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General Session VII: Pain Management with Alternative Interventions

General Session VII: Pain Management with Alternative Interventions
Endometriosis 2023:
Global Patient Symposium

Together for Tomorrow

March 18-19, 2023 (8:30am - 5pm) - Einhorn Auditorium, Lenox Hill Hospital, NYC

Erica Michitsch PT, DPT, WCS
Lexi Burtman, PT, DPT, PRPC
Gerald DeGregoris MD
Mila Mintsis, DAc, LAc
Mindy Pickard, MS, LAc

Hello everyone. I hope you're having fun chatting and getting to connect. We are going to start resuming our schedule. I feel like such the mom right now. Um, so please find your way back to your seats so that we can begin our next informative panel, pain management with alternative interventions panel. We'll just give a minute more for everyone to come back. Okay.

As many of us know all too well, endometriosis can cause debilitating pain that intervenes with our daily activities, as well as causes havoc to our body. Today we have an esteemed panel of pain management experts to discuss possible ways to manage your endometriosis related pain. Erica Mi a Doctor of Physical Therapy with a specialty in endometriosis and a co-owner of Solstice PT in New York. Lexi Burtman, also a Solstice PT who also has a specialty in endometriosis treatment. Dr. Jerry Dick DiUS is a pain medicine specialist and has his own, uh, pain practice, chronic pain in Midtown Manhattan. We also have Mila Mink, Holter doctor and acupuncture and specializes in pelvic floor dysfunction and pain management through her office in Manhattan. And Mini Picart is an acupuncturist at three treasures, acupuncture also in Manhattan, and specializes in pelvic pain and pelvic floor dysfunction, fertility and pregnancy. Thank you all for being here. So I am standing, so sorry it's a little awkward. We ran out of chairs. <laugh>, um, <laugh>. Let's start with understanding pelvic floor dysfunction. What exactly is it?

Hi everyone, I'm Erica. Um, it's an honor to be here and answering, um, your questions. And so, um, pelvic floor dysfunction is the pelvic floor muscle and it's either being not functioning as it's properly should. Right. So what we see in our clinic in related to endometriosis is that the muscle tone in the pelvic cavity might be hypertonic or, um, not coordinated properly and it could be affecting nerves and blood flow, um, relating to bladder, bowel and sexual function. Um, and so an orthopedic function. So we are generally treating that. Uh, do you have anything to add Lex

<laugh>? Uh, no, but just um, that, you know, pelvic floor dysfunction can be spasms in the muscles and they can fluctuate, um, around your period around ovulation and and highly tied to hormones and endometriosis symptoms.

How exactly does endometriosis and pelvic floor dysfunction correlate?

So, um, pelvic floor dysfunction can be secondary to endometriosis or it can come from come before, but um, basically with endometriosis what we're seeing is that when pa so in just a general term, when patients are in pain or chronic pain and they're clenching, they might clench their bodies or you know, if you're feeling, even if like you have a headache, you might be super tense in your bodies. So someone with endometriosis, if they're having pain for long periods of time, you're in that area in your pelvis, you might subconsciously clench the area. So in orthopedic terminology, um, the pelvic floor muscle might start spasming, like Lexi said, um, have trigger points in it and cause pain all throughout the month and not just during your cycle. So it could happen afterwards. Um, or for years of having endometrial pain, um, you could start having pelvic floor symptoms. So anything to add

On that. Um, and as well, so if there's endometriosis on the bowel on the rectum in the vaginal canal, that can also cause a lot of pain. So we can work on the muscle as much as we can, but sometimes the endometriosis is still present there and it will still cause pain. Um,

Yeah, throughout. Yeah,

I think, um, another thing that's worth considering is, um, inflammation globally as well as specifically. So we've observed that patients with endometriosis have not only focal areas of inflammation, but sort of global areas of inflammation. Well, so endo can cause pain by several mechanisms. It can directly invade the pelvic viscera. It can also, um, in invade or become part of or embedded onto the bowel wall, which can cause pain, which is located near these viscera as well. It can affect the nerves and directly affect the nerves in the pelvic area, which can also cause pelvic floor dysfunction. And then we've also observed that people with endometriosis just tend to have more inflammation other places as well. So there's um, uh, a rule that I think we've observed, which is inflammation anywhere can make inflammation worse everywhere. So if someone has an endo flare, they may also find that hey, their old orthopedic shoulder injury or hip injury also acts up on a similar cycle. So there's a couple of different mechanisms by which endo can cause not only pelvic floor dysfunction, but also other forms of dysfunction as well.

And just to piggyback on that, so say a patient comes into our clinic and they're coming in with bloating and um, constipation and painful bowel movements. Right? So what we're seeing is, okay, this patient comes in and that kind of sounds like irritable bowel syndrome, right? So you could treat, we treat it, you know, we're treating the symptoms that we see, but these patients may also have endometriosis. So irritable bowel syndrome is also an inflammatory condition. Right. And that can also be tied with endometriosis. So we're seeing, so we're treating the bowel, the pelvic floor muscles in the bowel region as well, which could be limiting bowel function and it could be caused by endo.

So what exactly is pelvic floor physical therapy?

