Hello everyone and welcome back. I am here today with an incredible person, Dr. Madhu Bagaira Welcome.

Dr. Madhu Bagaria (00:08)

Thank you.

Dr. Ginger Garner PT, DPT (00:11)

I want to start out with today, we’re talking about something that rarely gets named out loud. And that’s how endometriosis reshapes sexual health from the inside out. ⁓ Not just the pain, but the real relentless ⁓ things like identity shifts, silence surrounding the problem and the way so many people are told that it’s normal or it’s in their head while their bodies are screaming for help.

So today, and before we get started, I want to do my normal bragging session. So I’m gonna read a little bit about her bio, but my guest today is Surgeon Madhu Bagaria, and she sees what most patients ⁓ are never shown. She sees the lesions, the scarring, the nerve involvement, ⁓ physical truth behind years of…

of pain, whether it’s painful sex, lost pressure, lost trust, ⁓ pleasure, or lost trust in their own bodies. And so today we’re just, we’re going to open that conversation up because ⁓ sexual health is health. It’s also our mental health. And as a listener, you deserve answers and validation and a path back to pleasure. So Dr. Bagaria brings exceptional training in a patient centered approach to endo treatment.

She is a board certified gynecologic surgeon with many years of extensive experience in minimally invasive techniques. She has over eight years of clinical experience at ⁓ the Mayo Clinic and then dual fellowship trained in both advanced pelvic surgery and MIGS, minimally invasive gynecologic surgery. She’s established herself as a trusted endo doctor for women seeking comprehensive care. She’s part of the New York based ⁓

now international endometriosis surgical specialists, international or the SE team. And here’s an important point.  impacts one in nine women and it requires individualized treatment plans that consider your needs, your lifestyle. And her commitment to that is crystal clear. She listens to patients, she understands their experience and ensures that women not only receive expert surgical care, but

Also emotional support and guidance necessary for their healing journey. Dr. Bagaria is uniquely qualified to identify and manage complex endo, infertility and miscarriage. So if you are experiencing any of those issues, you have pain, you can’t get pregnant, you are having, you know, all of these things that kind of swirl around endo, ