QC: Understanding Why Endometriosis Lesions Grow, Bleed, And Change Color

What if understanding how endometriosis builds its own blood supply could unlock safer, smarter treatment? We sit down with Professor Gaby Moawad—renowned robotic surgeon, educator, and leader in endometriosis care—to unpack the vascular engine that drives lesion growth, bleeding, and scarring. In five focused minutes, we translate complex molecular pathways into clear takeaways you can use to ask better questions and advocate for better care.

Dr. Moawad explains how hypoxia inside scarred tissue activates HIF alpha, which then boosts VEGF signaling to build new vessels. We explore how inflammation and locally produced estrogen amplify this process, why metalloproteinases (MMPs) cut space for vessels to form, and what immature pericytes have to do with leaky, bleeding lesions. He connects the dots from biology to the operating room: hypervascular lesions on MRI, the “powder burn” color changes created by hemosiderin, and the feedback loop that turns immune dysfunction into chronic pain and fibrosis.

We also touch on therapy frontiers. Anti-angiogenic drugs targeting VEGF show promise but raise concerns about wound healing and fertility. Dr. Moawad highlights where research is headed, including targeted delivery directly to lesions and cellular approaches that modulate endothelial progenitor cells. For anyone navigating diagnosis, imaging, fertility planning, or surgical decisions, this clear, science-backed overview offers a roadmap to discuss options with your care team and understand the trade-offs behind emerging treatments.

If this deep dive helped you see endometriosis through a sharper lens, follow the show, share it with someone who needs clarity, and leave a review so others can find it. Have a question you want answered fast? Send it our way and we’ll bring in the expert voice you need next.

Chapters

• 0:00 Quick Connect Format & Disclaimer
• 0:41 Guest Introduction
• 1:56 How Endometriosis Builds Blood Supply
• 3:45 Why Lesions Bleed And Change Color
• 6:59 Targeted Therapies And Research Directions
• 7:53 Closing And How To Submit Questions

Transcript

Alanna: 0:00

Life moves fast, and so should the answers to your biggest questions. Welcome to Endo Batteries Quick Connect, your direct line to expert insights. Short, powerful, and right to the point. You send in the questions, I bring in the experts, and in just five minutes, you get the knowledge you need. No long episodes, no extra time needed. And just remember, expert opinions shared here are for general information and not for personalized medical advice. Always consult your provider for your case-specific guidance. Got a question? Send it in, and let's quickly get you the answers. I'm your host, Alanna, and it's time to connect. Today's guest is someone who is truly changing the landscape of endometriosis care. Professor Gaby Moawad is a globally recognized leader in robotic surgery and endometriosis management. He's a board-certified gynecologic surgeon and the founder of the Center for Endometriosis and Advanced Pelvic Surgery in Washington, D.C. Dr. Moawad has dedicated his career to advancing minimally invasive and robotic techniques, combining surgical innovation with deep, compassionate, patient-centered care. As director of robotic gynecologic surgery and associate professor at George Washington University, he's trained surgeons worldwide and helped redefine how we approach complex pelvic disease. He's been named Top Doctor in Washington, D.C. for nearly a decade and has authored over 125 peer-reviewed publications leading global conversations on endometriosis and surgical innovation. It's an honor to sit down and welcome a true pioneer and advocate for better outcomes for women everywhere. Please help me in welcoming Dr. Gaby Moawad. And lymphatic pathways and how they might actually feed or spread with endometriosis.

Dr. Moawad: 2:02

Well, if you you're looking for complexity, here's your complex answer. So there are there are a few substances that I think every endometriosis patient should at least try to remember some names or understand what they do in endometriosis. Every endometriotic cell needs oxygen to grow, needs nutrients to grow, and then needs blood vessels to evacuate their waste. This is part of almost every cell in the body rather than endometriosis cells only. So in endometriosis cells, there are what we call VEGF, vascular endothelial growth factor, and then VEGF receptors. So there is a more a higher prevalence of VEGF that help producing what we call angiogenesis and vasculogenesis. Angiogenesis creating new blood vessels. So those lesions, because of the scarring that happens, they are in a hypoxic state or poor oxygen comes there. So they develop what we call hypoxia induced factor, HIF alpha. That what this produces, it upregulates the receptor to attract more VEGF to produce more blood vessels. So that HIF is a substance that says, I don't have any vessels coming to bring me oxygen, so let's bring in more of the vascular and telial growth factor so they produce more blood vessels. Now, in addition to that, the inflammatory mediators, interleukin A, tumor necrosis factor, they also promote inflammation and increase the VEGF in the endometriosis cells. So you can see how the circles is doing things, and the estrogen is present in high concentration in endometriosis lesions because there is the aromatase. They produce their own estrogen, the endometriosis cells. Now add to this through all that concoction, there is what we call MMPs. This is metalloproteinase. These are substances that break down the matrix around the cells for endometriosis, break down those proteins to create space for blood vessels to form. So now we see all those blood vessels have space to form, they start forming. And we can see a higher density even on imaging of endometriosis lesions when we do the contrast on MRI, they're hypervascularized. Now, throughout that whole medium, what happens? Those inflammation start promoting the bone marrow to produce EPCs, EPC endothelial progenitor cells. So these are cells that come and shear lead the formation of vessels. So you have a higher number of those cells, so everybody is engaged to produce more vessels in the endometriosis lesions. Then we do say, oh, endometriosis lesions bleeds. Why? Because there is on every blood vessel a lining of cells. We can call them pericytes. Peri means near, they lines, those sites mean cells, they line the blood vessels. So there is an immature support of those pericytes. That's why those blood vessels are leaky, and that's why they they tend to leak blood outside, and that's what they bleed. So you can see how that angiogenesis or the formation of blood vessel is led by inflammation, by hyperestrogenism, local hyperestrogenism in the lesions, by all those substances created to promote from the body, from the bone marrow, to promote further formations of immature cells that leads to bleeding and then engage further the body to inflame more.

Alanna: 6:12

Is that why we get variation in color for the lesions as well?

Dr. Moawad: 6:18

Yes, yes, yes, yes.

Alanna: 6:19

And you know, we hear about the powder burn lesions, but there's also a rainbow of color in lesions.

Dr. Moawad: 6:26

So when the blood leaks from those vessels, it is digested by the enzymes, and they're part of the metabolites of the digestion is hemofiderin, and they deposit there, and it gives the color of purple or powder burn lesion. And then you can have a different level of vascular or scarring because whenever you produce inflammation, your body reacts to scarring. And since we have an immune dysfunction with endometriosis, so the scarring is there is an over-reaction to the inflammation with extensive scarring.

Alanna: 6:59

Yeah.

Dr. Moawad: 7:00

So it's mostly really well understood on the molecular level, and this is help us a lot in trying to figure out therapeutic approaches. So there have been trials that did target the VEGF or anti-angiogenic therapeutic medication. These showed promising results, but they led to poor wound healing, and then their impact on fertility is unknown. So further study maybe about the delivery method of those substances, maybe direct delivery through the lesions, might help improving with minimizing the systemic side effects. So when we understand what's causing what, we can further our research to try to help through targeted therapies or cellular therapies for endometriosis.

Alanna: 7:53

That's a wrap for this quick connect. I hope today's insights helped you move forward with more clarity and confidence. Do you have more questions? Keep them coming. Send them in, and I'll bring you the expert answers. You can send them in by using the link in the top of the description of this podcast episode or by emailing contact at Indobattery.com or visiting the Indobattery.com contact page. Until next time, keep feeling empowered through knowledge.