sMater | Women's Health: Endometriosis | Dr Naguesh Gaunekar

In recognition of Endometriosis Awareness Month, we meet Mackay Gynaecologist and Obstetrician, Dr Naguesh Gaunekar.

Dr Gaunekar outlines why it can take in excess of six years to diagnose endometriosis and the impact this can have on fertility.

GP Education activity log:
  Podcast title - Women's Health: Endometriosis
  Provider - Mater Misericordiae Ltd
  Date published - March 20, 2024
  Certificate of completion - click here

To learn more about Mater, visit https://www.mater.org.au/

Transcript

Hello and welcome to this episode of sMater. A podcast by clinicians for clinicians brought to you by Mater, an Australian leader in healthcare for more than a century. My name is Glenn Mintern

and I'm excited to join you as we meet some of our clinicians and deep dive into specialty areas from across Mackay and Townsville. Today I'm coming to you from Yuwibara, the land on which this podcast is recorded and today I'm excited as we recognize endometriosis awareness month to be joined by Dr Naguesh Gaunekar, obstetrician and gynecologist at Mater Private Hospital Mackay. With more than 25 years medical experience Dr Gaunekar has special interest in minimally invasive Gynecology fertility and women's ultrasonography. He completed his specialist training at the Women's and Children's Hospital in Adelaide and worked as a specialist obstetrician and gynecologist in Adelaide before moving to Mackay with his family. 
Today he's joining us to talk about the detection and effective treatment of endometriosis.

We are Mater. We are Mater. We are Mater. This is sMater.

Naguesh why is it that it does take so long for a majority of women to be diagnosed with endometriosis?

That's such an important and relevant question Glenn that women are used to pain and we somehow inherently expect that there will be some period like pain and women accept that as part of normality but pain cannot be quantified across individuals. It's a very personal perception so you cannot say that this pain is acceptable and that pain is not and where does that line lie so often people accept that as normality. Another factor is that

endometriosis sometimes runs in the family so they say well my mother also had quite severe period pain so I'm going to just you know grin and bear it 
and put up with it so there is a large amount of I would't want want to use the word ignorance but lack of awareness of that there is a condition called endometriosis that could be the reason for those symptoms and then subsequently they manifest as different other symptoms that come out from there. You start having it affecting the quality of life, you start having missed days at school, missed days at work,  that impacts mental health that creates fatigue, that creates anxiety depression, so you have a wide variety of symptoms that come from endometriosis but the acceptance that it can be related to something biological the penny drops a lot later and that's the experience if you look at the data that's available.

Endometriosis Australia has revealed more than 14% of Australian women live with endometriosis at some stage in their life but the average amount of time it takes for it to be diagnosed is 6 and half years.

What sort of age are you starting to look at for symptoms of endometriosis?

So it's endometriosis is a condition that can occur from puberty to menopause so it's the entire reproductive career of a woman and
we can call them children but they are women in in a sense from a biological perspective and once they start having ovulation once they start having menstruation, they can have endometriosis. Endometriosis is a very interesting relationship a very intimate relationship with estrogen and estrogen is a is a female hormone that's comes into its own with ovulation which is the release of the egg and that's where the whole story starts when it comes to endometriosis.
So some of those early symptoms what are they and are there additional tests that can be done that maybe can help diagnose where the lady sit.

Absolutely. The symptoms mostly are period pain. The period pain that last before during and after the periods that's called triple dysmenorrhea that can be a condition that is

quite classically described but not all will have that so and as I said period pain or pain is a personal perception so how do you say that this is way beyond normality it depends on each individual's pain threshold. I'm of the 
belief that women have much higher pain thresholds than men because of what they are coming in for and that's natural evolution but the downside of that is that they put up with a lot and they manifest that much later in the piece. Coming to tests that we can do to diagnose endometriosis the cardinal test is a very targeted focused ultrasound. A lot of times an ultrasound would come back as normal because they're looking only at the uterus the ovaries and saying oh it looks normal normal ovaries normal uterus so it should not have any dramas what we call normal on imaging doesn't necessarily be normal from endometriosis perspective because you will not see subtle degrees of endometriosis that is present. You will also not see certain features that are that are a part of a dynamic testing which is basically the operator dependent part of testing for endometriosis so I truly believe that alround for endometriosis needs to be done by a very specialized individual trained for that that purpose for looking at those subtle signs because if you're only looking at the images you will miss a lot of them. The ultrasound is very good at diagnosing endometriosis if it involves the ovaries but that can be a much later manifestation so ultrasound is a basic investigation. Laparoscopy remains the gold standard.

