Understanding the Gut-Endometriosis Connection

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, President of Main Campus, colorectal surgeon, and here at beautiful Cleveland, Ohio. And today, I'm very pleased to welcome back Dr. Cara King, who's the Section Head of Minimally Invasive Gynecological Surgery and Medical Gynecology at the Cleveland Clinic. Dr. King is also the Program Director of the MIGS Fellowship, and is also the Director of Innovation within our Obstetrics and Gynecology Institute. Cara, welcome back to Butts & Guts.

Dr. Cara King: Thank you so much. It's an honor to be here.

Dr. Scott Steele: So for those who didn't listen in the past, go ahead and give us a little bit about your background. Where'd you train, where you're from, and how'd it come to the point that you're here at the Cleveland Clinic?

Dr. Cara King: Yeah, so I am from Western Mass originally, trained with my fellowship in minimally invasive GYN surgery at Magee-Womens in Pittsburgh. And then I moved here to Cleveland approximately six years ago to start the fellowship and really get the minimally invasive GYN surgery group a little bit more robust. My practice right now is focused on advanced laparoscopy. Endometriosis is a main niche, with fibroids and Mullerian anomalies as well.

Dr. Scott Steele: Well, as you said, today we're going to talk a little bit about the relationship between gut health and what you just mentioned, endometriosis. So as a Butts & Guts podcast, we don't talk a lot about endometriosis, so let's start there. Can you define endometriosis for our listeners, and what causes it, and how common is it?

Dr. Cara King: I love that you're pulling in endometriosis into your world, because there is a lot of overlap, as you're referencing. So endometriosis is a disease where tissue similar to the lining of the uterus can implant outside of the uterus, and it can really be anywhere, primarily in the pelvis, on the ovaries, the pelvic sidewalls, also bowel, bladder, and even in the upper abdomen, diaphragm, appendix. And it's a disease that impacts a lot of women. I say women. I mean people with uteri. Approximately 10 to 15% of the population has endometriosis.

Dr. Scott Steele: Cara, how does it get there? Is this a cancer that we're talking about?

Dr. Cara King: It is not a cancer, but I also hesitate to call it a benign disease, and I say that just because of how aggressive it can be. So underneath the microscope there is no malignant cells per se, but it can be exceptionally aggressive.

Dr. Scott Steele: So does it just travel where it shouldn't be? Is it to go back through the fallopian tubes? How's it getting to the belly from within that type of uterus tissue?

Dr. Cara King: Yeah. So there's a lot of different theories on how it starts, and I don't think there's any one theory that's 100% correct. And I say this because retrograde menstruation, so menstrual blood going backwards through the fallopian tubes, over 90% of women have some element of that. And like I said, only about 10 to 15% of people have endometriosis. So retrograde menstruation is definitely one way, but we think there's also probably lymphatic flow, possibly through the bloodstream, Müllerianosis, a lot of different theories in how it can spread throughout the body.

Dr. Scott Steele: So I'm listening to this podcast out there because I'm interested in it. What are the specific symptoms that patients should look out for that might indicate whether or not you have endometriosis?

Dr. Cara King: The main symptoms that we look for are going to be pain symptoms. And those pain symptoms are oftentimes associated with periods, so cyclic pain symptoms, but it could also be bladder symptoms, so painful urination, bowel symptoms, painful bowel movements, and also pain with intercourse. I will say though that adolescents typically have acyclic pain, so pain in between periods, and they also present more frequently with GI symptoms such as nausea.

Dr. Scott Steele: So why is endometriosis so misunderstood or maybe even underdiagnosed?

Dr. Cara King: I think there's a lot of reasons for that. I think one reason for that is likely cultural. So period pain is oftentimes normalized. You're a woman, you're having periods, this is just what you're supposed to feel like. I think part of it may be embarrassment to bring up. I think, back again to our adolescents, talking about period pain or going to the nurse for that, it can be difficult to talk about. I think also a lot of physicians don't know what they don't know, and so if it's not taught in medical school or residency well, it can just be missed. And I think the last component of this is going to be the difficulty with diagnosis. There's no blood tests that we can collect. It's really based on symptoms. It's based on imaging, which is, thank goodness, improving. But the gold standard for diagnosis still remains laparoscopy, which is obviously a more invasive way to diagnose it.

Dr. Scott Steele: So can women have endometriosis in their post-menopausal stage of life, or is it only those that are having periods?

Dr. Cara King: Any time. Any time in their life, premenarchal or even post-menopausal, yes.

Dr. Scott Steele: So obviously we're here on a Butts & Guts podcast, so what digestive conditions can endometriosis be misdiagnosed as, and why do you think that's the case?

