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Introduction
Dr. Bob: And welcome to The Dr. Bob Show. Thank you
so much for taking your time to learn a little bit about making
your life healthier and happier, because that's what we're
trying to do on The Dr. Bob Show-give you facts that you can
use so that you understand how to make your health much, much
better. I'm Dr. Robert Overholt and I'll be your host for
the next 30 minutes on The Dr. Bob Show. We're going to spend
most of our time talking about pelvic pain, the different
causes of pelvic pain and we have an outstanding guest. My
guest is Dr. Jeffrey Dell, urogynecologist who has developed
an Institute of Female Pelvic Medicine and a lot of information
that he has. Later on we'll be talking about bee sting allergies.
We'll be talking about statin drugs and how good they are.
And if you're a smoker, we're going to be talking about how
to kick the habit! Be sure that you're doing those things
that we want you to do every week also. That's exercise, start
the day off with fruit and fiber, start the day off with eight
hours of sleep and, most of all, we want laughter in your
life. Stay tuned-we've got huge amounts of information for
you on this show.
Dr. Bob: We're talking with Dr. Jeffrey Dell who specializes
in urogynecology (urology and gynecology at the same time)
and Dr. Dell has developed an Institute of Female Pelvic Medicine.
Jeffrey Dell, welcome to The Dr. Bob Show.
Dr. Dell: Thank you. Thank you.
Dr. Bob: It's always nice to have you. You've been
a guest before and you're a great teacher. I'm interested…how
did you decide to develop an Institute of Female Pelvic Medicine?
Dr. Dell: Well, I tell you, issues dealing with women's
pelvic health-that is urinary incontinence, pelvic pain and
pelvic floor disorders and prolapse-are areas that affect
so many women and in the past five years there's been really
so much innovation…new techniques, new materials that
we use surgically, and new medications and drugs that can
be used to treat these things effectively. We've been privileged
to be involved in some multi-center research trials. In addition,
we're involved with several companies involved in teaching
some of these new surgical techniques to visiting surgeons
who come in, and so that's what gave us the impetus to start
this institute.
Dr. Bob: We're going to be talking about pelvic pain.
Let's get right into endometriosis. First of all, what is
endometriosis?
Dr. Dell: Well, endometriosis is a situation where
endometrial cells- the cells that make up the lining of the
uterus, those cells that shed every month due to hormone fluctuations
during the reproductive years-when those cells begin to grow
anywhere else in the pelvis where they don't belong, in other
words, they only belong inside the uterus, but if they begin
to grow outside the uterus on the tubes, on the ovaries, on
the bowel around the lining of the pelvis and begin to cause
pain, that's the definition of endometriosis.
Dr. Bob: So, endometriosis means you can find uterine
tissue anywhere in the abdomen. How does it get there?
Dr. Dell: That's a subject of debate. We think that
probably it has to do with cells that move in the opposite
direction through the tubes and into the pelvis. That is,
the lining of the uterus typically should only move one direction
and that is during the menstrual flow when they move through
the cervix and out the vagina. But when those cells move in
the opposite direction, they can perhaps go backwards through
the tubes and then implant elsewhere in the pelvis and begin
to grow.
Dr. Bob: Now, if you have uterine tissues in the abdomen,
I take it you start getting symptoms in the abdomen?
Dr. Dell: That's right. Very often the most common
symptoms that a woman would have with endometriosis would
be very painful (more than typically painful) periods that
begin to happen during the month. Sometimes it leads to pain
that is not just during the period but really all the way
through the month, painful sexual relations, and pains that
just can be in the lower back, across the abdomen or lower
pelvis.
Dr. Bob: How is the diagnosis established?
Dr. Dell: Technically the diagnosis has to be established
at the time of surgery where we actually look and then ideally
biopsy the sites. The pathologists can confirm the fact that
indeed this is endometrial cell growth where they don't belong.
