symptoms are very pronounced, as far as particularly if they have bowel symptoms, they don't go away. Bowel symptoms stays. If they're sexually active, pain with sex will be there. Painful bowel movement will be there. Very different than perimenopausal years when they feel ovulatory pain, or menstrual pain, that goes away. That component probably disappear of the pain component. But other components stays there.

Diana Falzone:

See, I think that's another generalization that's a mis-truth, that women with endo are told, "Oh, as soon as you hit menopause, it goes away. You're going to feel completely fine." And then you're menopausal, and you don't feel completely fine. You're still having pangs of endo. And you think, "I'm not supposed to have this."

Tamer Seckin, MD:
Yeah. The take home message from this conversation, as I have to underline to my other patients, because you talk about this a lot, but we don't know what it means for the patient also most of the time. So we need to learn this from this conversation. The menstrual components of endometriosis, like uterine origin pain, painful period, prolonged bleeding, or pain after period counting, or painful ovulation, yes, they will go away with menopause. However, painful bowel movement, gas, bloating, or other components may stay. And if they stay, despite the elimination of the ovulation and ceasing of the periods going away, if they stay, that is definitely something to pay attention to.

Diana Falzone:
Thank you. This is an anonymous question. It's regarding IBS presentation. And I know that you're passionate about IBS being BS with endo. The woman writes, "I have endometriosis on my bowel. But when I had surgery, my surgeon let me know if they removed it, it would risk," as you were speaking earlier, "Severe damage to my bowel. Is this a common problem? And what is the best thing I can do for the bowel symptoms if surgery is not an option?"

Tamer Seckin, MD:
Well, first of all, let's make it very clear. My first presentation on multiple organ involve diaphragm, chest, that kind of thing. One of the most common repeat surgery of endometriosis or persistent pain, or recurrent endometriosis we'll say is something to do with the doctors who are operating. And I have to be very, very clear on this. Number one reasons for patients to be re-operated is incomplete, inadequate job that is done before. I think patients before they've put full trust to their doctors, they have to do their own investigation and understanding of the disease to the full picture, that nothing comes between the doctor and the patient unanswered.

First of all, patients should be operated by people who respects endometriosis and who have been doing this job for a long time. You don't get to be an endometriosis so-called specialist, in five years, you're out of any program. It doesn't come like that. Doing laparoscopy is not looking inside and taking one biopsy, is not endometriosis surgery. The disease has to be removed in every form, in every degree of infiltration and every degree of color, every degree of scar formation. So I can speak for myself and for some others that I know. In general, when I go in, I remove 14, 15, 16, 17 specimens on the average. There are people we move 60 specimens.

These specimens go to pathology. That is the evidence of the work you've done. That is equal, that equals the validation of what we've done. If the bowel endometriosis usually is multi centered. It's not in one area only, so multifocal. In one area, it could be multiple spots. It could be rectal, it could be sigmoid. It could be appendix area. This patient that you're [inaudible 00:16:38] still have IBS symptoms. She has to get her pathology reviewed. And most of the time, there is incomplete resection, incomplete surgery. This is what I warn patients to be careful. When you go for a consult, you should not be rushed. The doctor should take time, be patient, questioning you in every aspect of the endometriosis as a disease.

Your question about the uterus, uterine symptoms, bleeding, heavy bleeding, uterine pain, cramps, your ovulation, its laterality, one side, two side, your recurrence every month. Ovulatory pain, very important. That talks about the pelvic sidewall. Your pain with intimacy, if they are sexually active, with deep contact, the pain the intimacy, deep contact, there is pain, especially recurrent always signifies rectal, vaginal endometriosis. If you have painful bowel movements and it flares up with your period especially, or around the period, that's very meaningful. There's rectal, vaginal endometriosis.

If there is diarrhea and constipation alternating, there's sigmoid disease or even higher location of rectum. If your bowel calibers are pencil thin, your bowel movements are little by little, like marble pieces, that means there is partial obstruction somewhere. If your diarrhea prominent IBS symptoms are diarrhea prominent, your endometriosis is in your appendix area, appendix and ileocecal area, which is on the right side. So these are little things that you learn. If you have prominent gas and bloating, you have diffuse peritoneal endometriosis most likely involving bowel symptoms. You have to ask whether there's chest pain, shoulder pain around the period time. That shows some diaphragm involvement, may show.

Tamer Seckin, MD:
So taking time, asking these questions, and symptom directed thinking, educating patient, is the most essential part of understanding how much this doctor is really into your care, or how much you can trust. They should share their statistics. They should be able to give their time. Surgery, I think in ideal setting, I like to do it, and I'm doing with every patient, I record my surgeries for the patient and for myself for future reference because the symptoms do come back. The symptoms do come back. Doesn't mean endo's back, but the scarring will be back because scarring is part of healing, and it will be back in 30% to 35% of patients in the end, even though they feel incredible in the first six months. Their symptoms will come back 30% of their initial magnitude six months later.