Are there long-term impacts let's say if treatment begins 5 years rather than 10 years after diagnosis?

That's another fantastic question but it is very hard to tell you isn't it because you would not know when did the endometriosis start. We often see that endometriosis symptoms and endometriosis disease is not always proportional to each other so each journey is different. Do I propose that every patient that comes with period pain should be put through a laparoscopy? No not really. We need to look at it very in a very individualized manner a very targeted manner. What's the symptoms ?

How much is it affecting the quality of life.

So I guess that brings me to the next question - what is the impact of endometriosis particularly on pregnancy?

Endometriosis and pregnancy have an interesting relationship you know the the standard teaching was that pregnancy is a good cure for endometriosis because as we talked about earlier that it's the ovulation and the rise in estrogen that pretty much feeds endometriosis so when you have this pregnancy you have 9 months of a holiday for endometriosis and if you then go on to breastfeed another six months of lactation which then gives a 15 month good holiday and that will lead to a lot of atrophy of endometriosis or active endometriotic lesions and that could pretty much cure people to a to a quality of life that is acceptable but on the other side on the flip side, endometriosis makes it harder to get pregnant so you have something that you'd like to treat with a with a pregnancy if I can you say that but on the other side it's harder to get pregnant so you have to work on all sorts of interventions to say what's right for the patient and where they are in their journey to say where do we go from here to make them achieve the goal that they are setting for themselves so is it a better quality of life a less painful period,
a less painful intercourse or is it targeted towards having a baby.

The ABC reported it could take 7 to 12 years for a woman to be diagnosed with endometriosis due to barriers in accessing Specialist Care or dismissals from clinicians due to minimal or broad symptoms. The report also cited a University of Queensland study that revealed 40% of women with endometriosis require fertility treatment to assist in having children.

So Naguesh, in your experience have you seen pregnancy either lessen or worsen the symptoms of endometriosis.

Absolutely. Pregnancy does give endometriosis a long holiday so endometriosis is generally exacerbated by a menstrual period so when pregnancy gives you 9 months of no periods followed by laction breastfeeding which leads to another maybe 6 to 12 months you could get a good holiday from endometriosis being fed and as a result some of it will regress sometimes even they might become symptom free.

Is that common? Fairly common yes but it does as we talked earlier it becomes harder to get pregnant so it's not an easy solution in that in that regard.

So if it was to see the symptoms disappear is that forever is there a possibility that they could come back later on in time?

The data suggests that 30% of endometriosis would recur and I think that's even underrated because how often do we know it's come back until you put a telescope and have a look so that's 

basically the nature of the beast so we have to look at endometriosis as an entire journey from puberty to menopause and some of the symptoms will not even disappear after menopause so you have this extended spectrum of disease that is manifested over extended period of time with its ups and downs and you have to therefore tailor the treatment to where the target is or where the goal of that patient is for some part of that treatment it might be symptom relief that another part it might be enhancing their fertility.

Are there instances where you've seen patients who have been or even had to have a completely frozen pelvis to be able to fall pregnant? Absolutely there's an amazing patient and I just think that the degree of pain threshold they would have that they present to you when the pelvis is completely frozen with the disease with active disease and scar tissue so that's long-standing endometriosis.

So I had a patient like that who had a completely frozen pelvis and we were debating as to how do we go about it and she was very keen on 
having babies so we had a long discussion with her, myself and a colorectal surgeon and we then went in to do a laparoscopy but we decided that we will do a minimal surgery to optimize fertility because that was her main goal and interestingly after five tries of trying naturally and we pinpointing when she was ovulating she fell pregnant with follicle tracking and just ultrasound so it was amazing because most of these patients end up needing much higher level of interventions and it was amazing to see that she succeeded she subsequently came back to me after after having that baby. Of course we delivered that baby but after having the baby she came back saying I need to have another child and
the story was again the same and we said okay we tried naturally for a few months with no success we then went in had a look at the pelvis again did very minimal intervention to free up the tubes the free up the ovary but did not try to do anything heroic because that would have involved taking pieces of the bowel out 

which can have its own morbidity so and you know amazingly she fell pregnant again without needing interventions like IVF so it's very rewarding and she's very very happy. Her symptoms after the pregnancy have been minimal although her disease is is quite massive.

