{"version":"1.0.0","segments":[{"speaker":"Dr Gavin Nimon","startTime":27.6,"endTime":28.880000000000003,"body":"Endometriosis, what is it?"},{"speaker":"Dr Gavin Nimon","startTime":28.880000000000003,"endTime":32.826,"body":"It affects 1 in 10 women,"},{"speaker":"Dr Gavin Nimon","startTime":28.880000000000003,"endTime":32.826,"body":"can lead to chronic pain, can"},{"speaker":"Dr Gavin Nimon","startTime":32.826,"endTime":34.166000000000004,"body":"lead to infertility issues."},{"speaker":"Dr Gavin Nimon","startTime":34.586,"endTime":36.519000000000005,"body":"Well today we're going to"},{"speaker":"Dr Gavin Nimon","startTime":34.586,"endTime":36.519000000000005,"body":"learn more about it with Dr."},{"speaker":"Dr Gavin Nimon","startTime":36.519000000000005,"endTime":39.89,"body":"Monika Juneja, a gynaecologist from the"},{"speaker":"Dr Gavin Nimon","startTime":36.519000000000005,"endTime":39.89,"body":"Flinders Medical Centre who specialises"},{"speaker":"Dr Gavin Nimon","startTime":39.89,"endTime":43.409000000000006,"body":"in laparoscopic surgery and is going"},{"speaker":"Dr Gavin Nimon","startTime":39.89,"endTime":43.409000000000006,"body":"to tell us more about it today."},{"speaker":"Dr Gavin Nimon","startTime":44.120000000000005,"endTime":45.13,"body":"Welcome to Aussie Med Ed."},{"speaker":"Dr Gavin Nimon","startTime":47.41,"endTime":50.6,"body":"G'day and welcome to Aussie Med Ed, the"},{"speaker":"Dr Gavin Nimon","startTime":47.41,"endTime":50.6,"body":"Australian medical education podcast,"},{"speaker":"Dr Gavin Nimon","startTime":50.88,"endTime":53.81,"body":"designed with a pragmatic approach"},{"speaker":"Dr Gavin Nimon","startTime":50.88,"endTime":53.81,"body":"to medical conditions by interviewing"},{"speaker":"Dr Gavin Nimon","startTime":53.81,"endTime":55.1,"body":"specialists in the medical field."},{"speaker":"Dr Gavin Nimon","startTime":55.699,"endTime":58.63,"body":"I'm Gavin Nimon, an orthopaedic"},{"speaker":"Dr Gavin Nimon","startTime":55.699,"endTime":58.63,"body":"surgeon based in Adelaide, and"},{"speaker":"Dr Gavin Nimon","startTime":58.63,"endTime":60.039,"body":"I'm broadcasting from Kaurna land."},{"speaker":"Dr Gavin Nimon","startTime":60.88,"endTime":63.899,"body":"I'd like to remind you that this"},{"speaker":"Dr Gavin Nimon","startTime":60.88,"endTime":63.899,"body":"podcast players and is also available"},{"speaker":"Dr Gavin Nimon","startTime":63.899,"endTime":65.239,"body":"as a video version on YouTube."},{"speaker":"Dr Gavin Nimon","startTime":65.929,"endTime":68.229,"body":"I'd also like to remind you that"},{"speaker":"Dr Gavin Nimon","startTime":65.929,"endTime":68.229,"body":"if you enjoy this podcast, please"},{"speaker":"Dr Gavin Nimon","startTime":68.259,"endTime":71.839,"body":"subscribe or leave a review or give us"},{"speaker":"Dr Gavin Nimon","startTime":68.259,"endTime":71.839,"body":"a thumbs up as I really appreciate the"},{"speaker":"Dr Gavin Nimon","startTime":71.839,"endTime":72.969,"body":"support and it helps the channel grow."},{"speaker":"Dr Gavin Nimon","startTime":73.279,"endTime":76.259,"body":"I'd like to start the podcast by"},{"speaker":"Dr Gavin Nimon","startTime":73.279,"endTime":76.259,"body":"acknowledging the traditional owners"},{"speaker":"Dr Gavin Nimon","startTime":76.259,"endTime":79.209,"body":"of the land on which this podcast"},{"speaker":"Dr Gavin Nimon","startTime":76.259,"endTime":79.209,"body":"is produced, the Kaurna people,"},{"speaker":"Dr Gavin Nimon","startTime":79.549,"endTime":82.279,"body":"and pay my respects to the Elders"},{"speaker":"Dr Gavin Nimon","startTime":79.549,"endTime":82.279,"body":"both past, present and emerging."},{"speaker":"Dr Gavin Nimon","startTime":86.929,"endTime":89.63900000000001,"body":"I'd like to remind you that all the"},{"speaker":"Dr Gavin Nimon","startTime":86.929,"endTime":89.63900000000001,"body":"information presented today is just"},{"speaker":"Dr Gavin Nimon","startTime":89.63900000000001,"endTime":92.669,"body":"one opinion and that there are numerous"},{"speaker":"Dr Gavin Nimon","startTime":89.63900000000001,"endTime":92.669,"body":"ways of treating all medical conditions."},{"speaker":"Dr Gavin Nimon","startTime":93.149,"endTime":95.399,"body":"Therefore, you should always seek"},{"speaker":"Dr Gavin Nimon","startTime":93.149,"endTime":95.399,"body":"advice from your health professionals"},{"speaker":"Dr Gavin Nimon","startTime":95.409,"endTime":96.509,"body":"in the area in which you live."},{"speaker":"Dr Gavin Nimon","startTime":97.249,"endTime":99.729,"body":"Also, if you have any concerns"},{"speaker":"Dr Gavin Nimon","startTime":97.249,"endTime":99.729,"body":"about the information raised today,"},{"speaker":"Dr Gavin Nimon","startTime":99.779,"endTime":102.959,"body":"Please speak to your GP or seek"},{"speaker":"Dr Gavin Nimon","startTime":99.779,"endTime":102.959,"body":"assistance from help organisations"},{"speaker":"Dr Gavin Nimon","startTime":103.229,"endTime":104.839,"body":"such as Lifeline in Australia."},{"speaker":"Dr Gavin Nimon","startTime":105.735,"endTime":107.075,"body":"It's my"},{"speaker":"Dr Gavin Nimon","startTime":105.735,"endTime":107.075,"body":"pleasure now to introduce Dr."},{"speaker":"Dr Gavin Nimon","startTime":107.075,"endTime":110.485,"body":"Monika Juneja, a gynaecologist"},{"speaker":"Dr Gavin Nimon","startTime":107.075,"endTime":110.485,"body":"with 25 years of experience"},{"speaker":"Dr Gavin Nimon","startTime":110.495,"endTime":111.675,"body":"in laparoscopic surgery."},{"speaker":"Dr Gavin Nimon","startTime":112.025,"endTime":115.275,"body":"Specialising in minimally invasive"},{"speaker":"Dr Gavin Nimon","startTime":112.025,"endTime":115.275,"body":"surgery and teaching it to her peers"},{"speaker":"Dr Gavin Nimon","startTime":115.495,"endTime":116.755,"body":"at the Flinders Medical Centre."},{"speaker":"Dr Gavin Nimon","startTime":117.315,"endTime":120.575,"body":"She's going to talk to us about"},{"speaker":"Dr Gavin Nimon","startTime":117.315,"endTime":120.575,"body":"endometriosis, in particular"},{"speaker":"Dr Gavin Nimon","startTime":120.575,"endTime":121.765,"body":"diagnosis and treatment."},{"speaker":"Dr Gavin Nimon","startTime":121.895,"endTime":122.69500000000001,"body":"Welcome, Monika."},{"speaker":"Dr Monika Juneja","startTime":123.245,"endTime":124.875,"body":"Thanks,"},{"speaker":"Dr Monika Juneja","startTime":123.245,"endTime":124.875,"body":"Gavin, for having me here."},{"speaker":"Dr Monika Juneja","startTime":124.895,"endTime":129.575,"body":"It's my pleasure and privilege to"},{"speaker":"Dr Monika Juneja","startTime":124.895,"endTime":129.575,"body":"be able to talk to this very common"},{"speaker":"Dr Monika Juneja","startTime":129.575,"endTime":133.945,"body":"condition which affects so many"},{"speaker":"Dr Monika Juneja","startTime":129.575,"endTime":133.945,"body":"women and girls across the world."},{"speaker":"Dr Gavin Nimon","startTime":134.055,"endTime":136.035,"body":"I've read actually"},{"speaker":"Dr Gavin Nimon","startTime":134.055,"endTime":136.035,"body":"the incidences between one"},{"speaker":"Dr Gavin Nimon","startTime":136.035,"endTime":137.305,"body":"in seven to one in ten women."},{"speaker":"Dr Gavin Nimon","startTime":137.315,"endTime":138.16500000000002,"body":"Is that correct?"},{"speaker":"Dr Monika Juneja","startTime":138.215,"endTime":139.585,"body":"Yes, that's correct."},{"speaker":"Dr Monika Juneja","startTime":139.64499999999998,"endTime":144.095,"body":"The diagnosis is difficult,"},{"speaker":"Dr Monika Juneja","startTime":139.64499999999998,"endTime":144.095,"body":"so probably the true incidence"},{"speaker":"Dr Monika Juneja","startTime":144.095,"endTime":145.66500000000002,"body":"could be close to one in seven."},{"speaker":"Dr Monika Juneja","startTime":145.9,"endTime":149.06,"body":"Women of reproductive age"},{"speaker":"Dr Monika Juneja","startTime":145.9,"endTime":149.06,"body":"group, that's between puberty"},{"speaker":"Dr Monika Juneja","startTime":149.06,"endTime":151.18,"body":"to before they hit menopause."},{"speaker":"Dr Monika Juneja","startTime":151.535,"endTime":151.79500000000002,"body":"Right."},{"speaker":"Dr Monika Juneja","startTime":151.805,"endTime":151.835,"body":"And"},{"speaker":"Dr Gavin Nimon","startTime":151.845,"endTime":154.625,"body":"after menopause, is"},{"speaker":"Dr Gavin Nimon","startTime":151.845,"endTime":154.625,"body":"it an issue after that or it's more"},{"speaker":"Dr Monika Juneja","startTime":154.625,"endTime":158.46499999999997,"body":"of a Generally not"},{"speaker":"Dr Monika Juneja","startTime":154.625,"endTime":158.46499999999997,"body":"because the estrogen production goes down."},{"speaker":"Dr Monika Juneja","startTime":158.46499999999997,"endTime":164.305,"body":"So that causes endometriosis to become"},{"speaker":"Dr Monika Juneja","startTime":158.46499999999997,"endTime":164.305,"body":"dormant and disappear unless it has led"},{"speaker":"Dr Monika Juneja","startTime":164.305,"endTime":169.85500000000002,"body":"to a fair bit of scarring inside or some"},{"speaker":"Dr Monika Juneja","startTime":164.305,"endTime":169.85500000000002,"body":"old endometrioma hidden in the ovary."},{"speaker":"Dr Monika Juneja","startTime":170.33499999999998,"endTime":173.02499999999998,"body":"But generally after"},{"speaker":"Dr Monika Juneja","startTime":170.33499999999998,"endTime":173.02499999999998,"body":"menopause, it's not an issue."},{"speaker":"Dr Gavin Nimon","startTime":173.575,"endTime":173.85500000000002,"body":"Okay."},{"speaker":"Dr Gavin Nimon","startTime":173.85500000000002,"endTime":175.21499999999997,"body":"What actually is a condition?"},{"speaker":"Dr Gavin Nimon","startTime":175.805,"endTime":178.79500000000002,"body":"Is it like a benign tumor or"},{"speaker":"Dr Gavin Nimon","startTime":175.805,"endTime":178.79500000000002,"body":"does it behave in such a way?"},{"speaker":"Dr Gavin Nimon","startTime":178.85500000000002,"endTime":179.385,"body":"It"},{"speaker":"Dr Monika Juneja","startTime":179.70499999999998,"endTime":183.685,"body":"is it can present as"},{"speaker":"Dr Monika Juneja","startTime":179.70499999999998,"endTime":183.685,"body":"like benign endometrioma, like a chocolate"},{"speaker":"Dr Monika Juneja","startTime":183.685,"endTime":189.41500000000002,"body":"cyst in the ovaries, but more than that"},{"speaker":"Dr Monika Juneja","startTime":183.685,"endTime":189.41500000000002,"body":"is just a generalized change in the lining"},{"speaker":"Dr Monika Juneja","startTime":189.45499999999998,"endTime":195.95499999999998,"body":"of the peritoneum outside the uterus, in"},{"speaker":"Dr Monika Juneja","startTime":189.45499999999998,"endTime":195.95499999999998,"body":"the abdomen, in the pelvis, and it can"},{"speaker":"Dr Monika Juneja","startTime":195.95499999999998,"endTime":198.235,"body":"affect the ligaments behind the uterus."},{"speaker":"Dr Monika Juneja","startTime":198.565,"endTime":202.53500000000003,"body":"So it's a, quite often it's"},{"speaker":"Dr Monika Juneja","startTime":198.565,"endTime":202.53500000000003,"body":"more of a diffuse change."},{"speaker":"Dr Monika Juneja","startTime":203.31,"endTime":206.29000000000002,"body":"Rather than just being"},{"speaker":"Dr Monika Juneja","startTime":203.31,"endTime":206.29000000000002,"body":"localised to the ovaries."},{"speaker":"Dr Monika Juneja","startTime":206.35000000000002,"endTime":209.82,"body":"It's benign and it's"},{"speaker":"Dr Monika Juneja","startTime":206.35000000000002,"endTime":209.82,"body":"difficult to diagnose."},{"speaker":"Dr Monika Juneja","startTime":210.11,"endTime":212.14999999999998,"body":"And it is present in various forms."},{"speaker":"Dr Monika Juneja","startTime":213.37,"endTime":213.76999999999998,"body":"Are there any"},{"speaker":"Dr Gavin Nimon","startTime":213.76999999999998,"endTime":215.5,"body":"particular"},{"speaker":"Dr Gavin Nimon","startTime":213.76999999999998,"endTime":215.5,"body":"blood markers or tests you can"},{"speaker":"Dr Gavin Nimon","startTime":215.5,"endTime":218.19,"body":"do for it or investigations to"},{"speaker":"Dr Gavin Nimon","startTime":215.5,"endTime":218.19,"body":"help diagnose the condition?"},{"speaker":"Dr Monika Juneja","startTime":219.14,"endTime":222.57,"body":"We don't have"},{"speaker":"Dr Monika Juneja","startTime":219.14,"endTime":222.57,"body":"any biomarkers like we can't"},{"speaker":"Dr Monika Juneja","startTime":222.57,"endTime":228.45,"body":"detect it with a cervical screen"},{"speaker":"Dr Monika Juneja","startTime":222.57,"endTime":228.45,"body":"test or urine test or blood test."},{"speaker":"Dr Monika Juneja","startTime":228.45,"endTime":232.05,"body":"So the diagnosis is"},{"speaker":"Dr Monika Juneja","startTime":228.45,"endTime":232.05,"body":"generally with laparoscopy."},{"speaker":"Dr Monika Juneja","startTime":232.05,"endTime":236.22000000000003,"body":"We are getting better"},{"speaker":"Dr Monika Juneja","startTime":232.05,"endTime":236.22000000000003,"body":"at doing the ultrasound."},{"speaker":"Dr Monika Juneja","startTime":236.22000000000003,"endTime":242.61,"body":"Specialized ultrasounds can sometimes"},{"speaker":"Dr Monika Juneja","startTime":236.22000000000003,"endTime":242.61,"body":"give an indication of the disease on"},{"speaker":"Dr Monika Juneja","startTime":242.61,"endTime":245.08999999999997,"body":"more on the moderate to severe extent."