Mapping Endo & Considering Coexisting Conditions with Dr. Victoria Vargas & Dr. Melissa McHale

Hello and welcome back. And I have to finish the laugh that I started like right as I hit record because we have been having so much fun before we hit the record button and I really wanted to hit it earlier. ⁓ But welcome back everyone. I want to welcome two incredible guests with me here today. Dr. Victoria Vargas and Dr. Melissa McHale. Endometriosis is more than pelvic pain.

It can affect identity, work, fertility, movement, intimacy, and trust in medicine and yourself. And for far too many patients, the hardest part is not just the disease, but the years spent being dismissed. On today’s episode of the vocal pelvic floor, I’m joined by two surgeons who are working hard to raise the standard of care in endotreatment.

Dr. Victoria Vargas and Dr. Melissa McHale. We’re talking about complex surgery, dynamic ultrasound, multidisciplinary care, overlapping conditions, that’s a big one, and what it really means to listen to the full story a patient brings into the room. Welcome.

Dr. Vargas And Dr. McHale (01:18)

Thank you for having us. Thanks, we’re excited to be here.

Dr. Ginger Garner PT, DPT (01:20)

Yeah, I’m so glad that you are both here. And I just want to tell the listener that, ⁓ you guys, do you all know how hard it is to get two amazing, incredible world-class surgeons in the same room and on the same podcast at the same time? Like, So thank you. Yeah, thank you so much for being here. Before we jump in,

Dr. Vargas And Dr. McHale (01:37)

Like that.

Battle of the calendars.

Dr. Ginger Garner PT, DPT (01:48)

⁓ I just want to do a little bragging like I usually do and introduce you to people. So here we go. Dr. Victoria Vargas is an internationally recognized endometriosis surgeon and leader in MIGS, minimally invasive gynecologic surgery. She trained at the Harvard affiliated Brigham and Women’s Hospital, Massachusetts General Hospital, OBGYN residency program and completed fellowship training in minimally invasive.

gynecologic surgery at GW, George Washington University, where she later served as assistant professor. She went on to lead MIGS for Johns Hopkins Medicine in the national capital region before co-founding Washington Endometriosis and Complex Surgery. She is well known for multidisciplinary patient-centered approach to complex endo care. And then we have rock star number two.

in no particular order, Dr. Melissa McHale. She is a gynecologic surgeon, also specializing in MIGS, endosurgery and compassionate individualized care. She earned her medical degree from Boston University School of Medicine, completed her OB-GYN residency at Johns Hopkins, and then pursued advanced fellowship training in endosurgery and dynamic ultrasound. She’s especially passionate about early diagnosis, multidisciplinary care and supporting patients with endometriosis alongside

commonly associated conditions such as hypermobility, POTS, and MCAS.

That’s a mouthful. I mean…

Dr. Vargas And Dr. McHale (03:24)

Aren’t we both so lucky to

work together?

Dr. Ginger Garner PT, DPT (03:29)

You two are amazing. I really admire the work that you’re doing. I just, I’m always humbled by the amount of effort and schooling and education that you have to put into all of this to get here and then being a business owner and launching that on top of everything else. And also there’s the obvious things that no one really

talks about enough and that is doing that as women who are diverse.

All right, so that’s a lot. So I just want to say, mad respect, mad respect. Yeah, yeah. So let’s set the stage a little bit. ⁓ Patience are up against a lot and as much as we can celebrate the changes that have been made, I think we still have a long way to go. And so I would love to get started with a big picture.

Dr. Vargas And Dr. McHale (04:09)

Thanks. Thank you.

Dr. Ginger Garner PT, DPT (04:35)

So many listeners to this show have spent years trying to get answers. And before we get into treatment or anything like that, I want to start with what patients are actually facing when they enter the medical system. So for both of you, what are patients with endo still most commonly not getting from the healthcare system?

Dr. Vargas And Dr. McHale (04:57)

I think the low hanging fruit is like a diagnosis. I think, you know, patients report that they’re seeing multiple different physicians and that they’re discussing their concerns about pain and they don’t feel listened to. I don’t think this comes from a malicious place. I truly believe it comes from a place of not understanding endometriosis and not recognizing it. ⁓

Dr. Ginger Garner PT, DPT (05:02)

Mm-hmm.

Dr. Vargas And Dr. McHale (05:27)

For patients, it has a profound impact on their trust in the medical field and other physicians. It really creates trauma and mistrust of the whole entire field of obstetrics and gynecology. I think it’s something that is really impacting our whole entire field and our patients. Yeah, I think Vicky really hit the nail on the head, honestly. ⁓

The biggest obstacle, honestly, is education of providers. I know it’s been said by a million people in the advocate space, but really, patients with endometriosis know so much more about endometriosis than 99.9 % of doctors. ⁓ But what really frustrates me is that ⁓ even if in medical school you learned nothing about endometriosis, which is the case for many people,

you at least learned about Occam’s razor, which is the principle that the simplest explanation that requires the fewest assumptions is usually best, right? And I’ll see a patient who has a list of like a million things, right? They’re like, okay, you have interstitial cystitis and overactive bladder and IBS and, ⁓ you know, functional dyspepsia and a hip labral tear and…

you know, the list – and you have vaginismus and you have that, like, it’s like a list of like 30 things and they see it endo isn’t on there and they’ll see a doctor who’s like, I know, let’s add another thing. And it’s like, there’s one condition that could explain all of these problems, right? The simplest explanation is usually best. The patient has one problem with many manifestations rather than, and so not everyone has one problem and we’re going to get into that, but like there, there is a problem with many manifestations.

Dr. Ginger Garner PT, DPT (06:57)

Right.

Mm-hmm.

Yes.

Dr. Vargas And Dr. McHale (07:19)

as opposed to being like, I know, let’s assign you 17 different conditions and you can take two different medicines for every single thing. And now you take 35 medicines a day and you still don’t feel better, but that’s probably a you problem because like, you know, I don’t, I don’t specialize in that. And it’s like, whoa, guys.

Dr. Ginger Garner PT, DPT (07:36)

Yes.

Yeah. You hit the nail on the head with something that you said. I want to just rewind for a second when you said ⁓ patients know more about their condition than 99 % of doctors. That’s a mic drop moment. And I think that explains why people with endo so often get minimized, misunderstood, misdiagnosed, and dismissed for years. So when you see that person walk in,

and sit down, what do you think they need most in that first encounter?

Dr. Vargas And Dr. McHale (08:11)

I think they need to be listened to. You need to sit there and listen to them. You need to have looked at their intake forms and sort of

Try to.

understand on a deep level everything they’ve been through because a lot of times intake forms really they lay it all out and that it’s even goes way deeper than what they say in words to you. The intake form I think lays bare the experience. A lot of times patients come in here and they’re not able to recreate the impact that ⁓ the disease has had on them in words. They laid it out in writing. And so I feel like oftentimes I look at the form, make sure even though I could predict

90 % of what’s on there for most of the patients, I look at it and I read it and I say the first thing I say is acknowledge what they wrote and that I read it and then I let them talk. Yeah, I think that’s so true and I think that that collaborative approach that Vicky’s describing is huge because I think that a lot of our patients have encountered doctors in the past who are very

They know what they know and that’s what they have to offer and that’s it, right? And the reality is like, sometimes people will ask me like, does this happen? And I’ll be like, well, you’ve told me it happened to you. So it sounds like it happens. I don’t know if I have an explanation for it, but I want to work with you to figure out whether this makes sense as what you’re experiencing. I’m not here to deny your experience. You’ve already told me you have the experience. So.

