Endometriosis, PMOS and Feeling Heard with Miss Lauren Green

Dr Nick Dunn is joined by Consultant Obstetrician and Gynaecologist Miss Lauren Green to discuss two common but often misunderstood conditions: endometriosis and Polyendocrine Metabolic Ovarian Syndrome (PMOS), previously known as PCOS.

Lauren explains why endometriosis can be so hard to diagnose, the symptoms that shouldn't just be accepted as part of having periods, and what treatment can look like across primary and specialist care. She also talks about why women so often grow up believing that living with pain is normal.

Nick and Lauren also unpack what's behind the PMOS name change. Lauren explains how insulin resistance can make weight loss metabolically more difficult, and talks about the physical and emotional impact the condition can have. We hear how, for Lauren, taking the time to really listen so patients feel heard is often the first step towards managing symptoms and protecting long-term health.

Nick also finds out what brought Lauren back to Guernsey after training in the UK, why continuity of care is one of the most rewarding parts of her job, and how she unwinds outside the consulting room.

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If this conversation sounds familiar, or you’re experiencing any of the symptoms discussed, don’t put off seeking advice. Book an appointment with your GP to discuss your concerns and the treatment options available.

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Transcript

SPEAKER_00 0:00

Hi, I'm Nick. Welcome to the Doctor's Decoded Podcast. Today we're going to talk about endometriosis and polycystic ovarian syndrome. With me today, we've got Dr. Lauren Green, who is a specialist in Guernsey in obstetrics and gynecology. So, Lauren, for people who don't know you, can you tell us just a bit about what you do and what kind of work you specialise in?

SPEAKER_01 0:25

Yeah, sure. So I'm a women's health specialist. As you said, I um did my training in the UK and decided to come back to Guernsey for a consultant post here, initially as the obstetric lead. And I'm now the chairperson for women and children's health and a partner at the medical specialist group. I'm a generalist, so I see women throughout pregnancy, but also with gynecological issues at all stages of their life, through childhood, reproductive years, um, into menopause and postmenopause. And I split my time between working um on call at the hospital and um doing clinics and seeing my patients at the MSG.

SPEAKER_00 1:05

And what would you say are the most common reasons for women being referred to CU?

SPEAKER_01 1:10

Um for women of reproductive age, it's most commonly um some period issues. So that might be um heavy or painful periods. We see um women with more um profound pain that might represent conditions like endometriosis. Um we would then see women who are struggling to conceive and then later in life um issues surrounding perimenopause and menopause, bleeding pain, um, all manner of symptoms.

SPEAKER_00 1:44

So today we're going to talk about endometriosis, as you mentioned earlier on, very common reason for women coming to see you. Um but we're also going to touch upon a condition which has recently been relabeled, um, one which I would know as PCOS or polycystic ovarian syndrome. Can you tell me the new label for that now?

SPEAKER_01 2:01

Yeah, so um PCOS has been returned polyendocrine metabolic ovarian syndrome to better represent the issues that women with that condition have.

SPEAKER_00 2:12

So what we're going to do, we're going to think about those conditions in particular. Um and you can maybe tell me a bit about, I suppose, endometriosis to start with.

SPEAKER_01 2:21

Sure. So endometriosis is a um a condition that manifests predominantly as quite severe pelvic pain and also causes issues with problematic periods, very heavy and painful periods. And a lot of women um encounter heavy, painful periods, and it can take women um often a very long time to achieve a diagnosis for endometriosis, often with a delay from first presenting, perhaps to see someone in primary care, like Eunic as a GP, through to being referred to secondary care to achieve a diagnosis can take on average up to about 12 years. So it's a burden of symptoms that women really live with that is often kind of unrecognised and it's much more common than we think. So up to about one in ten women of reproductive age would have goodness. And it might even be more than that, because of course we don't we have those issues with being able to diagnose it. Diagnosing it's challenging because there's no test that we can do in as a blood test or an or or even ultrasound necessarily that would um secure the diagnosis.

SPEAKER_00 3:29

It's often something that women complain about is that their endometriosis goes undiagnosed for a long time. Um and one of the things that we struggle with as GPs is you know, how do we diagnose it? And you know, who do we miss? So that's quite an interesting point you made.