},{"speaker":"Dr Monika Juneja","startTime":245.70999999999998,"endTime":245.86,"body":"So"},{"speaker":"Dr Monika Juneja","startTime":245.86,"endTime":245.99,"body":"it's"},{"speaker":"Dr Gavin Nimon","startTime":245.99,"endTime":250.17000000000002,"body":"based on clinical symptoms"},{"speaker":"Dr Gavin Nimon","startTime":245.99,"endTime":250.17000000000002,"body":"and then investigations after that."},{"speaker":"Dr Gavin Nimon","startTime":250.44,"endTime":251.48000000000002,"body":"That's right, yeah."},{"speaker":"Dr Gavin Nimon","startTime":251.57,"endTime":253.14,"body":"And the cause of the condition?"},{"speaker":"Dr Gavin Nimon","startTime":253.16000000000003,"endTime":256.56,"body":"Is there any particular known"},{"speaker":"Dr Gavin Nimon","startTime":253.16000000000003,"endTime":256.56,"body":"cause for why this uterine lining"},{"speaker":"Dr Gavin Nimon","startTime":256.56,"endTime":258.36,"body":"study appears outside the uterus?"},{"speaker":"Dr Gavin Nimon","startTime":258.64,"endTime":258.95,"body":"Yeah,"},{"speaker":"Dr Monika Juneja","startTime":258.95,"endTime":260.19,"body":"there"},{"speaker":"Dr Monika Juneja","startTime":258.95,"endTime":260.19,"body":"are various theories."},{"speaker":"Dr Monika Juneja","startTime":260.2,"endTime":264.05,"body":"So, it's you know,"},{"speaker":"Dr Monika Juneja","startTime":260.2,"endTime":264.05,"body":"everything is possible here."},{"speaker":"Dr Monika Juneja","startTime":264.05,"endTime":267.21,"body":"So the commonest theory, which is"},{"speaker":"Dr Monika Juneja","startTime":264.05,"endTime":267.21,"body":"taught in med school and it's still"},{"speaker":"Dr Monika Juneja","startTime":267.21,"endTime":271.85,"body":"valid to some extent is retrograde"},{"speaker":"Dr Monika Juneja","startTime":267.21,"endTime":271.85,"body":"menstruation but I guess retrograde"},{"speaker":"Dr Monika Juneja","startTime":271.85,"endTime":278.26,"body":"menstruation will happen in majority"},{"speaker":"Dr Monika Juneja","startTime":271.85,"endTime":278.26,"body":"of women but why that endometrium"},{"speaker":"Dr Monika Juneja","startTime":278.26,"endTime":283.45500000000004,"body":"implants Outside the uterus, in some"},{"speaker":"Dr Monika Juneja","startTime":278.26,"endTime":283.45500000000004,"body":"and not others, we don't know that."},{"speaker":"Dr Monika Juneja","startTime":283.825,"endTime":288.555,"body":"Then there is theory of genetic"},{"speaker":"Dr Monika Juneja","startTime":283.825,"endTime":288.555,"body":"predisposition, like it's that's the"},{"speaker":"Dr Monika Juneja","startTime":288.555,"endTime":293.625,"body":"latest where they say that these embryonic"},{"speaker":"Dr Monika Juneja","startTime":288.555,"endTime":293.625,"body":"nests are already there, but in some"},{"speaker":"Dr Monika Juneja","startTime":293.635,"endTime":299.665,"body":"women they change to endometriosis"},{"speaker":"Dr Monika Juneja","startTime":293.635,"endTime":299.665,"body":"and they become a clinical problem."},{"speaker":"Dr Monika Juneja","startTime":300.555,"endTime":306.55,"body":"Then there is theory of like spread around"},{"speaker":"Dr Monika Juneja","startTime":300.555,"endTime":306.55,"body":"lymphatic channels and blood vessels"},{"speaker":"Dr Monika Juneja","startTime":306.95,"endTime":311.96000000000004,"body":"that's where we see it under the diaphragm"},{"speaker":"Dr Monika Juneja","startTime":306.95,"endTime":311.96000000000004,"body":"at lungs and those, all those organs."},{"speaker":"Dr Monika Juneja","startTime":312.59000000000003,"endTime":315.95,"body":"And then there is theory of"},{"speaker":"Dr Monika Juneja","startTime":312.59000000000003,"endTime":315.95,"body":"coelomic metoplasia that the"},{"speaker":"Dr Monika Juneja","startTime":315.95,"endTime":320.26,"body":"endo that the Peritoneum suddenly"},{"speaker":"Dr Monika Juneja","startTime":315.95,"endTime":320.26,"body":"decides to change its character."},{"speaker":"Dr Monika Juneja","startTime":320.90000000000003,"endTime":325.62,"body":"So basically everything and we're"},{"speaker":"Dr Monika Juneja","startTime":320.90000000000003,"endTime":325.62,"body":"not sure of what actually causes"},{"speaker":"Dr Gavin Nimon","startTime":325.64000000000004,"endTime":325.93,"body":"it."},{"speaker":"Dr Gavin Nimon","startTime":326.08000000000004,"endTime":330.1,"body":"So retrograde menstruation is when the"},{"speaker":"Dr Gavin Nimon","startTime":326.08000000000004,"endTime":330.1,"body":"uterine lining actually goes back up the"},{"speaker":"Dr Gavin Nimon","startTime":330.1,"endTime":331.79,"body":"fallopian tubes into the pelvis, does it?"},{"speaker":"Dr Monika Juneja","startTime":331.98,"endTime":335.91,"body":"So the menstrual"},{"speaker":"Dr Monika Juneja","startTime":331.98,"endTime":335.91,"body":"blood, it backflows through the tubes."},{"speaker":"Dr Monika Juneja","startTime":336.32,"endTime":340.7,"body":"Back in the abdominal cavity, but normally"},{"speaker":"Dr Monika Juneja","startTime":336.32,"endTime":340.7,"body":"body should be able to deal with that."},{"speaker":"Dr Monika Juneja","startTime":341.1,"endTime":346.29,"body":"But in some women, obviously the"},{"speaker":"Dr Monika Juneja","startTime":341.1,"endTime":346.29,"body":"endometrium is perhaps more sticky or"},{"speaker":"Dr Monika Juneja","startTime":346.29,"endTime":352.3,"body":"there are some immunological factors"},{"speaker":"Dr Monika Juneja","startTime":346.29,"endTime":352.3,"body":"and it just decides to grow inside."},{"speaker":"Dr Monika Juneja","startTime":352.57,"endTime":352.81,"body":"So"},{"speaker":"Dr Gavin Nimon","startTime":353.6,"endTime":355.0,"body":"with the normal"},{"speaker":"Dr Gavin Nimon","startTime":353.6,"endTime":355.0,"body":"menstrual periods, do you actually"},{"speaker":"Dr Gavin Nimon","startTime":355.0,"endTime":358.14000000000004,"body":"get blood loss and loss of the uterine"},{"speaker":"Dr Gavin Nimon","startTime":355.0,"endTime":358.14000000000004,"body":"lining into the pelvis as well, like"},{"speaker":"Dr Gavin Nimon","startTime":358.14000000000004,"endTime":359.8,"body":"you do with normal menstrual periods?"},{"speaker":"Dr Monika Juneja","startTime":360.20500000000004,"endTime":364.665,"body":"Yes, so these"},{"speaker":"Dr Monika Juneja","startTime":360.20500000000004,"endTime":364.665,"body":"endometrial implants, they just swell up,"},{"speaker":"Dr Monika Juneja","startTime":364.675,"endTime":370.96500000000003,"body":"they get inflamed, they release cytokines"},{"speaker":"Dr Monika Juneja","startTime":364.675,"endTime":370.96500000000003,"body":"and interleukins and they cause fibrosis."},{"speaker":"Dr Monika Juneja","startTime":371.295,"endTime":377.375,"body":"That's why we see premenstrual buildup"},{"speaker":"Dr Monika Juneja","startTime":371.295,"endTime":377.375,"body":"of symptoms and during periods, again,"},{"speaker":"Dr Monika Juneja","startTime":377.445,"endTime":381.875,"body":"they have worse period pain than"},{"speaker":"Dr Monika Juneja","startTime":377.445,"endTime":381.875,"body":"Someone who hasn't got endometriosis."},{"speaker":"Dr Monika Juneja","startTime":382.065,"endTime":382.475,"body":"Yeah, that must be"},{"speaker":"Dr Gavin Nimon","startTime":382.485,"endTime":382.805,"body":"awful."},{"speaker":"Dr Gavin Nimon","startTime":382.805,"endTime":385.40500000000003,"body":"It's almost like someone injecting"},{"speaker":"Dr Gavin Nimon","startTime":382.805,"endTime":385.40500000000003,"body":"a cytotoxic agent into the"},{"speaker":"Dr Gavin Nimon","startTime":385.445,"endTime":386.945,"body":"peritoneum on a regular basis."},{"speaker":"Dr Monika Juneja","startTime":386.96500000000003,"endTime":390.345,"body":"The severity of"},{"speaker":"Dr Monika Juneja","startTime":386.96500000000003,"endTime":390.345,"body":"the symptoms doesn't always correlate"},{"speaker":"Dr Monika Juneja","startTime":390.885,"endTime":392.315,"body":"with the extent of the disease."},{"speaker":"Dr Monika Juneja","startTime":392.325,"endTime":397.345,"body":"So, you know, at times you can see a big"},{"speaker":"Dr Monika Juneja","startTime":392.325,"endTime":397.345,"body":"endometrioma and lots of endometriosis"},{"speaker":"Dr Monika Juneja","startTime":397.355,"endTime":402.975,"body":"inside and a woman is not symptomatic"},{"speaker":"Dr Monika Juneja","startTime":397.355,"endTime":402.975,"body":"and then you'll see a young girl with"},{"speaker":"Dr Monika Juneja","startTime":402.985,"endTime":408.21000000000004,"body":"one or two spots of Patchy superficial"},{"speaker":"Dr Monika Juneja","startTime":402.985,"endTime":408.21000000000004,"body":"endometriosis and her symptoms are"},{"speaker":"Dr Monika Juneja","startTime":408.56,"endTime":412.6,"body":"completely out of proportion to"},{"speaker":"Dr Monika Juneja","startTime":408.56,"endTime":412.6,"body":"what on laparoscopic inspection."},{"speaker":"Dr Monika Juneja","startTime":412.78000000000003,"endTime":412.93,"body":"Is"},{"speaker":"Dr Gavin Nimon","startTime":412.93,"endTime":415.98,"body":"there an increase in"},{"speaker":"Dr Gavin Nimon","startTime":412.93,"endTime":415.98,"body":"incidents with time as well or are"},{"speaker":"Dr Gavin Nimon","startTime":415.98,"endTime":417.69,"body":"they just identifying greater numbers?"},{"speaker":"Dr Monika Juneja","startTime":417.77000000000004,"endTime":420.6,"body":"Probably the"},{"speaker":"Dr Monika Juneja","startTime":417.77000000000004,"endTime":420.6,"body":"actual incidence would be the"},{"speaker":"Dr Monika Juneja","startTime":420.6,"endTime":423.0,"body":"same but there is more awareness."},{"speaker":"Dr Monika Juneja","startTime":423.48,"endTime":426.29,"body":"Girls are delaying"},{"speaker":"Dr Monika Juneja","startTime":423.48,"endTime":426.29,"body":"starting their families."},{"speaker":"Dr Monika Juneja","startTime":426.3,"endTime":430.22,"body":"So the average age of having"},{"speaker":"Dr Monika Juneja","startTime":426.3,"endTime":430.22,"body":"first baby has gone up now."},{"speaker":"Dr Monika Juneja","startTime":430.36,"endTime":434.92,"body":"So it's kind of, you know,"},{"speaker":"Dr Monika Juneja","startTime":430.36,"endTime":434.92,"body":"generally around 30 or even 31."},{"speaker":"Dr Monika Juneja","startTime":435.42,"endTime":441.96000000000004,"body":"So, pregnancy somewhat protects to"},{"speaker":"Dr Monika Juneja","startTime":435.42,"endTime":441.96000000000004,"body":"some extent from endometriosis, but"},{"speaker":"Dr Monika Juneja","startTime":442.46000000000004,"endTime":444.79,"body":"we see it more as the age goes up."},{"speaker":"Dr Monika Juneja","startTime":445.26,"endTime":447.3,"body":"And there is more awareness."},{"speaker":"Dr Monika Juneja","startTime":447.35,"endTime":452.12,"body":"Girls talk a lot about their"},{"speaker":"Dr Monika Juneja","startTime":447.35,"endTime":452.12,"body":"periods to their parents and"},{"speaker":"Dr Monika Juneja","startTime":452.12,"endTime":453.46000000000004,"body":"their general practitioners."},{"speaker":"Dr Monika Juneja","startTime":453.46000000000004,"endTime":458.31,"body":"There are there, there are educational"},{"speaker":"Dr Monika Juneja","startTime":453.46000000000004,"endTime":458.31,"body":"talks from health professionals."},{"speaker":"Dr Monika Juneja","startTime":458.31,"endTime":459.41,"body":"They have been to school."},{"speaker":"Dr Monika Juneja","startTime":459.41,"endTime":463.05,"body":"So, generally there is better access."},{"speaker":"Dr Monika Juneja","startTime":463.05,"endTime":465.36,"body":"GPs are more open to it."},{"speaker":"Dr Monika Juneja","startTime":465.84000000000003,"endTime":466.32,"body":"The."},{"speaker":"Dr Monika Juneja","startTime":466.345,"endTime":471.385,"body":"We try conservative measures and if"},{"speaker":"Dr Monika Juneja","startTime":466.345,"endTime":471.385,"body":"someone is not responding to pill"},{"speaker":"Dr Monika Juneja","startTime":471.385,"endTime":476.58500000000004,"body":"and anti inflammatories, they do"},{"speaker":"Dr Monika Juneja","startTime":471.385,"endTime":476.58500000000004,"body":"make a referral to gynecologist."},{"speaker":"Dr Monika Juneja","startTime":476.58500000000004,"endTime":481.105,"body":"So I think we are detecting it"},{"speaker":"Dr Monika Juneja","startTime":476.58500000000004,"endTime":481.105,"body":"more, but the actual incidence"},{"speaker":"Dr Monika Juneja","startTime":481.125,"endTime":483.165,"body":"probably would be the same."},{"speaker":"Dr Gavin Nimon","startTime":483.45500000000004,"endTime":486.415,"body":"So the pathology is"},{"speaker":"Dr Gavin Nimon","startTime":483.45500000000004,"endTime":486.415,"body":"purely endometrial lining outside"},{"speaker":"Dr Monika Juneja","startTime":486.445,"endTime":487.08500000000004,"body":"the uterus?"},{"speaker":"Dr Monika Juneja","startTime":487.385,"endTime":494.83500000000004,"body":"So, it is benign lining but it can be"},{"speaker":"Dr Monika Juneja","startTime":487.385,"endTime":494.83500000000004,"body":"in various It can be like just as if"},{"speaker":"Dr Monika Juneja","startTime":494.83500000000004,"endTime":498.175,"body":"someone has sprayed pepper on a steak."