Hello everyone and welcome back. I have with me tonight a particularly unique guest. Yes, she’s a surgeon in our lineup of amazing surgeons that we have been interviewing this season, but you guys will want to listen to this entire podcast all the way through. So without any further delay, I want to welcome Dr. Cindy Mosbrucker to the podcast. Welcome.

Cindy Mosbrucker (00:25)

Howdy.

Ginger Garner PT, DPT (00:26)

Yeah, that’s the way I prefer to say hello. Howdy, how’s it going? Being from the South. All right, so I always do a little brag alert. So I wanna do this for you guys first. Here goes. Dr. Cindy Mosbrucker is a nationally recognized expert in excision of endometriosis. She trained with Dr. David Redwine, widely considered a pioneer of endometriosis surgery.

Cindy Mosbrucker (00:30)

Yeah.

Ginger Garner PT, DPT (00:54)

She believes strongly in a collaborative approach to patient care and as such has put together an informal multidisciplinary consortium of professionals who all contribute expertise in their respective specialties in order to give our patients the absolute best treatment of pelvic pain. She’s also board certified in the new subspecialty of female pelvic medicine and reconstructive surgery, FPMRS.

also known as urogynecology. Dr. Mosbrucker is one of the only endometriosis excision specialists who is also at FPMRS, giving her a unique understanding of how pelvic pain affects the pelvic floor. Super important. As well as bowel and bladder function. Welcome.

Cindy Mosbrucker (01:39)

Thank you, Ginger. It’s a pleasure to be on your podcast.

Ginger Garner PT, DPT (01:42)

I’m so glad you’re here. I am thrilled to see you. I know we haven’t seen each other in a while and so I’m just over the moon. I want to kick off the discussion because you, was reading something that was on the End of Endo project website and we’ll be putting all these links we’re discussing into the show notes. So don’t worry about stopping what you’re doing. Just keep listening. They’re going to be in the show notes.

So on the website, End of Endo Project, you’re discussing the importance of multidisciplinary approach to pelvic pain. And I’m wondering if your origin story of how you even got interested in all of this has fed that interest in emphasizing the multidisciplinary aspect of treating pelvic pain.

Cindy Mosbrucker (02:31)

Well, so when I went to medical school, I thought I wanted to be an orthopod. And then I fell in love with the finesse of belly surgery and abdominal surgery. And so I had to decide between general surgery and urology and gynecology. General surgery at the time at Northwestern where I went to school was…

Ginger Garner PT, DPT (02:38)

Wow.

Cindy Mosbrucker (02:57)

every other night call and I knew I needed too much sleep and my body wouldn’t tolerate every other night call. And so it really came down to do I do urology? Do I do GYN? And, you know, it was sort of a coin flip, but it was kind of, well, would I rather do pap smears on little old ladies or prostate exams on little old men? And so I chose the ladies. And yeah, so.

Ginger Garner PT, DPT (03:21)

Mm.

We’re glad you did.

Cindy Mosbrucker (03:27)

So I kind of had this affinity for urogyne from the very beginning because it was kind of both things that I liked. And we had a couple of attendings when I was at Bethesda in the Navy finishing up my residency who were big into urogyne. I mean, it was a very early specialty back then. And so we did a lot of it. And then I worked with the urologists a lot.

after that. And, one day when I was practicing in Hawaii, it just, you know, I felt like there was this, you know, in the cartoons, you see the little angels and devils on people’s shoulders. And it felt like there was this little angel tapping me on the shoulder saying, you know, there’s something more you’re supposed to be doing. And that’s when I met Dr. Redwine. And I was

Ginger Garner PT, DPT (04:17)

wow.

Cindy Mosbrucker (04:20)

Hawaii was getting expensive and our parents were getting older and needed us to be closer and kind of seemed like we needed to move back home to the Northwest. so I met David and he’s like, why you come work with me? I’m trying to, you know, retire and I want to train somebody to do what I do before I retire. And when he first wrote to me and told me what he did, I just thought that he was

blow and smoke up my butt because I’m like, holy smokes, this is everything I’ve ever loved, right? It’s a combination of general surgery, it’s urology, it’s GYN, it’s pelvic PT, it’s the orthopedics of the pelvis and the hips and the spine and all that kind of stuff. And it’s everything that I have ever been passionate about. And so,

Ginger Garner PT, DPT (04:55)

Wow.

Cindy Mosbrucker (05:20)

I went to, I spent two years training with him and then I moved back up to Washington where I grew up. And when I was in Finland, I went skiing one day and the upper part of the summit was crusty. And then I got down below where the snow had kind of melted a little, where the crust had melted and my…

boots kind of sunk down a foot into the snow and I took this twisting fall and I thought, my goodness, this is gonna hurt. And shortly thereafter, my hips started bothering me and I saw this friend of mine who was a PT, who was like, well, I think you might have a labral tear or impingement or something like that. And I started working with a lot of PTs and over the years I became

Ginger Garner PT, DPT (05:52)

Mm.

Mm-hmm.

Cindy Mosbrucker (06:15)

really good friends with Carrie Hall, who was taking care of me, but also kind of a sounding board for my patients because I’d see these women and they would have pain from endo, their pelvic floors would be tight, but they’d also have a lot of hip kind of symptoms and their obturator muscles and their piriformis and their psoas would all be tight. And that was kind of my clue that that triad of

Ginger Garner PT, DPT (06:35)

Yeah.

Cindy Mosbrucker (06:44)

of muscle spasm, they’re all hip rotators, hip flexors, they’re the closest muscles to the capsule. And when those things are all pissed off, it seems like there’s a much higher incidence of true things going on in the hip, rather than just like a functional impingement because the pelvic girdle is torqued and the acetabulum is rotated forward. So anyways,

Ginger Garner PT, DPT (06:51)

Mm

Cindy Mosbrucker (07:14)

I spent many hours with Carrie, with her working on my hip and my back and everything, and talking about how do we approach this. And so I learned an awful lot from her. it’s kind of a kuzumet or something like that, that I had this hip injury, but it really taught me a lot about beyond what I…

knew from urogyn and the function of the pelvic floor and the bladder and the rectum and all that kind of stuff, kind of taught me firsthand more about how everything interacts down there.