SPEAKER_01 3:44

So often um things that would make you consider endometriosis or be suspicious of that over and above just sort of problematic periods themselves would be if the if you have a s a cyclical element of pain often that precedes the period itself. And that can be really quite debilitating for women when there's often an expectation that they just carry on and do all the things they normally do in their busy lives without it um affecting them. Um and um endometriosis is um happens when some of the cells from the lining of the womb um or cells that are similar to the lining of the womb cells are found within the pelvis. So outside of the womb, they can attach to the um structures around. So either the external surface of the womb, the tubes, the ovaries, or even the bowel and the bladder. Um, and in they respond to those same cyclical changes in hormones that would govern the menstrual cycle. Right. So as soon as there's um a stimulation of those cells as there is in the latter half of the menstrual cycle, there will be kind of deep-seated inflammation that can really cause um really problematic pain. And this isn't just period type pain, it's really deep. Um, people describe it as sort of stabbing or drilling. It can be really debilitating for people.

SPEAKER_00 5:04

So those cells that would normally be on the lining of the womb respond to that hormonal cycle you talked about, and these cells have attached to other structures around the abdominal cavity, you're saying. Yeah. And then they respond to the hormones and then they cause the symptoms. Exactly. Yeah. So do the symptoms tend to be cyclical?

SPEAKER_01 5:24

Yes, that's one of the kind of um biggest giveaways of endometriosis, is it as opposed to persistent pain. So, as we know, lots of people have kind of chronic pain that doesn't fluctuate um and is there really persistently all day, every day. But endometriosis does tend to differ from that. So um it's different in in different individuals, but um, some women might be um uh very aware of when they ovulate, for example. So they might get a get some pain mid-cycle, and that can be very normal for a lot of women, they'll be able to tell you when they've ovulated. Um, but for women with endometriosis, because that causes some stimulation of those cells that aren't usually there, um, it's mu it's much more painful. Um yeah.

SPEAKER_00 6:11

And when people come to see you, they've often waited a long time before even going to their GP to ask about the symptoms. How long usually is it that people have had symptoms, that women have had symptoms before they see you with their endometriosis, would you say?

SPEAKER_01 6:26

Well, there's lots of things that GPs can do for women with endometriosis without necessarily needing to see a specialist. Um, but you are absolutely right that women will kind of make do and try and think that it's normal or be told that it's normal. Um, as you said at the start, often um well, things like endometriosis certainly have got a familial element where they'll run in families. We don't really understand how endometriosis or why it happens in in specific people, um, but there does tend to certainly be a familial tendency. So sometimes people just expect that it's normal. Um, once they've been to see their GP, it can sometimes take multiple attendances to be heard and for their symptoms to be taken seriously. Um, and there's lots of things that can be tried to help manage those symptoms. Um, we're we're really lucky in Guernsey, each of each of your primary care practices has got women's health specialist GPs and um they'll be very used to seeing people with these symptoms. And the mainstay of treatment would be to try and offer some kind of medical hijacking of that menstrual cycle, and we use hormones to do that.

SPEAKER_00 7:38

So before we go to the treatment, I was quite interested to hear that you feel that patients or women often go to their doctors and they're not listened to or the symptoms are not linked to endometriosis. What other conditions or what other explanations do you think women receive when they initially present with these kind of symptoms?

SPEAKER_01 7:57

Yeah, sure. So if if it's mainly an issue around um uh heavy painful periods, then sometimes that will just be viewed as a variant of normal. Um, and that's certainly something that a lot of women do deal with. So sometimes it might not be appreciating the other cyclical elements of their symptoms. If um the endometriosis, for example, has attached itself to the bowel, there can be quite profound changes in bowel habit through the course of the month. Um, and so sometimes women can um think that they or are sort of implied that they have a diagnosis of kind of IBS or irritable bowel syndrome. It's very common during menstrual cycle with the difference in um hormones in the run-up to and during the period to have a bit of a looser bowel, um, uh prone to kind of diarrhea. Um, but if you have got deep-seated pain or it's very painful to have a bowel motion, then that's not normal. Um, and so sometimes they can be kind of mislabelled with a bowel diagnosis, such as IBS, rather than seeing that it's linked with endo. The same thing for bladder symptoms. So if it's um if it's affecting the outside wall of the bladder, it can be very painful to pass urine, and women can be um treated for recurrent urinary tract infections when actually there isn't evidence of infection, they're just having the outward symptoms. And similarly, because because when these cells are being stimulated, they become very inflamed and they kind of they they'll they'll degrade and cause a lot of cause they'll cause the women's the women's immune system to be very busy in kind of dealing with that and and and our body find fighting that inflammation, it can be very fatiguing. So women can become profoundly tired, um, not able to cope with what's normally on their plate at different times in the cycle, and that can sometimes lead to a misdiagnosis of kind of chronic fatigue or ME or fibromyalgia. Endometriosis very rarely can travel to more distant areas in the body, so um it can manifest, it can be it can be found on the diaphragm in the lungs, even in kind of bone and muscle, very rarely. Um so it can cause focal pain where that is, and and when it's deep within the pelvis, it can also really cause that kind of horrible sciatic burning pain down legs and and um really yeah, cause cause really cause chaos for women.