},{"speaker":"Dr Monika Juneja","startTime":498.175,"endTime":501.605,"body":"So sometimes it can be"},{"speaker":"Dr Monika Juneja","startTime":498.175,"endTime":501.605,"body":"just that diffuse change."},{"speaker":"Dr Monika Juneja","startTime":501.96500000000003,"endTime":506.135,"body":"Or it can be like plaques,"},{"speaker":"Dr Monika Juneja","startTime":501.96500000000003,"endTime":506.135,"body":"which can be fibrous."},{"speaker":"Dr Monika Juneja","startTime":506.175,"endTime":508.165,"body":"They can be yellow, they can be white."},{"speaker":"Dr Monika Juneja","startTime":508.625,"endTime":512.895,"body":"Along with fibrosis and"},{"speaker":"Dr Monika Juneja","startTime":508.625,"endTime":512.895,"body":"endometrial glands and stroma."},{"speaker":"Dr Monika Juneja","startTime":513.3249999999999,"endTime":516.925,"body":"Then it can be a nodular"},{"speaker":"Dr Monika Juneja","startTime":513.3249999999999,"endTime":516.925,"body":"disease where it's quite lumpy."},{"speaker":"Dr Monika Juneja","startTime":517.215,"endTime":521.275,"body":"And it can be deeply"},{"speaker":"Dr Monika Juneja","startTime":517.215,"endTime":521.275,"body":"infiltrative in organs."},{"speaker":"Dr Monika Juneja","startTime":521.275,"endTime":524.905,"body":"Like it can go in the bladder"},{"speaker":"Dr Monika Juneja","startTime":521.275,"endTime":524.905,"body":"and it can involve the"},{"speaker":"Dr Monika Juneja","startTime":524.935,"endTime":527.22,"body":"peritoneum of pouch of Douglas."},{"speaker":"Dr Monika Juneja","startTime":527.22,"endTime":532.99,"body":"And then it can also involve the"},{"speaker":"Dr Monika Juneja","startTime":527.22,"endTime":532.99,"body":"rectal sigmoid, and also sigmoid colon."},{"speaker":"Dr Monika Juneja","startTime":532.99,"endTime":538.04,"body":"So that's quite hard to deal with because"},{"speaker":"Dr Monika Juneja","startTime":532.99,"endTime":538.04,"body":"then you have to involve colorectal"},{"speaker":"Dr Monika Juneja","startTime":538.1,"endTime":541.0899999999999,"body":"colleagues or urologists accordingly."},{"speaker":"Dr Monika Juneja","startTime":541.0999999999999,"endTime":544.9,"body":"So, it probably increases"},{"speaker":"Dr Monika Juneja","startTime":541.0999999999999,"endTime":544.9,"body":"the risk of adenocarcinoma."},{"speaker":"Dr Monika Juneja","startTime":545.51,"endTime":549.16,"body":"I've seen that and that's generally"},{"speaker":"Dr Monika Juneja","startTime":545.51,"endTime":549.16,"body":"in the rectovaginal septum."},{"speaker":"Dr Monika Juneja","startTime":549.17,"endTime":550.7299999999999,"body":"It's not, it's uncommon."},{"speaker":"Dr Monika Juneja","startTime":551.665,"endTime":553.5849999999999,"body":"But generally it's a benign disease."},{"speaker":"Dr Monika Juneja","startTime":553.985,"endTime":554.045,"body":"Are"},{"speaker":"Dr Gavin Nimon","startTime":554.045,"endTime":555.745,"body":"there any risk"},{"speaker":"Dr Gavin Nimon","startTime":554.045,"endTime":555.745,"body":"factors for endometriosis?"},{"speaker":"Dr Gavin Nimon","startTime":555.755,"endTime":557.995,"body":"Is there any particular genes that"},{"speaker":"Dr Gavin Nimon","startTime":555.755,"endTime":557.995,"body":"occur that actually make you at"},{"speaker":"Dr Gavin Nimon","startTime":557.995,"endTime":559.435,"body":"greater risk of developing it?"},{"speaker":"Dr Gavin Nimon","startTime":559.785,"endTime":562.645,"body":"Or are there any other particular"},{"speaker":"Dr Gavin Nimon","startTime":559.785,"endTime":562.645,"body":"factors that may make you at greater"},{"speaker":"Dr Gavin Nimon","startTime":562.645,"endTime":564.025,"body":"risk of having endometriosis?"},{"speaker":"Dr Monika Juneja","startTime":565.3499999999999,"endTime":569.62,"body":"No particular"},{"speaker":"Dr Monika Juneja","startTime":565.3499999999999,"endTime":569.62,"body":"chromosomal or gene factors which we"},{"speaker":"Dr Monika Juneja","startTime":569.62,"endTime":571.88,"body":"can conclusively say that this is it."},{"speaker":"Dr Monika Juneja","startTime":571.88,"endTime":575.9,"body":"If you have this gene, then yes,"},{"speaker":"Dr Monika Juneja","startTime":571.88,"endTime":575.9,"body":"you will get it, but there is"},{"speaker":"Dr Monika Juneja","startTime":575.9,"endTime":577.7099999999999,"body":"some clustering in some families."},{"speaker":"Dr Monika Juneja","startTime":577.7099999999999,"endTime":582.3199999999999,"body":"So if mother or sister have had it,"},{"speaker":"Dr Monika Juneja","startTime":577.7099999999999,"endTime":582.3199999999999,"body":"then probably that would increase the"},{"speaker":"Dr Monika Juneja","startTime":582.39,"endTime":585.8399999999999,"body":"odds of that girl having endometriosis."},{"speaker":"Dr Monika Juneja","startTime":617.65,"endTime":622.39,"body":"Early menarche, starting of"},{"speaker":"Dr Monika Juneja","startTime":617.65,"endTime":622.39,"body":"periods at an earlier age."},{"speaker":"Dr Monika Juneja","startTime":623.77,"endTime":630.0699999999999,"body":"Nulliparity some environmental factors,"},{"speaker":"Dr Monika Juneja","startTime":623.77,"endTime":630.0699999999999,"body":"probably, Too much of environmental"},{"speaker":"Dr Monika Juneja","startTime":630.12,"endTime":636.16,"body":"toxins and estrogens, whether they"},{"speaker":"Dr Monika Juneja","startTime":630.12,"endTime":636.16,"body":"increase the risk, they cause endocrine"},{"speaker":"Dr Monika Juneja","startTime":636.16,"endTime":641.16,"body":"disruption and increase the odds of"},{"speaker":"Dr Monika Juneja","startTime":636.16,"endTime":641.16,"body":"endometriosis but we're not sure."},{"speaker":"Dr Monika Juneja","startTime":642.3199999999999,"endTime":642.62,"body":"Right."},{"speaker":"Dr Gavin Nimon","startTime":642.93,"endTime":645.28,"body":"Okay, so it sounds like"},{"speaker":"Dr Gavin Nimon","startTime":642.93,"endTime":645.28,"body":"it's a bit associated with estrogen"},{"speaker":"Dr Gavin Nimon","startTime":645.28,"endTime":648.81,"body":"release, just the same way the breast"},{"speaker":"Dr Gavin Nimon","startTime":645.28,"endTime":648.81,"body":"cancer is associated with estrogen"},{"speaker":"Dr Gavin Nimon","startTime":648.81,"endTime":653.29,"body":"release in the sense that having"},{"speaker":"Dr Gavin Nimon","startTime":648.81,"endTime":653.29,"body":"children reduce the amount of estrogen"},{"speaker":"Dr Gavin Nimon","startTime":653.29,"endTime":654.91,"body":"and reduce the risk of breast cancer."},{"speaker":"Dr Gavin Nimon","startTime":655.1999999999999,"endTime":659.36,"body":"Is there an association also between"},{"speaker":"Dr Gavin Nimon","startTime":655.1999999999999,"endTime":659.36,"body":"endometriosis and breast cancer"},{"speaker":"Dr Gavin Nimon","startTime":659.36,"endTime":662.06,"body":"because of the same association"},{"speaker":"Dr Gavin Nimon","startTime":659.36,"endTime":662.06,"body":"with estrogen release as well?"},{"speaker":"Dr Monika Juneja","startTime":662.0699999999999,"endTime":666.5,"body":"No nulliparity can"},{"speaker":"Dr Monika Juneja","startTime":662.0699999999999,"endTime":666.5,"body":"increase the risk of breast cancer."},{"speaker":"Dr Monika Juneja","startTime":667.17,"endTime":673.0649999999999,"body":"Estrogen window being open for too"},{"speaker":"Dr Monika Juneja","startTime":667.17,"endTime":673.0649999999999,"body":"long increases the risk of Breast and"},{"speaker":"Dr Monika Juneja","startTime":673.275,"endTime":677.375,"body":"endometrial cancer but I'm not aware"},{"speaker":"Dr Monika Juneja","startTime":673.275,"endTime":677.375,"body":"of any studies where they've said"},{"speaker":"Dr Monika Juneja","startTime":677.385,"endTime":681.485,"body":"that if someone has had endometriosis,"},{"speaker":"Dr Monika Juneja","startTime":677.385,"endTime":681.485,"body":"they're more likely to have breast"},{"speaker":"Dr Gavin Nimon","startTime":681.485,"endTime":681.885,"body":"cancer."},{"speaker":"Dr Gavin Nimon","startTime":681.9749999999999,"endTime":684.035,"body":"Okay, what about hormone"},{"speaker":"Dr Gavin Nimon","startTime":681.9749999999999,"endTime":684.035,"body":"replacement therapy in someone"},{"speaker":"Dr Gavin Nimon","startTime":684.035,"endTime":685.275,"body":"who's approaching menopause?"},{"speaker":"Dr Gavin Nimon","startTime":685.985,"endTime":689.0949999999999,"body":"Is endometriosis a contraindication"},{"speaker":"Dr Gavin Nimon","startTime":685.985,"endTime":689.0949999999999,"body":"to giving hormone replacement"},{"speaker":"Dr Gavin Nimon","startTime":689.0949999999999,"endTime":690.265,"body":"therapy in that scenario?"},{"speaker":"Dr Monika Juneja","startTime":691.255,"endTime":694.495,"body":"So if someone has"},{"speaker":"Dr Monika Juneja","startTime":691.255,"endTime":694.495,"body":"had severe endometriosis and they've"},{"speaker":"Dr Monika Juneja","startTime":694.525,"endTime":700.92,"body":"gone through Menopause, in the early"},{"speaker":"Dr Monika Juneja","startTime":694.525,"endTime":700.92,"body":"menopause hormonal replacement therapy"},{"speaker":"Dr Monika Juneja","startTime":701.17,"endTime":703.68,"body":"can aggravate the endometriosis."},{"speaker":"Dr Monika Juneja","startTime":705.24,"endTime":708.06,"body":"symptoms but it's not contraindicated."},{"speaker":"Dr Monika Juneja","startTime":708.39,"endTime":712.54,"body":"And if they still have uterus,"},{"speaker":"Dr Monika Juneja","startTime":708.39,"endTime":712.54,"body":"then we have to obviously give"},{"speaker":"Dr Monika Juneja","startTime":712.5799999999999,"endTime":717.73,"body":"them combined HRT but cautiously,"},{"speaker":"Dr Monika Juneja","startTime":712.5799999999999,"endTime":717.73,"body":"but it's not a contraindication."},{"speaker":"Dr Monika Juneja","startTime":718.0,"endTime":718.23,"body":"Okay."},{"speaker":"Dr Monika Juneja","startTime":718.23,"endTime":718.36,"body":"What"},{"speaker":"Dr Gavin Nimon","startTime":718.36,"endTime":719.8,"body":"about the"},{"speaker":"Dr Gavin Nimon","startTime":718.36,"endTime":719.8,"body":"younger person with someone on"},{"speaker":"Dr Gavin Nimon","startTime":719.8,"endTime":721.0,"body":"the oral contraceptive pill?"},{"speaker":"Dr Gavin Nimon","startTime":721.01,"endTime":724.31,"body":"Does endometriosis affect what"},{"speaker":"Dr Gavin Nimon","startTime":721.01,"endTime":724.31,"body":"dose or what type of pill you"},{"speaker":"Dr Gavin Nimon","startTime":724.31,"endTime":725.4599999999999,"body":"actually give in that scenario?"},{"speaker":"Dr Monika Juneja","startTime":725.615,"endTime":732.005,"body":"contraceptive pill"},{"speaker":"Dr Monika Juneja","startTime":725.615,"endTime":732.005,"body":"where it can help with mild to minimal"},{"speaker":"Dr Monika Juneja","startTime":732.135,"endTime":738.665,"body":"disease and we can do a regime of"},{"speaker":"Dr Monika Juneja","startTime":732.135,"endTime":738.665,"body":"continuous OCP suppression where"},{"speaker":"Dr Monika Juneja","startTime":738.665,"endTime":743.415,"body":"girls can skip the sugar pills and"},{"speaker":"Dr Monika Juneja","startTime":738.665,"endTime":743.415,"body":"just take the active pills together."},{"speaker":"Dr Monika Juneja","startTime":743.925,"endTime":747.555,"body":"So that way they can avoid periods"},{"speaker":"Dr Monika Juneja","startTime":743.925,"endTime":747.555,"body":"and the related discomfort."},{"speaker":"Dr Monika Juneja","startTime":747.555,"endTime":750.0949999999999,"body":"So it's called a pseudopregnancy regime."},{"speaker":"Dr Monika Juneja","startTime":750.115,"endTime":755.605,"body":"So you're just producing an environment"},{"speaker":"Dr Monika Juneja","startTime":750.115,"endTime":755.605,"body":"inside where they're not having a period."},{"speaker":"Dr Monika Juneja","startTime":755.625,"endTime":757.045,"body":"So that can help."},{"speaker":"Dr Monika Juneja","startTime":757.045,"endTime":762.3249999999999,"body":"It's a medical management of endometriosis"},{"speaker":"Dr Monika Juneja","startTime":757.045,"endTime":762.3249999999999,"body":"and that can be successful I'll"},{"speaker":"Dr Monika Juneja","startTime":762.3249999999999,"endTime":765.905,"body":"say 30 40 percent of girls, yes."},{"speaker":"Dr Gavin Nimon","startTime":765.995,"endTime":768.505,"body":"Okay, how else would"},{"speaker":"Dr Gavin Nimon","startTime":765.995,"endTime":768.505,"body":"someone present with endometriosis?"},{"speaker":"Dr Gavin Nimon","startTime":768.505,"endTime":770.4649999999999,"body":"What other symptoms present to you?"},{"speaker":"Dr Gavin Nimon","startTime":770.8249999999999,"endTime":773.9649999999999,"body":"and make you aware that"},{"speaker":"Dr Gavin Nimon","startTime":770.8249999999999,"endTime":773.9649999999999,"body":"endometriosis may be a cause of"},{"speaker":"Dr Gavin Nimon","startTime":774.305,"endTime":775.515,"body":"a condition that's occurring."},{"speaker":"Dr Monika Juneja","startTime":775.625,"endTime":780.245,"body":"So it can present with"},{"speaker":"Dr Monika Juneja","startTime":775.625,"endTime":780.245,"body":"having terrible periods as you have said."