Like let’s work together and try to come up with a solution. And, ⁓ you know, one thing that I think I took away from fellowship is being free, you know, I trained with Dr. Vidali who I know you know, and he would always say the cure should not be worse than the disease, right? Oftentimes patients get told like, here is my medical treatment for you, take it or leave it. And the patient’s like, well, when I took that, I felt suicidal. And it’s like,

Dr. Ginger Garner PT, DPT (10:07)

Mm-hmm.

Yeah.

Dr. Vargas And Dr. McHale (10:21)

That’s

not gonna work. You can’t take it or leave it with that, you know? And so I think that that collaborative approach of just being willing to say to the patient, like, hey, I may not have all the answers, but we are in this together. That is what, you know, when I sit down with a patient, that’s what I try to convey is like, I don’t know where this is going yet, but like we’re working on it together and we’re gonna make a plan. And I believe you. I believe you. I believe what you’re telling me. And even if I don’t understand it,

Dr. Ginger Garner PT, DPT (10:44)

Yes.

Dr. Vargas And Dr. McHale (10:50)

you know, like you said, we will work this out together because I think a lot of times when it’s when doctors and I really don’t want to bash other doctors because I really actually want to uplift the other doctors that our patients interact with to recognize this. And I think there are lot of constraints that we aren’t acknowledging, which is that within the insurance system, you have 10 minutes per patient and your training is 80 % obstetrics and like 15 %

Dr. Ginger Garner PT, DPT (11:13)

Mm-hmm.

Dr. Vargas And Dr. McHale (11:19)

gynecology, and so there’s not an in-depth knowledge. it’s hard to dedicate your life to a field and then feel inadequate. I really do think it’s it’s an insecurity thing. It’s not personal at all to the patient, but I think many times when people feel that way, they act skeptical and patients feel like they’re not believed. ⁓ So yes, acknowledging

Dr. Ginger Garner PT, DPT (11:36)

Yeah.

Right.

Dr. Vargas And Dr. McHale (11:48)

the belief and what the patient is telling you. It is real. What you’re experiencing is real. I believe you.

Dr. Ginger Garner PT, DPT (11:56)

You know, listeners, think this is a common, I know this is a common thing I hear from my patients a lot, ⁓ but I want to get your perspective on it. For listeners who may still be wondering whether their symptoms are, I’m going to air quote, bad enough. What do you want them to know?

Dr. Vargas And Dr. McHale (12:16)

Well, I mean, I think there was a beautiful study, gosh, I really wish I could remember the authors and acknowledge them. Miss Herman, I think Miss Herman, she’s a famous author, she writes a lot about endo. ⁓ So she was part of this study where they broke this down, it was a qualitative study and they looked at the symptoms that patients experience from endo and then all the impairments that patients experience in educational attainment.

personal relationships, career, basically every facet of life. And they just broke it down in this very structured and systematic way. And I thought it was such a lovely study because it sort of like, it laid bare the impact this disease has on patients’ lives. And so when I meet with patients, I kind of like laid out, like,

this aspect of your life. And our intake has that. Like it includes all the different aspects of life that, ⁓ like it asks, does it impact you in these aspects, these areas of your life? And patients answer and you can see all the areas that the patients feel that this has impacted their life. then like using that, like, the decision, this disease, the decision to act on it is actually all a very personal thing.

Um, and that is determined by you and the level of impairment that you feel you have. And so it’s empowering to the patient, but you also have to acknowledge what their impairments are based on what they told you they were. Like in a very objective way and structured way, like, okay, all of these areas are impacted. that, is, can you live your life this way? Are you, are you at your limit? You know, or are you getting close to it? What is your, what is your threshold?

on a personal level. Yeah. think endometriosis in, you know, from hearing from, you know, patient after patient, consistently, I just, can tell that this disease is stealing people’s joy, right? Like, it’s just like, imagine like every thing you do, right? What percentage of the joy of this thing is endometriosis taking away from you? And so like,

Dr. Ginger Garner PT, DPT (14:08)

Mm-hmm.

Yeah.

Dr. Vargas And Dr. McHale (14:37)

Imagine that it was anything else in your life. If it was like a toxic person or a bad job or whatever, you’d be like, I don’t need this negative energy in my life, right? But for some reason, like people feel differently about their own body. It’s like, no, like it’s okay to say this thing is taking my joy. I don’t want it to take, even if it’s 2 % of my joy, 2 % of your joy every year for how many decades? Like, you know.

There’s no Olympics of suffering. There’s no like, well someone else had it worse, so ⁓ they get to have surgery and I don’t. It’s not a finite resource, right? Like you’re like, yes, there aren’t as many endo experts as there should be, but like that doesn’t mean you don’t deserve help, right? Anyone who has pain, anyone who is having their joy stolen from them deserves help.

You know, I find the same thing when people, and I’m sure you see it too, when people are like, ⁓ is it worth it to travel for care, right? Like to get the best treatment, is it worth it? And I’m always like, and then I asked, it was actually a patient who broke it down for me who traveled and she was like, I would travel to go to the best beach or the nicest mountain. And that’s just one week that I get.

Right? I’m going to have my body and the care I get for the rest of my life, for every trip to the beach and every trip to the mountains. And so I’m going to go for the best where I know I’m going to get the best care because like, like this is, this is not like confined to this trip. This is like, this is, get one go at this. And I think that that’s such a great attitude where it’s like, yeah, it’s not going to be as fun as going to the Bahamas, but like,

Dr. Ginger Garner PT, DPT (15:58)

Yes. Yes.

Dr. Vargas And Dr. McHale (16:19)

it’s gonna be, you’re gonna take it with you for every trip to the Bahamas forever. But it would be great if people didn’t have to travel and there were more specialists. Or, or. to be, you know, like there should be, I think, I don’t think you should minimize like the importance of your health and I do think you should do what you need to do to take care of yourself. And there’s gonna be some care that you’re gonna have to travel for and that’s the reality. But I do think ideally there would be more access. Sure.

Dr. Ginger Garner PT, DPT (16:25)

⁓ that is so good.

Yeah.

Yeah.

Dr. Vargas And Dr. McHale (16:47)

But the other good option is we could open Bahamas and Endometriosis second complex surgery and then you get both. I’m ready, we’re doing it.

Dr. Ginger Garner PT, DPT (16:53)

Yeah.

⁓ the possibilities are endless.

you know, I think that was so moving. I love the way that that patient that you referenced couched that and approached that. Because I do get that question a lot when I make the recommendation to send people to you or to Dr. Vidali or yes, or so many wonderful people, Center for Endocare. ⁓ Because I’m like right in the middle of all of you wonderful people.

wonderful surgeons, ⁓ that’s the question I get. ⁓ my gosh, I have to leave the state, you know? And we do need more providers, but I think that what you’re saying is such an important place to start because that you are basically essentially talking about ⁓ being heard. It’s the beginning of healing. It’s the place where then we can go on and talk about diagnosis and what it…

what it means to understand disease presentation before treatment decisions are made because you guys are the best and I wanna make sure that people get to the best people, my patients and anyone else that’s listening. So I wanna talk a little bit about diagnosis mapping and continuing the conversation on listening deeply. So.

Vicky, know that you do a lot of pre-op eval and radiographic staging, and of course, Melissa, chime in on this as well, but talk about that a bit, because really, historically in the past, you’re depending on surgery to make a confirmation of diagnosis, and I know that it’s shifting, and technology is, it’s a good time to be alive, right? So talk to the…

Talk to the listener a little bit about ⁓ what that means now versus what it meant even five years ago and what the future of this looks like.