SPEAKER_00 10:31

Yeah. So I suppose as GPs, that's why we find it so difficult sometimes to get to the bottom of these things, and it can take repeated consultations before people come back, and finally we can sort of drill down and get a better idea as to what's going on. Um and obviously a large part of endometriosis is about understanding what's going on and and living with some of that. But obviously, we want to hear about some of the treatment options available. And you're going to talk to a bit about that.

SPEAKER_01 10:57

Yeah, yeah, sure. Thank you. So um there can be simple non-hormonal treatments that can just help with the heavy painful period parts, things like tranxamic acid to reduce the um flow um during menstruation, during, during the actual period, or tranixamic acid is a painkiller that can just be used for short term pain relief when you're having your period. But these things won't affect the hormonal signalling that's causing the issue in the first place.

SPEAKER_00 11:25

And tranxamic acid, what does that do exactly?

SPEAKER_01 11:28

The tranxamic acid is um helps to reduce the um uh the amount that we bleed, essentially. So it's used in other areas of medicine as well to limit blood loss and it's proven to reduce the heaviness of your period. So that can that can mean that periods are a bit more easy for women to manage. Um whereas the methanamic acid, it sounds very similar, but they're completely different, is a is a painkiller, a bit like ibuprofen.

SPEAKER_00 11:54

Just anti-inflammatory.

SPEAKER_01 11:56

Exactly, yeah. Yeah.

SPEAKER_00 11:57

And and how often do people respond to that? Is that an effective treatment, do you find?

SPEAKER_01 12:02

It's effec it's effective for women when their symptoms are just limited to their period, which which really by definition is not women with endometriosis, but these are the simplest things to try in the first place. Beyond that, the the most effective way of treating endometriosis is trying to manipulate the menstrual cycle so that we're not getting stimulation to those unusual cells. And the way we do that is using um some form of a uh contracep contraceptive pill, such as the combined orocontraceptive or the progesterone only, or using other type of progesterone treatments to try and reduce the menstrual cycle. Right.

SPEAKER_00 12:41

So what we talked about earlier on that tissue that would normally be in the in the womb that's in other areas around the abdominal cavity that's then responding to the hormones, what you're trying to do is to kind of switch that off so that they're not being activated.

SPEAKER_01 12:55

Exactly. Yeah, that's the main goal of the treatment. Yeah. And um is that an effective treatment for most women, do you find so for a lot of women will respond to that in the first instance, and we often use that as a sort of test of cure. So if you can find something that suits a woman that will um reduce their uh symptoms, um sorry, re um kind of reduce their periods or make the periods much lighter, or in in some um people stop them having periods completely, if that leads to an improvement in their symptoms, then we can that's quite suggestive that it is hormonally driven.

SPEAKER_00 13:34

Right. So it's partly you're ensuring that you've got the right diagnosis to some extent if you respond to treatment. And you mentioned about completely switching off periods. Yeah. Is that almost like inducing early menopause? Is that how you would describe it?

SPEAKER_01 13:48

Or yeah, so there are there are ways some women will will um uh respond to certain pills um or other forms of progesterone. It can be given as an implant or in a as a coil with that sits within the womb. And for some people that would stop their periods, which can be very convenient, and it's also providing contraception, which is convenient to people also, or maybe convenient. Um the there are um some women that won't respond to those treatments and an in an escalation of treatments, and I suppose everything we've talked about so far could be initiated by a GP in in primary care to see if that could help the patient. Um, if we if those things haven't worked, then there are ways of inducing a kind of early chemical menopause to completely switch off the menstrual cycle, but we would um uh only use that very infrequently and usually only for people with very problematic symptoms. So that would certainly be within my remit as a specialist in that area. Um and yeah, so then there are other sort of symptoms that might make you think that perhaps surgery might be needed.