So pelvic floor physical therapy, it's an, uh, examination of all of the pelvic floor muscles in all of the muscles and bones involved. So the entire pelvis, the abdomen, the hips, the sacrum, the tailbone. Um, so we'll do an evaluation on how all of that is affecting your pain, um, and what symptoms are going on, are there bowel dysfunction, bladder dysfunction, or sexual dysfunction? And then we treat what we find, um, so you know, if you're having bladder frequency or bowel urgency, we, we work on, uh, techniques to minimize that. We see the, the role the muscles play in that and we teach, um, new habits and techniques to decrease your pain and alleviate your symptoms.

Yeah, so we do a lot of, um, like daily education and like Daphne was saying, routine change. So, um, what's going on with your bladder habits, right? Um, how much frequency do you have? What are you drinking all throughout the day? When is your bladder pain? If you're having bladder pain, when is it the worst? When is it better? Um, typically like we might find with, um, a patient with endometriosis, they might have more bladder frequency and urgency and pain during ovulation or during their period or a little bit before. Um, so we're working on things like that. Then we're doing bowel habit retraining, um, as well. And then with sexual dysfunction, what we'll see is if a patient is having pain with intercourse, we're doing a lot of treatments to help with dilators to help stretch, um, decrease sensitivity in the area, change positions, um, positioning with, um, sexual intercourse, things like that. Um, also we treat a lot of, and uh, like what Rachel Rose was saying, um, we treat a lot of like anorgasmia or pain with orgasm. Um, so we have a lot of techniques that help with that and especially patients with endometriosis that have adenomyosis, they tend to have more symptoms like that. So we, we give, um, different techniques to help with those, uh, symptoms.

And then I think also just, you know, as as physical therapists, someone comes in, we treat them, we work on them manually, we do exercises with them, but then ultimately we're teaching them how they can, uh, manage their symptoms at home and without us, um, whether it's manual or exercise. So we are really trying to like build a toolkit for the patient to have so that when they are in an endo flare, they are in more pain, they know exactly what is causing it and what they can do to alleviate it.

And in terms of pelvic floor pt, what are some of the techniques that are used? Because I know that there's a little apprehension when you go to a pelvic floor pt. It's not, it's not as normal as, let's say, or as I should say, in the mainstream as it is when you hurt your elbow or your knee.

Yeah. So, um, we, we generally check external first. Um, and then we do check internally vaginally and rectally. Um, however, if the patient is not comfortable with it, a pelvic floor PT should never be pushing that on a patient. The patient needs to be, they need to practice desensitization techniques, they need to, they need to, um, work on external first before internal work. Um, so every patient's different. Some patients are totally like, fine, oh, check me internally, no problem, I'm fine. Some patients you have to wean someone into it and you may not even get to that point. Um, they might have to do it themselves. And we give patients, depending on their hi, their, his or history, it could be trauma related, it could just be pain related. Um, we have patients, uh, like if we're using dilators with a patient, which is like a medical device that stretches the, um, vaginal opening, we will have the patient insert it themselves. Like we're not necessarily inserting it. So we like to give the patient control over their body and, and, and what, um, in what we're doing right. So that they, they're the boss, the patient really. Um, so what was the original question? The

Original question <laugh> is, um, how the techniques are used in

PT therapy. Okay, so the reason what I wanted to uh, say was that we don't like force anything on anyone, but technically, um, if we're doing internal work, we do a lot of myofascial release. If there's tension in the muscle and we do coordination training, can you relax? Can you en uh, engage your muscle? Can you bear down? Um, and this is all related with bowel bladder too. Like can you, uh, bear down properly to have a bowel movement without straining the muscle or straining the nerve and causing more symptoms? Can you contract, um, to hold in your urine, their techniques to contract your pelvic floor to push off having an urge, um, to urinate? So we, we do a lot of coordination training as well, but specifically with endometriosis, we do a lot of visceral mobilization, which is where we're working along, um, the bowel lines, the uterine lines, the um, in the abdomen. And we're doing a lot of myofascial work on the abdomen to help get rid of any adhesions that could be there. We do that pre and post-surgery and we, and a lot of scar tissue mobilization. Do you wanna add that?

We'll do also like pain management techniques, teaching proper breathing, teaching diaphragmatic breathing, working on people's diaphragm and um, working on their nervous system and teaching them how to down-regulate and how to, um, kind of use their breath to control their pain.

You mentioned something about post-op PT versus prior. What's the difference and can you treat someone who is preparing for a surgery? I know it's like a three part one, but

<laugh> No, we really, we really like seeing people pre-surgery because, um, if, you know, we go through kind of what their recovery might look like, what the surgery entails, some extra questions that they didn't get out, um, when they had their surgical consult, they'll, they're able to ask us, um, and just kind of prep them more for, um, surgery.

Yeah. So, and, and pre-op, it's really nice to come in because I think it could help limit. I, I think we give techniques, like you could do certain, we can give you like certain supplements to take after that could help with adhesion, certain stretches, um, how long to expect to be out of work. So I feel like there's like a misnomer about that too. And we want patients to be like fully prepared, like, okay, I took this amount of time off or this time off from school. So it's not like a shock to them. We like to prepare pain levels, um, and a lot of bowel regimen so that they're not constipated after surgery as well. We like to work on that.