Dr. Vargas And Dr. McHale (18:53)

This is like a big part of my journey as a surgeon. So it’s very near and dear to me. So, and I have to give full credit to the Europeans and the South Americans who I think have really led the way in creating protocols and recognizing the importance of preparing for surgery. And I’m talking like the best surgeons in the world prepare for surgery. They prioritize preoperative mapping or identification of endometriosis.

severity. And, you know, I, can’t say how important that is. So when I was a young surgeon, and I felt very, like anxious about doing cases and not knowing how bad it was going to be, and feeling unprepared, you know, like having to call in a colorectal surgeon at the last moment, thankfully, I had like our partner, Dr. Obias, I knew him and he was interested in endosurgery. So he would always help. But

I feel like that’s not a guarantee for most young surgeons. I had so much anxiety about not being prepared for surgery, I started looking into this. And no one, it wasn’t taught in my fellowship. It wasn’t taught in my residency. And I trained with amazing, incredible surgeons known worldwide, but I mean, it is not mainstream in the US, so it wasn’t part of my training to the extent that I went out of my way to learn.

Dr. Ginger Garner PT, DPT (20:15)

you

Dr. Vargas And Dr. McHale (20:19)

because as a young surgeon, felt even more so than any, like a surgeon who could walk into an OR and tackle anything. Like I felt like it was even more important for me as a young surgeon to be prepared. I owed that to my patients, you know? And I owed the counseling in advance to my patients for them to know what the heck they were getting into. So I went, I started reading, there’s the IDEA protocol. This is the most well-known and validated protocol. It’s from ⁓ Europe. ⁓

because in Europe there’s a lot of gynecologists that do ultrasound. It’s ultrasound based and in places with low resources, ultrasound’s available. And whereas MRI is more difficult to access, the Brazilians have mastered the MRI. You now have seen the MRI spread throughout Latin America and even Mexico, North America. ⁓ MRI is used widely in the US, but there’s no standardized protocol here in the US. Their IDEA protocol, the ultrasound protocol, which is what we use a lot of here,

Dr. Ginger Garner PT, DPT (20:57)

Mm-hmm.

Dr. Vargas And Dr. McHale (21:19)

is there’s like zero uptake in the U S like there’s one really, there’s a couple of really great surgeons in the U S ⁓ Yvette Grossman based in Boston. She’s not a surgeon. She is a dedicated GYN, ultra-synographer and Laurie Hockman who was in, ⁓ I believe Florida. You, I believe usf I believe, and they’re amazing. And I like went to them and they were amazing. They, they, they have taught me so much. I’ve done their courses. They do courses. ⁓

throughout the country and Matthew Leonardo in Canada too, he works with them. So I went out of my way to learn this and it like altered, I became a beast in the OR from doing this. Like I could take on any case because if I know what I’m getting into and I’m prepared and I have the right players in the room. And I think not only does it create a sense of security for me on a personal level, I feel like an incredible doctor that I can talk to my patients in advance and say,

this is what we’re gonna be doing, like, what do you, you this is what it means, you know, this is how you should prepare, this is how much time you need, this is the recovery process. And I build trust with my patient, it makes me feel secure in what I’m doing, I have all the key players in the room, I can plan the OR, the OR staff loves me because they know how long my cases are gonna take, because I know how long my cases are gonna take. So that was a very long-winded answer.

Dr. Ginger Garner PT, DPT (22:42)

Mm hmm.

Dr. Vargas And Dr. McHale (22:45)

Like I said, this is very near and dear to

me on a personal level. It has completely altered my ability, my surgical skill. I feel like I’ve become a much better surgeon because I know what I’m getting into. And I think the things that maybe, if I didn’t know Vicky so well, it would be hard for me to wrap my head around that. And what I think…

Like, and these are the things that I think make Vicky so amazing that I was like, I have to work with this person. And it was the, it’s these two elements that she has about her preoperative sort of attitude and how that translates into the OR. One is that like no blank checks attitude, right? Like Vicky will be like,

this is what I see and this is what’s gonna happen and this is what it’s gonna mean for you. And like the expectations are totally laid out. And I think that that’s extremely unique, right? Like it’s, you really can’t find a lot of endosurgeons who have that level of detail going into the surgery where they’re like, I know exactly where it is in relation to this artery and here and here. And like, no, no surgery’s perfect. no, surgery can be perfect, but there’s not,

Imaging’s not perfect, Unexpected things happen, but I think sometimes surgeons who are really good, they almost like, they rest on their laurels too much about being like, I’ll figure it out when I get in there and the patient will wake up and I’ll tell them about it. And Vicky has this attitude like, you don’t deserve that, right? Like you deserve to know what’s gonna happen to you in my best estimation and it’s my responsibility to be as good.

Dr. Ginger Garner PT, DPT (24:07)

Mm-hmm.

Dr. Vargas And Dr. McHale (24:33)

at telling you what’s gonna happen as I possibly can be. And that leads me into the second thing that is so unique about what she just said, which is that attitude of self-improvement, right? And you don’t find that with a lot of other people at her level. Most people who are as established as Vicky is are out there being like, what conference can I speak at today, right? And Vicky’s out there like, where can I learn more and make myself better? To the point where she was like, she was like, Melissa,

it’s the dead of winter, we’re going to go to Toronto and work on our ultrasound skills. And I was like, Toronto in, in what was it? January? was like, yeah, great. Love that for me. Honestly, amazing course, right? Like we had a great time. We met a bunch of amazing people. We both built on our skills and that that’s the difference between being like, I’m good enough. Right. And I think that’s one of the things that we bond over all the time is neither of us like

Dr. Ginger Garner PT, DPT (25:02)

Ha!

Dr. Vargas And Dr. McHale (25:29)

And like, yeah, we could unpack this with a therapist for sure, but like neither of us is ever good enough. And so, and instead of beating ourselves up about it, we’re like, how can we get better? How can we get better together? How can we make ourselves better? And I think that that’s the thing that like, like what the, that, that answer she gave you, like those are the things about that answer that are so amazing. Thank you. Oh you’re welcome.

Dr. Ginger Garner PT, DPT (25:51)

I love that. I

love that. But and, you know, and in all seriousness, this is changing everything. It’s changing absolutely everything. So there’s no guesswork as, you know, less guesswork, you know, as you go in and confidence building for patients, because I also hear this a lot from patients that are going in.

Dr. Vargas And Dr. McHale (25:56)

And you

Dr. Ginger Garner PT, DPT (26:20)

A, they question, it going to be bad enough? Are my symptoms bad enough to even warrant this kind of care? And then two, they’re gonna get in there and I don’t have endo, right? That is a level of anxiety creation that in all the patients I’ve seen, I don’t know if there’s anything higher than that, you know? Like.

Dr. Vargas And Dr. McHale (26:30)

Yeah. ⁓

Mm-hmm.

Dr. Ginger Garner PT, DPT (26:44)

more

anxiety producing than committing yourself to a surgical process and then gaslighting yourself over it and going, ⁓ they’re not gonna find anything. And I have made all this up in my head, you know, et cetera. So how do you explain the role of, because the general population just thinks an MRI is an MRI, you know, and ultrasound imaging is ultrasound imaging, and that’s not true. And we know that’s not true, but how do you explain that?

Dr. Vargas And Dr. McHale (26:50)

you

explain

Dr. Ginger Garner PT, DPT (27:14)

to patients the role of expert ultrasound

Dr. Vargas And Dr. McHale (27:14)

that to patients.

Dr. Ginger Garner PT, DPT (27:17)

and mapping endo.