Diana Falzone:
Why is that? Because of the way the So scar formation then pulls the nerves?.

Tamer Seckin, MD:
Scar formation takes slow, it takes six weeks to six months in the end. They grow and they kind of format. It's like a thin rubber tissue. It becomes stiff after six months because it's not ... The body heals. The way the body heals, with scarring. So at the end of every endometriosis surgery, the doctors should take extremely patient attitude to control every little bleeding at the capillary level. The most smallest level of blood vessels should be controlled. That's why we do second pause after the surgery is just done. We stop the case. We put the patient up, bringing her blood pressure up, get the gas off, and wait five, six minutes. I go to the bathroom and come back at that time, because it's a long surgery. Anyways, I say that because patients remember that. So the surgeons doing something during cases too, so they have to go to bathroom. But when I come back, I look below the [inaudible 00:20:53] again, put the patient down again, and look at the areas that we did surgery, look for every little oozing. That should be controlled.

Diana Falzone:
Once, if a patient's symptomatic, even though there's no more endo, but there's scar tissue, do they sometimes need to have that scar ... Wouldn't that be a cycle to keep getting the scar tissue removed?

Tamer Seckin, MD:
The issue is we think it's scar tissue, but we don't know what is inside the scar tissue. Many times, 50% of the time, those lesions that look white have endo in it. So in other words, they are active scar tissues. In other words, that scar tissue has receptors that responds to estrogen and progesterone like a sponge, they swell and they shrink. They swell and shrink. But you don't see classical endo there. So many times, endo lesions are white, not black and blue and red like everybody describes. Trust me, my experience with people who deal with endo, many people write what others have written.

Many people are talking what others are talking. Very few of them are really doing surgery and seeing this over years and understand how the disease get into different facades on different colors, how diseases disguise and difficult to diagnose. None of them really knows what I'm talking about. This is the most crucial part. Endo is disguised many time to different colors, especially in white. A [inaudible 00:22:27] format that people don't feel like it is a disease, and they leave it there. So everything abnormal in endo patients should be removed. That needs a lot of skill and experience, obviously.

Diana Falzone:
Right, right. We have a question from Claire. What do you all do, this is doctors in general, in the field to work towards preventing endometriosis as opposed to only treating symptoms? Is there even such a thing as preventing endometriosis at this point in science

Tamer Seckin, MD:
I think, look, I don't know how you're really picking the most important questions, so congratulations to that patient. So that's why we got the foundation going. The foundation's main purpose is not doing the best surgery, even though we like to provoke surgeons to be more meticulous and things like that. That's a different point. But the most important part is recognizing this problem early. The problem is painful period. The problem is the cardinal symptoms of endometriosis, the trilogy of symptoms, severe pain with periods, pain with sex, bowel symptoms. When you recognize this, these are until the ... Forget the sexual activity questions, but many time, these symptoms pop up during adolescence. And most important thing is awareness and recognizing how the symptoms flaring up with periods, killer cramps, these patients should be on birth control pills. There's no substitute for that.

That doesn't mean that we can prevent, but many times, birth control pills do help to halt the disease. Disease doesn't jump from one stage to another, or symptoms are subsided. Even though this is an empiric management, it helps 80% to 90% of the time. Patients may not need surgery. It's only remaining 10% that breaks through this type of management, will need surgery. Birth control pills, if there's heavy bleeding, and painful ovulation, or severe GI symptoms, severe GI symptoms with other symptoms of endo, they should be on birth control pills.

With heavy bleeding, IUD must be also be added to the regimen. So both elements, birth control pills and IUD, medicated IUD, one definitely blocks the heavy bleeding from the uterus, the IUD. And the birth control pill blocks the ovulation and the general symptomatology will help. I have patients who have been on 15 years on them. They come back for surgery, but 15 years after, their endometriosis is not that advanced, even though there are exceptions, not as ... I believe in this regimen tremendous. I believe this is a main crux of treatment and prevention in my opinion. And frequent sonograms also, yearly sonograms to make sure there's no endometrioma developing. Obviously, endometrioma becomes another entity when the ovaries involved, and they become cysts, they need to be controlled or frequently monitored. If they're getting bigger interruption is necessary. If the symptoms are severe, getting severe with endometrioma, there's no need to sit on it because that means they're leaking, and they affecting other organs we cannot prevent.