Ginger Garner PT, DPT (07:55)

Yeah, yeah, I do. I can definitely echo that feeling and observation about being in practice and seeing so many women and young girls with hip pain that also have endometriosis and, you know, back, you know, vice versa. And that it’s a mimicker, you know, it can, it can cover up things or reveal things. And so, yeah, including the hip in there is a critical piece of that.

So yeah, that sounds like a good injury, a good, bad injury. Tinking up like that. That made my right eye go like this. Yeah, did. Well, I just appreciate your acknowledgement of that, of the importance of multidisciplinary care, because it’s all really about person-centered, putting the patient right in the middle and listening to their story. And I know that at…

Cindy Mosbrucker (08:29)

Yeah

Yeah.

Ginger Garner PT, DPT (08:53)

Pacific Endo and pelvic surgery, that’s your focus. Like you’re listening to patients, you’re improving their quality of life. Can you share some strategies? Because I know every person comes in and sits down in that chair in front of you and it’s a lot. I mean, there’s stories, there are feelings about whether they thought they were dismissed or invalidated or completely flat out ignored or they had the wrong surgery or they had ablation six or seven times.

what do you employ? What strategies and practices do you employ to kind of maintain that patient-centered focus? Well, you know, also that’s a heavy place to be every day listening to, you know, to patients. So how do you approach that?

Cindy Mosbrucker (09:38)

Well, I think the first year I came home and cried, you know, after I heard these gals’ stories about, I mean, when I was with Redwine this one woman had 13 surgeries before she found us. And it’s so frustrating to hear what they go through. And then the second year, I stopped crying and I just got mad. And now it’s kind of like, yeah, what else is new?

Ginger Garner PT, DPT (09:49)

Mm.

Cindy Mosbrucker (10:08)

But I think the first thing you have to do is just listen to people, you know, and listen to their stories and believe them. Because patients are not gonna come to you and lie. And I think the problem that some women have is that they use language that doctors don’t understand. And so they get an idea in their head of what’s causing the pain that they feel.

And rather than sticking to a very strict, you know, I feel shooting electrical pain that goes down the back of my leg into my foot. You know, they say things like, I can’t even remember what language they use, but it’s the kind of thing that to doctors that don’t take care of chronic pain, they wouldn’t understand it. And so I actually had a friend of mine once.

I’m kind of going off topic, but I had a friend of mine who, well, she was a patient and we got to be somewhat friends. She lives in Alaska and she had a lot of spine issues and like, you know, ridiculous pain and all this kind of stuff. And she decided to go to Mayo Scottsdale and Mayo Scottsdale just totally blew her off. And I talked to her afterwards and

Ginger Garner PT, DPT (11:32)

Mm.

Cindy Mosbrucker (11:37)

The language that she was using was, I can’t remember the words, it made sense to me because I knew her and I knew what her pelvis looked like on the inside because she had really bad endo. And I’m like, Lisa, you gotta talk to them like this. You have to say X, Y, and Z. And so I got her to a friend of mine who’s a pain management guy up here who did an epidural and helped her quite a bit.

Ginger Garner PT, DPT (11:49)

Mm-hmm.

you

Cindy Mosbrucker (12:06)

I think listening and then somehow translating sometimes. mean, some patients, they come in, that’s why I love taking care of engineers because they’re very linear, they’re very, if X then Y, and they usually will give a pretty good history and people in medicine will give a pretty good history. Other patients, especially the

Ginger Garner PT, DPT (12:22)

Mm-hmm.

Cindy Mosbrucker (12:37)

what’s the artsy side of your brain, the right brain ones or the left brain ones, whatever the arts and music and all that kind of stuff, the opposite of the engineering side of your brain. Yeah, they sometimes are a little harder to figure out what they’re trying to say, but once you’ve done this long enough, you can kind of figure it out. And then,

Ginger Garner PT, DPT (12:42)

Yeah.

on the right. Yeah, yeah, not the left brain, but the right brain, the RT side.

Cindy Mosbrucker (13:06)

What people really appreciate, I think, is when they tell me about their period pain, they tell me about their pain in between their periods, they tell me about their bladder, they tell me about their intestines and their IBS kind of symptoms, and they tell me about the pain in their chest and their abdominal wall and other places, and I’m like, okay, well…

The endo is pissing off your pelvic floor, which is then affecting your bladder, which is, you know, and then your pelvic girdle is part of it and your abdominal wall muscles and you have traveling myofascial pain. And, you know, it all comes down basically to the endo. And they’re like, wow, you’re the only doctor that’s ever made sense out of all these.

variable symptoms that they have. And they think that they’re the only person in the world who has six different sources of pain when in actuality there’s one primary pain generator and then multiple secondary pain generators that will get better or go away sometimes when we address the primary pain generator, which is the endometriosis and sometimes the adenomyosis in the uterus.

Ginger Garner PT, DPT (14:25)

Mm-hmm. Yeah, it is such a relief for patients to hear that the dots can be connected, you know. Yeah.

Cindy Mosbrucker (14:34)

They’ll break down and cry. And

I feel so bad for these women because it’s like, how many visits, how many doctor’s offices have they been to? How many years have they been suffering waiting for somebody to tell them what they needed to, know, what’s going on? And it’s not rocket science. I’m not that smart.

Ginger Garner PT, DPT (14:56)

I beg to differ, but okay.

Cindy Mosbrucker (14:59)

What?