Dr. Vargas And Dr. McHale (27:19)

I think, I mean, I think I just explained it as like it helps I evaluate for mobility. I mean, like, this is so technical, and maybe you’ll have a more ⁓ articulate answer about this. But I’m like, you know, I want to see the if there’s like scar tissue, so I assess mobility of the pelvic organs. And then I look for deep nodules, ⁓ or endometriomas, because you can see these deep nodules, you can see endometriomas, and you can see

when there’s lack of mobility from scarring tissue. But sometimes that lack of mobility is from hypertonic pelvic floor. And I explained that as well. But, I explained that. And then I also explained something else, which I think you sort of alluded to a little bit in the last comment you made about ⁓ patients being worried about not having disease, is that 80 % of the time, people, our patients have superficial endometriosis and their ultrasounds will appear pretty normal, except for maybe features of adenomyosis, which we see.

often. ⁓ And so I also spend a lot of time saying, look, even if you have full mobility and there’s no evidence of deep endometriosis and or endometriomas, we cannot exclude, this is not exclude endometriosis. It just excludes the kind of disease that would require a multidisciplinary surgery for the most, with a very good ⁓ sensitivity, you know, it’s so.

Dr. Ginger Garner PT, DPT (28:19)

Mm-hmm.

Dr. Vargas And Dr. McHale (28:45)

If you have a pretty normal ultrasound with features of adenomyosis, it means most likely you’re not gonna end up, up with a bowel resection in the vast majority of cases or something like that. Yeah, I think I give my patients a similar disclaimer that when we’re doing imaging, it’s not so I can tell you if you do or don’t have endometriosis. Yes, if I see a big honk in endometrium or something, yeah, you have endometriosis, but I can never scan someone and say, oh yeah, you don’t have it.

So sorry, bye bye, right? It doesn’t work that way. And the analogy I use is like, let’s say you had like one of those crazy rashes that you see on the pit where there’s like blisters all over your arm, right? If we took an X-ray of your arm, it would show up totally normal. You know the blisters are there cause you’re looking at it, right? But this is superficial endo is like a pathology like that on the inside of your body, right? And so these superficial things, we can’t pick up on them with imaging yet.

You know, we can dream, ⁓ but as of yet, I can’t scan you and say you don’t have it. The purpose of the scan, like Vicky said, is preoperative planning and safety evaluation, right? Because I empower every patient to make her own decision about if and when it’s the right time to have surgery, right? Endometriosis is not something where it’s like, we gotta catch it when it’s stage run, because it’s gonna progress to stage four, right? It doesn’t work like that. And so the…

Dr. Ginger Garner PT, DPT (30:08)

Mm-hmm.

Dr. Vargas And Dr. McHale (30:11)

Most important empowerment to me is like if and when is the right time to have surgery. And so sometimes it’s like, well, do what you want, but I’m really worried because your ureter is really big over here and your kidney is starting to get bigger and that’s a safety issue. Right. And so the most important thing is like, are you physically safe right now? And so, you know, or like, you know, do you have such a big nodule that I’m worried that your colon is going to get blocked or like you have a 10 centimeter cyst in your pelvis, right? These are

Dr. Ginger Garner PT, DPT (30:26)

Yeah.

Dr. Vargas And Dr. McHale (30:38)

really important safety features we need to know about. And that empowers the patient to either know like, okay, I’m not in danger right now. I can wait until I get my new insurance or I finished my grad school degree because my symptoms are okay on medical management for the moment. like whatever she needs to do to get her life in the proper place so that she is in the right like mental, emotional, physical space to have surgery if that’s what she decides to do, right?

So it’s really giving her all of that information and all of those sort of resources to make the decision that’s right for her. That was a long answer for that. No, no, this is such an important aspect of what we do. And I would add, just to add to that fertility, the impact on fertility. I think a lot of our patients are very concerned about that. And so we spend a lot of time talking about.

Dr. Ginger Garner PT, DPT (31:30)

Mm-hmm.

Dr. Vargas And Dr. McHale (31:33)

the potential impact on fertility. And so the extent of disease correlates with the impact on fertility and it opens, know, people plan their lives around these surgeries. Like they’ll be like, okay, let me freeze eggs and then I’ll do surgery. then, you know, it really helps with planning life, life a little bit to have the idea of the extent of your disease. I also just want to add one thing, which I think

I thought of because I went to a conference and there was like this really well respected, like French surgeon saying like, ⁓ I don’t know about a test for endometriosis. ⁓ you know, like it’s 10 % of women and ⁓ and you know, like it’s it’s probably going to be expensive to do a test. like, are we going to really test everyone with this expensive test? And I

In the moment, I didn’t know what bothered me about that, but I’m always sort of slow to come to my conclusions. And then I thought about it more and I’m like, you know what, but surgery is a big step to get a diagnosis. And since 80 % of patients are gonna have a somewhat normal looking ultrasound and have to still go into this without any confirmation, I feel like it’s an important, it’s beyond ultrasound. I do think that there needs to be a diagnostic test.

Dr. Ginger Garner PT, DPT (32:53)

Mm-hmm.

Dr. Vargas And Dr. McHale (32:54)

for these patients. I really just feel like that’s a huge decision to take on the risk of surgery without being sure you have a disease. I don’t know why we do that to our patients or why we haven’t come up with some other solution. And it comes back to that uncertainty being so painful for people that you were talking about, the do I have it anxiety. Like if I could tell every single patient, like you have a positive test, you have an X percentage of having endometriosis. I mean, I think that that empowerment

Dr. Ginger Garner PT, DPT (33:06)

Right.

Dr. Vargas And Dr. McHale (33:24)

would help so many more people feel like, yes, I can have surgery because I know I have it. Because I do agree with you that what holds a lot of people back is the like, is it in my head? Am I imagining this? Like, what if I don’t have it scenario? And so, yeah, think, you know, I think both of what you guys have said dovetails in this. Like the more knowledge we can give patients, the more they…

Dr. Ginger Garner PT, DPT (33:38)

Yes.

Dr. Vargas And Dr. McHale (33:50)

like they are going to be able to advance their own health. And ultimately like you, you know, you are the number one agent of your own health. know, no one, we, every, every doctor, every provider you see works for you because you are, you are the captain of your own health ship.

Dr. Ginger Garner PT, DPT (34:07)

Yeah. I think that the, you know, coming up with a test for endo is, you know, anyone in the endo space, of course, that’s, on the brain ⁓ as a wishful thought of, and also a little bit of anger of why we don’t have anything yet. ⁓ Because if it affects one in nine, one in 10 women, that’s as, that’s the same incidence of diabetes. And we’re constantly screening for that, right?

Dr. Vargas And Dr. McHale (34:36)

And I want to

add one more thing. I’m sorry. It’s just because I have this fresh on my mind because you you can even have a surgery and not receive a diagnosis, right? Because disease can be really subtle. And if the surgeon is not using the techniques as defined by the World Endometriosis Research Foundation of how to look for disease and where to look, by the way, there’s a structured assessment that is recommended for surgery that is often not utilized.

Dr. Ginger Garner PT, DPT (34:47)

Mm-hmm.

Yes.

Dr. Vargas And Dr. McHale (35:05)

plus Dr. David Redwine’s close-tip laparoscopy technique, which says you need to get two centimeters from the tissue that you’re looking at with your laparoscope. And I just want to lay that out because that doesn’t happen. That doesn’t happen. So you could take on the risk of surgery, go have surgery and be told you don’t have it when you do. And I have a doctor, another physician whose mother was a physician who sent her to the best surgeon in the area who did not diagnose her endo.

Dr. Ginger Garner PT, DPT (35:18)

Hmm.

Dr. Vargas And Dr. McHale (35:35)

So she had a second surgery. I wanna go into the whole story, but she suffered years and years and and like didn’t get the diagnosis. And I think this is, so you could even have a surgery and it can be missed. So I think this is where I just wanna re-emphasize.