These days though, because there is so much concern about
trying to find more conservative measures, based on a very
careful history and symptoms that have been going on for longer
than six months, it's not unusual for patients to be treated
supposing that they probably have endometriosis and then if
they do get resolution of their symptoms or significant improvement,
they don't always have to undergo surgery.
Dr. Bob: What is the treatment? Is the treatment with
medications, with hormone replacement medications, or is it
with surgery and laser? What do you…?
Dr. Dell: Very often many of those things are often
used. We ideally start conservatively and so sometimes birth
control pills, injection type hormones like Depo Provera or
even Lupron which begins to shut down the normal axis of estrogens
and so on can all be used to really try to make those cells
more quiet and decrease the pain and symptoms. Very often
a patient will have to undergo laparoscopy surgical treatment
to be able to not only see the extent of the problem but to
try to remove those cells either by coagulation or sometimes
lasers are used. Sometimes just surgical excising those areas
that are most bothered is technically used. So, many of those
things can be used in any given patient.
Dr. Bob: In the last ten years the patients that I
see that have had endometriosis seem to be doing better under
treatment than in the 70's. Is that correct?
Dr. Dell: I think that is correct and I think that's
primarily because both from a medical and a surgical standpoint.
The type of modalities that we have really have come a long
way compared to what was available even 15 or 20 years ago.
Dr. Bob: Now, I want to switch to the ovaries. The
ovaries can cause pain. What kind of pain do they cause?
Dr. Dell: Well, ovaries in a normal patient, let's
say, will cause some pain. In order to ovulate, there will
be cyst formation on one or both ovaries every month or so,
and some women will have associated discomfort in the middle
part between cycles called mittelschmerz and they can tell
within a day or so when that ovulation is occurring. Usually
that's not severe and usually it's not a major problem for
patients. Sometimes the little cysts that form to allow ovulation
doesn't completely go away. Sometimes there is a little bit
of bleeding into the cysts which we would call a hemorrhagic
cyst and then there's a wide variety of benign cysts that
can enlarge and cause pain as well as both benign and malignant
tumors that can form on the ovaries.
Dr. Bob: The symptoms of ovarian pain?
Dr. Dell: Well, that would typically, well, that can
be very hard to distinguish initially from endometriosis or
even from gastrointestinal disorders like irritable bowel
syndrome or even some pelvic floor disorders. So, very often
it's important not only to have a careful exam to see if there
is any enlargement of the ovaries but also a pelvic ultrasound
so we can get a very clear picture of the size of the ovaries
and whether or not there are cysts actually present.
Dr. Bob: Any information that people should know about
ovarian cancer very briefly in 20 seconds?
Dr. Dell: Ovarian cancer is very concerning because
while it's not one of the more common GYN cancers, it's one
of the deadliest. Very often the cancer is advanced before
it is found. Probably the most important screening tool that
we have currently is annual examination. We hope that in the
very near future we will have some tumor markers similar to
a PSA for a prostate that men get. The tumor markers that
we currently have are not generally used well for screening
tools but are used to follow people with cancer. So it is
so important to get that annual exam. Have an examination
and make sure there is nothing abnormal palpated during that
exam in the office.
Dr. Bob: Do we have good treatment available for people
with menstrual cramps and menstrual pain?
Dr. Dell: Excellent question.
Dr. Bob: And that's what we're going to come back
and talk to you about. We're going to talk about how you treat
menstrual cramps. It's one of the problems that we have and
there're many approaches to that. But first, let's look at
a patient who had endometriosis and how her treatment went.
Patient: Well, I've had endometriosis for
many many years and in 1994 I was having a lot of abdominal
pain-lower abdominal pain-and had to have laser laparoscopic
surgery which was very successful. I've not had any more problems
since then until last year and at that time Dr. Dell found
a large ovarian cyst, too large to try to shrink with a conventional
treatment and I required surgery. I had a 9-cm. endometrioma
so when we first went in we really didn't know exactly that
it was going to be. We thought, you know, there was a possibility
that it could be cancerous, so he, you know, prepared me for
that. But we go in and he just found that it was part of endometriosis.