SPEAKER_00 15:01

Can you tell me a bit about surgery for endometriosis?

SPEAKER_01 15:04

Yeah. So surgery is technically the only way to absolutely confirm the diagnosis, and that is done is keyhole surgery called laparoscopy. Um, and it's sort of a it's a significant frustration for people who live with endometriosis that kind of being opened up is the only way that they can have their diagnosis confirmed. We can see signs of it sometimes on ultrasound. So if the endometriosis is affecting the ovaries, it can cause cysts where there's collections of those endometriotic cells on the ovary, and they're termed chocolate cysts because they are full of this sort of material that breaks down each month.

SPEAKER_00 15:44

And it looks like chocolate, is that right?

SPEAKER_01 15:46

Yeah, so when when when you're operating, it it looks like old blood, so it looks brown, and that's why they get their name. But they're a classic appearance of that that you can diagnose on ultrasound. And it's possible to see some deposits of endometriosis or or the death or the downstream effects of endometriosis on the internal organs on ultrasound. But really, the gold standard for confirming the diagnosis is only through actually visualizing the pelvis itself.

SPEAKER_00 16:15

Which is quite a big step, isn't it? It is, and it's that involves a general anesthetic. That's right. Um the actual operation of the laparoscopy itself, which isn't without risks, I suppose. It's not a high-risk procedure, but at the same time, yeah, it's a lot for women to go through to get a definitive diagnosis.

SPEAKER_01 16:30

Um, for some women that is the right thing to do in certain cases, because it allows us to stage the endometriosis. And what we mean by that is is it it can you see it? Can you see deposits of endometriosis in the pelvis? It does it look like it's superficial or deeper. Um, and then it that would be an opportunity to take the endometriosis away surgically, so to cut away the areas that are that are causing a problem. And that used to be done more commonly when it was more thought that that could lead to a cure. Yeah. But of course, unless you are doing something with the hormonal manipulation to reduce that signal, those cells are going to proliferate and come back. Right. And so, um, although there's definitely a role for surgery for some women, it doesn't cure the condition.

SPEAKER_00 17:18

Yeah. And that whole process of endometrial lining cells, cells coming from the womb and going into the abdominal cavity, is that a continuous process, do you think, or is it something that's thought to occur at one stage in a woman's life?

SPEAKER_01 17:31

We really don't know the answer. So unfortunately, although it's so common, it's if you think it's it's affecting as many people as might have type 2 diabetes, for example, it's really under-researched, and the funding for research has just not been there, which is a a repetitive um problem within women's health, unfortunately. Um, so we don't really understand why it happens to some women and not to others. Um, there's a couple of theories as to how it happens. So there's um the theory of retrograde menstruation, which is a technical term meaning that when you're having a period, some of the period blood that you're losing will instead of coming out through the neck of the womb, the cervix and the vagina, it will it will go backwards up through the fallopian tubes, which usually carry the eggs down into the um into the womb and out then through into the what's called the peritoneum, so the space outside of your womb and your pelvis. So that's one theory. Another um is that potentially um during your your own fetal development, so when you were in your in your mum's womb, um that's at the um due to the signalling from the mother's hormones that that can cause um some proliferation of the lining of the wombs in the fetal and the lining of the cells in the fetal womb, and that they can sometimes get stuck, and then when menstruation starts, those can um also go to where they're not supposed to be.

SPEAKER_00 19:03

That's amazing that it can occur at such an early stage.

SPEAKER_01 19:06

And we know that um the the endometriotic deposits are actually the cells are they're similar to the lining of the womb cells, but they actually seem to be stem cells. So these amazing cells our bodies produce that that can become whatever they choose to, and we don't really understand the process of why the body would make the decision to make endometriotic type cells not within the lining of the womb.

SPEAKER_00 19:31

Yeah. And why do you think it's so poorly researched?

SPEAKER_01 19:35

Um well, I think there's multiple factors that feed into that. Um, one of which, um, sadly, being that it it's something that's really been normalized. So women's symptoms and women's pain threshold has been very much normalized. And I could talk about this all day long. Um, it's a bit like women who have severe vomiting in pregnancy, hyper emesis gravida, and being told that you should you know you should be pleased you're pregnant, and that's just path of the course. And so some of it has been that kind of cultural normalization, an expectation that women would put up with pain um that would that it to a point that would really be unacceptable if you could standardize that pain. Um the um the other issue, sadly, is a lot of things that drive investment in research, is if there's money to be made through pharmaceutical companies. And because we don't have really any significant treatment options other than hormonal manipulation, um, it's a bit chicken or egg. Is that because we haven't had the research, or is that because there isn't very much that can be done to alter the course of endometriosis? And I think we don't know.