Diana Falzone:
Some women are more cystic. They get more cysts more commonly, ovarian cysts. But they're not always endometrioma. They could also be hemorrhagic, correct, where they won't necessarily bother?

Tamer Seckin, MD:
It's easy to differentiate between hemorrhagic cysts and endometrioma. They have classically different views. A hemorrhagic cyst usually disappears within a month, it gets smaller. Endometrioma cysts persist more than three months. And hemorrhagic cysts rarely puts people to emergency room and things like that.

Diana Falzone:
So we have another question from Gabriela. Can infertility treatment worsen endometriosis symptoms? Can it cause it to flare, progress?

Tamer Seckin, MD:
Somehow I thought that question was coming. I didn't get into it with my [inaudible 00:27:06]. So if you have small endometrioma, and you go to infertility treatment, or even egg freezing, egg freezing for embryo creation, embryo preservation, unfortunately I am opinionated from my area of surgery. Out of my patients who come after infertility treatment, almost half of them, their endometriosis have doubled in size. Ovarian stimulation, especially not the natural stimulation, but excess for getting the maximum egg, giving huge amount of hormones to stimulate for egg production is not the best idea for patients who have endometrioma.

For people who don't have endometrioma, I have no problem with them going through IVF treatment, getting the most from their ovaries as far as their egg numbers. But if there is an endometrioma, 50% of the endometrioma gets much bigger. Sometimes there are infections, abcess formation, which we see every year, a couple cases. So I warn very, very careful approach in these kind of situation. I think also, patients should be aware and ask their question rightfully, in the right time. The doctors should be addressing not for rupturing the cyst if they go.

IVF guys, people, do not have much respect to endometriosis and endometrioma. They are after the eggs, but unfortunately, the bowel is there, other structures are there. There are quite a few accidents when the endometrioma cysts are large, and they fail to get the right amount of eggs from there.

Diana Falzone:
Excellent, excellent question. Great answer. This is a good one. Yvonne says, "Why do some doctors claim pregnancy will 'cure' endometriosis?" She said, "It did not in my experience. Does it make it worse for some?" So let's go to the first part, the claim that pregnancy could cure endometriosis. That seems like a fallacy.

Tamer Seckin, MD:
More than fallacy, I think that chain of thought belongs to a cult of doctors that truly do not know this disease at all. Endometriosis causes fertility and sub fertility. In other words, even though many endometriosis patients may fail to get pregnant also, the people who get pregnant, they don't get more than one pregnancy. They may not go beyond that, even though I've seen very rarely multiple pregnancies. Even with multiple pregnancies, their endo has never, do not regress. I am just going to operate on a patient who got three kids, and they're doing terrible with their endo. If their symptoms are there and persist after pregnancies, they should look for treatment.

Look, having said that, I have to be fair that maybe there are a good number of patients who live with the disease, who live with their symptoms, and can deal with it maybe differently after they have their kids. That's another thing. We don't know some deep levels of how patients deal with their pain and with their lower pelvic issues. Those are all personal things that patients bring up. So in that sense, so in general, scientifically, pregnancy does not cure endo. Pregnancy does not treat endo. Pregnancy may manage endo. It delays the interruption time. It delays, during pregnancy, symptoms of endo usually subsides for many reasons. Rarely, pregnant patients have to be operated for endo, very rarely. I've never done one, for example, in pregnancy. I interrupted, I went for an endometriosis for pain reasons. It's unthinkable. So there is some reverse action. It's a great question. I hope I addressed some portions of it accurately.

Diana Falzone:
No, very much so.

Tamer Seckin, MD:
Don't forget, I am opinionated because I'm coming from surgical side, and I see patients that don't do well. And I bring my experience to the [inaudible 00:31:58].

Diana Falzone:
And just from my personal experience talking to women who have been, who've had three to four kids, will still be affected by endo. I knew someone who was in crippling pain, and she ended up on the floor in endo pain, and she had four children. So everybody's story is different and varied. Summer asks, "Are chronic UTIs a symptom of endometriosis?"

Tamer Seckin, MD:
Again, look, if the symptoms are overlapping the periods, menstruation, before, during and after, certainly a bladder endometriosis should be, must be suspected. An MRI or sonogram will help. I am not, I don't register to the field of the interstitial cystitis concept much. It is one of those dumped diagnosis like IBS. You can't make interstitial cystitis diagnosis without excluding endometriosis, number one. And so many patients we do cystoscopy with periods, with people who come with the ... You don't see anything. I personally think it's another avenue of cult avenue, people get treated. They do better for a little while, and then their symptoms either start and their symptom changes façade to something else. It becomes hip pain. It becomes ... What happened to the interstitial ? Well, it's still there, but my hip pain is more.