Dr. Ginger Garner PT, DPT (35:38)

Wow.

Yeah, that’s so, so important. I share different stories about patients who have come in because I think that a lot of pelvic PTs end up referring to surgery because we’re looking for that. Endo is on our radar and it’s one of the things that we’re screening for ⁓ in patients. And unfortunately, I hear that story all the time where a patient comes in, sits down, shares their story.

and they’ve had multiple surgeries, sometimes for hip arthroscopy, sometimes multiple hip arthroscopies before they sit down and no one has ever asked them about endo, you know, and then you know the rest of the story from there.

It brings up an important point ⁓ because endometriosis ends up touching every part of that person’s life, that woman’s life. And that brings us into talking about whole person care, whole person impact, and multidisciplinary care. And one of the things that I don’t think can be overemphasized is that endo effects far more than just the pelvis. ⁓

physically, obviously, but also social, emotional, relational and otherwise. So I know that, I already know kind of the answer to this question, but I want to hear you talk about it and I want the listener to learn about it too. What do you define as like true multidisciplinary care? What does it look like in your practice beyond like referring out?

Dr. Vargas And Dr. McHale (37:35)

Yeah, I mean, think right now the way that this is built is of course from, we began with the idea of multidisciplinary surgical care and the intestines are the most commonly affected site for endometriosis. And this is something especially like honestly, I learned a ton working with Dr. Obias because when I first started,

I was really limited in my knowledge of all of the different ways that you can take out part of the bowel. And ⁓ I find that a lot of endometriosis care is one of two things. It’s either shaving or just a segmental resection. And shaving, of course, is one of those things where the risk is like, okay, did you get it all if you’re just sort of shaving down a lesion? Like, you know, how good are we at actually identifying where the lesion stops and the normal, you know, intestine begins?

Dr. Ginger Garner PT, DPT (38:15)

Mm-hmm.

Dr. Vargas And Dr. McHale (38:30)

And a lot of these invasive lesions, they really go all the way through to the mucosa. But when you’re doing a segmental resection, the risk of complication is higher and the ⁓ surgical recovery is much more. And also it just, can impact people in much more long-standing ways because you lose a lot of the nerves and the blood vessels to that portion of the intestine. And learning from Dr. Obias, I was like, my gosh, like endometriosis patients need to have all of these tools that you have to offer. And so that was when I was like, okay,

Like I never, like I don’t, it’s not whether or not I can do like a shave or a segmental resection. It’s that the patient needs someone who is an expert in that part of the body and an expert in endo, right? So like we are an expert in the female pelvis and the gynecologic organs and endo, right? But Dr. Obias is an expert in endo and the intestines. And so the more you can grow a practice like that where people bring different elements of expertise,

That’s when patients, I think, get the best outcome. And then we added ⁓ Jen, who’s our nurse practitioner, who really is just unbelievably knowledgeable at the different ways that different hormones can impact someone’s ⁓ whole body, right? Because there’s a million different ways that our hormones affect us. And the truth is, no one can be an expert in everything. so having people who are really like, OK, like,

I offer this to the patient and then someone else offers something else to the patient, then that really enables everyone to get the most out of their care. And so that’s sort of the core that we’ve built so far here. And then we have just this vast network in the DMV of people we work with so that I can listen to a patient’s symptoms and be like, man, I really think you would benefit from a nutritionist. This is the one I work with most closely. Or, you you need to see a really good pelvic floor PT.

you live here, the best, the closest one who I know is really good is here, or there’s an allergist we refer to all the time because our MCAS patients get such great care there, and a performance cardiologist who does all the POTS management for it. It’s really knowing who are the providers who are going to listen to your patient and acknowledge the symptoms that are within their wheelhouse and work with them collaboratively.

Dr. Ginger Garner PT, DPT (40:36)

Mm-hmm.

Dr. Vargas And Dr. McHale (40:49)

to make it better and having those resources for your patient, I think is really, you know, that’s what multidisciplinary care means to me. Yeah, no, I can say to me, I think patients need multidisciplinary care outside of the OR and in the OR and the complexity of this disease and how it impacts the entire body is just so under recognized. And I think this is where like the general OB-GYNs really

don’t understand this disease. ⁓ Like in some ways they’ll do it like they’ll be like, you’re having urinary symptoms, go see urology and you’re having GI symptoms, go see GI and like everything’s normal and like that is not multidisciplinary care. So they’ll like, our patients will have had a colonoscopy, a endoscopy, a cisto and like have

Dr. Ginger Garner PT, DPT (41:20)

Right.

Mm-hmm.

Dr. Vargas And Dr. McHale (41:42)

seen like a multiple specialist and have had no answers. That is not multidisciplinary care. That is punting.

Dr. Ginger Garner PT, DPT (41:48)

So true. I’m so glad that you made that point because I think that that would

be easy for a patient to take away and go, oh yeah, gastroenterology is important, pain management, et cetera. But you just hit the nail on the head, like popping around and getting punted from provider to provider is exactly the problem. And that also happens across every discipline that you just named. So I think that…

how do patients navigate that? What do you wish that everyone that you just listed, pain specialists, GI, pelvic PTs, primary care, all the people, what do you wish that everyone understood better about endo just overall?

Dr. Vargas And Dr. McHale (42:38)

So I wish I wasn’t so passionate. I feel like I’m going to explode with emotion. She will. So the thing that I think about this disease that is so poorly understood, and I like to compare this disease to Crohn’s rheumatoid arthritis, ulcerative colitis. And there are scientific models that have shown how those inflammatory illnesses alter the autonomic nervous system.

Dr. Ginger Garner PT, DPT (42:42)

Hahaha

Let it fly.

Dr. Vargas And Dr. McHale (43:07)

increased sympathetic activity, which therefore increases inflammation and down regulates parasympathetic activity. just like for listeners, the autonomic nervous system is a part of the nervous system that regulates all of the subconscious functions of the body, like bowel function, bladder function, sexual function, your heart, your lungs, like your breathing, like, you know, all sorts of your so

So many parts of your thinking, a lot of parts of your body are impacted by the autonomic nervous system. Your entire body is impacted by the autonomic nervous system. And having a dysregulated autonomic nervous system is something that we have seen in these inflammatory diseases. And I read a review by these authors that stipulated that something similar happens with endometriosis and you can get this autonomic dysregulation or dysautonomia in endometriosis patients.

And it really impacts the entire body. Patients will say they have brain fog, they have fatigue, they have alternating constipation and diarrhea, they have urinary dysfunction, they are impacted on, they have non-restorative sleep. Every aspect of their lives is impacted. And we never talk about the autonomic nervous system. And I think this is something that Eastern medicine has really, that was the whole foundation of like,

Dr. Ginger Garner PT, DPT (44:11)

Mm-hmm.

Dr. Vargas And Dr. McHale (44:34)

the yogic traditions and Chinese medicine and acupuncture. This is not new. This is thousands of years old and highly developed, but not utilized in our modern Western medicine enough. And we’re moving towards that more and more. ⁓ But this is what I think isn’t recognized. If you have dysenteryomic dysfunction, people are like, I don’t know what your problem is.

Dr. Ginger Garner PT, DPT (44:36)

Mm-hmm.

Dr. Vargas And Dr. McHale (45:00)

I don’t know what to tell you, but I would say, you know what, lifestyle is very important for dysautonomic dysfunction or dysautonomia. Lifestyle is something we need to talk more about. It’s really hard to have ⁓ increased vagal tone when you’re working 60 hours a week and not moving and eating crap. You know, I’m not saying our patients are doing that. If anything, our patients are going above and beyond, you know, but I think these are the things that no one talks about with our patients that

Dr. Ginger Garner PT, DPT (45:20)

Mm-hmm.