Ginger Garner PT, DPT (15:02)

being able to connect those dots for these women who have been just blown off, dismissed, ignored. And then it must be really difficult to get a proper history sometimes, like you said, with like, you know, if they are in a science field, they’re probably gonna be a pretty good historian where they can rattle those numbers off to you and be more exact about what they’re talking about. But I find that when someone sits down in my…

chair and maybe there I had someone specific I’m thinking about who is an attorney and very smart but doesn’t have that you know medical background and so for her what she was what she was describing to me over a telehealth session was completely different than what she was pointing out you know in person but because she’d been blown off so many times she was gaslighting herself

She had already turned it on herself or she had normalized it and overlooked like seven or eight symptoms that were actually super important to the case, but she felt like they weren’t because maybe she had been told a dozen times that they weren’t. And so I get what you’re saying about it being sometimes hard to understand when someone sits down because maybe they are gaslighting themselves into leaving half their symptoms out and they can’t describe it.

Cindy Mosbrucker (15:54)

Mm-hmm.

Mm-hmm.

Ginger Garner PT, DPT (16:21)

accurately because someone else had gotten to them and gaslit them before. So let’s talk a little bit about just advancements in excision surgery because I know that’s what all of our listeners want to hear about too. Tell me a little bit about your history because I don’t think the listener would have. You have such a unique, iconic, you know,

point here working with Dr. Redwine. Can you tell the listener a little bit about, tell us about the story? You know, how did your training influence your surgical techniques? What advancements have you observed being in practice, you know, as an expert? Just give us a little bit of an overview of that.

Cindy Mosbrucker (17:07)

Well, when I trained in medical school, I spent a lot of time with a couple of surgical oncologists at Evanston in Chicago, and they taught me very good surgical techniques. So even before I met David, I think I was a better than average GYN surgeon, but I had never done excision of endometriosis. I had never gone and dug out a ureter. I’d done…

of ovarian cystectomies, but not that many big endometriomas. And so when I went to work with him, it was kind of like I was learning surgery all over again, because I was learning retroperitoneal anatomy, which I didn’t really learn in school the first time around. And…

I was learning about this disease that never got talked about in medical school or residency. Other than, well, you may as well just take both ovaries out. Because if you don’t take them out the first time, then you’re going to have multiple, multiple surgeries. So you may as well just rip them out. And so when I went to work with David and I watched him operate,

He was a very elegant surgeon. He had perfect technique. so working with him was revelatory as far as, kind of took me from here to going up like that as far as my technique and my skills and everything. And…

2008, so I started with him in 2006, and then 2008, the recession came and it became obvious that the practice was really a one-person practice and he was gonna retire, but he had some investment properties that lost money and he decided to keep working for another couple years. So I moved up to Gig Harbor, which is…

almost where I was born and raised in Tacoma and started working up here. And because I was new and I didn’t have, know, Facebook hadn’t been invented yet. And, you know, there wasn’t a ready-made source of pelvic pain patients. I started doing a lot of UroGyn and probably over the next two or three years, my practice kind of flipped from

Ginger Garner PT, DPT (19:45)

Yeah.

Cindy Mosbrucker (20:00)

primarily urogyne and a little bit endo to primarily endo with a little bit of urogyne. so learning, being able to learn to operate from a man who’s probably one of the best surgeons in the world was a privilege that not too many people have. And it was really a blessing.

Ginger Garner PT, DPT (20:23)

Yeah.

Yeah. So, have, you know, just take us on a journey from that point forward once you, you you moved back to near Tacoma and you started to practice. It’s kind of a two-part question of how have things shifted now and, you know, telling us, sharing with us what FPMRS means, how that enhances your surgical work to the listener who is in healthcare. They’re like, wow, that’s amazing. She’s like,

everything, you you do all of it. But for those who may, they’re listening and you think you have endo or you know somebody or love somebody that has endo or you do have endo, can you tell us a little bit about that, how that enables you to do more and be probably more comprehensive, more careful and more elegant like you were saying about Dr. Redwine.

Cindy Mosbrucker (21:18)

Well, part of… So I moved to Gig Harbor and started operating up here and we had a DaVinci robot which was somewhat new back in 2008. so anyways, I did the robotic training and I started operating robotically which was a tremendous boost to my technical ability, not because the robot…

was doing it, but it was just ergonomically so much easier. And you can see in three dimensions, I can have control of two instruments plus the camera. And then I have my assistant at the bedside sectioning and irrigating and putting sutures in and out and pulling specimens out and things like that. so operating with the robot allowed me to do very complex surgeries, much

more easily than if I was doing them laparoscopically with straight sticks. And doing the urogyne procedures where you dissect in relatively normal spaces, the vescovaginal space between the bladder and the vagina, and then the rectivaginal space between the rectum and the vagina, going all the way down to the pelvic floor muscles. like literally I can see the levators, I can see the puborectalis, I can see the

the piriformis, the sacrospinal ligament, all those, the structures of the, you know, the inside of the pelvis, I can see all that stuff and know where it is. I think that really helped my ability to dissect out the stage four endocases where everything on the surface is all messed up and stuck together, the rectum.

is stuck to the ovaries, which are stuck together to the back of the uterus. And you have to dissect all the way down into the rectivaginal septum, into the pararectal spaces, into the paravesical spaces, which are essentially the deep pelvic spaces around all the organs, the bladder, the rectum, the ovaries, and the space where the ureter lives and where the uterine

artery and veins are and all the nerves. And so being familiar with those spaces in the urogyne patients who have relatively normal anatomy, I think really kind of jumpstarted my ability to do the more complex endocases and made it easier for me to do that. And then my understanding of the pelvis,

And the PT that I’ve had in understanding orthopedic things has really helped me. A couple of days ago, we saw this gal with fairly severe scoliosis in her lumbar spine. And her pelvis was kind of like this when she stood up. And she had pain in her hip and her groin on the right that went…

like part way down her leg. And I’m like, when did this pain start? Well, when I was about 20 and she was in her late 40s and had a hysterectomy a couple of years ago, but she’d also had a diagnostic laparoscopy before the hysterectomy where they saw endo in her pelvis. And they’re like, yeah, you have endo. They did a hysterectomy and took both her ovaries out at age, I don’t know, 44, 45, something like that, but didn’t take her endo out.