SPEAKER_02 20:43

Yeah.

SPEAKER_01 20:43

And women are complex creatures, so they're much harder to include in research studies because of the changes through the menstrual cycle, whereas men tend to be much more easy to standardize. And so that's something thankfully it's getting much better now with um uh sort of equity in in recruitment to medical studies. But it it's really uh an it's multifactorial, I would say. Yeah.

SPEAKER_00 21:08

So it'd be interesting to switch to, as I said, polycystic ovarian syndrome, or the the new label just remind me of what that is again.

SPEAKER_01 21:16

Yeah. So it's um you're really testing me here. It's um polyendocrine metabolic ovarian syndrome. So that's been a very recent development from a paper that was published in The Lancet, which is a really um outstanding medical journal, and it's really welcomed change in women's health. So PCOS, as it was called, was polycystic ovarian syndrome, and it kind of put the focus on the ovaries, making one assume that there was a physical issue with the ovary itself, making it full of cysts. And ovarian cysts can become very problematic for people and cause pain, but really the the picture of the ovarian changes in PCOS is would more correctly be termed poly follicular ovaries. So the even the use of the word cyst is kind of poorly placed and leads to a lot of um confusion for patients and clinicians um in terms of what PCOS is. And so the fact that it's been relabeled to polyendocrine metabolic ovarian syndrome is really welcome because it's actually the ovaries responding to the downstream effects of changes to the endocrine and metabolic syndrome that lead to those changes.

SPEAKER_00 22:25

Yeah. So can we try and unpick that term a bit more? Because I think you know people listening might not understand some of these terms the way that we do. So polyendocrine presumably means hormonal in some shape or form. Yeah. Yeah. And metabolic, what's the significance of that in the in the title?

SPEAKER_01 22:41

Yeah, so um metabolic refers within medicine refers to conditions that um are um commonly seen as sort of part of a um a Western lifestyle, should we say. So things like high blood pressure, high cholesterol, insulin resistance, so your body not being as responsive to insulin and not clearing glucose or sugar in the bloodstream as quickly as other people would. Um and these things um occupy a lot of GP's time, of course, um, but can happen at an earlier age in women with PMOS due to kind of hormonal imbalances where you have fundamentally a slightly higher ratio of the androgens, which are the commonly thought of as the male sex hormones. We're talking about testosterone. Um, but testosterone is very important for women's health as well.

SPEAKER_00 23:36

Which will be a surprise, I'm sure, for people listening.

SPEAKER_01 23:39

So women um need testosterone for for bone and muscle health and for energy and libido and all sorts of very normal physiological functions. So testosterone is not something to be scared of as a woman. But when our body produces too much testosterone, that can have an impact on um how the ovaries function. And so the the main hallmark of someone with PMOS, uh previous PCOS is is is infrequent periods. And um, we would expect people generally to roughly to have a period once a month. That can alter for different people, can vary from sort of three to six weeks potentially, because the exact time when a woman ovulates is not always the same, and it might be quite individual. But for women who have very few periods, that could represent potentially an issue with the hormonal signalling and the fact that the ovaries are maybe not listening to those hormones in the way that we usually would expect them to. And that's important because if you're not taking any hormonal contraceptives, um, if you're just having a natural cycle and you have fewer than four periods a year, that puts you at increased risk of kind of estrogen that's then not leading to ovulation, right? Can cause a buildup of the lining of the womb. So those cells that we discussed earlier with endometriosis, where they're supposed to be within the lining of the womb, ideally regularly they need to be shed and come out through the neck of the womb and the vagina. And if that's not happening, it can cause a build-up, which can put people at increased risk of um a precursor to essentially cancer of the lining of the womb. So it'd be very important for women to know that they should have at least four periods a year. So one for each season, um, unless they're on a hormonal contraceptive that's meaning they're not having periods because of that reason.

SPEAKER_00 25:34

So are women with PMOS more likely to have endometrial cancer, sort of cancer of the womb than Yeah.