Dr. Cara King: The most common in your world, Butts & Guts - I love this name - the most common butt diagnosis would be probably IBS or IBD. And we're seeing a lot of overlap with our endometriosis patients having IBS. Approximately 23% of our endometriosis patients have underlying IBS. Approximately 2.2 to 3% of our patients have IBD. We're also seeing an overlap in Crohn's, meaning symptoms when they come in misdiagnosed as Crohn's, when it can be underlying endometriosis. There's also a term that is becoming more popular called endo belly, and what it's really referencing is this state of severe bloating, severe cramping, and almost feeling exceptionally distended, which is, again, just that overlap between GI dysfunction and endometriosis.

Dr. Scott Steele: So what are menstruation-related GI symptoms, and why do they happen? Looking at it a little bit further there. And do they automatically indicate that someone might have endometriosis or a GI condition?

Dr. Cara King: Yeah, and this is what's so fascinating, in that in someone who is menstruating, having cyclic hormone changes not on hormonal suppression, the prostaglandin release is going to naturally oftentimes cause more loose stools or diarrhea or sometimes some bloating, so there's some natural GI overlap that's going to happen whether somebody has endometriosis or not. So just because someone has a change in bowel habits, for example, that does not mean they have endometriosis. Really where the overlap is going to happen is someone comes in with those symptoms, we oftentimes start them on something such as a hormonal suppression option, some type of birth control. If three months of that birth control does not improve those symptoms, that's when the light bulb should go off. There's something else going on.

Dr. Scott Steele: So we have a lot of providers that listen to Butts & Guts as well, so why is it so important for physicians to understand the gut-endometriosis connection, and how might this understanding actually improve patient outcomes?

Dr. Cara King: Okay, are you ready for this? I'm going to tell you something that's going to rock your world potentially. The delay in diagnosis of endometriosis is approximately five to 10 years. In adolescents, the average number of physicians that they see before diagnosis is three to four physicians before they're even considered to have endometriosis. That delay in diagnosis is astronomical not only from a personal patient standpoint, but from the entire picture that it creates in regard to pelvic floor spasm, central sensitization, absenteeism from school, et cetera, et cetera. And so if we can educate other providers to look for this, shorten that time to diagnosis, we're going to completely change the lives of our patients.

Dr. Scott Steele: So we talked a little bit about one of the effect on the other. Let's look at it in reverse. How does gut health come into play regarding endometriosis?

Dr. Cara King: Yes. So this is a really exciting space right now, looking at the gut microbiome. And honestly, you guys oftentimes are probably looking at this more than we are, but in regard to how dysbiosis, when the bowel is becoming out of balance with the natural flora, what that can do in regard to inflammation, in regard to estrogen being reabsorbed. So endometriosis is an estrogen-dominant disease, and so if we have a bowel microbiome that is not functioning properly, it can in turn lead to many down-the-line changes in regard to inflammation and estrogen overall.

Dr. Scott Steele: Cara, one of the things I'm always struck by when we operate on these cases is the degree of either implantation that can occur, the degree of inflammation secondarily that is involved in surrounding structures from endometriosis, so can you talk a little bit about how they affect the GI or digestive tract when they do implant?

Dr. Cara King: Yes. This is one of my favorite surgeries to perform because of the complexity that ensues. So as you're mentioning, when we have a stage 4 type of endometriosis picture... So endometriosis has four stages, stage 4 being the most invasive. It can involve the rectosigmoid colon up to 5 to 12% of cases. Within my population, it's the majority of my patients. And it can form very firm nodules that are infiltrating right through that rectosigmoid, through and through lesions mucosa, cause narrowing of the bowel, cause such severe adhesions that it's exceptionally torturous, where people can't even have bowel movements because of just the anatomy of what it looks like. The endometriosis not only impacts the rectosigmoid colon, even though it is the most common location within the bowel. It also can impact the appendix, the small bowel, most common the terminal ileum within the small bowel, but it can impact any part of the GI tract.

Dr. Scott Steele: So I know we have had other providers on here on the podcast that have talked about role of diet and specifically anti-inflammatory diets. And so a lot of research has seemed to suggest that poor gut health can increase inflammation. So how does inflammation impact endometriosis, and can changes in diet or nutrition improve symptoms of endometriosis?

Dr. Cara King: So endometriosis is an overall, total-body inflammatory disease. And so although diet cannot, quote, unquote, "fix" endometriosis or remove it, it can absolutely help with the total inflammation process in lowering that. So what we have found is that diets that decrease inflammation, so for example, omega-3 fatty acids, unsaturated fats, high-fiber diets, that can decrease the inflammatory markers and have patients have improved pain. There's also evidence for vitamin D, vitamin C, vitamin E in helping to reduce some of the pain as well. So diet can't treat it, but it can definitely be complementary in the overall picture.