Ginger Garner PT, DPT (24:53)

Hmm.

Cindy Mosbrucker (25:15)

And so she comes

to me for pain and I’m like, okay, well, you have several different kinds of pain going on. And I think part of your pain is from the endo and part of your pain is from your orthopedic issues. And she was from Louisiana and just moved up here. And I’m like, have you ever seen a good pelvic PT? And she’s like, no. She’s like, they don’t exist down there. And, and,

Ginger Garner PT, DPT (25:40)

Hmm. Hmm.

Cindy Mosbrucker (25:45)

And so I’m like, okay, well, we might eventually need to go take your endo out, but that’s not, I don’t think what’s causing her hip and glute and IT band and all that kind of pain. And so I sent her to these gals that used to work with Carrie that are adept at doing pelvic floor stuff as well as pelvic girdle and spine.

PT and I’m like, you know, let’s give this a shot and calm all this stuff down and then see where we get to. And it may be that she still has pain with sex that is not relieved by any of that stuff that we still have to go in and get the endo out. I think that’s, you know, patients with other complicating factors and atypical presentations and things like that.

Ginger Garner PT, DPT (26:22)

Mm-hmm.

Cindy Mosbrucker (26:43)

I think are where my experience with the urogyne and the pelvic floor stuff helps me.

Ginger Garner PT, DPT (26:53)

Yeah, you kind of went right into the next question actually, using that case. and for the listener who isn’t watching on YouTube, when you said the pelvis looked like this, she was just meaning it wasn’t level. The pelvis wasn’t level.

Cindy Mosbrucker (27:10)

There’s

a fancy medical word for that. It’s called cattywampus.

Ginger Garner PT, DPT (27:15)

That’s right. That’s what it was. That’s what it is. So it kind of segues into my next question, which was about, you know, persistent pain. Like this person, I almost said, you know, has a unique case, but not really because half, at least half the people that sit down in the chair in front of me in my clinic have already had some version of quote, air quotes here, endosurgery, but it was ablation or a hysterectomy. It wasn’t actually treating or.

Cindy Mosbrucker (27:18)

Yeah.

Ginger Garner PT, DPT (27:41)

you know, or solving the problem. So they end up with persistent pain post-surgery.

Cindy Mosbrucker (27:45)

So they were diagnosed with endo, but

they did not have necessarily adequate treatment.

Ginger Garner PT, DPT (27:51)

Correct, yeah, yeah. And so that’s where, of course, they get an immediate surgical consult, actual surgical consult by the end of their treatment with me. But it also, you bring up an important point about differentiating between the orthopedic issues and the pelvic health issues versus obviously what can be treated with pelvic PT versus what is going to be a persistent issue where maybe they’ve already had surgery, they still have pain.

And I’m sure there are cases too, because I see many of those where they had excision surgery but actually didn’t get referred or couldn’t access it or didn’t see anyone following up. So I have some idea of what you’ll say to this question, but for the listener, what diagnostic steps and treatment options do you consider?

Because we would love everything to be one and done, you know, with excision surgery and sometimes it is and sometimes it isn’t. So take us, like walk us through what a patient goes through if they come in and they’re still having persistent pain.

Cindy Mosbrucker (29:01)

Well, let me first say that all excision is not the same. The good thing about the last few years is that there has been a lot more talk about excision of endometriosis probably over the last five to 10 years than there ever has before. And we’re doing presentations at AGL where we’re showing other docs how to do excision. We’re showing them what

endo looks like in all of its various forms. And we’re trying to educate gynecologists on how to be better surgeons for endo. But the problem is, that endo is really complicated sometimes. And it takes somebody who has very good technical skills, as well as a lot of patience and a lot of diligence. the slogan, nevertheless, she persisted.

was said first about the notorious Ruth Bader Ginsburg, but it could be said about every female endosurgeon. Nevertheless, they persisted at trying to get the disease out despite no matter where it is. And so a lot of patients come to me with operative notes that say, the procedure was excision of endometriosis.

Ginger Garner PT, DPT (30:11)

Yeah. Yeah.

Cindy Mosbrucker (30:30)

but yet they still have significant disease. And there’s a gal that I’m thinking of specifically who came to me after having four different surgeries in Seattle by people who claim to be endo experts. And she had an ovarian remnant from an endometrioma that was not completely excised. And she had a five centimeter mass in her rectum.

Ginger Garner PT, DPT (30:59)

my gosh.

Cindy Mosbrucker (31:00)

that

was missed on laparoscopy all four times and on an MRI where they, know, the MRI was read as, there’s a little bit of thickening of the uterus sacrales between the vaginal cuff and the rectum because she’d already had a hysterectomy. And so we operated on her. mean, well, when she came to my office, so the first thing that I do to,

Ginger Garner PT, DPT (31:06)

Mm.

Cindy Mosbrucker (31:29)

try to answer your question, is that I look at the operative reports and if the patients have their photographs that were taken at the last surgery, that’s really helpful too. Because sometimes gynecologists don’t understand what endo actually looks like. They miss it when it’s big and bulky because it doesn’t have these little black spots.

Ginger Garner PT, DPT (31:30)

Mm-hmm.

Cindy Mosbrucker (31:55)

And then they can miss it when it’s early, especially in teenagers, they’ll miss it because they don’t recognize all the visual manifestations of endometriosis. And so the op report would give me an idea of what was done or what wasn’t done. But then mostly it’s, I talk to them, I take their history, I find out when did their pain start. Did it start when you were 12 years old?

Ginger Garner PT, DPT (31:59)

Mm.