},{"speaker":"Dr Monika Juneja","startTime":780.915,"endTime":786.005,"body":"It can also present as a girl saying that"},{"speaker":"Dr Monika Juneja","startTime":780.915,"endTime":786.005,"body":"my periods were not so bad and now in"},{"speaker":"Dr Monika Juneja","startTime":786.005,"endTime":788.245,"body":"the last few years they have worsened."},{"speaker":"Dr Monika Juneja","startTime":788.255,"endTime":793.2049999999999,"body":"I used to be able to cope with my periods"},{"speaker":"Dr Monika Juneja","startTime":788.255,"endTime":793.2049999999999,"body":"and now they're really affecting my life."},{"speaker":"Dr Monika Juneja","startTime":793.2249999999999,"endTime":797.8149999999999,"body":"I get uncomfortable several days"},{"speaker":"Dr Monika Juneja","startTime":793.2249999999999,"endTime":797.8149999999999,"body":"actually before my period is starting"},{"speaker":"Dr Monika Juneja","startTime":798.255,"endTime":802.875,"body":"and the pain radiates to back, knees"},{"speaker":"Dr Monika Juneja","startTime":798.255,"endTime":802.875,"body":"and it affects me, it affects my mood."},{"speaker":"Dr Monika Juneja","startTime":803.125,"endTime":807.2249999999999,"body":"Also, they can have painful"},{"speaker":"Dr Monika Juneja","startTime":803.125,"endTime":807.2249999999999,"body":"intercourse, deep dyspareunia."},{"speaker":"Dr Monika Juneja","startTime":807.685,"endTime":811.175,"body":"They can have trouble on holding urine."},{"speaker":"Dr Monika Juneja","startTime":811.175,"endTime":813.7249999999999,"body":"They can have bladder sensitization."},{"speaker":"Dr Monika Juneja","startTime":814.175,"endTime":818.805,"body":"In severe cases of endometriosis"},{"speaker":"Dr Monika Juneja","startTime":814.175,"endTime":818.805,"body":"Especially with involvement of pouch"},{"speaker":"Dr Monika Juneja","startTime":818.805,"endTime":824.5749999999999,"body":"of Douglas, they can have painful"},{"speaker":"Dr Monika Juneja","startTime":818.805,"endTime":824.5749999999999,"body":"defecation and if they have endometriotic"},{"speaker":"Dr Monika Juneja","startTime":824.5849999999999,"endTime":828.655,"body":"implants which are close to the"},{"speaker":"Dr Monika Juneja","startTime":824.5849999999999,"endTime":828.655,"body":"bowel or intraluminal, then they can"},{"speaker":"Dr Monika Juneja","startTime":828.655,"endTime":831.785,"body":"also have cyclical rectal bleeding."},{"speaker":"Dr Monika Juneja","startTime":832.385,"endTime":838.7149999999999,"body":"It can affect the mood and low energy"},{"speaker":"Dr Monika Juneja","startTime":832.385,"endTime":838.7149999999999,"body":"levels and not coping with general"},{"speaker":"Dr Monika Juneja","startTime":840.005,"endTime":845.045,"body":"work, missing school, fainting"},{"speaker":"Dr Monika Juneja","startTime":840.005,"endTime":845.045,"body":"There is 30 percent overlap probably"},{"speaker":"Dr Monika Juneja","startTime":845.0849999999999,"endTime":846.865,"body":"with Irritable Bowel Syndrome."},{"speaker":"Dr Monika Juneja","startTime":846.865,"endTime":852.5649999999999,"body":"So, they can say that , they get quite"},{"speaker":"Dr Monika Juneja","startTime":846.865,"endTime":852.5649999999999,"body":"distended and uncomfortable and bloating."},{"speaker":"Dr Monika Juneja","startTime":853.0749999999999,"endTime":855.285,"body":"We see that a lot as well."},{"speaker":"Dr Monika Juneja","startTime":855.775,"endTime":861.305,"body":"And the diagnosis is harder and"},{"speaker":"Dr Monika Juneja","startTime":855.775,"endTime":861.305,"body":"natural periods also are not pleasant."},{"speaker":"Dr Monika Juneja","startTime":861.3249999999999,"endTime":866.605,"body":"So, our job is to work out whether"},{"speaker":"Dr Monika Juneja","startTime":861.3249999999999,"endTime":866.605,"body":"it is just painful periods or"},{"speaker":"Dr Monika Juneja","startTime":866.605,"endTime":871.8499999999999,"body":"actually Whether it's something"},{"speaker":"Dr Monika Juneja","startTime":866.605,"endTime":871.8499999999999,"body":"pathological going on with that person."},{"speaker":"Dr Monika Juneja","startTime":872.5999999999999,"endTime":873.1999999999999,"body":"Right."},{"speaker":"Dr Gavin Nimon","startTime":873.7199999999999,"endTime":876.16,"body":"So, you obviously"},{"speaker":"Dr Gavin Nimon","startTime":873.7199999999999,"endTime":876.16,"body":"got these symptoms that makes you"},{"speaker":"Dr Gavin Nimon","startTime":876.16,"endTime":877.9699999999999,"body":"think that it may be endometriosis."},{"speaker":"Dr Gavin Nimon","startTime":877.99,"endTime":878.26,"body":"Yes."},{"speaker":"Dr Gavin Nimon","startTime":878.26,"endTime":879.03,"body":"What's the next step?"},{"speaker":"Dr Gavin Nimon","startTime":879.25,"endTime":881.75,"body":"How do we go down the path"},{"speaker":"Dr Gavin Nimon","startTime":879.25,"endTime":881.75,"body":"of diagnosis and then also"},{"speaker":"Dr Gavin Nimon","startTime":881.76,"endTime":883.25,"body":"staging the condition as well?"},{"speaker":"Dr Gavin Nimon","startTime":883.65,"endTime":883.8499999999999,"body":"What staging"},{"speaker":"Dr Monika Juneja","startTime":883.8499999999999,"endTime":884.81,"body":"options do you have?"},{"speaker":"Dr Monika Juneja","startTime":884.81,"endTime":889.06,"body":"If I can add to your previous question,"},{"speaker":"Dr Monika Juneja","startTime":884.81,"endTime":889.06,"body":"we'll also find endometriosis in"},{"speaker":"Dr Monika Juneja","startTime":889.48,"endTime":896.56,"body":"about 30 to 40 percent of couples who"},{"speaker":"Dr Monika Juneja","startTime":889.48,"endTime":896.56,"body":"are coming to us with infertility."},{"speaker":"Dr Monika Juneja","startTime":896.9599999999999,"endTime":902.49,"body":"So there, the women may not have symptoms,"},{"speaker":"Dr Monika Juneja","startTime":896.9599999999999,"endTime":902.49,"body":"but there could be a component of"},{"speaker":"Dr Monika Juneja","startTime":902.52,"endTime":908.635,"body":"asymptomatic endometriosis or Just, period"},{"speaker":"Dr Monika Juneja","startTime":902.52,"endTime":908.635,"body":"pain which she has just taken as normal."},{"speaker":"Dr Monika Juneja","startTime":909.235,"endTime":912.785,"body":"We also see non menstrual"},{"speaker":"Dr Monika Juneja","startTime":909.235,"endTime":912.785,"body":"pain in severe cases."},{"speaker":"Dr Monika Juneja","startTime":913.3249999999999,"endTime":917.645,"body":"So, in terms of diagnosis"},{"speaker":"Dr Monika Juneja","startTime":913.3249999999999,"endTime":917.645,"body":"careful history taking."},{"speaker":"Dr Monika Juneja","startTime":918.2249999999999,"endTime":920.5649999999999,"body":"Looking at what has been tried."},{"speaker":"Dr Monika Juneja","startTime":921.255,"endTime":923.765,"body":"And then getting a pelvic ultrasound."},{"speaker":"Dr Monika Juneja","startTime":923.775,"endTime":928.675,"body":"So pelvic ultrasound can be completely"},{"speaker":"Dr Monika Juneja","startTime":923.775,"endTime":928.675,"body":"normal, but That woman can still have"},{"speaker":"Dr Monika Juneja","startTime":929.655,"endTime":934.2049999999999,"body":"extensive endometriosis, but that's just"},{"speaker":"Dr Monika Juneja","startTime":929.655,"endTime":934.2049999999999,"body":"to make sure that the anatomy is normal."},{"speaker":"Dr Monika Juneja","startTime":934.2049999999999,"endTime":939.9449999999999,"body":"There is no big endometrioma in"},{"speaker":"Dr Monika Juneja","startTime":934.2049999999999,"endTime":939.9449999999999,"body":"the ovary, or there's no fibroid or"},{"speaker":"Dr Monika Juneja","startTime":940.185,"endTime":947.175,"body":"adenomyosis, and adenomyosis is like"},{"speaker":"Dr Monika Juneja","startTime":940.185,"endTime":947.175,"body":"a cousin of Endometriosis, where the"},{"speaker":"Dr Monika Juneja","startTime":947.2149999999999,"endTime":952.885,"body":"endometrium is inside the myometrium"},{"speaker":"Dr Monika Juneja","startTime":947.2149999999999,"endTime":952.885,"body":"in the muscle fibers of the uterus."},{"speaker":"Dr Monika Juneja","startTime":952.9549999999999,"endTime":954.885,"body":"And it is a diffuse change."},{"speaker":"Dr Monika Juneja","startTime":955.4549999999999,"endTime":961.015,"body":"And so once we have done this, then we'll"},{"speaker":"Dr Monika Juneja","startTime":955.4549999999999,"endTime":961.015,"body":"also make sure that at the same time."},{"speaker":"Dr Monika Juneja","startTime":961.915,"endTime":968.255,"body":"We are checking the cervix, add on the"},{"speaker":"Dr Monika Juneja","startTime":961.915,"endTime":968.255,"body":"routine cervical screening test and"},{"speaker":"Dr Monika Juneja","startTime":968.8149999999999,"endTime":974.3249999999999,"body":"discuss with them about what stage of"},{"speaker":"Dr Monika Juneja","startTime":968.8149999999999,"endTime":974.3249999999999,"body":"life they are, whether they want to start."},{"speaker":"Dr Monika Juneja","startTime":975.04,"endTime":979.14,"body":"Family, or if they are very young,"},{"speaker":"Dr Monika Juneja","startTime":975.04,"endTime":979.14,"body":"then, you know, we have to also"},{"speaker":"Dr Monika Juneja","startTime":979.17,"endTime":981.13,"body":"address their contraceptive needs."},{"speaker":"Dr Monika Juneja","startTime":981.61,"endTime":986.55,"body":"If there are any psychological factors,"},{"speaker":"Dr Monika Juneja","startTime":981.61,"endTime":986.55,"body":"lifestyle factors whether they have"},{"speaker":"Dr Monika Juneja","startTime":986.55,"endTime":991.24,"body":"regular cycles or whether there's a"},{"speaker":"Dr Monika Juneja","startTime":986.55,"endTime":991.24,"body":"component of polycystic ovaries there."},{"speaker":"Dr Monika Juneja","startTime":991.89,"endTime":997.1999999999999,"body":"And then generally for diagnosis"},{"speaker":"Dr Monika Juneja","startTime":991.89,"endTime":997.1999999999999,"body":"we have to do a laparoscopy which"},{"speaker":"Dr Monika Juneja","startTime":997.1999999999999,"endTime":999.0799999999999,"body":"is under general anesthesia."},{"speaker":"Dr Monika Juneja","startTime":999.0799999999999,"endTime":1000.6899999999999,"body":"It's a hospital procedure."},{"speaker":"Dr Monika Juneja","startTime":1000.6899999999999,"endTime":1006.5699999999999,"body":"Laparoscopy is extremely common, but"},{"speaker":"Dr Monika Juneja","startTime":1000.6899999999999,"endTime":1006.5699999999999,"body":"one in 750 cases  anywhere in the world."},{"speaker":"Dr Monika Juneja","startTime":1007.915,"endTime":1012.555,"body":"Any surgeon doing laparoscopy, there"},{"speaker":"Dr Monika Juneja","startTime":1007.915,"endTime":1012.555,"body":"can be complications, so I'll present"},{"speaker":"Dr Monika Juneja","startTime":1012.5649999999999,"endTime":1020.6949999999999,"body":"to them that this is what I think we"},{"speaker":"Dr Monika Juneja","startTime":1012.5649999999999,"endTime":1020.6949999999999,"body":"need  to get a diagnosis and these days"},{"speaker":"Dr Monika Juneja","startTime":1020.6949999999999,"endTime":1026.725,"body":"generally, we don't really subject them"},{"speaker":"Dr Monika Juneja","startTime":1020.6949999999999,"endTime":1026.725,"body":"to 2 anesthetics if possible so do a"},{"speaker":"Dr Monika Juneja","startTime":1026.725,"endTime":1032.215,"body":"laparoscopy and treat endometriosis"},{"speaker":"Dr Monika Juneja","startTime":1026.725,"endTime":1032.215,"body":"as seen suitable at the same time."},{"speaker":"Dr Monika Juneja","startTime":1033.59,"endTime":1037.8,"body":"Along with that, generally, I'll add"},{"speaker":"Dr Monika Juneja","startTime":1033.59,"endTime":1037.8,"body":"hysteroscopy as well, which is the"},{"speaker":"Dr Monika Juneja","startTime":1037.8,"endTime":1044.57,"body":"assessment of the cavity of the  uterus"},{"speaker":"Dr Monika Juneja","startTime":1037.8,"endTime":1044.57,"body":"and for prevention of endometriosis"},{"speaker":"Dr Monika Juneja","startTime":1044.6299999999999,"endTime":1049.49,"body":"and prevent its recurrence as well"},{"speaker":"Dr Monika Juneja","startTime":1044.6299999999999,"endTime":1049.49,"body":"as to deal with periods after."},{"speaker":"Dr Monika Juneja","startTime":1050.48,"endTime":1056.07,"body":"Quite often, we propose, most"},{"speaker":"Dr Monika Juneja","startTime":1050.48,"endTime":1056.07,"body":"gynecologists will propose, Putting in"},{"speaker":"Dr Monika Juneja","startTime":1056.07,"endTime":1058.77,"body":"a Mirena, which is a progesterone IUD."},{"speaker":"Dr Monika Juneja","startTime":1059.2199999999998,"endTime":1063.0,"body":"So that will help in dealing"},{"speaker":"Dr Monika Juneja","startTime":1059.2199999999998,"endTime":1063.0,"body":"with the periods post surgery."},{"speaker":"Dr Monika Juneja","startTime":1063.75,"endTime":1066.6299999999999,"body":"Because we can't cure endometriosis."},{"speaker":"Dr Monika Juneja","startTime":1066.6299999999999,"endTime":1070.01,"body":"So, you know, you have done one"},{"speaker":"Dr Monika Juneja","startTime":1066.6299999999999,"endTime":1070.01,"body":"laparoscopy, and then if you do"},{"speaker":"Dr Monika Juneja","startTime":1070.01,"endTime":1075.995,"body":"nothing about it, and if the girl still"},{"speaker":"Dr Monika Juneja","startTime":1070.01,"endTime":1075.995,"body":"continues to go on naturally without any"},{"speaker":"Dr Monika Juneja","startTime":1075.995,"endTime":1081.75,"body":"hormonal suppression of periods, then"},{"speaker":"Dr Monika Juneja","startTime":1075.995,"endTime":1081.75,"body":"it will recur in 30 percent of cases."