Dr. Scott Steele: So, Cara, walk us through. I'm a patient there and I'm going to go in and see you about this. What can I expect? What kind of exam? What kind of tests? And then ultimately, what are some of the treatments? And then if you will, go into the future. Are there any advancements on the horizon that comes to either what you mentioned, a timely diagnosis, not years, and treatment of this disease?

Dr. Cara King: Yeah, thank you for asking this really important question in regard to the patient journey and experience.

Dr. Cara King: So first and foremost, if someone comes to myself or any of my partners, the number one thing we say to them is that we believe you. Your experience is real. Because when you experience a 5-to-10-year delay in diagnosis and you're seeing four or five physicians, it can make you doubt yourself and your own symptoms. So number one, we believe you and your story is true.

Dr. Cara King: From there, after we get a good story and understand your journey, we'll then review any previous medical records, operative reports, images from previous surgeries. From there, we typically do a physical exam, and that can sometimes just be on the outside. I know patients who've had potential medical trauma from previous exams, are nervous about that, but the patient always dictates how much of an exam we do.

Dr. Cara King: From there, we move to imaging, and we have very advanced imaging here that has taken years and years to get to where we are today with very invested radiologists. We have benign tumor boards, where we actually meet with our radiologists pre-op. We review symptoms. We review the images with our radiologists. We do surgery, we get the pathology, and then we circle back with our radiologists to re-review those images. So ultrasound plus or minus MRI.

Dr. Cara King: From there, we offer expected management, medical suppression or surgical intervention and any intermix of those things. The main thing that we will ask is about pain versus fertility, because unfortunately, the treatment for endometriosis oftentimes directly opposes fertility. If we're looking at hormonal suppression. So we again meet our patients where they are. We build a tribe of people around them, which, again, with the delay in diagnosis, can sometimes also include pelvic floor physical therapists, GI psychologists, our functional medicine team, our anesthesia regional pain team, ourselves. And oftentimes it does land in surgical intervention. That's oftentimes laparoscopy, where we go in and we can either do uterine conservation treatments, where we maximize fertility while optimizing pain, versus if somebody is done with their fertility journey, it sometimes can include hysterectomy. And then we have the post-op journey of making sure everyone is set up after that.

Dr. Cara King: In regard to looking future, to that point, things that we're looking for are non-invasive ways to diagnose endometriosis more accurately. We're looking at different types of biomarkers. We're looking at blood serum markers. We're looking at potential endometrial cells, different ways that we can diagnose from a non-surgical perspective. We're also looking at EVG, so looking at different gut motility movement to see if there are certain characteristics of small bowel motility that can be related to endometriosis. And then always improving our imaging. So non-invasive ways to diagnose this.

Dr. Scott Steele: That is fantastic. It's great to know that things are on the horizon there. So now it's time for our quick-hitters, a chance to get to know you a little bit better. So first of all, salt or sweet?

Dr. Cara King: Salt.

Dr. Scott Steele: What was your first car?

Dr. Cara King: A Toyota Celica, Cherry Bomb.

Dr. Scott Steele: Fantastic. And if you had a superhero power that you could have, what would that superhero power be?

Dr. Cara King: Flying.

Dr. Cara King: And then finally, if you maybe could share with the audience one of the maybe best or top pieces of advice that somebody ever gave you, what would it be?

Dr. Cara King: That is a great question. I would say having grit and forming relationships is one of the most powerful messages I've ever had, and that it's not always what you know or your skill level when you start, but having grit to persevere and build that tribe around you to raise you up will completely change the trajectory of your career.

Dr. Scott Steele: Fantastic. And so give us a final take-home message to our listeners regarding this entire gut-endometriosis connection.

Dr. Cara King: I think the take-home message is going to be do not work in silos, meaning open up your vision to include all different subspecialties. And in regard to patients, listen to their journey. Listen to their story. They know their bodies better than anybody else. And keeping endometriosis on the differential early on can completely change our patients' lives.

Dr. Scott Steele: Such sage advice. And so to connect with the Center for Endometriosis and Chronic Pelvic Pain here at the Cleveland Clinic, please call 216.444.6601. That's 216.444.6601. You can also visit clevelandclinic.org/endometriosiscare, that's clevelandclinic.org/endometriosiscare, for more information. Cara, thanks so much for joining us on Butts & Guts.

Dr. Cara King: Thank you so much.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.