Cindy Mosbrucker (32:24)

from your first period. This gal the other day told me that three months before her first period, she started getting nauseated once a month, you know, and then, and then she got her period and she had to stay home from school and she was throwing up and, you know, just all the typical stuff. classically endometriosis will start with painful periods and

Ginger Garner PT, DPT (32:31)

Mmm.

Yeah.

Cindy Mosbrucker (32:52)

The other three weeks out of the month, people feel fairly good. And then, you know, it’s two days before your period starts, you have pain. And then it’s a week before your period starts, you have pain. And then you have a flare with ovulation. And then it gets better. And then it ramps up before your period. And then from ovulation to menses, it’s bad basically three weeks out of the month. And it’s just this gradual progression of more and more and more of time that it takes out of your life.

Ginger Garner PT, DPT (33:20)

Yeah.

Yeah.

Cindy Mosbrucker (33:22)

And so sometimes that’s interrupted, that progression is interrupted by birth control. Sometimes it’s interrupted by pregnancies. Sometimes it’s interrupted by other things. And so it’s not quite so obvious, but the basic story of endo and pelvic pain is very similar.

It’s kind of like variations on a theme person to person. I mean, there’s obviously individual variation in where people have pain and exactly what it feels like. But there is an awful lot of consistency and patterns that we see. And so then what I do is I do a very detailed pelvic exam where I

I feel their abdomen, I feel where their pain is, I feel their pelvic girdle. We do a one finger pelvic exam, internal in the vagina, feeling the pelvic floor muscles, the bladder, the cervix, behind the cervix, the rectum. And I generally don’t do a rectal exam unless there’s a good reason for it. And then we do an ultrasound.

Ginger Garner PT, DPT (34:44)

Mm-hmm.

Cindy Mosbrucker (34:49)

that is a dynamic ultrasound and we can see how things move. So we can see if the ovaries move freely over the top of the sidewalls. We can see if the uterus and the ovary are stuck together. If the ovary is stuck to the sidewall, we can see masses in the colon. We can see endo in the bladder sometimes if it’s big enough. What we cannot see is superficial

endometriosis on the peritoneal surfaces. But we can get an idea based on the adhesions and how well things move and then where they’re tender. So the uterus sacral ligaments are kind of like if my hand is the uterus and then my fingers are the uterus sacral ligaments going kind of backwards and upwards towards the sacrum. The uterus sacral ligaments in the cul de sac are the most

common places for endometriosis to be found. And if somebody has a history that is consistent with endometriosis and then they’re a tender on the uterus sacral ligaments in the cul-de-sac, then in our practice, there’s at least a 95, if not a 97, 98 % chance that we will find endometriosis.

Ginger Garner PT, DPT (36:10)

Yeah, yeah. So going back to that case where she came and had persistent, you know, post-surgical pain and they had removed her ovaries, of course, but not the endo, like, curious of that that story. What was the outcome there?

Cindy Mosbrucker (36:12)

on pathology.

So I documented the size of the rectal nodule, which is the biggest one I’ve ever seen. It literally was over five centimeters long and probably two centimeters wide circumference-wise and then at least a centimeter thick. So there’s this huge mass in her colon. It was fairly low in the rectum. And so I had it.

Ginger Garner PT, DPT (36:40)

Wow.

Cindy Mosbrucker (36:56)

I had her see Dr. Linda Pye, my general surgeon that I’ve been working with for 15, 16 years. And Lynn and I operated on her. We removed all of her disease. Because of how low the rectal resection was, we wound up doing a diverting ileostomy for six, eight weeks, and then put that back together. But she was a lovely lady.

Ginger Garner PT, DPT (37:19)

Mm-hmm.

Cindy Mosbrucker (37:26)

And this was, I think right before COVID or right after COVID. And she’s doing well.

Ginger Garner PT, DPT (37:38)

That’s great. Can you describe to the listener? Because I think that’s, anyone with endo or thinking they could have endo, I think it’s always a concern going into surgery. like, what’s the bowel going to look like? Am I going to have to have a resection? And more, can you talk about defining those terms for the listener about ileostomy and redirecting and then reversing it in six to eight weeks? What’s the process for the patient there?

Cindy Mosbrucker (38:06)

Yeah, so everybody’s biggest fear is that they have to poop in a bag. And I get it, I wouldn’t want to have to do that for the rest of my life either. But when, so when we operate on the colon, essentially there’s three types of surgeries, surgical techniques that we do to remove endometriosis from the colon. The biggest nodules that are too large,

to do it any other way. We do what’s called a segmental resection, which is where we cut the colon below the disease, then we pull it up onto the skin and we cut it above the disease and we cut out, typically it’s like six or eight inches of the rectus sigmoid. And then we put it together, splice it back together like you’re splicing a garden hose. That is probably…

10 % of our bowel cases. What we do probably 90 % of the time is called a partial thickness shaving because the endometriosis is smaller, thinner, and we can shave that off. So the colon actually has four layers, the outer serosal covering, which is like the saran wrap covering that covers all of our…

inside. It’s just kind of like the peritoneum. And then the outer muscular layer runs longitudinally. The inner muscle layer runs circumferentially. And then the mucosa is on the inside, obviously. And so the vast majority of endometriosis lives in the outer muscular layer. And so we can

we can get into that potential space between the inner muscularis and the outer muscularis and then peel the endometriosis off. Then we close the defect to basically bring together the full thickness layers of bowel wall so that we reproduce the strength of the colon so that it’s not at risk to blow out later on or anything.