It was just endometrial tissue that had formed into a really
large cyst. So, we were all very happy about that. But it
had just formed and, you know, I didn't really know that it
was there until I started having pain from it. And I do have
another smaller one that we are just kinda watching right
now and it has actually shrunk in the past few months. So,
we're not really doing a whole lot for it. When you've had
this problem for a while, you probably know, you know what's
going on because you've probably had some diagnosis of endometriosis
at some point and I think you really just have to work and
find a good doctor. That's a huge portion of it-somebody that
you really trust and you know. I have all the trust in the
world in my doctor and he did a great job explaining everything
and what to expect and I think that's a big part of your recovery
as well. You need to know what to expect.
Dr. Bob: If you have pelvic pain, it could be endometriosis
and the treatment is so good now, or it could be ovarian disease.
It's very important that you get a yearly exam so you can
find out if that pelvic pain that you have can be fixed. We're
talking with Dr. Jeffrey Dell who is a urogynecologist who
has developed the Institute of Female Pelvic Medicine and
Jeffrey, let's go right into dysmenorrhea or menstrual cramps-menstrual
pain. Why do people have it and what can we do about it?
Dr. Dell: Most women have some degree of menstrual
cramps every month that causes bloating and cramping and discomfort.
It's not exactly understood what causes that. We think that
it has something to do with some prostaglandins that might
be released as that endometrium lining sheds and sort of separates
from the uterine wall and begins to come out. While most women
have sort of a mild degree of cramps that come along, some
women have very, very severe cramps that really are incapacitating
to their quality of life. And literally they are in bed for
three or four or five days or more every month.
Dr. Bob: And sometimes people are not sympathetic
to those people, you know, especially a woman that has very
slight pain is not very sympathetic to another one that has
severe pain. They are not sympathetic. It can be very distressing.
I'm glad that you brought that out. It can almost put you
in bed.
Dr. Dell: You're absolutely right and some women literally
feel like their life, their quality of life is absolutely
gone for one or more weeks during the month. We don't understand
if it's because they have more prostaglandin release than
in a typical case, but what's exciting is because we think
it has something to do with prostaglandins, nonsteroidal anti-inflammatory
medications tend to decrease the effect that prostaglandins
have.
Dr. Bob: Now, Ibuprofen is one of those. Is there
any Ibuprofen that the pharmaceutical industry thinks is better
than another or the OB doctor feels is better than the other?
Dr. Dell: Well, certainly over the past several years
there have been several sort of new generation nonsteroidals
that have come up, come about. They are a tremendous help
to the orthopedic type patients with all kinds of joint issues
but some of those are also of tremendous benefit to women
with severe cramps.
Dr. Bob: Celebrex?
Dr. Dell: Celebrex.
Dr. Bob: Vioxx?
Dr. Dell: Vioxx, Anaprox which has been around for
quite sometime and Naproxen or Naprosyn. Those will very often
have a greater effect than just Motrin Ibuprofen but there
is no problem with starting with that.
Dr. Bob: And the nice thing about that is that people
are not taking them for a long period of time so you don't
have to worry about some side effects.
Dr. Dell: That's right. Usually it's a very time limited
situation every month.
Dr. Bob: If that doesn't help…?
Dr. Dell: Very often then what we do is try to manipulate
or modulate the hormone pattern. So, sometimes just by placing
a women on birth control pills that will significantly decrease
the amount of discomfort she has. In some cases we can even
essentially eliminate the period from happening by placing
them on a hormone regimen that just kind of keeps everything
even keel, steady as she goes, without getting into that awful
cycle every month.
Dr. Bob: I want to talk about another very important
issue. And you are a urogynecologist. Uro is urology. Tell
me about where bladder comes into pelvic pain. Is that just
the urge to urinate?