And then, and then post-op, it kind of depends on the surgery Yeah. That they had and then the extensive of it and, and you know, what their surgeons said, um, they're cleared to do by the time they come in. But usually we'll start with, you know, deep breathing. We can do scar mobilization, work on the abdominal scar, go over their bowels, and then just any symptoms that are still present. Yeah. Um, we work on those

And we do, yeah, a lot of abdominal work, which I think makes a huge difference. Especially cuz a lot of times with the endo excisions, um, they're doing appendectomies too. So when you get your appendix out on the right side, there's a lot of, I mean, I'm sure many of you know that's had the surgery. Um, there's a lot of adhesion there too, so we tend to work on mm-hmm. <affirmative>, um, a lot of abdominal work. Yeah. And, and some nerve and, and, um, we've had a lot of patients with some nerve symptoms that had before and after, and that could be sciatic versus, um, like a hypogastric nerve versus pand nerve pain. Um, so we do a lot of nerve gliding and, and things like that to get the nerves to move better in the tissue.

In transitioning from PT to acupuncture, how is acupuncture able to alleviate symptoms of endometriosis?

Does this work? Hi everybody. Does this work? Yes.

<laugh>. I'm Mindy. Um, one of the key things that acupuncture does is that it downregulates the ner nervous system. Um, many women who have endometriosis, of course, your nervous system's gonna be really riled up. You're in pain, you're worried, you, you don't know what to do. You've had a lot of, you've seen a lot of doctors. So that's the first thing that I try to do is down-regulate the nervous system. Uh, after that I try to work on the local area to help with pain management. And then thirdly, sometimes I use herbs to help with the symptom management. Mila, what about you? Yeah,

So just to add, so when you're looking at endometriosis, you have to think about, you know, what it's doing to the central nervous system. So just like, you know, what Mindi said, and then you're looking at the local impact and that could be, you know, that adhesions and everything else that has been mentioned, nerve pain, local inflammation. And I find just from personal experience that for the local treatments to hold, you really do have to focus on the central nervous system. And then a lot of the times, you know, once there's a lot of central sensitization present, which means the pain signal is just over firing in your nervous system is upregulated. And a lot of the times that leads to the, it's called sympathetic dominance. So when we are stuck in, you know, if there are physical symptoms that have been present for a long time and you know, specifically pain, and a lot of the times there are emotional symptoms that come with that as well.

Our bodies get stuck in the, um, fight of flight mode and it becomes very difficult to switch to the parasympathetic mode. And if you're stuck in that mode, it actually intensifies all the physical and all the emotional symptoms as well. And if you don't take your body out of that, you know, sympathetic dominance, then it is just gonna be really difficult for those symptoms. They do get better, but it is just your, every time you're exposed to something that is stressful or a memory from the past comes back or something else happens, the symptoms tend to come back. So with acupuncture, it's actually, it's one of the modalities that is really good for, uh, treating sympathetic dominance because for the body to be able to switch to the parasympathetic mode, one of the ways to do that is to stimulate the vagus nerve. And the vagus nerve is probably one of the most, in my opinion, important nerves in the body because it's responsible for the calming function in the body.

And then, you know, it slows down our heart rate. Um, suppresses inflammation, you know, increases peristalsis in the stomach and the intestines. And the problem with the vagus nerve, the fact is that, you know, it's, it's deep in the body, it's in, it's not easy to access it, but there are actually two spots where you can come close to stimulating it. And that is one is you knows in the ear that is the ocular branch and then also the neck. So by treating, by doing acular acupuncture and stimulating the vagus nerve in the ear and then actually treating s cm, which is the front of the neck, you're able to stimulate that vagus nerve, which helps to promote that parasympathetic balance and allows for the body to heal basically, because then your body is able to be longer in that rest and digest state. And that's what helps it, you know, to get better. It gives it that, uh, environment where your body can actually heal, uh, physically and mentally. Thank

You. Yeah. And just to piggyback, so we as PTs love to work with acupuncturists because, um, we, when a patient with endometriosis comes in, there's so much trunk inflammation and bloating and it really limits the, the way the diaphragm descends in the cavity. So, you know, we, for Lexi and I, we're working on the diaphragm muscle externally, and we're mobilizing it so that it moves better so that the whole trunk moves better and flows and there's less bloating. And they call it, they'll call it like, um, a domino phrenic dysuria and all these other terms. But basically it's like your diaphragm is stuck and then it's not allowing it to, to when your diaphragm moves, the pelvic floor moves and when your diaphragm stuck, the pelvic floor stays stuck. But when the acupuncturist too, and I know Mila does specifically, you'll do diaphragm work. Like you'll work, you'll do needles all along here.

Yeah, diaphragmatic, yeah, yeah. For diaphragmatic restrictions, you can specifically needle for that. Mm-hmm. <affirmative>.

Yeah. So it just,

Yeah. And then basically the two modalities really compliment each other. And also with, you know, needling, you're basically with endometriosis as has been mentioned already, there are a lot of myofascial restrictions and a lot of the pain that a patient can feel can actually come from, you know, the actual adhesions in the organs. And then also our bodies physically, the muscles respond to that and form our trigger points. And those trigger points themselves can actually create a lot of pain and then they disrupt the proper function in the body and that can have a, uh, an effect on the organ. So it's like, it's a cycle that, you know, one affects the other and then the myofascial can have the restrictions in the organs can cause the, you know, improper functioning of the organ. And with needling, you're actually, so to break that cycle, you need to, uh, you know, it's called deactivating trigger points.