There, and that’s probably 90 % of our patients with intestinal endo. And then there’s maybe two or 3 % of small amount where we do what’s called a, like a full thickness discoid resection. So it’s too deep to shave it off partial thickness, but it’s not so big that it really needs a full resection. And sometimes we’ll do that with the stapler and just staple the anterior wall.

of the colon. And the reason that that is much less invasive than doing a segmental resection is because the nerves in the blood vessels come in to the colon from the mesentery, which is posterior in the backside. Almost all the endometriosis is directly opposite of that on the front side, called the anti-mesenteric surface. And so by leaving the nerves and the blood vessels intact,

then that wound heals much faster, is at lower risk for leakage and fistula formation, which are the biggest complications of bowel surgery. And lowers the risk of what they call like functional bowel syndromes, which is like sometimes if we remove too much of the rectum,

The rectum is like the storage function for the colon. And so it’s kind of like the bladder of the colon in the sense that the stool can move down into the rectum and you can hold it there until you find a nice clean bathroom to go in. And some of these gals that have really low rectal nodules and wind up with six or eight centimeters of rectum, that’s not much storage. And so they will have to go much more frequently.

and may not be able to defer going number two until they get to a nice happy toilet. So if we can do the discoid, then that lessens the likelihood that they’re gonna have more frequent bowel movements and more urgent bowel movements.

Ginger Garner PT, DPT (42:23)

Mm-hmm.

Yeah, yeah, which is everything for quality of life. Yeah, thank you for explaining that.

Cindy Mosbrucker (42:42)

Mm-hmm.

But

I have to say, even our patients who do have to poop three, four, five times a day, as long as they’re not passing out on the toilet, as long as they’re not feeling like somebody’s sticking a steak knife up their butt and they’re not in miserable, I mean, I’ve had patients who would have to get up for work two hours early just so that they could.

Ginger Garner PT, DPT (43:01)

Mm-hmm.

Yeah.

Cindy Mosbrucker (43:12)

have

a bowel movement at home before they went to work because it was such an ordeal for them to pass stool past this big rectal nodule. And…

Ginger Garner PT, DPT (43:20)

Mm-hmm, yeah.

I hear patients describe it as like shards of glass.

Cindy Mosbrucker (43:26)

Yeah, exactly. And so going back to the ileostomy thing, I just want to say, Linipai and I have never done a colostomy for a patient, which colostomy is where the colon is brought up and the solid stool goes in a bag. When we need to, which is probably 3 % of the time, maybe a little higher than that, depending on where the…

where the incision is and how good the blood supply is to that part of the colon because the blood supply to the rectum is not as good as it is up a little bit higher. So for some of our patients who have these big nodules that you can actually feel in the vagina and they have what’s called like an ultra low rectal resection, we will do a temporary

Ginger Garner PT, DPT (44:13)

Mm-hmm.

Cindy Mosbrucker (44:21)

protective diverting ileostomy, which that is bringing the ileum or the end of the small bowel up. And it’s liquid stool. And typically at six weeks, we’ll do a CT with rectal contrast to make sure that that incision has healed where the anastomosis is. And then once we know that’s healed, then we’ll schedule the takedown and it’s a faster.

quicker, safer surgery to reverse an ileostomy than it is to reverse a colostomy.

Ginger Garner PT, DPT (44:56)

Yeah, Well, hopefully that, I know that to hear all of that in a row, all of the three different approaches and such should kind of take down some of the fear surrounding that because that’s a lot of the questions that I would get and I’m sure that you get in practice too about, gosh, okay, when the bowels involved, what are the options? So you.

Cindy Mosbrucker (45:21)

Almost

a third of our patients, and this was true in Red Wine’s practice too, about a third of women with fairly significant endometriosis, bad enough that they go to a specialty center, will have intestinal involvement. So it is really common.

Ginger Garner PT, DPT (45:40)

Yeah.

Cindy Mosbrucker (45:42)

And

the sad thing is that, a lot of GI docs don’t understand endo because only 3 % of intestinal endometriosis penetrates the mucosa. So what that means is 97 % of women with endo, they cannot see it on a colonoscopy. So sometimes if there’s a really big mass, they’ll see this compression from

Ginger Garner PT, DPT (45:49)

Yeah.

Mm-hmm.

Cindy Mosbrucker (46:06)

outside the lumen of the colon and the smarter, more savvy GI docs will recognize that there’s the words that they use is extrinsic compression and figure something out. And then there are colonoscopes, actually I think there’s sigmoidoscopes that have a 360 degree ultrasound in the tip. rarely we will get referrals from those

GI guys that can actually image the mass of endometriosis in the rectum and the sigmoid with their fancy ultrasound on the end of the FlexSig scope. And that’s really handy. But it’s just sad that more gastroenterologists don’t understand endometriosis because they tell all these gals that they have IBS.

Ginger Garner PT, DPT (46:50)

Nice. Yeah.

Yep, they sure do.

Cindy Mosbrucker (47:03)

as my old neighbor in Hawaii says, IBS is just the last two letters.

Ginger Garner PT, DPT (47:11)

Yeah, yeah. Well, as an endo patient myself, I think the worst gas lighting for me came from the GI doc. Yeah, I got it from the GYN. I mean, I got it from a bunch. But that was absolutely the worst. They just wanted to send you down a protocol, ignore absolutely everything else. yeah, and it turned out to be bowel endo. So yeah, I’m a part of that, you know.

part of that one third. I always make sure to carefully pay attention to those signs and symptoms in the checking out the gut microbiome and how they’re doing with gut health and digestion and constipation and all that stuff is so important. So you are in a unique situation to be able to speak to the benefit of what you see from physical therapy because you understand the intricacies of the pelvic floor. You’re evaluating that whereas

Other surgeons are not going to be doing that. They don’t have the urogyne background. So how do you integrate pelvic PT into treatment? And what are the benefits you observed from that collaboration?