Dr. Dell: Well, I tell you, this is probably one of
the hottest areas for women in chronic pelvic pain. Over 10
million women in this country suffer from chronic pelvic pain
that has a major effect on their quality of life. One out
of every six women has difficulties with this and yet only
a minority have sought help. What we've found is that many
women have been evaluataed, maybe seen by many doctors and
evaluated for possibilities of endometriosis or ovarian problems
or irritable bowel syndrome or even other things like fibromyalgia
and while they have been seen by multiple folks and had multiple
different tests and sometimes multiple surgeries, they still
struggle with the pain. We were fortunate enough a year ago
to be involved in a pilot research study where we looked at
just that type of patient. The patients who continue to struggle
with chronic pain issues and had not obtained relief from
all the conventional methods and finally, and what we looked
for was bladder origin pain because that has not historically
been sort of in the gynecologic thought process for pelvic
pain. We found that 80% (this was in multiple centers across
the country) 80% of women fitting that picture that had been
struggling for a long period of time and never gotten relief,
really-80% had evidence of bladder origin pain.
Dr. Bob: Wow!
Dr. Dell: And then there was a tremendous cross over
of pain coming from bladder origin problems as well as endometriosis
and so, that's what can make it so difficult on the initial
interview to really be able to separate things out.
Dr. Bob: And what did you find out was going wrong
with the bladder?
Dr. Dell: In the majority of these cases it has to
do with the fact that there is a problem with a protective
liner. A normal bladder has a protective lining to it that
shields the bladder muscle and the surrounding tissues from
urine, which can be very damaging to normal tissue. It's got
salts and all kinds of waste products from the kidney in it.
But if that protective liner is doing its job, we're not bothered
by that. What we found is that if that protective lining begins
to develop holes or gaps or leaks in it, then particularly
potassium that's in the urine can get into the bladder wall
and set up all kinds of miserable symptoms for the woman.
Not only severe pain problems that can actually get worse
just prior to the period, but also it can make intercourse
extremely uncomfortable and then it can be involved with lots
of urgency-frequency or urge incontinent symptoms.
Dr. Bob: This is called interstitial cystitis.
Dr. Dell: That's right.
Dr. Bob: And how's the diagnosis made?
Dr. Dell: The diagnosis is made one of two ways these
days. Either by an outpatient operative procedure where we
put a scope in the bladder and hydro distend or overfill the
bladder looking for characteristic changes in the bladder
wall, but more exciting is something that's come about in
just the last few years and that is an office base test, which
is a very, very effective test. It's something we can do in
the office without putting the patient asleep. Much cheaper,
must less risk, where we can place a couple of different solutions
in the bladder one at a time. The patient simply tells us
what she is experiencing. Do they feel good? Do they feel
bad? Do they feel the same? Do they feel different? And we
can gather a tremendous amount of information about whether
or not that protective liner is functioning or malfunctioning
based on how they respond or don't respond to the solutions.
Dr. Bob: And if you find somebody does have interstitial
cystitis, there is a new medicine available. What's it called?
Dr. Dell: Well, the primary medication we're using
these days is a drug called Elmiron. Elmiron has been around
for just the last five years. It helps resurface or heal that
bladder lining. Certainly we talk to the patient about certain
dietary modifications that can be a tremendous benefit. Very
often an overactive bladder (and there is a lot of information
about these days…the "gotta go, gotta go" commercials)
is part of the symptom complex in interstitial cystitis. Sometimes
we use drugs like Ditropan XL or Detrol to try to help control
those urgency and frequency symptoms at the same time.
Dr. Bob: So much information! I think we're going
to come back and talk about each one of the big four that
we've talked about, especially interstitial cystitis, because
it seems to be such a big problem. Jeffrey Dell, thank you
so much for coming to The Doctor Bob Show.
Dr. Dell: Thank you
Dr. Bob: Great information! Bottom line-if you've
got pelvic pain, see your OB doctor. He can help you and if
he doesn't help you, keep searchin- there is a cause.
Dr. Bob: And now you're going to want to stay tuned
because we've got several other things that you're going to
want to listen to that will help your health. Are you smoking?
We're going to talk about how to stop. Bee sting allergy?
It can be a real problem in your life-more than 50 deaths
a year. So, stay tuned. We've got a lot to talk about.
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