},{"speaker":"Dr Monika Juneja","startTime":1082.1699999999998,"endTime":1084.26,"body":"In somewhere between three to five years."},{"speaker":"Dr Monika Juneja","startTime":1084.27,"endTime":1087.11,"body":"Severe cases, it can"},{"speaker":"Dr Monika Juneja","startTime":1084.27,"endTime":1087.11,"body":"actually recur very soon."},{"speaker":"Dr Monika Juneja","startTime":1087.11,"endTime":1090.6499999999999,"body":"And then, you know, you're back to"},{"speaker":"Dr Monika Juneja","startTime":1087.11,"endTime":1090.6499999999999,"body":"square one with pain and dealing with it."},{"speaker":"Dr Monika Juneja","startTime":1091.09,"endTime":1093.58,"body":"And repeated surgeries get challenging."},{"speaker":"Dr Monika Juneja","startTime":1094.855,"endTime":1100.595,"body":"So endometriosis is always"},{"speaker":"Dr Monika Juneja","startTime":1094.855,"endTime":1100.595,"body":"in tricky locations and it is"},{"speaker":"Dr Monika Juneja","startTime":1100.595,"endTime":1102.305,"body":"not in convenient locations."},{"speaker":"Dr Monika Juneja","startTime":1102.305,"endTime":1106.7649999999999,"body":"I always tell the girls that, you"},{"speaker":"Dr Monika Juneja","startTime":1102.305,"endTime":1106.7649999999999,"body":"know, it's not like cherry picking"},{"speaker":"Dr Monika Juneja","startTime":1106.7649999999999,"endTime":1114.7749999999999,"body":"that I go and just pick it up and So"},{"speaker":"Dr Monika Juneja","startTime":1106.7649999999999,"endTime":1114.7749999999999,"body":"it can be in quite vascular locations."},{"speaker":"Dr Monika Juneja","startTime":1114.7749999999999,"endTime":1117.195,"body":"It can be in the ovarian fossa."},{"speaker":"Dr Monika Juneja","startTime":1117.625,"endTime":1120.7749999999999,"body":"It can be on the peritoneum"},{"speaker":"Dr Monika Juneja","startTime":1117.625,"endTime":1120.7749999999999,"body":"overlying the ureter."},{"speaker":"Dr Monika Juneja","startTime":1121.2849999999999,"endTime":1126.885,"body":"It can be,  close to the rectum and"},{"speaker":"Dr Monika Juneja","startTime":1121.2849999999999,"endTime":1126.885,"body":"sigmoid in the pararectal region."},{"speaker":"Dr Monika Juneja","startTime":1126.885,"endTime":1130.865,"body":"So, we don't want to go there"},{"speaker":"Dr Monika Juneja","startTime":1126.885,"endTime":1130.865,"body":"again and again if possible."},{"speaker":"Dr Monika Juneja","startTime":1131.415,"endTime":1136.145,"body":"And so, if they are not quite ready"},{"speaker":"Dr Monika Juneja","startTime":1131.415,"endTime":1136.145,"body":"to start family, then probably"},{"speaker":"Dr Monika Juneja","startTime":1136.145,"endTime":1141.0149999999999,"body":"at the same time, we consider the"},{"speaker":"Dr Monika Juneja","startTime":1136.145,"endTime":1141.0149999999999,"body":"option of putting in a mirena."},{"speaker":"Dr Monika Juneja","startTime":1141.675,"endTime":1144.7749999999999,"body":"If they say that, yeah, no,"},{"speaker":"Dr Monika Juneja","startTime":1141.675,"endTime":1144.7749999999999,"body":"maybe, you know, I'll have"},{"speaker":"Dr Monika Juneja","startTime":1144.815,"endTime":1147.445,"body":"endometriosis surgery done."},{"speaker":"Dr Monika Juneja","startTime":1147.485,"endTime":1151.365,"body":"And then, you know, maybe in a"},{"speaker":"Dr Monika Juneja","startTime":1147.485,"endTime":1151.365,"body":"year or two, I'll start family."},{"speaker":"Dr Monika Juneja","startTime":1151.365,"endTime":1155.845,"body":"So in that case, we can skip the"},{"speaker":"Dr Monika Juneja","startTime":1151.365,"endTime":1155.845,"body":"long acting progesterone IUD and"},{"speaker":"Dr Monika Juneja","startTime":1155.845,"endTime":1159.5249999999999,"body":"consider other short acting measures."},{"speaker":"Dr Monika Juneja","startTime":1159.955,"endTime":1162.125,"body":"But I'll normally not do a MRI."},{"speaker":"Dr Monika Juneja","startTime":1163.72,"endTime":1169.29,"body":"In every case, but if there is suspicion"},{"speaker":"Dr Monika Juneja","startTime":1163.72,"endTime":1169.29,"body":"of deeply infiltrated endometriosis, then"},{"speaker":"Dr Monika Juneja","startTime":1169.54,"endTime":1178.29,"body":"I'll get an MRI just to see the extent and"},{"speaker":"Dr Monika Juneja","startTime":1169.54,"endTime":1178.29,"body":"Also to make arrangements and liaise with"},{"speaker":"Dr Monika Juneja","startTime":1178.67,"endTime":1186.62,"body":"my colorectal colleagues In case we have"},{"speaker":"Dr Monika Juneja","startTime":1178.67,"endTime":1186.62,"body":"to excise endometriosis from the wall."},{"speaker":"Dr Monika Juneja","startTime":1187.12,"endTime":1189.35,"body":"So that case we need their help."},{"speaker":"Dr Monika Juneja","startTime":1189.44,"endTime":1190.76,"body":"Yeah A few"},{"speaker":"Dr Gavin Nimon","startTime":1190.76,"endTime":1193.06,"body":"questions come to"},{"speaker":"Dr Gavin Nimon","startTime":1190.76,"endTime":1193.06,"body":"mind in what you're saying there."},{"speaker":"Dr Gavin Nimon","startTime":1193.33,"endTime":1195.01,"body":"The first one is the Pelvic Ultrasound."},{"speaker":"Dr Gavin Nimon","startTime":1195.01,"endTime":1197.73,"body":"Is that a transvaginal Pelvic"},{"speaker":"Dr Gavin Nimon","startTime":1195.01,"endTime":1197.73,"body":"Ultrasound that's required or is"},{"speaker":"Dr Gavin Nimon","startTime":1197.73,"endTime":1199.3,"body":"it done just through the abdominal"},{"speaker":"Dr Monika Juneja","startTime":1199.56,"endTime":1199.98,"body":"wall?"},{"speaker":"Dr Monika Juneja","startTime":1200.22,"endTime":1200.44,"body":"Yeah."},{"speaker":"Dr Monika Juneja","startTime":1200.84,"endTime":1207.6499999999999,"body":"So, transvaginal is far superior"},{"speaker":"Dr Monika Juneja","startTime":1200.84,"endTime":1207.6499999999999,"body":"to diagnose endometriosis or"},{"speaker":"Dr Monika Juneja","startTime":1207.82,"endTime":1213.35,"body":"adenexal pathology but if they've"},{"speaker":"Dr Monika Juneja","startTime":1207.82,"endTime":1213.35,"body":"never been sexually active, then we"},{"speaker":"Dr Monika Juneja","startTime":1213.3799999999999,"endTime":1215.79,"body":"obviously say, okay, transabdominal."},{"speaker":"Dr Monika Juneja","startTime":1216.37,"endTime":1220.3999999999999,"body":"Which is fine, , but, you know, if"},{"speaker":"Dr Monika Juneja","startTime":1216.37,"endTime":1220.3999999999999,"body":"you're heading towards laparoscopy, I"},{"speaker":"Dr Monika Juneja","startTime":1220.3999999999999,"endTime":1222.67,"body":"don't worry too much about transvaginal."},{"speaker":"Dr Monika Juneja","startTime":1223.6499999999999,"endTime":1226.62,"body":"Someone is very shy and very young."},{"speaker":"Dr Monika Juneja","startTime":1227.21,"endTime":1230.8899999999999,"body":"I won't push for a transvaginal"},{"speaker":"Dr Monika Juneja","startTime":1227.21,"endTime":1230.8899999999999,"body":"in that case, but generally"},{"speaker":"Dr Monika Juneja","startTime":1230.8999999999999,"endTime":1232.73,"body":"speaking, it's transvaginal."},{"speaker":"Dr Monika Juneja","startTime":1233.37,"endTime":1237.57,"body":"The endometriosis specific ultrasound"},{"speaker":"Dr Monika Juneja","startTime":1233.37,"endTime":1237.57,"body":"actually goes a step forward."},{"speaker":"Dr Monika Juneja","startTime":1237.58,"endTime":1241.96,"body":"So they need little bit of"},{"speaker":"Dr Monika Juneja","startTime":1237.58,"endTime":1241.96,"body":"bowel prep also, and only"},{"speaker":"Dr Monika Juneja","startTime":1241.96,"endTime":1244.45,"body":"specialized centers can do that."},{"speaker":"Dr Monika Juneja","startTime":1244.59,"endTime":1246.37,"body":"The routine ultrasound."},{"speaker":"Dr Monika Juneja","startTime":1246.845,"endTime":1249.135,"body":"Is not endometriosis specific."},{"speaker":"Dr Monika Juneja","startTime":1249.665,"endTime":1255.5349999999999,"body":"So in the specialized ultrasound they"},{"speaker":"Dr Monika Juneja","startTime":1249.665,"endTime":1255.5349999999999,"body":"can measure the thickness or change in"},{"speaker":"Dr Monika Juneja","startTime":1256.095,"endTime":1262.675,"body":"appearance of the uterus sacral ligaments,"},{"speaker":"Dr Monika Juneja","startTime":1256.095,"endTime":1262.675,"body":"the mobility of the ovaries the adherence"},{"speaker":"Dr Monika Juneja","startTime":1262.675,"endTime":1265.915,"body":"of colon to the back of the uterus."},{"speaker":"Dr Monika Juneja","startTime":1266.545,"endTime":1274.0049999999999,"body":"It's not 100 percent specific but it has"},{"speaker":"Dr Monika Juneja","startTime":1266.545,"endTime":1274.0049999999999,"body":"certainly helped us and recently I did a"},{"speaker":"Dr Monika Juneja","startTime":1274.045,"endTime":1281.615,"body":"case so they were spot on and that girl"},{"speaker":"Dr Monika Juneja","startTime":1274.045,"endTime":1281.615,"body":"had endometriosis in the utero-sacral"},{"speaker":"Dr Monika Juneja","startTime":1282.0049999999999,"endTime":1285.155,"body":"ligaments so that was impressive so Right,"},{"speaker":"Dr Gavin Nimon","startTime":1285.205,"endTime":1285.895,"body":"so it's getting better"},{"speaker":"Dr Monika Juneja","startTime":1285.895,"endTime":1286.585,"body":"the investigation."},{"speaker":"Dr Monika Juneja","startTime":1286.675,"endTime":1287.245,"body":"It is getting"},{"speaker":"Dr Gavin Nimon","startTime":1287.465,"endTime":1288.2849999999999,"body":"better, yeah."},{"speaker":"Dr Gavin Nimon","startTime":1288.725,"endTime":1292.795,"body":"When you do a formal excision is that"},{"speaker":"Dr Gavin Nimon","startTime":1288.725,"endTime":1292.795,"body":"actually done as an ablation using"},{"speaker":"Dr Gavin Nimon","startTime":1292.795,"endTime":1296.435,"body":"diathermy or other devices or you"},{"speaker":"Dr Gavin Nimon","startTime":1292.795,"endTime":1296.435,"body":"actually excise the actual deposit?"},{"speaker":"Dr Monika Juneja","startTime":1297.1399999999999,"endTime":1300.42,"body":"So, it can"},{"speaker":"Dr Monika Juneja","startTime":1297.1399999999999,"endTime":1300.42,"body":"be either ablation or excision."},{"speaker":"Dr Monika Juneja","startTime":1300.95,"endTime":1305.55,"body":"Ablation is really suitable only"},{"speaker":"Dr Monika Juneja","startTime":1300.95,"endTime":1305.55,"body":"when it is a superficial disease."},{"speaker":"Dr Monika Juneja","startTime":1306.1299999999999,"endTime":1310.93,"body":"Generally speaking, if it is"},{"speaker":"Dr Monika Juneja","startTime":1306.1299999999999,"endTime":1310.93,"body":"anything nodular or significant if"},{"speaker":"Dr Monika Juneja","startTime":1310.93,"endTime":1315.52,"body":"we ablate it, the thermal spread will"},{"speaker":"Dr Monika Juneja","startTime":1310.93,"endTime":1315.52,"body":"happen to the underlying structure."},{"speaker":"Dr Monika Juneja","startTime":1316.445,"endTime":1317.805,"body":"So that's not advisable."},{"speaker":"Dr Monika Juneja","startTime":1318.595,"endTime":1323.415,"body":"So in that case, I'll say"},{"speaker":"Dr Monika Juneja","startTime":1318.595,"endTime":1323.415,"body":"more often it is excision."},{"speaker":"Dr Monika Juneja","startTime":1323.985,"endTime":1330.365,"body":"But if it is, in a tricky location,"},{"speaker":"Dr Monika Juneja","startTime":1323.985,"endTime":1330.365,"body":"like I had one spot recently on."},{"speaker":"Dr Monika Juneja","startTime":1331.245,"endTime":1333.75,"body":"external iliac vessel, very close to it."},{"speaker":"Dr Monika Juneja","startTime":1333.75,"endTime":1338.29,"body":"So, and it was superficial, so I"},{"speaker":"Dr Monika Juneja","startTime":1333.75,"endTime":1338.29,"body":"just retracted it and diathermied it."},{"speaker":"Dr Monika Juneja","startTime":1338.92,"endTime":1341.26,"body":"But it is a combination."},{"speaker":"Dr Monika Juneja","startTime":1341.26,"endTime":1346.27,"body":"So in one particular case, you know, there"},{"speaker":"Dr Monika Juneja","startTime":1341.26,"endTime":1346.27,"body":"could be a very superficial spot where"},{"speaker":"Dr Monika Juneja","startTime":1346.27,"endTime":1352.22,"body":"you may just ablate it, and then if it"},{"speaker":"Dr Monika Juneja","startTime":1346.27,"endTime":1352.22,"body":"is significant, then generally we excise"},{"speaker":"Dr Monika Juneja","startTime":1352.22,"endTime":1355.1,"body":"it and every surgeon has their preferred."},{"speaker":"Dr Monika Juneja","startTime":1355.3999999999999,"endTime":1357.56,"body":"Modality how they want to do it."},{"speaker":"Dr Monika Juneja","startTime":1357.56,"endTime":1362.54,"body":"So, bipolar cautery is very"},{"speaker":"Dr Monika Juneja","startTime":1357.56,"endTime":1362.54,"body":"common to do the ablation."},{"speaker":"Dr Monika Juneja","startTime":1362.87,"endTime":1369.1,"body":"And for excision, we can go traditional"},{"speaker":"Dr Monika Juneja","startTime":1362.87,"endTime":1369.1,"body":"with monopolar cautery, or else we can"},{"speaker":"Dr Monika Juneja","startTime":1369.105,"endTime":1371.71,"body":"use ultrasound based energy sources."},{"speaker":"Dr Monika Juneja","startTime":1371.74,"endTime":1374.81,"body":"So like harmonic scalpel or thunder beat."