So fixing the myofascial restrictions. And these patterns actually, you know, they take time to develop, but unfortunately it takes time for endometriosis to be properly diagnosed. So it gives it time to develop basically. And then, so a lot of the pain, uh, can be managed by just, you know, deactivating the trigger points and, uh, restoring proper myofascial function and tissue. And, you know, myofascial compressions can also cause neuro rotation as well. Um, and with needling, with the acupuncture, what it allows you to do, the beauty of it is the fact that, you know, is that you, you're getting past the skin level and you're getting into whatever structures need to address. So it lets, it basically lets you to get in a little bit more. And when you're doing that, you're increasing blood flow to the tissues, you're decreasing inflammation, uh, you're, you know, restoring proper function. And that's how it allows for things to get better.

The, the other thing that we can do is acupuncturist is, um, post-op, we work on scar needling, so we horizontally needle underneath the scar to get rid of the adhesions. And that also helps with what the PTs are working on. Yeah,

Yeah. And that it's very, it, it allows you to get in more, right? Because the scar tissue is not only what you see on the outside, but a lot of the actual damages deeper in and deeper inside. And, you know, needles allow, it might sound scary, but it's actually, it's not that painful. It's not, it not, it's a pleasant procedure in a way. Uh, but it, it allows you to get in deeper into the tissues and, you know, break down those adhesions in the scar tissue.

The needles are very fine <laugh>, they bend easily.

I guess you have to experience the, to get over your fear, right. Then once you're, okay, but we're talking so much about pain and endometriosis, but why, why Dr. Jerry? Does, does endometriosis cause so much pain? What is the culprit?

Uh, well there's um, a couple of mechanisms, um, by which endo can cause pain. I, um, alluded to a couple of them in my early response. Um, but there's sort of a couple of broad classes of pain. We think of ordinary, no susceptive pain is probably the most obvious sense of pain, and that's one aspect of the pain from endo. So no susceptive pain is typically sharp pain. It's well localized to a specific area. It's the pain that most of us deal with on a daily basis. When we accidentally stub our toe or back our, you know, arm into a wall or something like that, you accidentally hit your thumb with the hammer. It's pain that's conducted by pain receptors for impulses, which are usually supposed to be painful so much. But not all of post-surgical pain is no susceptive. It's transmitted by pain receptors or no perceptors whose evolutionary function.

They've evolved to teach us how to use our bodies appropriately. The theory being if something hurts, if I hit my thumb of the hammer, well next time I'll be more careful with that hammer. Right? So that's no susceptive pain. And ordinarily, um, no subception is supposed to be temporary. So once I do strike my thumb with a hammer, okay, I've learned my lesson. Uh, a small amount of pain is adaptive in the sense that it teaches me how to use my body and how to not abuse my body. But what happens when no subception persists beyond to a point where it becomes maladaptive, where it's no longer teaching me what I should and shouldn't do. It's inhibiting me from doing other things that I need to do. Maybe it's making it so that I can't walk well, that I can't focus on my job or take care of my family.

So no susceptive pain and other forms of pain as well sometimes last too long and then become maladaptive. And that's rarely where all these people on the stage come in, each of us with our own sort of face, uh, you know, facets to it. Um, so that's one component of pain. And, and the reason why pain can sometimes persist too long is, uh, by several phenomena, but one that I think is, is instructive to consider is this wind up phenomenon. So when nociceptors fire, when we hurt ourselves post-surgically, for instance, there are components of the spinal cord and the brain that sort of come into action and to start to dial down naturally the instance that instinctive pain. So they'll tone down the sense of pain, but sometimes for a variety of reasons, that natural pain alleviating system becomes impaired over time. And people don't understand exactly why that happens.

But in some people it happens more than others. So we lose our body's own innate ability to decrease pain to damp down our pain. One of the things that can decrease our own ability to damp down pain is chronic exposure to opioids. So we know that the body has natural endorphins, natural opioid, um, that get secreted after people have pain. So if you hurt yourself opioid, your body, your brain will secrete opioids to help control and decrease that pain impulse. But when people are exposed to opioids on a chronic basis, day in day out, your body loses that ability to produce our own endogenous opioids. That's one example of when pain that ordinary would be short-term can become long-term if our body's own natural pain damping mechanisms are impaired. Another reason why pain can become chronic or maladaptive is if we get this component called windup.

So there are a couple of components of the spinal cord that, for reasons which I haven't figured out yet, and a lot of other people haven't figured out yet either can sometimes serve to amplify pain. And this windup phenomenon, um, serves to have a positive feedback whereby when a nerve receptor fires and sends a pain signal, it then the, the, the spinal cord then sensitizes that nerve cell, that nerve pathway so that it becomes more likely to fire tomorrow. And that is called wind up. And there are several ways that we can treat that wind up. So there are some novel drug classes of, uh, calcium channel blockers. So drugs like gabapentin are thought to affect this windup phenomenon. Drugs like ketamine are thought to affect this windup phenomenon. So treating windup is another potential target that we have to try and prevent pain from becoming chronic, prevent pain from becoming maladaptive.

And then another thing that we often do, uh, and that I spend a lot of time thinking about is trying to use interventional procedures, needle based procedures to try and break this cycle of pain. So if we can temporarily anesthetize one of these nerves that is firing in our opinion too long and inappropriately, we can sometimes break that cycle of wind up where the spinal cord then gets a chance to almost like reset and these peripheral nerves can reset. And when sometimes when the local anesthetic wears off the nerve is not quite as hypersensitive as it was before. And I find that some of these procedures that I do that are really aimed up breaking this positive feedback cycle of pain work best when they're used in concert with the other techniques that you've heard about from these four professionals to my le my left, I think they work really well when used, you know, within a few days or maybe even less depending on how on, on the, the, the style of each practitioner, um, of adding acupuncture and adding pelvic floor pt.