The Australian Disease Expenditure studies showed that in the 2020/21 financial year an estimated $247.2 million was spent on endometriosis in the Australian health system that covered everything from public and private hospital admissions and services to pathology and GP services and PBS expenditure. But the cost of the disease is not just financial, it also affects people's ability to work or do the activities they enjoy leading to the total estimated economic burden of endometriosis in Australia to be $9.7 billion annually.

So Naguesh, it is endometriosis Awareness Month. What is the message that you have for the medical community when it comes to diagnosis and treatment of this condition?

I think the thing which is an ongoing struggle but also something that we should be doing is to recognize that endometriosis is real and endometriosis is a condition although it  
is a benign Condition it's not a cancer 
it is robbing women of their potential and if you can understand that aspect I think the rest of it falls in place now that applies to young child I wouldn't call them a child but a young adolescent that is just getting into puberty where school work can be affected their social life can be affected. As they grow up they they are the impact that endometriosis has on their reproductive life, their sex life.

It is a major impact to the person sitting across from you.

Probably one of the real keys is in the title awareness it is something that's so important awareness now Gynecology and fertility it's a bit of a family affair for you and
and your wife Dr Sally Rodriguez. What does it mean to be able to provide those services that between you you're able to to put out there to Mackay and the Whitsunday's region together?

Well when you said a family affair I just feel affair and the family doesn't go in the same sentence but jokes aside it is truly a family for me. For me the workplace, we've been here for a good 18 years and we invite them into our family every time 
they come in to see us and myself and my wife,

Sally Rodriguez, she's of course she's the boss and she is very much cardinal to the practice. We provide a service that we can deliver the best to every couple, every family that come and see us for it. And the journey, we've been part of 6,000 babies being delivered in Mackay. I couldn't ask for anything more. These are 6,000 
families that have partnered with us in their most intimate journeys. Their most aspirational goals of life and I think they are they are part of our family for good so it is truly a family journey for me.

Fascinating stuff but right now we're going to find out a little bit more about you in a segment we like to call The Checkup. 

So Naguesh, in this segment we get to find out
a little bit more about you the person Naguesh the person as opposed to Naguesh the medical professional. I've got a number of quickfire questions. I'm going to throw them at you. I don't want you to think too hard about the answer. First answer that comes to your mind is probably the best one when it comes to this. Are you ready to go? Let's go. All right question number one. How do you unwind or relax? Well music is my therapy.

Do you play? No I sing, I sing. I train into classical music Indian classical music but I also sing western music 
at the Eisteddfod at the Conservatorium. Fantastic yes .

Do you sing in the surgery? Yes I do actually.
In fact some of my colleagues in the surgery said that the surgery it does go much better when they're singing. I like to believe that. Well ties into the next question. Do you have a theater playlist - is there a set of group of songs that you like to listen to in the surgery? They have to listen to my voice.

Not a bad thing by the sound of it. Can you give me an idea what TV show best portrays your profession do you think?

Is there one? I've gone off TV because that's the agenda on that is just they take you away from what you want to achieve. 
I'd like to talk about books there's a beautiful book by Adam Kay he talks about It's Going to Hurt. It's a journey of a young doctor obstetrician that went through the NHS and it's a wonderful journey and there was a documentary on that. I think that's the TV would like to see. Absolutely Have you ever had to deal with a medical emergency when you haven't been working?

I came very close to one when I was flying and usually when they ask you know is there a doctor in the in the passenger list I try to pretend that I'm sleeping because I say I'm an obstetrician what can I do with a heart attack you know and I suddenly found that there was once a pregnant patient and I said my goodness but luckily we were lucky to get her to the next destination before she could do something drastic up in the air 30,000 ft I guess. Would certainly be one to write your own book about and just finally do you have any

superstitions? Not really I try to stay away from superstitions because I think that they can sway on your life because they can start you know you start believing them. It's interesting how they play on your on your mind it's life is a mind game and I think you need to just learn to play it on your turf and your on your term.
If you try to get sucked into other superstitious stuff I think God save you.

Great answer. Naguesh thank you so much for joining us on sMater. Thank you Glenn. For our listeners at home, in the car or having a well-deserved break between patients thank you so much for tuning in today. We'll see you next time on sMater.