Cindy Mosbrucker (48:18)

So I would say probably 80 % of our patients with endo have pelvic floor pain and spasm. Probably 90 % of one or the other. There’s a few that have super high pain tolerances, like the ones with stage four disease that they’re like, well, yeah, I have bad periods. And they come in and they’ve got six centimeter endometriomas.

big bowel nodules and their pelvic floor is just stuck like anything and they’re like, yeah, my periods were bad, but I just thought that was the way it’s supposed to be. so the vast majority of our patients have pelvic floor involvement. usually if we can get them into surgery within six, eight weeks,

I usually wait to have them start PT until afterwards because the PT will be much more successful. But if they have to wait a long time or if they have a lot of bladder symptoms, you know, like if they have interstitial cystitis, which is where you feel like you have a UTI, but there’s no infection. It’s just urgency and frequency and pain with a full bladder and all that stuff.

Ginger Garner PT, DPT (49:33)

Alright.

Cindy Mosbrucker (49:44)

then sometimes I’ll try to get them into PT prior to surgery to help calm down their symptoms somewhat. But typically before you remove the stimulus that is, so the reason that the pelvic floor goes into spasm when there’s endometriosis or adenomyosis or really any kind of painful condition in the…

lower half of the abdomen, so the internal part of the pelvis. So diverticulitis can do it, ulcerative colitis, Crohn’s, PID, any of that stuff can cause pelvic floor spasm. And it’s kind of like a reflex, but the fancy technical term is viscerosomatic convergence. And what happens is that the pain signals go from the endometriosis or the colon or the

uterus into the spinal cord. And instead of synapsing and going up to the brain, the spinal cord’s job is to protect the brain from too many signals that it doesn’t want to hear from. And in a way, you can think of it as kind of like the bouncer keeping the riff-raff out. The boss doesn’t want to see you go away. And so the spinal cord kind of puts this backstop up and says, no, go away.

Well, the impulse on the sensory nerve actually is the action potential actually has electrons moving in it. It’s an electric thing and that those electrons have to go somewhere. And so they go, they synapse with the sensory nerve to the pelvic floor and the bladder and they go backwards into these other areas. And that’s why we get the

patients get the spasm of the pelvic floor. That’s why the bladder gets sensitized because the sensory neuron doesn’t know how to receive a signal. It only knows how to send a signal. And so in the bladder, it releases all these little inflammatory chemicals which break down the lining that protects the cellular

part of the lining of the bladder from the chemicals in the urine, and that’s why the bladder gets irritated. So I would say roughly 50 % or so of our patients after surgery, the pelvic floor and the bladder just calmed down because we’ve taken away the stimulus that’s irritating them. And the rest of them have had that for so long that

Ginger Garner PT, DPT (52:18)

Yeah.

Cindy Mosbrucker (52:38)

muscle memory kicks in and the pelvic floor just stays and spasms and it’s like, too bad, you’re stuck with me just the way I am. And those are the gals that we send to PT. And we have a list of the good PT’s because apparently it’s pretty easy to get a certificate that says I’m a women’s health PT.

Ginger Garner PT, DPT (52:43)

Mm-hmm. Mm-hmm.

Mm-hmm.

Mm-hmm.

Cindy Mosbrucker (53:02)

but

a lot of them, all they know how to do is to teach women how to do Kegels after they’ve had babies. And that is absolutely the opposite of what you want to do when you have endo. And so we keep a list of all of our favorite PT’s in Western Washington and the ones that we can find in Eastern Washington, there aren’t a lot. And as far as our patients go, which is pretty much the whole Northwest,

Ginger Garner PT, DPT (53:07)

Mm-hmm. Yeah.

Cindy Mosbrucker (53:31)

in California and the mountain states. So we try to keep track of who we can send our patients to.

Ginger Garner PT, DPT (53:41)

Yeah, it’s a really good point to make because, you know, just like there are a lot of surgeons that can hang a shingle and say they do it, they’re doing excision, pelvic PT and OT is also a hot topic. Like everybody wants to do pelvic health. And so any PT can pretty much hang a shingle and say they do pelvic floor PT. Unfortunately, it’s hard to give a percentage to it, but unfortunately, yeah, you will get a lot who…

Cindy Mosbrucker (53:49)

Yep.

Ginger Garner PT, DPT (54:10)

Like I had someone today and I said, and this was someone, it was telehealth, so it was at a distance. And I said, okay, what did the therapist work with you on? Because this particular therapist was doing ultrasound imaging, which does take more advanced training. It’s something that I do regularly and use in my practice. And so I thought, this is great. She’s doing imaging. This is wonderful. This is going to be good. And the only thing that she gave her was pelvic floor contraction, kegels. Yeah.

I was like, okay, so let’s talk about this. And that speaks to kind of patient education and advocacy because I know you want to empower your patients with knowledge about their condition, knowledge about follow-up rehab, what role patient education plays in all of that. So what are some of the ways that you help? It is kind of like breaking the cycle. So they’re not gaslighting themselves.

and they don’t get gaslit by anyone else and they know exactly, they’re empowered to know what kind of care they need and deserve.

one is just sitting them down and educating them on the different, on the things we’ve talked about now, but that must be also somewhat of a delicate topic too, because A, okay, you got a limited amount of time on your hands in which to do this, right? So how do you convey that message to help them to start believing in themselves again, to trust themselves, to trust their symptoms?

Cindy Mosbrucker (55:37)

Well, I think that’s, this is, you’re kind of hitting the nail on the head for why we’re out of network. I spend at least an hour with all of my new patients because it takes a while for them to tell me what they’re feeling. It takes a little while for me to do their exam and their ultrasound. And then sometimes it takes a long time to explain to them everything that’s going on and the interactions between

their endo, their uterus, their rectum, their bladder, their pelvic floor, their pelvic girdle, their hips, their feet, you know? And not to mention when they have thoracic symptoms, you know? They have pain into their shoulder blade and, you know, is it their neck causing pain? Is it endo in the diaphragm? Is it…

Myofascial pain attached where the abdominal wall attaches to the rib cage causing pain in the upper quadrants and all that kind of stuff. And so we educate them to the best that we can in our visit with the understanding that people are gonna remember some of what they’re told, but the vast majority of people are not gonna remember half of what we tell them.