And I'd love to hear from the other four folks on the stage as to what the ideal timing is in terms of, let's say a patient has some pain, gets a block from me, how soon do they lend like to then apply treatments? Cause I think patients tend to like to focus on one thing. Some patients really wanna focus on one thing at a time. That's what we, we do in life generally. But I think that if we can all work together, we can make more of a dent. So maybe I'll just pass the microphone over and see. If I were to do a block on day on Monday, how soon would you be interested in doing, you know, a treatment?

I would be okay with doing a treatment on Wednesday or Thursday. I would give it at least 24 hours. And I say that with all modalities. I try not to have, uh, people do more than one modality in a day if they can help it, unless they're coming in from some far away place. I think the body can, you know, take just so much and more.

I would say, I don't know if you would say the same, Lexi, I always say two days if we send for an injection, I would think two days just because, um, allowing some of like the anesthetic to wear off. Right. Um, and then we'd see them and, and generally just for you all to understand, like if Lexi and I have a patient, um, that we're seeing for eight to 12 weeks and they have that wind up phenomenon that you're saying and they, we feel like there's a lot more like nerves firing in the area and the muscle tissue actually feels much more healthy than when they originally came in. Um, we'll say, you know, maybe you should see Dr. Degre and, and have him assess you cuz you might be, you might benefit from getting a certain level of your spine blocked, which could help just stop the nerves. I don't, I don't know if that's how you would describe it, like stop the nerves from firing in the area, but yeah, just to kind of like calm the area down so that you could have a sensation of having less of that nerve pain going on, um, and retraining your brain. So we, we definitely depend on physicians like Dr. Degres to help piggyback what we're doing if it's not necessarily getting rid of that specific pain that they're having. But two days was, is the answer. I would say for us,

I'm actually a little more conservative announced because, um, in case it, it doesn't happen often, but if there is an adverse reaction and if you have more than one modality, then you know more than one treatment done in the same day or even within like 24 or 48 hours, you're not gonna know what caused it. So only for that reason, I like to separate it and just have a few days in between. Uh, but I would say in general, most of my patients, we all, um, they don't just do one, you know, they don't just do acupuncture. And if, let's say if I do get a patient that only wants to try acupuncture, I always tell them that they need to explore, you know, other modalities as well, other interventions, um, because we all, they all approach the same condition, but just, you know, from different angles and endometriosis is a difficult disease to treat. It has a lot of, you know, complications and just having all the different approaches, it really does make a difference. So it's at the same time, but just not on the same day. I, I

Want to ask a question of the thought making


Am I on the microphone here? Okay. So there is, uh, no susceptive pain as a somatic or visceral. So the question was what does endometriosis, why does endometriosis causes pain? So it's truly a, there's a visceral component of it because endometriosis, a visceral disease of the bowel and peritoneum adhesion and retroperitoneal fibrosis, that's how it gets deeper and deeper to neuropathic pain. That's, can you explain the no deceptiveness of this is to my good friend, Dr. D Berg. I'm asking you the hardest question. Nociceptive component of the visceral pain, the pain that comes from the bowels organs because these organs compete with each other inside palace, especially in competition with uterus, bowel, uh, rectum intimacy, if I may say, or and the bladder, they all function differently. They all have different innovation and activity time. So when they're scarring between them, bang, that's how things get bad.

With respect to pain, this is the way I, I see it as a surgeon. The rest is when retroperitoneal already the nerves are entrapped fibrosis, hypo nerve involvement, the bladder dysfunction is cul de sac, painful intimacy and painful bowel movement, obviously pand and sciatic, which we see as neuropathy is very, very deep form of the disease. Many times in my, the way I see it, it's referred pain when it's very, and we ask these question very specific. The patients when they come to us, we have a pain questioning leg pain is it in the front? Inside we know what those, those nerves are. And patients really pointed and you look back, you see for example, posa region or earlier, they really, if laterality is such an insignificant thing in our interview, when I ask is it in your one side and it's recurrent or persistent, I know that there's more disease on that side and usually it is.

So would you comment on ity or pain? And the second portion of the question is this Gabapentin business, I have this thing against them. Gabapentin, let me tell you, don't get me on gabapentin <laugh> please. [inaudible] We look beautiful buddy. I want your feedback on that. Sure. Because there's a lot of people, unfortunately you see on practice and the public should be aware there's chemical dependency and pa patients are innocently being railroaded to that path with some reason or another. It's two in a month, it's history, they're gone, they're, they wanted more and you can't blame them.

Two, two great questions, um, which, um, which we could talk a long time about both. But, um, from a fairly high level, I think the first point of teasing out visceral pain from no susceptive pain is a good one to go through. So oftentimes earlier on in the disease, people will have more visceral symptoms like Dr. Sketching first mentioned too. Uh, visceral pain tends to be harder to localize. So it tends, you can't point to it with a finger usually you'd have to point to it with a whole hand. Visceral pain will oftentimes feel like it's deeper, perhaps is more localized to the pelvis, less likely to go south of the inguinal ligaments, which is the, the, the crease approximately in your, in your groin, in your hip there. And, um, visceral pain, uh, tends to come on slower and perhaps persists longer in each individual episode.