},{"speaker":"Dr Monika Juneja","startTime":1375.32,"endTime":1377.46,"body":"Laser used to be a thing in the past."},{"speaker":"Dr Monika Juneja","startTime":1377.46,"endTime":1381.1499999999999,"body":"I've never used laser, so I"},{"speaker":"Dr Monika Juneja","startTime":1377.46,"endTime":1381.1499999999999,"body":"think that was more in 80s."},{"speaker":"Dr Monika Juneja","startTime":1382.19,"endTime":1387.8999999999999,"body":"So, also at the time of surgery,  we"},{"speaker":"Dr Monika Juneja","startTime":1382.19,"endTime":1387.8999999999999,"body":"have to take care that, you know,"},{"speaker":"Dr Monika Juneja","startTime":1387.9099999999999,"endTime":1392.06,"body":"we are checking the tubes and swing"},{"speaker":"Dr Monika Juneja","startTime":1387.9099999999999,"endTime":1392.06,"body":"the camera around and check the"},{"speaker":"Dr Monika Juneja","startTime":1392.06,"endTime":1394.57,"body":"appendix, upper abdomen, adhesions."},{"speaker":"Dr Monika Juneja","startTime":1394.6299999999999,"endTime":1399.1299999999999,"body":"And also with surgery, if we've"},{"speaker":"Dr Monika Juneja","startTime":1394.6299999999999,"endTime":1399.1299999999999,"body":"done a significant excision of"},{"speaker":"Dr Monika Juneja","startTime":1399.17,"endTime":1404.24,"body":"endometriosis, we don't want the ovaries"},{"speaker":"Dr Monika Juneja","startTime":1399.17,"endTime":1404.24,"body":"to go and stick to those raw areas."},{"speaker":"Dr Monika Juneja","startTime":1404.25,"endTime":1411.24,"body":"So Quite often in severe cases I'll do"},{"speaker":"Dr Monika Juneja","startTime":1404.25,"endTime":1411.24,"body":"ovariopexy where I can tie the ovaries"},{"speaker":"Dr Monika Juneja","startTime":1411.24,"endTime":1416.74,"body":"to the round ligament with an absorbable"},{"speaker":"Dr Monika Juneja","startTime":1411.24,"endTime":1416.74,"body":"suture and put an adhesion barrier"},{"speaker":"Dr Monika Juneja","startTime":1417.06,"endTime":1422.21,"body":"on the raw areas so that at least the"},{"speaker":"Dr Monika Juneja","startTime":1417.06,"endTime":1422.21,"body":"ovaries, they don't go and stick to"},{"speaker":"Dr Monika Juneja","startTime":1422.81,"endTime":1424.81,"body":"and become a cause of pain down the"},{"speaker":"Dr Gavin Nimon","startTime":1424.81,"endTime":1425.1299999999999,"body":"track."},{"speaker":"Dr Gavin Nimon","startTime":1425.48,"endTime":1425.8999999999999,"body":"Brilliant."},{"speaker":"Dr Gavin Nimon","startTime":1425.8999999999999,"endTime":1426.52,"body":"Very clever."},{"speaker":"Dr Gavin Nimon","startTime":1427.435,"endTime":1431.335,"body":"What about the, I can imagine with"},{"speaker":"Dr Gavin Nimon","startTime":1427.435,"endTime":1431.335,"body":"these tight spaces, the robotic"},{"speaker":"Dr Gavin Nimon","startTime":1431.335,"endTime":1432.715,"body":"surgery might have a place."},{"speaker":"Dr Gavin Nimon","startTime":1432.715,"endTime":1434.205,"body":"Does that have a role in this sort of area"},{"speaker":"Dr Gavin Nimon","startTime":1434.205,"endTime":1440.945,"body":"?"},{"speaker":"Dr Gavin Nimon","startTime":1434.205,"endTime":1440.945,"body":", Dr Monika Juneja: yes, robotic"},{"speaker":"Dr Gavin Nimon","startTime":1440.965,"endTime":1442.975,"body":"You don't need it for every case."},{"speaker":"Dr Gavin Nimon","startTime":1442.975,"endTime":1446.0,"body":"And the vision will be much better."},{"speaker":"Dr Gavin Nimon","startTime":1446.05,"endTime":1448.46,"body":"It will be less tiring for the surgeon."},{"speaker":"Dr Gavin Nimon","startTime":1449.09,"endTime":1452.4099999999999,"body":"I haven't taken it on"},{"speaker":"Dr Gavin Nimon","startTime":1449.09,"endTime":1452.4099999999999,"body":"because it wasn't there."},{"speaker":"Dr Gavin Nimon","startTime":1453.8,"endTime":1459.86,"body":"When I first started doing it, and now"},{"speaker":"Dr Gavin Nimon","startTime":1453.8,"endTime":1459.86,"body":"I'm comfortable with what I'm doing,"},{"speaker":"Dr Gavin Nimon","startTime":1459.92,"endTime":1466.47,"body":"but a few of my colleagues in Gold Coast"},{"speaker":"Dr Gavin Nimon","startTime":1459.92,"endTime":1466.47,"body":"and Brisbane who are using robot they"},{"speaker":"Dr Gavin Nimon","startTime":1466.47,"endTime":1471.123,"body":"have commented that actually they have"},{"speaker":"Dr Gavin Nimon","startTime":1466.47,"endTime":1471.123,"body":"found that robotics really helped them"},{"speaker":"Dr Gavin Nimon","startTime":1471.123,"endTime":1478.445,"body":"with Severe endo disease more so, rather"},{"speaker":"Dr Gavin Nimon","startTime":1471.123,"endTime":1478.445,"body":"than doing robotic hysterectomy, they"},{"speaker":"Dr Gavin Nimon","startTime":1478.475,"endTime":1485.465,"body":"said it was much easier more productive"},{"speaker":"Dr Gavin Nimon","startTime":1478.475,"endTime":1485.465,"body":"to use a robot for endometriosis case."},{"speaker":"Dr Gavin Nimon","startTime":1485.465,"endTime":1490.355,"body":"You can't really stage it"},{"speaker":"Dr Gavin Nimon","startTime":1485.465,"endTime":1490.355,"body":"prior to a laparoscopy unless"},{"speaker":"Dr Gavin Nimon","startTime":1490.365,"endTime":1491.955,"body":"on ultrasound you are seeing."},{"speaker":"Dr Gavin Nimon","startTime":1492.055,"endTime":1493.845,"body":"Two big endometriomas."},{"speaker":"Dr Gavin Nimon","startTime":1494.345,"endTime":1496.415,"body":"We call it as kissing ovaries."},{"speaker":"Dr Gavin Nimon","startTime":1496.415,"endTime":1501.2649999999999,"body":"You can get indication of the"},{"speaker":"Dr Gavin Nimon","startTime":1496.415,"endTime":1501.2649999999999,"body":"ovaries are stuck to each other."},{"speaker":"Dr Gavin Nimon","startTime":1501.315,"endTime":1506.145,"body":"They're big, they're stuck to back"},{"speaker":"Dr Gavin Nimon","startTime":1501.315,"endTime":1506.145,"body":"of the uterus and on ultrasound they"},{"speaker":"Dr Gavin Nimon","startTime":1506.145,"endTime":1508.115,"body":"can say it's fixed retroversion."},{"speaker":"Dr Gavin Nimon","startTime":1508.125,"endTime":1512.5249999999999,"body":"Uterus is not moving and it's"},{"speaker":"Dr Gavin Nimon","startTime":1508.125,"endTime":1512.5249999999999,"body":"really pathologically retroverted,"},{"speaker":"Dr Gavin Nimon","startTime":1512.5349999999999,"endTime":1515.0049999999999,"body":"which is it's pointing backwards."},{"speaker":"Dr Gavin Nimon","startTime":1516.135,"endTime":1520.96,"body":"And There you know before you go"},{"speaker":"Dr Gavin Nimon","startTime":1516.135,"endTime":1520.96,"body":"in that, okay, this is a stage"},{"speaker":"Dr Gavin Nimon","startTime":1520.97,"endTime":1523.36,"body":"four case of endometriosis."},{"speaker":"Dr Gavin Nimon","startTime":1523.37,"endTime":1528.18,"body":"So there is a American Fertility"},{"speaker":"Dr Gavin Nimon","startTime":1523.37,"endTime":1528.18,"body":"Society classification which goes from"},{"speaker":"Dr Gavin Nimon","startTime":1528.2,"endTime":1532.46,"body":"minimal to mild to moderate to severe."},{"speaker":"Dr Gavin Nimon","startTime":1533.06,"endTime":1540.3,"body":"Even in stage four, there is variation and"},{"speaker":"Dr Gavin Nimon","startTime":1533.06,"endTime":1540.3,"body":"practically I don't find it very useful."},{"speaker":"Dr Gavin Nimon","startTime":1540.85,"endTime":1547.81,"body":"What I find handy is taking pictures"},{"speaker":"Dr Gavin Nimon","startTime":1540.85,"endTime":1547.81,"body":"and taking a close shot,  before I've"},{"speaker":"Dr Gavin Nimon","startTime":1547.81,"endTime":1554.03,"body":"done anything and After pictures and"},{"speaker":"Dr Gavin Nimon","startTime":1547.81,"endTime":1554.03,"body":"then drawing a diagram and just noting"},{"speaker":"Dr Gavin Nimon","startTime":1554.03,"endTime":1560.99,"body":"it down in the case notes and also"},{"speaker":"Dr Gavin Nimon","startTime":1554.03,"endTime":1560.99,"body":"noting the number of the lesions."},{"speaker":"Dr Gavin Nimon","startTime":1561.36,"endTime":1563.56,"body":"So, practically that is more."},{"speaker":"Dr Gavin Nimon","startTime":1564.0249999999999,"endTime":1568.495,"body":"Useful for us and also whether the"},{"speaker":"Dr Gavin Nimon","startTime":1564.0249999999999,"endTime":1568.495,"body":"ovaries were involved or not and if on"},{"speaker":"Dr Gavin Nimon","startTime":1568.495,"endTime":1572.7849999999999,"body":"the ovary they have got endometriosis"},{"speaker":"Dr Gavin Nimon","startTime":1568.495,"endTime":1572.7849999999999,"body":"whether therefore that was just some"},{"speaker":"Dr Gavin Nimon","startTime":1572.7849999999999,"endTime":1577.145,"body":"spots on the surface or whether there"},{"speaker":"Dr Gavin Nimon","startTime":1572.7849999999999,"endTime":1577.145,"body":"was an endometrioma and if there is"},{"speaker":"Dr Gavin Nimon","startTime":1577.145,"endTime":1582.2649999999999,"body":"a chocolate cyst or endometrioma in"},{"speaker":"Dr Gavin Nimon","startTime":1577.145,"endTime":1582.2649999999999,"body":"the ovary how big that was and if we"},{"speaker":"Dr Gavin Nimon","startTime":1582.2649999999999,"endTime":1588.185,"body":"have excised that then how much of"},{"speaker":"Dr Gavin Nimon","startTime":1582.2649999999999,"endTime":1588.185,"body":"normal ovarian tissue is remaining."},{"speaker":"Dr Gavin Nimon","startTime":1588.185,"endTime":1592.115,"body":"So that is more of a practical approach."},{"speaker":"Dr Gavin Nimon","startTime":1592.115,"endTime":1596.125,"body":"Location based and visual."},{"speaker":"Dr Gavin Nimon","startTime":1597.295,"endTime":1597.955,"body":"Excellent."},{"speaker":"Dr Gavin Nimon","startTime":1598.145,"endTime":1600.595,"body":"What about the"},{"speaker":"Dr Gavin Nimon","startTime":1598.145,"endTime":1600.595,"body":"patients having problems with fertility"},{"speaker":"Dr Gavin Nimon","startTime":1600.895,"endTime":1602.585,"body":"and they've got endometriosis?"},{"speaker":"Dr Gavin Nimon","startTime":1603.495,"endTime":1605.675,"body":"What's the options for"},{"speaker":"Dr Gavin Nimon","startTime":1603.495,"endTime":1605.675,"body":"treatment in this scenario?"},{"speaker":"Dr Monika Juneja","startTime":1607.305,"endTime":1613.5249999999999,"body":"So it will"},{"speaker":"Dr Monika Juneja","startTime":1607.305,"endTime":1613.5249999999999,"body":"depend on symptoms and say"},{"speaker":"Dr Monika Juneja","startTime":1613.5249999999999,"endTime":1615.835,"body":"if a woman is Close to 40."},{"speaker":"Dr Monika Juneja","startTime":1616.085,"endTime":1619.875,"body":"She hasn't got any"},{"speaker":"Dr Monika Juneja","startTime":1616.085,"endTime":1619.875,"body":"symptoms of endometriosis."},{"speaker":"Dr Monika Juneja","startTime":1620.445,"endTime":1623.855,"body":"And ovarian reserve is on the lower side."},{"speaker":"Dr Monika Juneja","startTime":1624.57,"endTime":1626.84,"body":"She may have endometriosis, we don't know."},{"speaker":"Dr Monika Juneja","startTime":1627.09,"endTime":1632.35,"body":"She has got regular cycles, so we don't"},{"speaker":"Dr Monika Juneja","startTime":1627.09,"endTime":1632.35,"body":"think it's an ovulatory infertility due"},{"speaker":"Dr Monika Juneja","startTime":1632.35,"endTime":1635.76,"body":"to not producing eggs in a timely manner."},{"speaker":"Dr Monika Juneja","startTime":1636.51,"endTime":1642.46,"body":"So in those sort of cases,"},{"speaker":"Dr Monika Juneja","startTime":1636.51,"endTime":1642.46,"body":"we can go straight for IVF."},{"speaker":"Dr Monika Juneja","startTime":1644.155,"endTime":1645.725,"body":"Provided the ultrasound is normal."},{"speaker":"Dr Monika Juneja","startTime":1646.675,"endTime":1652.725,"body":"Whereas if a woman is younger we have"},{"speaker":"Dr Monika Juneja","startTime":1646.675,"endTime":1652.725,"body":"got time and if she has got any symptoms"},{"speaker":"Dr Monika Juneja","startTime":1652.725,"endTime":1657.115,"body":"or maybe no symptoms, then we have"},{"speaker":"Dr Monika Juneja","startTime":1652.725,"endTime":1657.115,"body":"got time to do laparoscopy and assess."},{"speaker":"Dr Monika Juneja","startTime":1657.885,"endTime":1664.335,"body":"So, even in mild to minimal cases"},{"speaker":"Dr Monika Juneja","startTime":1657.885,"endTime":1664.335,"body":"one of the studies it did show that"},{"speaker":"Dr Monika Juneja","startTime":1664.345,"endTime":1668.5149999999999,"body":"the chances of conceiving naturally"},{"speaker":"Dr Monika Juneja","startTime":1664.345,"endTime":1668.5149999999999,"body":"actually doubled where you have just"},{"speaker":"Dr Monika Juneja","startTime":1668.5149999999999,"endTime":1671.135,"body":"treated the mild disease as well."},{"speaker":"Dr Monika Juneja","startTime":1671.825,"endTime":1680.915,"body":"So the outcome improves with treatment"},{"speaker":"Dr Monika Juneja","startTime":1671.825,"endTime":1680.915,"body":"of endometriosis laparoscopically prior."},{"speaker":"Dr Monika Juneja","startTime":1680.915,"endTime":1684.795,"body":"So if I've diagnosed someone"},{"speaker":"Dr Monika Juneja","startTime":1680.915,"endTime":1684.795,"body":"with significant endometriosis,"},{"speaker":"Dr Monika Juneja","startTime":1684.795,"endTime":1689.405,"body":"I'll always tell the girls that"},{"speaker":"Dr Monika Juneja","startTime":1684.795,"endTime":1689.405,"body":"consider starting family earlier,"},{"speaker":"Dr Monika Juneja","startTime":1689.475,"endTime":1691.305,"body":"you know, don't wait till 35."