True.

Dr. Vargas And Dr. McHale (45:30)

that I’m a surgeon that I have to talk about with, I spend like so much time talking about with our patients. Why are these types of things not more mainstream and like not more discussed about just overall health for every person, not necessarily endo patients? I think we need to talk about the mind-body integration. And I think we need to talk about how endo impacts the entire body a lot more than we do and how all diseases do.

Dr. Ginger Garner PT, DPT (45:59)

Yeah. my goodness. You’re speaking my language and I’m going to, this is going to perfectly segue Melissa into a big giant question that I have for you. But I just want to say that as, you know, as a pelvic PT, as someone living with endo, I think that what organically led me into way before I knew this was even an issue, you know, for me, what

Dr. Vargas And Dr. McHale (46:00)

I.

Great. ⁓

Dr. Ginger Garner PT, DPT (46:28)

helped me manage my entire life and the experience that I was having was integrative medicine, was lifestyle medicine. And then I remember that I just put my two, I’m gonna move my camera here because my first two books were actually therapeutic yoga and then the second one was a lifestyle medicine. And I just started to laugh out loud because you just see the evolution and the integration of how

you naturally come into those things. that’s, you know, saving my own life meant practicing yoga and taking it very seriously and getting board certified in lifestyle medicine and taking that seriously and realizing how, you know, that is as equally, you know, as important as the expert surgery that we get. So I want to thank you for bringing that up because that is often what helps, I think,

Honestly, when I got out of school myself, I realized that really nothing I had learned in school was going to help me in my job, was gonna help me help patients. And I almost quit, I really almost quit. if it wasn’t for yoga, integrative medicine, lifestyle medicine, maybe I would have, maybe I wouldn’t be here today. ⁓ it brings up an important point. And Melissa, I know that you have… ⁓

and thank you both for the intensity and the passion that you bring to this. I’ve been moved to tears several times listening to you talk, but your interest in hypermobility, connective tissue disorders, dysautonomia, so we’ve got POTS under that umbrella, and MCAS, I don’t think that our listeners, to, listener, I’m not saying that you don’t understand, I’m saying that.

It’s not appreciated enough, it’s not talked enough about how these things overlap. So let’s talk about that for a few minutes.

Dr. Vargas And Dr. McHale (48:29)

Totally.

I think, you know, much as I like to say, you know, the simplest explanation is best and you don’t have 12 conditions when you can have one, the reality is often pelvic pain disorders are like bananas where they only show up in bunches. ⁓ And I think a lot of this really just has to do with getting to know your patient so that you can appropriately counsel them about what things they need to do. ⁓

Dr. Ginger Garner PT, DPT (48:44)

Yeah. Yeah.

Dr. Vargas And Dr. McHale (48:58)

to actually get the result they want. And this is why I think I spend more time than zero, which I think is not common in lot of appointments about what are the things getting in your way? What are your goals for this? Tell me more about you as a person so that I know what are we focusing on here? Because that helps me tell someone what is going to be most high yield for the symptoms getting in their way.

And everybody’s different, right? Like sometimes I will see a patient where like it really sounds like endo is 99 % of their problem. And sometimes it’s like, it sounds like you have endo, but what you’ve described to me also really sounds like you have hypermobility and you have pelvic congestion and you have, you know, you have POTS and it’s probably from your venous occlusive disorder. you know, and so

that really allows me to say like, okay, here’s how I forecast your entire care journey, right? And for some people, it’s reasonable to say like, okay, I think you should have surgery and then really the next steps for you are gonna be like, let’s see how you feel, plus minus physical therapy. I don’t know if you’re gonna need more than that. You may just feel awesome. Other people, it’s like, your arms bend in ways that I didn’t know arms could bend.

And so, I know there are elements for planning for surgery for you that we have to think about. And then there are elements for lifelong care, right? We need to actually have a probably lifelong PT and strengthening plan for you because a lot of your pelvic pain probably comes from that, ⁓ But in the more immediate, it’s a lot of the like…

Dr. Ginger Garner PT, DPT (50:25)

Thank

Dr. Vargas And Dr. McHale (50:49)

Okay, how am gonna protect your knees during your surgery? How are we gonna make sure your anesthesiologist is protecting your jaw and your C-spine during your surgery, right? These kinds of things in a hypermobile patient where, you know, if your doctor doesn’t even know you’re hypermobile, they are not thinking about these things. And if your doctor doesn’t know anything about hypermobility, then, you know, I find, unfortunately, a lot of patients are like, okay, the doctor will know. And so they’ll say like, before my surgery, I want you to know I have hypermobility. And the doctor’s like,

Dr. Ginger Garner PT, DPT (50:51)

you

Yeah.

Dr. Vargas And Dr. McHale (51:18)

okay. And then they just they don’t say like, and what would you like me to do about it, which is how most doctors, you know, would think about something like that. And so it’s like, it’s not enough to tell them you like they need to know, like, what are we doing here for this, right? And, ⁓ and then it’s a lot of like, what’s the plan afterwards, because the thing that I find often is like, one of the tragedies of patients with overlapping conditions is they will

Dr. Ginger Garner PT, DPT (51:22)

Right? Right.

Mm-hmm.

Dr. Vargas And Dr. McHale (51:48)

have surgery for endometriosis. And their endo is gone, and so they feel some improvement. And that relief, like it hits them like a gust of wind. And they are living their life for six months because they feel so much better than they did. But they still have all of the instability of the joints of the pelvis, and then they still have all of the excessive muscle tension that comes with that instability. And they also have pelvic congestion that’s untreated, and those things catch up with them.

Dr. Ginger Garner PT, DPT (52:18)

Mm-hmm.

Dr. Vargas And Dr. McHale (52:18)

And they

usually catch up with them sometime between six months and two years after that surgery. And the reaction is always, ⁓ my endometriosis is back. And then they go see another surgeon and the surgeon says, well, I am the best surgeon of all surgeons. And so if you have surgery with me, you will feel better because it must just be that either your endo is back or your surgery is incomplete. And so the patient has another surgery and they may or may not get now, you know, now it’s like, okay, you got

Dr. Ginger Garner PT, DPT (52:42)

Yeah.

Dr. Vargas And Dr. McHale (52:47)

a year of relief last time and maybe you’ll get three to six months this time, but they got some improvement. And so then when their symptoms come back, they’re like, my gosh, do I just have really aggressive endo? And it’s just back again. And then they have like seven surgeries with seven different, and sometimes they’re really well regarded, super talented surgeons, right? And they had a beautiful surgery, right? But a beautiful surgery that doesn’t help you, doesn’t help you.

Dr. Ginger Garner PT, DPT (53:16)

Yeah.

Dr. Vargas And Dr. McHale (53:16)

And I think that’s so, I don’t know. And

oftentimes these patients have horrible recoveries too. So like they have a much more difficult time recovering from surgery. I think it’s really, have to be thoughtful about it. Like you said, you have to talk to, you have to have these long conversations. We spend a lot of time with our patients discussing these things and the other risks, the things that are at risk were like the pelvic congestion. If you have Ehlers-Danlos, your higher risk for having venous.

Dr. Ginger Garner PT, DPT (53:22)

Mm-hmm.

Yeah.

I know.

Dr. Vargas And Dr. McHale (53:45)

compression disorders and needing treatment of those things. And I think we spend a lot of time on that because no one else does. Yeah. And I find, I just see so many misconceptions where people will be like, well, you know, fine. If you have pelvic congestion, like I’ll just see some dilated veins during your surgery and I’ll just ligate them when I’m in there and then you’ll be fine. And the patient will be like, that’s what, that’s the plan I’m going to go with, with somebody else. And I’m like breathing into a paper bag in the corner.