The no susceptive pain, so no susceptive pain oftentimes comes on like a lightning bolt come, may come off like a light, like a light switch. Visceral pain might come on slower and come off kind of slower as well. In terms of, uh, so that's the other, the other side of, of, uh, of endo pain. Um, in terms of opportunities for treatment, um, yeah, the, the non-steroidal antiinflammatories are, are certainly, you know, a go-to. And I would say, you know, first line in most cases, cor ketorolac is a good example of one. Um, more familiar examples would be things like ibuprofen over the counter, which, uh, is oftentimes used for even very, very painful surgeries. Um, you know, when people have hand surgery and foot surgery, orthopedists really, really lean into the NSAIDs. Um, non NSAID being N S A I D, non-steroidal anti-inflammatory drugs. The trouble is that, um, they have side effects, but of course everything has side effects, right?

So there's always typically side effects are dose dependent. So side effects that we become concerned about for NSAIDs with too much they can cause, um, stomach discomfort because it's, it so happens that when you decrease these, use these anti-inflammatory drugs that decrease these, these chemicals called cytokines. Some of these cytokines are actually protective in, uh, causing the cells in your stomach to secrete a mucus that protects your stomach from the acid. So yes, it will decrease some of the inflammatory mediators, but it may also decrease your own body's natural protection against the acid in your stomach. So it can cause dyspepsia stomach discomfort would be one common side effect that NSAIDs have. And that's why we don't put people on high doses of NSAIDs forever. But most people with healthy kidneys and livers can get away with a, a pulse dose of it, take a high dose for a few days, and then take a break for some time.

Um, and uh, and that's one strategy just try to mitigate side effects. Although you're always gonna have some risk of side effects. Um, the aversion to gabapentin I think is very understandable cuz gabapentin has a lot of side effects also. Um, we know that uh, probably the most troubling side effect of gabapentin is sleepiness. And a lot of patients describe word-finding difficulty in overall brain fogginess. And one of the troubling things about gabapentin is it's hard to know how much each person needs. It's a drug that has a very, very wide therapeutic index, which means one person might get benefit from a hundred milligrams a day and another person may require 3000 milligrams a day and, and still not get any benefit or may get some benefit at 3000 per day. So how do you know where to start? Well you start low and you go slow.

So you start with a low dose and if it helps you continue it and if it doesn't help and there's no side effects you consider going up. But you know, like I said, like Drs alluded to, everything has risk and everything has side effects and a lot of people, uh, will describe sleepiness on gabapentin. It can interfere with, uh, driving and you shouldn't drive if you're taking gabapentin cuz it can slow, uh, response time. So then it's hard to become a fully functioning person of society if you can't drive, that's for sure. So there's lots of reasons to not use any of these drugs. Gabapentin would be one of them. Um, there is a very small subset of people who may um, report, um, addiction with gabapentin, although it's pretty small, certainly much less than opioids. But, um, in some of the fda, some of the studies that, um, drug companies submitted to the FDA for approval, there was a minority of drug addicts that did report liking gabapentin in a way similar to drugs of addiction. Um, but it was a lot less than than the opioids to be sure of. So I think in many instances the benefits outweigh the risks of gabapentin. So, uh, it might not be a first line agent, but it's still on the list I think at some point. Uh, and it can be helpful with both visceral pain and no susceptive pain. To try and tie back to the initial question,

I just have a comment too, please. So like in pt, uh, related to, to that question, um, so there's two things I can think of like right off the top of my head. So someone, a patient comes in and they have pain with insertion during intercourse, um, we're treating that patient, we're treating all the muscles and, and we've done everything and they've been coming in a long time and they're still telling us, okay, every time I have intercourse, I have very, very deep pain. Um, that's when we would think, okay, it's not just no susceptive, it would be more visceral that there could possibly be endo in the, in the vaginal rectal wall. Um, so that's, so we're treating them for a while in the treat, in the timeframe that they're coming in. It should have gotten better by this point and they're still having those deep symptoms.

I would say it's more visceral. Someone that comes in that just comes in with a complaint of pain with orgasm, pain with orgasm could be muscular, right? So they could have, uh, hypertonic pelvic floor and when they have an orgasm, it's spasms, right? So we're treating them and giving them all these treatments for, um, orgasm pain. But if none of those treatments work over a period of time and they're feeling it sup very deep, um, into the pelvis, we're thinking, okay, maybe this is coming from the uterus, maybe it's adenomyosis. So that's when we think more visceral. So sometimes it does take time, um, for a patient to come in that we're gonna determine the difference too.

Can we open up the floor for a couple questions now? Questions? Thank you. First, a second.

Hi, my name is Amy. Thank you for your time and all this information. Speaking about, we were just talking about different drugs. What can you tell us about the use of medical cannabis for pelvic pain and what advice would you give patients in terms of researching that if they think that that might be something they want to explore?

Um, so the question I I think everyone heard it is what role can medical cannabis play in, um, addressing pelvic pain? And I think, uh, in a, in a quick phrase, I could say certainly an ever increasing role in the future, um, I foresee it becoming more and more, um, a drug that's tried earlier on in the pathway as opposed to right now it's kind of a, certainly most professionals think of it as a drug of last resort, but it's coming up in our algorithm. And the reason why it's a drug of last resort is, is a couple fold. Um, first of all, the drugs that are out there, it's by far the least studied for a variety of reasons. Uh, I think that's the most important one. So it has the most unknowns about, um, safety and side effects. Another reason is that, um, it's not really one drug, it's, it's really hundreds of compounds that, that typically are used together.