It's an interesting bladder obviously do represent one of the pelvic organs. Its nerve innervation is on the path of where endometriosis gets localized, deep in pelvis, in the back. So in that sense, bladder symptoms should not be taken lightly. I pay attention. We operate so many patients with deep endometriosis of the bladder, nodules there. And so bottom line is there is endometriosis of the bladder. There is endometriosis of the kidney system. It's part of the multi organ endometriosis. It rarely becomes just solitary bladder lesion. There's always lesions somewhere else. There's always other symptoms around. It should be evaluated in total with the multi organ symptom searching questionnaire by us.

Diana Falzone:
Very interesting. From Brittany, "Why can you get endo belly even after excision surgery where all the endo was removed?"

Tamer Seckin, MD:
How does she know all the endo's removed? I mean, I could answer that question accurately if I see Brittany's pathology report, and I see Brittany's little video clip where the endometriosis was. Endo belly is, yes, there are symptoms of endo belly that may persist. There may be other issues hormonally too. We don't know the bottom line molecular aspect to it. But one single reason why people get endo belly with endometriosis is the molecules of inflammatory molecules, cytokines. There are 70 different cytokines that at least, maybe there's 7000, we don't know. We don't know every molecule. But every lesion produces its own inflammatory lesion into peritoneum, and that causes the bowels react. That's why they become gassy, stomach gets distended.

Many patients with endo belly after accurate, good surgery diminishes. But I have to say, and I give her credit for this question, I also have, despite I removed so many lesions, patients continue to have endo belly, but not as much. I mean, in general, when you remove as much as possible, there is a difference in patients' symptoms. That's what I have seen. But not complete, I have to agree with that. But these patients do get pregnant. Their overall pain is diminished. Some people are more sensitive to bowel symptoms than others. Some people have different nerve, everybody has a different perception of their gut system, how they are felt here.

You may feel gassy. The other patients do not feel gassy with the same food. It's the same sense. It's a rather sensitivity issue. So the subject is more complex. That's a very, very challenging aspect of endometriosis care.

Diana Falzone:
Yeah. And endo belly is one of those phrases that evokes a lot of reaction from the endo community because so many of us, it affects our overall sense of self and self esteem and body issues, really. It's a tough one. Since we're running short on time, this is from anonymous. How often after excision surgery with uterus and ovarian cysts should you get checked? Oh, that's a good one.

Tamer Seckin, MD:
It depends. I think if the symptoms are completely diminished and patient's happy with the surgery, I think after three months of checkup, every six months, a sonogram is needed next two to three years. Two times a sonogram a year is not much for people who suffer from this disease for many, many years. So that's the way to check. Make sure there's nothing really developing. And I think ovarian is from this patient's side develop new symptoms like bowel symptoms or other deep endo symptoms should be known by the patient. They should report that, in other words, flank pain, bowel symptoms, prominent or bladder symptoms.

Patients who have endometrioma surgery, endometrioma is one of the culprits of why this disease is also difficult to treat from the pregnancy aspect, also the way the disease spreads inside. Endometrioma is a difficult thing to deal with. To me, endometrioma surgery happens to be the most difficult, challenging surgery because you're dealing with the eggs that are not visible, and they are not born yet. They are sitting frozen there. And endometrial, growing endometrioma brings a physical force, increased pressure within the ovary to compress and deprive these eggs from nutrition and oxygen. So even though they're sleeping, hibernating there, they still need good vascular oxygen supply to them.

So endometrioma, if someone is operated for endometrioma, make sure they don't recur because the recurrence rate in the literature is very high. And doctors may inadequately treat endometriomas. They leave cysts behind. They don't really remove the capsule well. They don't reconstruct the ovary. There's different opinions how endometrioma is treated. Ideally, it should be restructured like a plastic surgery, put together like new. And it should be suspended after surgery for a good time, so adhesions and symptoms don't develop at all, or minimize. And basically, these after surgery, endometrioma has to be checked every six months, definitely.

Diana Falzone:
Oh, really?

Tamer Seckin, MD:
If you have endometrioma surgery, get checked every six months. Otherwise, with non endometrioma surgery, check your own symptoms, go to doctor if they come. At least every nine months, there should be one sonogram and pelvic exam is needed. If they are still tender on pelvic exam when the doctor touches inside of there, there are new symptoms of pain with sex develops, there's a recurrence of the disease, definitely.

Diana Falzone:
Well, thank you so much for your time today, Dr. Seckin, and answering these questions. We're going to be doing this monthly, so make sure to send your questions to the EndoFound. Thank you.

Tamer Seckin, MD:
Thank you for having me, as always.

Diana Falzone:
Bye.