Like, you know, please don’t do that. Like, no, no, no, no, no, please. Let’s have someone who specializes in the problem you have fix that problem. Like people, doctors need to stay in their, like stay in your lane, right? Like you don’t call me to do your taxes. Don’t call me to like fix your pelvic congestion. ⁓ I got one thing for you.

Dr. Ginger Garner PT, DPT (54:15)

That’s a really good point. That’s a really good point. Mm-hmm. That’s what I wanted to…

Yes. Yes.

Stay in the

Yeah, that’s a really important point and a really good segue into what I wanted to talk about next, which is surgery. And to underscore the importance of what you’re talking about with the overlapping conditions with dysautonomia, MCAS, EDS and hypermobility, ⁓ we do need those specialized providers that can follow up with that. mean, one of the ways that I see it every day, ⁓ and I just…

referred someone out for pelvic congestion the other day, which turned out to be exactly what it was because we weren’t getting anywhere. But one of the things that I see ⁓ after resolving the other issues is ⁓ from the ultrasound imaging on my side that I end up using is with EDS, with these overlapping issues is that the connective tissue doesn’t even act normally under imaging. so,

they’re not getting the recruitment patterns to restore pelvic girdle function. I’m not seeing the balance between the internal oblique and the transversus abdominis the way it should be or any fascial gliding or anything like that because of the way they’re scarring, because of the way the connective tissue acts. And so that becomes very validating. And then there’s solutions for that. ⁓ But what you said was so incredibly important because I don’t think

And I just had a patient two weeks ago that sat down and said, well, I’m just going to try the surgeon here. They said they’d go in. I’m going to air quote again, see what’s going on, right? And I’ll just try that here because it’s local, et cetera. I said, some things. But the point of that is, is I would love for you to then just, you know, elucidate, illuminate for people why it’s so important. You’re known for complex.

complex endometriosis surgery, you’re defining excellence of surgical care in the field. How do we communicate this? What do you wish more patients understood about the difference between having surgery, right? Like the patient that sat down a couple of weeks ago and said, I’m just gonna go to the general GYN, they’ll just see what’s going on. And I had to then take that next step and say, this is really what you want to do with endometriosis. So how do you explain the difference between having surgery and having

surgery in a truly specialized setting.

Dr. Vargas And Dr. McHale (57:08)

So I think we talked about this, Melissa and I talk about this all the time. It’s like the most important surgery is the first surgery. The first surgery is the most important surgery. And the evidence supports this with regards to both pain and fertility. The most important surgery you have is the first surgery. And you really want to make that a perfect surgery. If you can, obviously. And that entails knowing the extent of disease before the surgery.

Dr. Ginger Garner PT, DPT (57:18)

Yes.

Dr. Vargas And Dr. McHale (57:38)

planning a multidisciplinary surgery if necessary, and discussing fertility goals if that’s an important priority for the patient. If that’s a priority for the patient, then you have to talk about the order of surgery. And I think, you know, there are, we see lots of patients that have had surgery before. There’s different things, there’s different surgeries that are worse than others, right? So if you have had ⁓ incomplete surgery,

in the past or incomplete excision of your endometriosis. It really varies, it can destroy, it really can destroy fertility. It can be that your endometriosis impacts fertility, but it can also be that your surgery impacts fertility. It can also just create further inflammation. Like think if you go in and disrupt your endometriosis, but don’t remove it. Think about the inflammation that causes for the.

So it can worsen overlapping conditions. And this is not like evidence-based. This is what we see. We see this in our patients. They got so much worse. They had new pain. They had new pelvic floor dysfunction. You know, they got worse after surgery. And those patients, you know, let’s say they have their second surgery with an expert who is able to remove all visible lesions. They may require, you know, much more post-operative, like,

for physical therapy and other treatments like trigger point injections, Botox, to get better because they had incomplete surgery before, you know, and they could require IVF because their fallopian tubes got destroyed. Incomplete surgery is not only ineffective, it can be harmful. Actively harmful. Yeah. I mean, there are certain things that we see all the time that should just never happen.

Dr. Ginger Garner PT, DPT (59:20)

Mm-hmm.

harmful. Yeah.

Dr. Vargas And Dr. McHale (59:35)

Right? Like I see people who have an ovary removed so often because they had surgery with a general GYN and they had an endometrium and they were like, well, I didn’t think we could save it. It’s, and that’s the kind of thing where it’s like, we cannot unring that bell. Right? Like ovaries, it’s not just like you have a backup, right? It’s, it’s not, it’s not that way. And so this is the kind of thing where it’s like people, you know, I think sometimes surgeons

or particularly non-expert surgeons, they don’t fully recognize the ramifications of some of their actions when they do a lot of harm. Because when your doctor harms you, you don’t usually go back to them to be like, hey, my life is way worse now. Let’s talk about it. I some people do, right? But the reality is that those doctors often don’t, it’s like they don’t even know how much harm they’re doing. And so,

Dr. Ginger Garner PT, DPT (1:00:24)

Yeah.

Dr. Vargas And Dr. McHale (1:00:33)

They keep doing it. and I don’t, again, I don’t mean to bash doctors. It’s, comes from a desire of wanting to help people, but not knowing or not having the right tools to do so. And, you know, patients ultimately are the ones who need to, to be saying like, okay, do I really trust this person? Right? Do I know that this person who’s like surgery is just an incredibly intimate experience, right? You need to trust your surgeon completely, not only to have the ability to do everything.

that needs to happen during your surgery, but also to understand your values and your priorities and to be able to say like, okay, like what, like this person gets one body, like what do they want, you know, what do they want me to do with it? How can I best forward their goals knowing them as a whole person? And I think that that’s, you know, really important. I just want to add one thought along that vein, which is like you were talking about the general OB-GYN removes the ovary.

And again, I respect my colleagues a lot and I recognize the barriers that they face to being, providing the best care for our endo patients. But like, I think a lot of times there’s this misconception that there’s a field called GYN oncology, ⁓ that they’re like the best surgeons in our field. And I think in many ways they are. They’re incredibly talented surgeons, but they’re cancer surgeons, which means they remove organs.

to prevent cancer or to remove cancer. And oftentimes patients will see a GYN oncologist because they’re told they’re the best surgeons, but they’re experts in cancer and they’ll end up doing like a hysterectomy and removing the ovaries and leaving all of the endo behind. I see this a lot. Or they’ll go in, dissect all the retroperitoneal spaces and leave all the disease. like any other, any future surgery is that.

that much more difficult. And I think that’s probably one of the things that I would love to be like to disprove, I guess, ⁓ as a myth of our field. Like there’s actually a field of benign surgeons that dedicate their training to endo and, you know, benign gynecologic diseases and fertility preservation. I’m not saying that’s a perfect situation, but I think that the surgeon dedicated to the area of care that you need care for.

is probably a better option.

Dr. Ginger Garner PT, DPT (1:02:57)

Yeah.

Really, you’re talking about shifting the standard of care and educating ⁓ everyone at all levels because we’re talking directly to the patient seeking care now because they’re the ones that are going to advocate and say, no, I need an endo specialist. I don’t want to go to a GYN who also delivers babies most of the time and then does a little side endosurgery. That’s not what they deserve. They deserve to

Dr. Vargas And Dr. McHale (1:03:21)

Yeah.

Dr. Ginger Garner PT, DPT (1:03:25)

to have someone who really specializes in it. Vicky, you’ve had major leadership roles in endo education, you’re developing broader research collaboration. Melissa, you’re so passionate about early diagnosis, improving access to effective care. Where do you want to see the field evolve? What changes do we need to see next?