So, um, we know that, you know, the two most important ones and the ones that have been most studied the most, I r THC and C B D, um, which, you know, people have given, you know, day long talks on the, on the differences between the two. But, um, you know, globally speaking, um, they both are centrally acting compounds. Um, THC tends to have more of the psychoactive components and C B D for the most part has little to no psychoactive components. Um, and I think one of the reasons why it's not thought of earlier is because, you know, people, you know, think of a, have a lot of negative stereotypes of the psychoactive component of it and don't want to be labeled that way or seen that way. And I think a lot of physicians don't want to feel like they're pushing that on people.

Um, but I think the CBD component for sure provides a an enormous potential for the future for treating these things aside from all the psychoactive components. So I think to, there's not a lot of great data on it, but I think the first step, um, is to talk, um, to really any providers like this. Cause we all people on the stage, we all know people who've used them, we can share experiences with where we've seen it help and um, the process to get it, um, is becoming more streamlined. Um, so now there's um, I don't know how many, but there, there have to be hundreds of providers in Manhattan who now have licenses to certify someone for medical marijuana in New York and then you go to a dispensary. Um, and uh, which that in of itself can be overwhelming, but there are a, a variety, variety of choices there.

Um, and again, these compounds are not one particular compound that you're getting. So typically you're getting at least a few things. Um, but it's on the order of, you know, certain number of milligrams of, of THC and a certain number of milligrams of CBD in various combinations. Um, but that's how you sort of get started is you talk to someone like this, then you go to a provider to get certified. Um, if you're thinking about it, I think, you know, at the very least it's worth talking to a, a potential certifying provider. I am not one, but there are many in in the city who are, um, cuz these people know the most about it. And I think it's, uh, it's worth at least talking to one of these certifying providers and they can give you realistic expectations. Here's what it can do, here's what it can't do. Um, like most other medications, I think it's definitely not gonna cure the problem. I think it's gonna be a small but significant part of treatment.

Um, and we will see, I don't know if Mindy if you want to say something, sorry, but, um, sometimes we'll see in Lexi, I like the first, uh, the first wave of like cbd, thc, um, uh, came, came about I feel like, like five years ago with us treating and a lot of patients we've found sometimes if patients come in, I know Dr. Session has an opinion about this, like with they're already ha using Valium suppositories to help muscle to help their pain, right? And they don't like it or they've been on it a really long time and it's just not a great drug to be on in general. So we have found that certain patients, not everyone, I it's definitely specific patient, um, could benefit from maybe using like a CBD b suppository, which is, which could really provide the same relief as Valium and, and have different effects on the patient. So it totally is patient specific.

Hi, thank you to everyone on this panel.

I was like, I shouldn't say this, but this is what we say Mike

One about other things that I'm really curious, have you seen practitioners using other than value like the Botox, Viagra, they use either,

That was also my question

About Botox.

That was her question also

On Botox,

Is it part of

The practice that do you see around vaginal Viagra or Botox and

Yeah, we see

How effective are they mean, what's your, you know, experience with respect to its feasibility and use?

I think it, and I know you guys probably all agree, it totally just depends on the patient. Some patients love value suppositories and it relieves their symptoms and some patients it doesn't do anything for them or it gives them diarrhea from just putting, you know, a suppository in. But

Bottom line is it goes to the system, right? Just of, you know, basically taking it local. It's like vaginal estrogen therapy versus oral estrogen therapy. So the effect and it's staying in the bloodstream is, uh, different probably when it's given from I could understand that. But you find that useful in some patients postop

Depends on the patient. I guess I, I know that's not a good answer. I don't know if you guys have another <laugh>.

I think sometimes it, it knocks them out, it helps 'em sleep better. Oh yeah. Like is that actually what it's helping them? You know, it's,

To be

Honest, I also sometimes it's hard to mean them

Often when it comes to endometriosis. Yeah. All right. Let's talk about endometriosis. Yeah. I am very, very careful when I have patients who are already taking very routinely pain medication, especially opioids because I to be helping to patients and sometimes my success rate gets limited because I cannot differentiate. I have really, this is the biggest challenge I have. I'm extremely careful I not deny treatment. However, prior to treatment I make sure they see the proper physical therapist. There is uh, you know, some degree of involvement, maybe pain medication doctor that like Dr. Ger is prior to surgery. I wanna format a very transparent, honest relationship with these patients because sometimes they, you really remove the whole disease and you think you did such a great job and the patient is not better and there's other reasons for pain goes continue. So I think it's important to have the right proper consultation with these patient. When you select patients. It's very, very challenging subject. Many patients are taking uh, you know, some significant, I should, I don't know the numbers to be honest with you, but I guess it is not very little I can tell that. Would you agree with uh, pain pa, pelvic pain patients on some sort of, uh, serious, uh, medications they take?

I mean I think it's less, I mean we're not seeing as many opioids and we right on that. Yeah. And a lot of times patients are trying gabapentin and they don't like the side effects, right? Cause of the fatigue. Um, but I think that there's a lot less, we never really see oral value I guess cuz it's addictive. Um, we'll see more vaginal value, but not everyone likes it. And then a lot of patients that really don't wanna be on any meds will go to CBD and tc.