SPEAKER_01 25:41

So this is why the that relabeling with the polyendocrine and metabolic components is really helpful because um women with that condition are more likely to develop um uh cancer of the lining of the womb over their life course than women without that, um, if they're not having regular periods or help to have regular periods through a kind of cyclical use of a progesterone or something similar. They're also more at risk of developing type 2 diabetes because of the insulin resistance, and it's important that a diagnosis can be made so that women can know what they need in terms of their long-term health. And that could that should include an annual blood pressure check for developing high blood pressure as part of that metabolic component and an annual glucose check of some description to check for developing type 2 diabetes.

SPEAKER_00 26:35

So it's really another risk factor, isn't it, in the chain of risks associated with things like heart disease, um, which we often like as you say, as GPs, we're always trying to be on the front foot with these things and identify risk factors so that we can manage them and deal with them and identify them. Um but obviously PMOS influences quality of life for women as well. Um what are the kind of treatment options for this? I mean, you mentioned obviously trying to influence the hormonal balance. Is there anything else that would be useful for them or or what kind of problems do people tend to present to you with when you see them with these conditions?

SPEAKER_01 27:09

Yeah, sure. So um it's there's still quite a lot of taboo over talking about periods and problems with your periods. And um when you're having infrequent periods, people often are worried that that might lead to them not being able to um get pregnant when they want to be. Um, and so often fertility is something that's on people's minds. Um the um the other um symptoms that it can cause due to the this um hormone imbalance is that it can cause um excessive hair growth. So um for women especially that can be excess hair in or around their chin um or um or on their legs, for example, or on their tummy. Um uh um and it can also increase the likelihood of having acne. Um, and often acne associated with PMOS will be um more severe than kind of general teenage acne. It can be really quite inflammatory, um, and that can that can lead to um real issues with body image, which um sometimes can be brushed off. Um, but women can that can cause quite a lot of sort of adverse psychological side effects. Um, and lots of women with PMS will have uh some degree of depression related to their symptoms, their worries, their body image. Um because the the other kind of hallmark of PMS or what people c often struggle with is excess body weight because it's metabolically much more difficult for them to keep weight off.

SPEAKER_00 28:44

Um and do we know why that is?

SPEAKER_01 28:47

Um we think it's because of that insulin resistance. So um thing the sort of old adage of eat less and move more is is true, yeah, but it can be quite unhelpful to people who are struggling metabolically. So treatments uh um really are lifestyle focused. So this is again, it's not something that can be cured, it's something that needs to be managed, and it's important for people to understand the diagnosis so that they know how to manage it.

SPEAKER_00 29:14

And how difficult do you find those kind of conversations? Because frequently, as GPs, but particularly as specialists, patients come to us looking for a cure and looking for an answer. Um and it can be quite a difficult conversation to have when you're explaining this is not something we can cure you of, we can help you manage it. So, how do you approach that side of things?

SPEAKER_01 29:36

Yeah. So often it's about um um having the time to hear someone and for them to feel heard and their symptoms to be heard so that a diagnosis can be made. Sometimes the diagnosis will involve blood tests or sometimes ultrasound, although that's not always required if you have infrequent periods and evidence of the higher levels of testosterone or those all those um symptoms that we talked about. That's enough to secure a diagnosis without needing an ultrasound. Um the often there's a lot of misinformation, or it's potenti it's possible to have um uh I've certainly met met people who are very worried that it means that they'll never be able to get pregnant, and that's not true. Um, they think that there isn't anything that they can do, or that because it this is again something that can tend to run in families. Yeah. So people sometimes think, oh, well, I you know, my mum and my sister and my auntie all had it so that so there's no hope for me.

SPEAKER_00 30:32

They can be a bit fatalistic about it.

SPEAKER_01 30:34

And you can understand why, because people didn't really advocate for these conditions in the past as as much as it's now possible to. Um, there's some great information available for patients from the Royal College of Obstetricians and gynecologists about what the condition involves and um how it can best be managed.

SPEAKER_00 30:53

Um and I find that as a GP, certainly um what you talked about earlier on, where women with this condition they struggle to lose weight. But the trouble is they sometimes feel stuck, they feel that they can't change that. Yeah. And it's getting the balance right, isn't it? Between obviously acknowledging that this will make it more difficult for them, but it's not impossible for them.