Small question.

Dr. Vargas And Dr. McHale (1:03:52)

I mean, it’s

good. I think we need multidisciplinary centers ⁓ of expertise where there’s all sorts of different providers because that’s the type of care these patients need. And that includes psychology. That includes nutrition and diet, know, dietitians and ⁓ physical therapy and acupuncture and like ⁓ mindfulness and yoga, which I think is incredibly therapeutic.

Dr. Ginger Garner PT, DPT (1:03:57)

⁓ yeah.

mental health and yeah.

Dr. Vargas And Dr. McHale (1:04:22)

⁓

surgeons and then long-term care. We’re really missing the long-term care, ⁓ providers. I really think there needs to be a medical counterpart to the surgeon. ⁓ there isn’t that. And we, as surgeons were, we know a lot, but like, we don’t know everything. And I think patients would be better served by someone dedicated to that care. ⁓ I think the multidisciplinary surgical teams, the dedicated imaging.

like specialists, we do our own ultrasounds, but wouldn’t it be amazing if we had an expert like in this type of imaging doing it ⁓ for us and helping us and having multi-disciplinary conferences to talk through patients together. And that’s my dream for the field. think right now we’re just trying to dream it right here in DC. But I think

Dr. Ginger Garner PT, DPT (1:04:56)

Yeah.

That’s a great dream. I love that dream. Yeah, absolutely. Okay,

Dr. Vargas And Dr. McHale (1:05:19)

I think also,

Dr. Ginger Garner PT, DPT (1:05:19)

go ahead.

Dr. Vargas And Dr. McHale (1:05:20)

there are so many movements for other conditions where you see like the American Heart Association or the Leukemia and Lymphoma Society or like so many different disease processes have like a big movement, right? like endometriosis, you see there’s a bunch of sort of different advocacy groups or research groups and often it’ll be sort of centered around like one.

doctor or one center, right? We don’t yet have one of those sort of like agnostic, if you will, for, you know, any governing body, right? Those kinds of things. Yeah. Like where, where it’s not, it’s not about an individual, right? Where it’s just about like a collective effort to improve the disease process. Right? Like we haven’t, we don’t have that for endometriosis there. You know, we haven’t had our ice bucket challenge moment where like I tell you, the funding and like all the

Dr. Ginger Garner PT, DPT (1:05:57)

Yeah.

Dr. Vargas And Dr. McHale (1:06:16)

and awareness happens. ⁓ But, you know, I am hopeful that that’s something that is coming our way in the endo world. And I want to add fertility doctors. I forgot them. Yes, they’re really important.

Dr. Ginger Garner PT, DPT (1:06:18)

Yeah.

That’s That’s true.

So in the spirit of the vocal pelvic floor, we’ve talked about deep listening. We have talked about what patients are trying to say through their symptoms, that the healthcare system that medicine often misses. So for the listener who has pelvic pain, suspects endometriosis or already has it,

or feels deeply discouraged by the medical system. What do you want them to hear today? How do you want them to use their voice?

Dr. Vargas And Dr. McHale (1:07:06)

Well, I want them to hear that there’s hope. I don’t want them to have a bleak outlook. I want them to know that there’s people that really care about this disease and they’re coming together. There’s basic science research that’s really interesting. There’s just more and more interest in this disease as a whole. And so that’s number one. And number two is say what you’re feeling, get multiple different opinions, advocate for yourself. I hate putting it back on the

patient because I think that’s like the most unfair part of this. But really like don’t be afraid to annoy people. who cares? Annoy everyone. Like yeah. And I think along that sort of advocate for yourself ⁓ vein, I wish I could empower more endo patients to just like

Dr. Ginger Garner PT, DPT (1:07:40)

Yeah.

Dr. Vargas And Dr. McHale (1:08:00)

pardon my French, but don’t take people’s shit. ⁓ I see so many patients who will be like, I had this appointment and they said all these horrible things to me and then they did this traumatic exam and then they said more horrible things to me. I’m like, so you don’t have to stay for the whole appointment. You don’t owe them anything. And so if somebody says something horrible, you can like…

Dr. Ginger Garner PT, DPT (1:08:05)

Yes.

Dr. Vargas And Dr. McHale (1:08:26)

The power move, right? You’re advocating for your body. The power move is to say, thanks so much for your time. I think I’ve gotten everything that I need out of this appointment, right? And what you needed was to know, like, this is not the dynamic for me. This is not my doctor. That’s okay. You know, you don’t have to take anybody’s shit. You’re like, be a savvy shopper, talk to different doctors, lots of specialists, us included. Like we do remote consultations for people who don’t live here.

you can find the right person for you. And then when you have somebody who’s on your team, that’s when you can be like, okay, now is when I’m getting into all my questions. Now is when we’re getting, we’re gonna make progress. I’m gonna understand this. We’re gonna make a plan together, right? Like if someone’s already being a jerk to you in the appointment, don’t sit there with your 20 questions and be like, let’s wait for another horrible answer from this doctor who doesn’t understand me. Don’t accept an exam.

Dr. Ginger Garner PT, DPT (1:09:21)

that’s so right.

Dr. Vargas And Dr. McHale (1:09:25)

You know what I mean? Like you don’t

Dr. Ginger Garner PT, DPT (1:09:26)

Yeah.

Dr. Vargas And Dr. McHale (1:09:27)

have to. You don’t owe the doctor an exam ever, ever. You know, and so you’re not going to let them do surgery on you. Yeah. It’s not, it’s like, don’t, don’t, don’t do it for your, like, it’s not, don’t do it for your doctor. Do it for you. If it’s going to be therapeutic for you.

Dr. Ginger Garner PT, DPT (1:09:36)

Yes.

You two are amazing. I want to thank you so much for being here, for doing the work to raise the standard of care, for being two incredibly talented, smart women doing work in this field, is like, creates a level of like, emotionality, if that’s a word in me that is hard to actually put words to. ⁓ This conversation has been about

It’s such a strong reminder that excellent treatment is not just about technical skill. You guys are rocking the technical skill and you have this level of compassion and passion for treating endo that’s just, you feel it. It’s like through the airwaves. So for everyone listening, ⁓ if this episode resonated with you, please share it with someone who you love ⁓ that needs to know their pain is real and that they deserve better care.

to both of you. ⁓ Please share with the listener where you can be found across Instagram, Instagram website, all the things. And again, thank you so much for being here today.

Dr. Vargas And Dr. McHale (1:10:53)

Thank you, Ginger for having us.

Dr. Ginger Garner PT, DPT (1:10:56)

So

tell us, and all this will be in the show notes as well. So you don’t have to like stop and write anything down. It’ll be, but tell us where we can find you.

Dr. Vargas And Dr. McHale (1:11:02)

yeah.

We’re in Washington, DC. ⁓ Our practice is Washington Endometriosis and Complex Surgery. We’re on Instagram. We are. Just our names. think it’s like Dr. Melissa McHale and Dr. Vicky Vargas. And there’s one for the practice too that shares all, think it’s just like endosurgeons or something like that. Yeah. And that’s all on our website, which is www.washingtonendometriosis.com.

Dr. Ginger Garner PT, DPT (1:11:07)

Okay.

Dr. Vargas And Dr. McHale (1:11:34)

Thank you.

Dr. Ginger Garner PT, DPT (1:11:35)

All right. Thank you so much for being here

again today. You guys are, I don’t know, I really, I’m not often at a loss for words at the end of an interview and today I am. So I just want to say thank you.

Dr. Vargas And Dr. McHale (1:11:51)

Thanks so much for having us. Yeah, it was a pleasure.