I think there's serious awareness on the subject.

It's getting better. Yes. And a lot of physicians are really not prescribing it. Definitely. Um, but like for instance, like a patient that I've shared with Dr. Sukin, like she, he did a big surgery on her, she had a lot of stuff removed and she still was having the same exact pain in a specific area and he sent her to PT and it was really just muscle and adhesion and you know, so, so that's someone that if she didn't go to pt, she might have went to another physician that wasn't, would be giving her opioids or something. So I think it's super important just to be aware that you should try acupuncture or pain management or uh, pelvic PT before you're going to any sort of, uh, serious drug.

Yeah. And actually with acupuncture you're getting natural opioids, so it's just, you know, so it's, it should be definitely something not, you know, once you try. And then also it's important to know that there are different styles of acupuncture. So even Mindy and I practice a little bit differently. So if you tried it and it did not help you, you know, don't give up on it, but you know, go to somebody else, maybe a different practitioner, somebody who's more experienced in treating pelvic floor or endometriosis and you know, maybe different approach would be more helpful for you. And then also if you're willing, or if you're thinking about getting Botox, you can actually needle the same way into the pelvic floor muscles as you know, Botox. But it's just, it's natural when you're a needle and you're able to, uh, release tension in the muscles without having to inject anything. So that's also an option.

I just wanted to make sure your question was answered. Okay. Oh yes.

Hi. Um, good afternoon. Thank you for ev thank you for all you do. So this, uh, question is for everyone, but especially for Dr. Gregorys. Um, is the block that you're talking about, because I work with a spine doctor who does bilateral superior hypogastric plexus block. Is it the same block that you're doing and um, if it is, uh, how effective it is with regards to, uh, patient, uh, pain relief of the patient?

Great question. So the question is, what kind of blocks are we talking about? The, um, superior hypogastric plexus is one opportunity for a nerve block. Um, it all depends on where you think the pain is coming from, which is largely driven by the location of the pain. And that's a very common, uh, block to try. The, the blocks that we often do for deep visceral pain as opposed to no susceptive pain that might be facilitating this wind up, addressing this wind up are addressing the sympathetic nervous system, which is a little bit different than your somatic nervous system. The somatic nervous system is what you think of when you think of everyday nerves. The nerve that moves my arm, the nerves that makes me recoil from pain, that's somatic nervous system, that's somatic symptoms. The sympathetic nervous system is a more primitive nervous system that has more to do with visceral style pain.

It's not well localized. Um, it tends to be broader areas and it may come on slower, come off slower. Uh, it oftentimes is more dollar achy as opposed to sharp or stabbing. So if you think that some of those adjectives apply, then you might think, okay, a sympathetic block might be appropriate. And, and the one that you mentioned is an example of a sympathetic block that's among the most common one. Another commonly performed one is the ganglion empire block, which is a different set of nerves, part of the same nervous system. Um, that I think that is your

Question. We do find with the, um, endometriosis population, the ganglion empire block is what we start with. Is that Yeah. Could be super, super helpful for the patient. Yeah.

What does that mean?

It's, it's just that if we're treating the patient and

What is it?


Blah blah, what

Is it? Oh, the ganglion in par. Oh yeah, yeah. So we'll say so. So say the patient's, you know, still having a lot of pelvic pain, I'll say, okay, Dr. Degas, can you see this patient? Maybe they need a ganglion in par block and you could describe exactly what it's

<laugh>. So the, the ganglion of ipar, um, a ganglion is a type of nervous cells. So it's a collection of nerve cells and then ipar, I think it's an anatomist name of some person who attached their name, who first I think dissected it probably in a cadaver or something like that. Or maybe it's a physician's name, I don't know, but I think it's someone's name. So it's the ganglion of impart and uh, it's one location in the sympathetic nerve system that provides opportunity for treatment of pelvic or urethral or vaginal pain. So it's a type of nerve block, it's a specific location and it's one of the, um, it's a good target because it's fairly superficial to the surface. You can get to it without causing a lot of collateral damage, without irritating other things. And it oftentimes can provide benefit if that nerve is indeed causing pain. So it's diagnostic as well as therapeutic. If you think this nerve might be causing pain, you block it and the pain may get better and it may not. If it does get better, then probably that nerve was least causing part of the pain.

Okay. Right. So like we're working on the muscle and then we're like, okay, the muscle's good, let's check the nerve.

And then nerves in this spine,

It's at the very bottom of this spine. Near the tailbone? Yes, it's part of the spine. Thank

You. Sorry, one more. One more. Uh, yeah. Can one still benefit from these modalities that you offer if they've had the surgery say three years ago and did not go into to any therapy that you offer?

Certainly with the pelvic PT we see people three years, 10 years, you know, very long after surgery. Um, they can still have scar tissue adhesions we can work on. They can still have disc coordination of the pelvic floor that could be causing a lot of pain. Even muscle spasms in the pelvic floor that could be causing a lot of pain. So yeah, we see people far out from surgery

Also, like bad bladder habits and bowel habits could make the pain even worse. So even just like focusing on that, um, could, and that's, you know, could come any time 10 years after surgery. So yes, definitely.

Thank you so much. That was incredibly informative. Really appreciate your time.