},{"speaker":"Dr Monika Juneja","startTime":1691.915,"endTime":1695.055,"body":"So,, prioritize Conceiving first."},{"speaker":"Dr Monika Juneja","startTime":1695.065,"endTime":1700.675,"body":"So the best thoughts of conception will be"},{"speaker":"Dr Monika Juneja","startTime":1695.065,"endTime":1700.675,"body":"when we have just cleared endometriosis."},{"speaker":"Dr Monika Juneja","startTime":1700.735,"endTime":1703.7549999999999,"body":"It hasn't had a chance to grow back."},{"speaker":"Dr Monika Juneja","startTime":1704.175,"endTime":1706.5049999999999,"body":"So that's the best time"},{"speaker":"Dr Monika Juneja","startTime":1704.175,"endTime":1706.5049999999999,"body":"actually to conceive."},{"speaker":"Dr Monika Juneja","startTime":1706.5149999999999,"endTime":1709.2849999999999,"body":"Now if someone is 20,"},{"speaker":"Dr Monika Juneja","startTime":1706.5149999999999,"endTime":1709.2849999999999,"body":"obviously they are not ready."},{"speaker":"Dr Monika Juneja","startTime":1709.795,"endTime":1716.975,"body":"But at times girls will change their"},{"speaker":"Dr Monika Juneja","startTime":1709.795,"endTime":1716.975,"body":"plans and say at 28, 29, if I've cleared"},{"speaker":"Dr Monika Juneja","startTime":1716.975,"endTime":1722.58,"body":"endometriosis and I'll go back to them"},{"speaker":"Dr Monika Juneja","startTime":1716.975,"endTime":1722.58,"body":"and say well this is what it is you know"},{"speaker":"Dr Monika Juneja","startTime":1722.58,"endTime":1727.7,"body":"it's better to prioritize having baby"},{"speaker":"Dr Monika Juneja","startTime":1722.58,"endTime":1727.7,"body":"first so then they take the message on"},{"speaker":"Dr Monika Juneja","startTime":1727.76,"endTime":1733.2,"body":"board and if they say no not quite ready"},{"speaker":"Dr Monika Juneja","startTime":1727.76,"endTime":1733.2,"body":"yet but maybe you know in few months or"},{"speaker":"Dr Monika Juneja","startTime":1733.2,"endTime":1738.3999999999999,"body":"next year after I get married so in that"},{"speaker":"Dr Monika Juneja","startTime":1733.2,"endTime":1738.3999999999999,"body":"time you know we can suppress the cycles"},{"speaker":"Dr Monika Juneja","startTime":1738.42,"endTime":1743.46,"body":"with other progesterone tablets and"},{"speaker":"Dr Monika Juneja","startTime":1738.42,"endTime":1743.46,"body":"things and then they can start trying."},{"speaker":"Dr Monika Juneja","startTime":1743.8799999999999,"endTime":1749.77,"body":"So even if Every bit of endometriosis"},{"speaker":"Dr Monika Juneja","startTime":1743.8799999999999,"endTime":1749.77,"body":"is cleared up it's not a surety that"},{"speaker":"Dr Monika Juneja","startTime":1749.78,"endTime":1751.48,"body":"everyone will conceive naturally."},{"speaker":"Dr Gavin Nimon","startTime":1751.92,"endTime":1755.29,"body":"So is the infertility"},{"speaker":"Dr Gavin Nimon","startTime":1751.92,"endTime":1755.29,"body":"issue related obviously then to"},{"speaker":"Dr Gavin Nimon","startTime":1755.29,"endTime":1758.83,"body":"the endometrial deposits as opposed"},{"speaker":"Dr Gavin Nimon","startTime":1755.29,"endTime":1758.83,"body":"to I assumed it might just be the"},{"speaker":"Dr Gavin Nimon","startTime":1758.84,"endTime":1761.87,"body":"scarring causing adhesions that caused"},{"speaker":"Dr Gavin Nimon","startTime":1758.84,"endTime":1761.87,"body":"infertility, but it's actually even"},{"speaker":"Dr Gavin Nimon","startTime":1761.87,"endTime":1765.4099999999999,"body":"the endometrial deposits can cause"},{"speaker":"Dr Gavin Nimon","startTime":1761.87,"endTime":1765.4099999999999,"body":"infertility issues as well, is it?"},{"speaker":"Dr Monika Juneja","startTime":1766.09,"endTime":1770.37,"body":"So we're not sure"},{"speaker":"Dr Monika Juneja","startTime":1766.09,"endTime":1770.37,"body":"how exactly endometriosis affects"},{"speaker":"Dr Monika Juneja","startTime":1770.4099999999999,"endTime":1774.03,"body":"the Fertility, what the mechanism is."},{"speaker":"Dr Monika Juneja","startTime":1774.72,"endTime":1779.18,"body":"So there are various theories and"},{"speaker":"Dr Monika Juneja","startTime":1774.72,"endTime":1779.18,"body":"what is happening in a particular"},{"speaker":"Dr Monika Juneja","startTime":1779.18,"endTime":1781.29,"body":"person is anybody's guess."},{"speaker":"Dr Monika Juneja","startTime":1781.29,"endTime":1788.485,"body":"So it can be due to release of"},{"speaker":"Dr Monika Juneja","startTime":1781.29,"endTime":1788.485,"body":"inflammatory chemical cytokines,"},{"speaker":"Dr Monika Juneja","startTime":1788.485,"endTime":1794.49,"body":"interleukins, which can cause oocyte"},{"speaker":"Dr Monika Juneja","startTime":1788.485,"endTime":1794.49,"body":"release, the transport of egg through the"},{"speaker":"Dr Monika Juneja","startTime":1794.49,"endTime":1800.45,"body":"tube, the motility of the tubes could be"},{"speaker":"Dr Monika Juneja","startTime":1794.49,"endTime":1800.45,"body":"affected it could be on fertilization, it"},{"speaker":"Dr Monika Juneja","startTime":1800.45,"endTime":1808.0,"body":"could be on implantation it can be a very"},{"speaker":"Dr Monika Juneja","startTime":1800.45,"endTime":1808.0,"body":"inflammatory environment in the pelvis it"},{"speaker":"Dr Monika Juneja","startTime":1808.0,"endTime":1810.71,"body":"can be due to fibrosis and dyspareunia."},{"speaker":"Dr Monika Juneja","startTime":1811.35,"endTime":1815.61,"body":"In severe cases, it can also"},{"speaker":"Dr Monika Juneja","startTime":1811.35,"endTime":1815.61,"body":"be due to the egg quality."},{"speaker":"Dr Monika Juneja","startTime":1816.04,"endTime":1817.74,"body":"That the ovarian reserve is low."},{"speaker":"Dr Monika Juneja","startTime":1817.74,"endTime":1820.3999999999999,"body":"The quality of the eggs is not good."},{"speaker":"Dr Monika Juneja","startTime":1820.44,"endTime":1824.52,"body":"That could be affecting"},{"speaker":"Dr Monika Juneja","startTime":1820.44,"endTime":1824.52,"body":"their odds of conceiving."},{"speaker":"Dr Monika Juneja","startTime":1824.52,"endTime":1826.52,"body":"So, the per cycle fecundity."},{"speaker":"Dr Monika Juneja","startTime":1827.205,"endTime":1831.845,"body":"For conception, which is, so if a"},{"speaker":"Dr Monika Juneja","startTime":1827.205,"endTime":1831.845,"body":"normal couple you know, the conception"},{"speaker":"Dr Monika Juneja","startTime":1831.845,"endTime":1836.725,"body":"is say 15 to 20 percent per cycle,"},{"speaker":"Dr Monika Juneja","startTime":1831.845,"endTime":1836.725,"body":"in endometriosis it will go down"},{"speaker":"Dr Monika Juneja","startTime":1836.725,"endTime":1840.2549999999999,"body":"to somewhere between 2 to 10%."},{"speaker":"Dr Monika Juneja","startTime":1840.455,"endTime":1845.105,"body":"And this is based on a very old"},{"speaker":"Dr Monika Juneja","startTime":1840.455,"endTime":1845.105,"body":"study that doesn't take into account"},{"speaker":"Dr Monika Juneja","startTime":1845.115,"endTime":1850.605,"body":"the staging, but statistically"},{"speaker":"Dr Monika Juneja","startTime":1845.115,"endTime":1850.605,"body":"that has been put forward by them."},{"speaker":"Dr Gavin Nimon","startTime":1851.73,"endTime":1855.32,"body":"It's amazing if you are"},{"speaker":"Dr Gavin Nimon","startTime":1851.73,"endTime":1855.32,"body":"doing a laparoscopic surgery to ablate"},{"speaker":"Dr Gavin Nimon","startTime":1855.4099999999999,"endTime":1857.93,"body":"or to remove the endometrial tissue."},{"speaker":"Dr Gavin Nimon","startTime":1858.11,"endTime":1858.44,"body":"Yes."},{"speaker":"Dr Gavin Nimon","startTime":1858.49,"endTime":1861.135,"body":"And the person's thinking"},{"speaker":"Dr Gavin Nimon","startTime":1858.49,"endTime":1861.135,"body":"about  a family and they're in,"},{"speaker":"Dr Gavin Nimon","startTime":1861.315,"endTime":1862.965,"body":"say they're an order age group."},{"speaker":"Dr Gavin Nimon","startTime":1863.445,"endTime":1866.055,"body":"Is there a role for harvesting"},{"speaker":"Dr Gavin Nimon","startTime":1863.445,"endTime":1866.055,"body":"eggs exit at the same time?"},{"speaker":"Dr Gavin Nimon","startTime":1866.055,"endTime":1867.855,"body":"Would that be considered or"},{"speaker":"Dr Gavin Nimon","startTime":1866.055,"endTime":1867.855,"body":"is that something that's a"},{"speaker":"Dr Gavin Nimon","startTime":1867.855,"endTime":1870.435,"body":"separate group that would do that"},{"speaker":"Dr Gavin Nimon","startTime":1867.855,"endTime":1870.435,"body":"through a second laparoscopy?"},{"speaker":"Dr Monika Juneja","startTime":1870.715,"endTime":1874.055,"body":"So harvesting the"},{"speaker":"Dr Monika Juneja","startTime":1870.715,"endTime":1874.055,"body":"egg is we can't do it at the same time."},{"speaker":"Dr Monika Juneja","startTime":1874.2649999999999,"endTime":1874.355,"body":"Right."},{"speaker":"Dr Monika Juneja","startTime":1874.655,"endTime":1876.545,"body":"So basically they have to."},{"speaker":"Dr Monika Juneja","startTime":1877.075,"endTime":1878.985,"body":"see the fertility specialist."},{"speaker":"Dr Monika Juneja","startTime":1878.985,"endTime":1882.495,"body":"I have to refer them on to an IVF clinic."},{"speaker":"Dr Monika Juneja","startTime":1882.825,"endTime":1884.2649999999999,"body":"It's a separate process."},{"speaker":"Dr Monika Juneja","startTime":1884.2849999999999,"endTime":1891.295,"body":"So you have to give a lot of hormones,"},{"speaker":"Dr Monika Juneja","startTime":1884.2849999999999,"endTime":1891.295,"body":"gonadotropins to stimulate the ovaries."},{"speaker":"Dr Monika Juneja","startTime":1891.795,"endTime":1896.665,"body":"And then the ovaries have to produce"},{"speaker":"Dr Monika Juneja","startTime":1891.795,"endTime":1896.665,"body":"the eggs and then the egg retrieval"},{"speaker":"Dr Monika Juneja","startTime":1896.665,"endTime":1902.995,"body":"is ultrasound guided under  sedation"},{"speaker":"Dr Monika Juneja","startTime":1896.665,"endTime":1902.995,"body":"and then those eggs have to be stored."},{"speaker":"Dr Monika Juneja","startTime":1904.385,"endTime":1910.425,"body":"So we normally cannot just cut the ovary"},{"speaker":"Dr Monika Juneja","startTime":1904.385,"endTime":1910.425,"body":"and save it for use at a later date."},{"speaker":"Dr Monika Juneja","startTime":1910.555,"endTime":1911.885,"body":"There's an orthopaedic based question."},{"speaker":"Dr Monika Juneja","startTime":1913.415,"endTime":1915.435,"body":"I get that asked a lot by patients."},{"speaker":"Dr Monika Juneja","startTime":1915.615,"endTime":1919.835,"body":"Oh, can you just save my eggs at the"},{"speaker":"Dr Monika Juneja","startTime":1915.615,"endTime":1919.835,"body":"same time that you are doing the surgery?"},{"speaker":"Dr Monika Juneja","startTime":1920.5349999999999,"endTime":1923.235,"body":"So it is a common question."},{"speaker":"Dr Monika Juneja","startTime":1925.205,"endTime":1926.475,"body":"Right, so I'm not alone then."},{"speaker":"Dr Monika Juneja","startTime":1926.5149999999999,"endTime":1927.875,"body":"No, you're not alone there."},{"speaker":"Dr Gavin Nimon","startTime":1928.415,"endTime":1928.5249999999999,"body":"Okay."},{"speaker":"Dr Gavin Nimon","startTime":1928.965,"endTime":1931.475,"body":"It's a question off the top"},{"speaker":"Dr Gavin Nimon","startTime":1928.965,"endTime":1931.475,"body":"of my head as we're speaking."},{"speaker":"Dr Gavin Nimon","startTime":1932.445,"endTime":1935.095,"body":"What is multidisciplinary"},{"speaker":"Dr Gavin Nimon","startTime":1932.445,"endTime":1935.095,"body":"approach for endometriosis?"},{"speaker":"Dr Gavin Nimon","startTime":1935.125,"endTime":1938.955,"body":"Obviously it sounds like it's basically"},{"speaker":"Dr Gavin Nimon","startTime":1935.125,"endTime":1938.955,"body":"gynecologist treatment,  and you"},{"speaker":"Dr Gavin Nimon","startTime":1939.0149999999999,"endTime":1942.225,"body":"mentioned the colorectal teams when it's"},{"speaker":"Dr Gavin Nimon","startTime":1939.0149999999999,"endTime":1942.225,"body":"involving the rectum and other areas."},{"speaker":"Dr Gavin Nimon","startTime":1942.5249999999999,"endTime":1944.925,"body":"Are there any other teams that you"},{"speaker":"Dr Gavin Nimon","startTime":1942.5249999999999,"endTime":1944.925,"body":"have involved in the treatment?"},{"speaker":"Dr Gavin Nimon","startTime":1944.925,"endTime":1947.0249999999999,"body":"I mean, is there a specialist"},{"speaker":"Dr Gavin Nimon","startTime":1944.925,"endTime":1947.0249999999999,"body":"nurse that is involved in"},{"speaker":"Dr Gavin Nimon","startTime":1947.0249999999999,"endTime":1948.345,"body":"intermediate treatment as well?"},{"speaker":"Dr Gavin Nimon","startTime":1948.365,"endTime":1951.125,"body":"Or is there other teams that are"},{"speaker":"Dr Gavin Nimon","startTime":1948.365,"endTime":1951.125,"body":"involved like there are for other"},{"speaker":"Dr Gavin Nimon","startTime":1951.125,"endTime":1953.295,"body":"conditions we have around medicine?"