SPEAKER_01 31:16

And there are some again, some hormonal treatments that could be tried. So for example, as long as there's not a reason not to have the combined or a contraceptive pill, that's a really great option for people. Um some and then in the in if we're planning pregnancy and having very infrequent periods, that can be quite challenging. That's something that we can help with in secondary care. So we can use um uh sort of we can induce a period and then be recommending ovulation induction medication um to help someone ovulate so that that improves their chances of conceiving.

SPEAKER_00 31:52

What kind of medication would that be these days?

SPEAKER_01 31:55

Um so we use um something called clomids, which is clomophene citrate, or we can around for a long time, hasn't it? Yeah, or we can use um an injectable medication called Gonalf. Um what does that do? Um that essentially is like follicle stimulating hormone. So one of the hormones that governs our um is released normally from the pituitary gland to stimulate the ovaries. We're giving that as a as a as a synthetic version to do the same thing. But that not all women with PCOS will require that to get pregnant. Um if you're having that kind of um ovulation induction treatment, it's really important to have regular follicular tracking scans, which which we can offer in secondary care. Um, but really to reassure people that's not for everybody with PMOS. Um, other things that can help with the insulin resistance is using metformin, like a drug that we would commonly use for type 2 diabetes. Um, but not for all women, again, it's very individualized. And there are other medications that can help specifically with the acne or the or the um excess hair growth.

SPEAKER_00 33:00

Yeah. Yeah. So that I think that's the value of knowing that we can refer to specialists because some of these things, whilst they're available, we wouldn't be comfortable prescribing that in primary care, whereas you've got the knowledge to know who's going to benefit and what problems might arise. You touched earlier upon the internet and um what's available online. Um how do we manage that? I mean, obviously, we've got the growth of AI, we've got patients coming in to see us who have researched things on Chat GPT or anything else, and often quite well informed, actually. Yeah. Um, and it's difficult because we're trying to empower people to take control of their health, find out more about their health. So I don't want to undermine that, but at the same time, it can be a bit of a threat, especially when, like you say, there's some misinformation there. How do you approach that side of things?

SPEAKER_01 33:47

So I would just always recommend my patients to kind of pick their sources. So um there's so much information and that and that's got to be a positive thing. But like you said, it's picking and choosing where to where to get your info from. So um a lot there's quite a few um uh people who specialise in these areas who will um who have got successful sort of influencer accounts where they'll put up the latest research and make sure that it's evidence-based. What you really want to be looking for is evidence-based information rather than one individual's experience. Um so it can be tricky, but looking at um things that come from um charities to do with these conditions. So there's um an excellent um patient uh organization called Endometriosis UK for women with who think they might have endometriosis, and there's lots of information there about um get how it whether or not the symptoms might be suggestive of endometriosis with a great patient questionnaire that people can do. It gives you a letter that you can then take to your doctor to summarize the symptoms. It sometimes can be quite muddling or stressful in the consultation to remember everything that you're living with, um, and that can be really helpful as well as kind of symptom diaries. For PMOS, there I'm not aware of any charity, but the information from the Royal College of Obstetricians and Gynecologists is brilliant. And also there's loads of information you can get on the NHS website with with links to appropriate charities. Yeah. Um, so I'd always re start there and then see what you can find um through social media platforms, just be careful.

SPEAKER_00 35:31

Yeah. So I think that take-home message from this sounds as though you're saying that um there are conditions which aren't necessarily curable but are manageable, um, but have been affecting people's quality of life for a long time. And you know, women are putting up with these symptoms sometimes or being told to put up with the symptoms, and in fact, if they're listened to properly, I think that's the key thing. I would totally agree with you. I think that people need to be listened to. Yeah, absolutely. And that's the the kind of initial starting point, isn't it? Um there are actually things that we can do to help. Um, and from your point of view, are there any kind of key take-home messages that you would like to pass on?

SPEAKER_01 36:14

Um, I think if you think that there's something wrong, um, then talk to somebody about it. Um so, like I've mentioned, there's still quite a lot of taboo over um all of the things we've talked about really today. And so if if if I if I could achieve one thing, it would be normalizing talking about your periods or or problems with your periods, um, then um going to see your GP to see what um it to to have that consultation. So to get that expertise of um do we think that there is an issue or not.

SPEAKER_00 36:47

And it's also a safe space, isn't it? It's like confidentiality and be able to be open and yeah, yeah.

SPEAKER_01 36:52

And that's especially um useful here if you're able to see one of the women's health specialists.

SPEAKER_02 36:58

Absolutely.