We have a nurse practitioner who spends half an hour, 45 minutes with them in a pre-op visit, going over some of these same things and going over what to expect at the time of surgery, what to expect post-op, all that kind of stuff. The gals with fairly significant bladder symptoms, I try to get them to come in and see my nurse to teach them how to do bladder installations.

and then they learn more about interstitial cystitis and the difference between infection and IC symptoms, the dietary changes. We refer them to, there’s a website called ICA.org, which is the Interstitial Cystitis Association, which is a great website for patients with interstitial cystitis talking about dietary changes and.

Ginger Garner PT, DPT (57:34)

Mm-hmm.

Cindy Mosbrucker (57:57)

behavioral therapies and things that people can do on their own without a PT. PT obviously helps that quite a bit. And then afterwards, we see them a couple of different times. If I send them to PT and PT gets them to a certain point, but then they’re stuck, then we’ll talk about, should we do Botox?

Ginger Garner PT, DPT (58:23)

Mm-hmm.

Cindy Mosbrucker (58:24)

You

know, do we do Botox in the bladder as well as the pelvic floor or just the pelvic floor? You know, it depends on what’s going on with their symptoms. So there’s, you know, there’s a whole process that we go through with our patients and it takes time. And practices that are in network and expect you to see a new patient in a half an hour or less, you just can’t do that.

Ginger Garner PT, DPT (58:54)

Yeah, yeah. And that’s a huge, huge difference. It’s a true biopsychosocial, you know, addressing all of the bits and pieces, which, you know, can also include, you know, the addition of maybe mental health as well, because they have, I mean, that’s a lot of trauma to experience if you’ve had even one bad surgery. But as you well know, you hear stories all the time of five, six plus surgeries that didn’t really treat the cause. So…

One more question actually two questions one question is What do you see is the future ready? What are you excited about for the future and then where can everybody find you?

Cindy Mosbrucker (59:35)

So what I am really excited about is that a couple of friends of mine are going into practice together on the East Coast. Vicki Vargas and Melissa McHale, who was Dr. Vidal’s fellow, are going to be opening a practice in August. And Vicki is a gal who

I’m gonna get this wrong. But she did, I wanna say she did her residency in Baltimore at Hopkins and then went to the Brigham to do her fellowship in minimally invasive GYN and then she went back down to Baltimore DC area to practice afterwards. And then I kinda mentored her on endometriosis and we’ve gotten to be friends.

And so she and Melissa are passionate about doing research. And the goal is, if we can put it together, is to develop a consortium of surgeons who are doing good excision and then create a database that we can then mine for

you know, whatever kind of data we want to pull out of it and essentially track patients to see how well they’re doing post excision. And then we will ultimately eventually have the data that we need to prove to the world because ACOG, which is the American College of OBGYN, does not think that endometriosis is a surgical disease. don’t

think that it’s a subspecialist disease, they think that all of their baby catching OB docs, generalists, should be able to throw drugs at it and fix it. And that’s not the way it works. And unfortunately, most of the studies of excision have been single center, single doctor, small numbers. And some of the Europeans, especially Dr. Horace Roman,

Ginger Garner PT, DPT (1:01:41)

Mm-hmm.

Cindy Mosbrucker (1:02:01)

who’s one of my intellectual heroes, is doing a little bit more volume in publishing. The Brazilians have quite a lot, large numbers of patients. But I think it’s going to take a database of multiple centers doing

you know, thousands of cases to have the statistical power that we need to have the heft, the intellectual heft to convince these people who are bought and paid for by the drug companies that excision is really better than orlyssa. And it’s better than ablation and that ablation is terrible. We shouldn’t do it anymore.

Ginger Garner PT, DPT (1:02:31)

Mm-hmm.

Yeah. Yeah.

Mm-hmm.

Cindy Mosbrucker (1:02:59)

because it just

doesn’t work. so hopefully one day we’ll get there.

Ginger Garner PT, DPT (1:03:08)

That is exciting to think about that future. I mean, it’s exactly what we need. And hopefully it won’t be too far away. Yeah.

Cindy Mosbrucker (1:03:14)

There’s a lot of, yeah,

there’s a lot of younger, primarily female endosurgeons coming up in the world. And I’m optimistic about the next generation. I’m training two of them. so hopefully I can retire one day and leave the world a better place. But there’s quite a few,

really, really passionate and I think technically sound young female surgeons that are coming up. And I met a lot of them last year at the Endo Summit. I’ve met them at AGL and other places. And so I think that…

you know, the world will be in a better place in a few years than it is now as far as excision of endo. But we’ve got to keep working to change what is considered the standard of care. And the only way to do that is with data.

Ginger Garner PT, DPT (1:04:26)

Yeah.

Mm-hmm. Yeah. It is an awesome message of hope. And of course, the world is a much better place because of all your work already. And so I’m just, I’m very thankful for that and everything that you’ve contributed and the work that you’re doing now. Tell everybody where they can find you.

Cindy Mosbrucker (1:04:52)

Well, we are in Giga Harbor, Washington. My practice is called Pacific Endometriosis and Pelvic Surgery. I believe our website is www.pacificendometriosis.com. We just redid it. And so it is fresh and new and not old in stagy like the one I made 10 years ago.

I mean, I didn’t think there was anything wrong with it, but you know, all these young girls around me, they’re like, we need a better website. I’m like, you just do what you think is right. Don’t ask me my opinion because my opinion will be ancient. But yeah, so my office manager, Lindsay, and my fellow Dr. Yagy just totally revamped our website. So much appreciation to the two of them.

Ginger Garner PT, DPT (1:05:25)

gosh.

Yep.

my gosh.

Yeah, fantastic. Thank you, Dr. Cindy Mosbrucker. Thank you so much for being here with us.

Cindy Mosbrucker (1:05:53)

Thank you, Ginger, always a pleasure.