},{"speaker":"Dr Monika Juneja","startTime":1954.0349999999999,"endTime":1958.495,"body":"So, in terms of"},{"speaker":"Dr Monika Juneja","startTime":1954.0349999999999,"endTime":1958.495,"body":"specialties I involve urologists,"},{"speaker":"Dr Monika Juneja","startTime":1958.545,"endTime":1960.165,"body":"fortunately not very often."},{"speaker":"Dr Monika Juneja","startTime":1960.165,"endTime":1966.855,"body":"If there is hydronephrosis or a suspicion"},{"speaker":"Dr Monika Juneja","startTime":1960.165,"endTime":1966.855,"body":"of bladder involvement, then Yes, we"},{"speaker":"Dr Monika Juneja","startTime":1966.855,"endTime":1973.455,"body":"involve the urologist, but quite common"},{"speaker":"Dr Monika Juneja","startTime":1966.855,"endTime":1973.455,"body":"involving a gastroenterologist especially"},{"speaker":"Dr Monika Juneja","startTime":1973.465,"endTime":1979.575,"body":"if they have got bowel symptoms or Upper"},{"speaker":"Dr Monika Juneja","startTime":1973.465,"endTime":1979.575,"body":"abdominal discomfort or unresolved pain."},{"speaker":"Dr Monika Juneja","startTime":1979.955,"endTime":1986.335,"body":"So we have cleared endometriosis and they"},{"speaker":"Dr Monika Juneja","startTime":1979.955,"endTime":1986.335,"body":"still have bloating and GI disturbance,"},{"speaker":"Dr Monika Juneja","startTime":1986.335,"endTime":1991.7849999999999,"body":"then I'll get a gastroenterology colleague"},{"speaker":"Dr Monika Juneja","startTime":1986.335,"endTime":1991.7849999999999,"body":"to have a look into other factors."},{"speaker":"Dr Monika Juneja","startTime":1992.625,"endTime":1993.805,"body":"Also a psychologist."},{"speaker":"Dr Monika Juneja","startTime":1994.475,"endTime":1998.2549999999999,"body":"Quite often, you know, you have"},{"speaker":"Dr Monika Juneja","startTime":1994.475,"endTime":1998.2549999999999,"body":"treated the endometriosis, but about 20"},{"speaker":"Dr Monika Juneja","startTime":1998.2549999999999,"endTime":2000.375,"body":"percent can still have persistent pain."},{"speaker":"Dr Monika Juneja","startTime":2000.905,"endTime":2006.325,"body":"So psychologist for support and coping"},{"speaker":"Dr Monika Juneja","startTime":2000.905,"endTime":2006.325,"body":"mechanisms physiotherapist, so pelvic"},{"speaker":"Dr Monika Juneja","startTime":2006.325,"endTime":2012.135,"body":"floor physio for vaginismus and pelvic"},{"speaker":"Dr Monika Juneja","startTime":2006.325,"endTime":2012.135,"body":"floor dysfunction where they can"},{"speaker":"Dr Monika Juneja","startTime":2012.145,"endTime":2014.305,"body":"have overactive pelvic floor muscles."},{"speaker":"Dr Monika Juneja","startTime":2014.305,"endTime":2018.5349999999999,"body":"So that can cause"},{"speaker":"Dr Monika Juneja","startTime":2014.305,"endTime":2018.5349999999999,"body":"dyspareunia and ongoing pain."},{"speaker":"Dr Monika Juneja","startTime":2019.725,"endTime":2023.895,"body":"Pain specialist, where you have"},{"speaker":"Dr Monika Juneja","startTime":2019.725,"endTime":2023.895,"body":"done surgery, you have suppressed"},{"speaker":"Dr Monika Juneja","startTime":2023.905,"endTime":2028.615,"body":"the cycles, but they've still got"},{"speaker":"Dr Monika Juneja","startTime":2023.905,"endTime":2028.615,"body":"pain, so they're involving the"},{"speaker":"Dr Monika Juneja","startTime":2028.815,"endTime":2030.685,"body":"chronic pain team is quite common."},{"speaker":"Dr Monika Juneja","startTime":2030.745,"endTime":2035.345,"body":"And having a good support from the"},{"speaker":"Dr Monika Juneja","startTime":2030.745,"endTime":2035.345,"body":"GP is of course very important."},{"speaker":"Dr Monika Juneja","startTime":2035.705,"endTime":2040.725,"body":"So someone who is sympathetic"},{"speaker":"Dr Monika Juneja","startTime":2035.705,"endTime":2040.725,"body":"and can be the anchor point to"},{"speaker":"Dr Monika Juneja","startTime":2040.965,"endTime":2042.705,"body":"coordinate the care as well."},{"speaker":"Dr Gavin Nimon","startTime":2044.055,"endTime":2044.605,"body":"Brilliant."},{"speaker":"Dr Gavin Nimon","startTime":2044.665,"endTime":2046.055,"body":"There's a huge team involved."},{"speaker":"Dr Gavin Nimon","startTime":2046.065,"endTime":2048.285,"body":"There's a lot more than I expected"},{"speaker":"Dr Gavin Nimon","startTime":2046.065,"endTime":2048.285,"body":"and it's great to hear it."},{"speaker":"Dr Gavin Nimon","startTime":2048.915,"endTime":2053.3650000000002,"body":"It's a it's an amazing condition"},{"speaker":"Dr Gavin Nimon","startTime":2048.915,"endTime":2053.3650000000002,"body":"and I'm still so surprised"},{"speaker":"Dr Gavin Nimon","startTime":2053.625,"endTime":2054.925,"body":"I don't know more about it."},{"speaker":"Dr Gavin Nimon","startTime":2055.225,"endTime":2058.535,"body":"Obviously I'm an orthopaedic surgeon,"},{"speaker":"Dr Gavin Nimon","startTime":2055.225,"endTime":2058.535,"body":"so I understand that, but it should"},{"speaker":"Dr Gavin Nimon","startTime":2058.545,"endTime":2061.285,"body":"be more in the media and I think"},{"speaker":"Dr Gavin Nimon","startTime":2058.545,"endTime":2061.285,"body":"it is coming out more in the media."},{"speaker":"Dr Gavin Nimon","startTime":2061.285,"endTime":2063.565,"body":"Where do you think the"},{"speaker":"Dr Gavin Nimon","startTime":2061.285,"endTime":2063.565,"body":"advances are in the future?"},{"speaker":"Dr Gavin Nimon","startTime":2063.565,"endTime":2065.455,"body":"Where do you think things are"},{"speaker":"Dr Gavin Nimon","startTime":2063.565,"endTime":2065.455,"body":"heading for this condition?"},{"speaker":"Dr Gavin Nimon","startTime":2065.455,"endTime":2069.145,"body":"Can you see light at the end of the tunnel"},{"speaker":"Dr Gavin Nimon","startTime":2065.455,"endTime":2069.145,"body":"or is it still far away at this stage?"},{"speaker":"Dr Monika Juneja","startTime":2069.745,"endTime":2073.5,"body":"I think we'll"},{"speaker":"Dr Monika Juneja","startTime":2069.745,"endTime":2073.5,"body":"have better imaging modalities."},{"speaker":"Dr Monika Juneja","startTime":2074.27,"endTime":2078.66,"body":"So the ultrasound diagnosis"},{"speaker":"Dr Monika Juneja","startTime":2074.27,"endTime":2078.66,"body":"will continue to improve."},{"speaker":"Dr Monika Juneja","startTime":2079.52,"endTime":2084.6499999999996,"body":"There is funding now for MRI,"},{"speaker":"Dr Monika Juneja","startTime":2079.52,"endTime":2084.6499999999996,"body":"so it is rebatable if we are"},{"speaker":"Dr Monika Juneja","startTime":2084.69,"endTime":2086.7999999999997,"body":"suspecting severe endometriosis."},{"speaker":"Dr Monika Juneja","startTime":2086.7999999999997,"endTime":2092.8849999999998,"body":"Also I think with time we'll see a"},{"speaker":"Dr Monika Juneja","startTime":2086.7999999999997,"endTime":2092.8849999999998,"body":"better Non invasive biomarker, hopefully,"},{"speaker":"Dr Monika Juneja","startTime":2092.8849999999998,"endTime":2099.115,"body":"which will reduce the need for operative"},{"speaker":"Dr Monika Juneja","startTime":2092.8849999999998,"endTime":2099.115,"body":"laparoscopy, which is obviously invasive."},{"speaker":"Dr Monika Juneja","startTime":2099.835,"endTime":2106.785,"body":"Also, new oral medications, so I think"},{"speaker":"Dr Monika Juneja","startTime":2099.835,"endTime":2106.785,"body":"there are phase 3 trials and we are"},{"speaker":"Dr Monika Juneja","startTime":2106.835,"endTime":2113.725,"body":"close to having a GNRH antagonist which"},{"speaker":"Dr Monika Juneja","startTime":2106.835,"endTime":2113.725,"body":"is available orally in combination"},{"speaker":"Dr Monika Juneja","startTime":2113.725,"endTime":2116.445,"body":"with estrogen and progesterone."},{"speaker":"Dr Monika Juneja","startTime":2116.445,"endTime":2119.685,"body":"That might improve the outcome"},{"speaker":"Dr Monika Juneja","startTime":2116.445,"endTime":2119.685,"body":"and it can also hopefully"},{"speaker":"Dr Monika Juneja","startTime":2119.735,"endTime":2122.235,"body":"reduce the size of fibroids."},{"speaker":"Dr Monika Juneja","startTime":2122.485,"endTime":2123.005,"body":"And"},{"speaker":"Dr Monika Juneja","startTime":2123.045,"endTime":2129.585,"body":"think for prevention of pain newer"},{"speaker":"Dr Monika Juneja","startTime":2123.045,"endTime":2129.585,"body":"IUD where a non steroidal can be"},{"speaker":"Dr Monika Juneja","startTime":2129.815,"endTime":2135.095,"body":"added to the progesterone in the IUD"},{"speaker":"Dr Monika Juneja","startTime":2129.815,"endTime":2135.095,"body":"itself to help with chronic pain."},{"speaker":"Dr Monika Juneja","startTime":2135.645,"endTime":2143.305,"body":"The IUDs which have got a different"},{"speaker":"Dr Monika Juneja","startTime":2135.645,"endTime":2143.305,"body":"hormone and combination of medications to,"},{"speaker":"Dr Monika Juneja","startTime":2143.695,"endTime":2147.1349999999998,"body":"Help to deal with the problem long term."},{"speaker":"Dr Monika Juneja","startTime":2147.805,"endTime":2151.3849999999998,"body":"And perhaps better pain control measures."},{"speaker":"Dr Monika Juneja","startTime":2151.935,"endTime":2154.495,"body":"This stage, that's what I can think of."},{"speaker":"Dr Monika Juneja","startTime":2155.1349999999998,"endTime":2155.345,"body":"That's"},{"speaker":"Dr Gavin Nimon","startTime":2155.355,"endTime":2155.645,"body":"brilliant."},{"speaker":"Dr Gavin Nimon","startTime":2155.745,"endTime":2157.8849999999998,"body":"There's a lot of better things"},{"speaker":"Dr Gavin Nimon","startTime":2155.745,"endTime":2157.8849999999998,"body":"on the horizon there, which"},{"speaker":"Dr Gavin Nimon","startTime":2157.895,"endTime":2159.245,"body":"is good news for the future."},{"speaker":"Dr Gavin Nimon","startTime":2159.325,"endTime":2163.855,"body":"So,   there's actually light at the"},{"speaker":"Dr Gavin Nimon","startTime":2159.325,"endTime":2163.855,"body":"tunnel, . One in seven or one in ten"},{"speaker":"Dr Gavin Nimon","startTime":2163.855,"endTime":2167.215,"body":"is a huge number and it's a really"},{"speaker":"Dr Gavin Nimon","startTime":2163.855,"endTime":2167.215,"body":"important topic to hear about it."},{"speaker":"Dr Gavin Nimon","startTime":2167.235,"endTime":2169.365,"body":"I'm really pleased you're able to"},{"speaker":"Dr Gavin Nimon","startTime":2167.235,"endTime":2169.365,"body":"come along and give us some more"},{"speaker":"Dr Gavin Nimon","startTime":2169.365,"endTime":2170.625,"body":"information about this topic."},{"speaker":"Dr Gavin Nimon","startTime":2170.625,"endTime":2173.175,"body":"So I'd like to thank you"},{"speaker":"Dr Gavin Nimon","startTime":2170.625,"endTime":2173.175,"body":"very much for your time."},{"speaker":"Dr Gavin Nimon","startTime":2173.175,"endTime":2173.793,"body":"And we'll see you next time."},{"speaker":"Dr Gavin Nimon","startTime":2173.843,"endTime":2177.083,"body":"Really appreciate the advice and the"},{"speaker":"Dr Gavin Nimon","startTime":2173.843,"endTime":2177.083,"body":"information you've given us today."},{"speaker":"Dr Gavin Nimon","startTime":2177.163,"endTime":2177.733,"body":"Thank you very much,"},{"speaker":"Dr Monika Juneja","startTime":2177.733,"endTime":2178.133,"body":"Monika."},{"speaker":"Dr Monika Juneja","startTime":2178.583,"endTime":2180.1929999999998,"body":"Thanks a lot for having me here."},{"speaker":"Dr Monika Juneja","startTime":2180.1929999999998,"endTime":2181.9629999999997,"body":"It was my pleasure to be here."},{"speaker":"Dr Gavin Nimon","startTime":2182.393,"endTime":2182.793,"body":"Excellent."},{"speaker":"Dr Gavin Nimon","startTime":2182.843,"endTime":2183.793,"body":"Thank you very much."},{"speaker":"Dr Gavin Nimon","startTime":2183.956,"endTime":2185.846,"body":"Thank you very much for"},{"speaker":"Dr Gavin Nimon","startTime":2183.956,"endTime":2185.846,"body":"listening to our podcast today."},{"speaker":"Dr Gavin Nimon","startTime":2186.136,"endTime":2188.466,"body":"I'd like to remind you that the"},{"speaker":"Dr Gavin Nimon","startTime":2186.136,"endTime":2188.466,"body":"information provided is just general"},{"speaker":"Dr Gavin Nimon","startTime":2188.466,"endTime":2190.766,"body":"advice and may vary depending"},{"speaker":"Dr Gavin Nimon","startTime":2188.466,"endTime":2190.766,"body":"on the region in which you are"},{"speaker":"Dr Gavin Nimon","startTime":2190.766,"endTime":2192.056,"body":"practicing or being treated."},{"speaker":"Dr Gavin Nimon","startTime":2192.456,"endTime":2194.6259999999997,"body":"If you have any concerns or"},{"speaker":"Dr Gavin Nimon","startTime":2192.456,"endTime":2194.6259999999997,"body":"questions about what we've"},{"speaker":"Dr Gavin Nimon","startTime":2194.6259999999997,"endTime":2197.146,"body":"discussed, you should seek advice"},{"speaker":"Dr Gavin Nimon","startTime":2194.6259999999997,"endTime":2197.146,"body":"from your general practitioner."},{"speaker":"Dr Gavin Nimon","startTime":2197.666,"endTime":2199.716,"body":"I'd like to thank you very much"},{"speaker":"Dr Gavin Nimon","startTime":2197.666,"endTime":2199.716,"body":"for listening to our podcast"},{"speaker":"Dr Gavin Nimon","startTime":2200.006,"endTime":2202.426,"body":"and please subscribe to the"},{"speaker":"Dr Gavin Nimon","startTime":2200.006,"endTime":2202.426,"body":"podcast for the next episode."},{"speaker":"Dr Gavin Nimon","startTime":2202.576,"endTime":2204.326,"body":"Until then, please stay safe."}]}