SPEAKER_01 36:59

I think in in my experience, the the quality of the assessments that can be done in primary care by my colleagues who do women's health in primary care is excellent, and we're really lucky in Guernsey to have that. Um and then it would be through discussing with them whether or not an an onward referral to secondary care is required or whether or not they're these first-step um uh sort of management plans could be instigated in in with your GP. Yeah. Yeah.

SPEAKER_00 37:26

No, certainly from my point of view, it's really helpful to have an expert in the practice that I can send women on to for this kind of thing. Um, from your point of view, and obviously you've worked in the UK, just out of interest. Have you noticed a change in that pattern in terms of the referrals that you get here compared to what you would see in the UK?

SPEAKER_01 37:43

Yeah, so I think we're we're so lucky, and I speak as a patient now. I'm so lucky here that we can get to see a GP so promptly. Um, and one of the things that I appreciate both as a service user patient and as a clinician is that continuity of care that we're able to have with our patients here in Guernsey. And that's really been really kind of career-changing for me as compared to my experience in the UK. Um, not only could I not ever really get a GP appointment as a non-well person at times, um, but when I was a consultant in Oxford in our antenatal clinic, we would maybe have 40 people coming through per clinic, and I'd have a team of training doctors who would be the people who'd need to be seeing those patients, and then I'd be kind of dipping in here and there if there was something particularly challenging or complex, whereas I wasn't afforded the time to spend with patients to build up that kind of doctor-patient relationship, which is so rewarding as a clinician. So I've I've been here um, yeah, nearly five years now, so long enough to see people through one or two pregnancies. Um, being able to see people in that kind of life course approach to women's health is a phrase that the Royal College of Obstetricians and Gynecologists um promote, meaning that we want to take a holistic view over that woman's care. And that's been such a privilege to be able to see that working here in Guernsey. And I've seen people through pregnancy who are now dealing with kind of perimenopause and and um uh yeah, so uh or or pr planning a complex pregnancy and then getting a good outcome that is so rewarding.

SPEAKER_00 39:26

And you mentioned a second ago about speaking as a person and not as a doctor. So how how do you unwind out with work?

SPEAKER_01 39:34

Oh, well, my um I used to use my commute down the motorway to do that because it lasted about 40 minutes, whereas it only takes me 10 minutes to get home now. So I've had to um I've got more time to um unwind once I get home, which is lovely. Um I love living near the sea. Um and um you're from Guernsey originally, aren't you? I am, yes, yeah. And um, yeah, but so kind of being outside, um taking it it sounds like a cliche, guernsey cliche, but taking the dog down for a uh a run along the beach. Um I enjoy going to the gym and um walking outside and spending time on the cliffs um and time with family and friends and um when I when I can. Yeah.

SPEAKER_00 40:20

So obviously you've talked in a lot of detail about these conditions and there's been some really complex ideas there. But essentially what you've returned to is some of it is about empowering women to take control of their health. On a practical level, what can they do?

SPEAKER_01 40:37

Yeah. So it's um uh really absolutely empowering women and people living in a female body. We didn't really focus on that, but that's just as important to state that a lot of these things, because they're so complex and have psychological impacts as well, that um um really, really good evidence that being able to it do the things that you enjoy, which can be hard if you're in pain um or struggling with other issues, but um kind of physical activity, being able to spend time outdoors, which we're so lucky in Guernsey to live in such a beautiful space, um, can really help improve people's ability to cope with with pain. So I'm not saying that those things would cure the condition, but certainly they're really powerful tools to help people cope with what they're living with. So that kind of lifestyle medicine side of side of things as well.

SPEAKER_00 41:28

Yeah, no, that's really helpful. Well, Lauren, thanks again. That was fascinating. Thank you. Um and um hopefully we'll catch up another time.

SPEAKER_01 41:36

Yeah, thank you, Nick. Thanks.

SPEAKER_00 41:37

So that was a really interesting discussion I had with Lauren about endometriosis and polycystic ovarian syndrome, which we know has now been relabeled. The big takeaway for me is that a lot of these symptoms are experienced by women who put up with them and don't realize that there might be something wrong with them that they can address. And particularly that the lifestyle measures that they can undertake might make a big difference to their lives and how they feel. Lauren talked about some of the treatments available at a very basic level in primary care, but also for specialists, right up to and including specialist drugs and surgery. And it's important that women identify that they might have a problem and come along to speak to their GP because we are usually able to help.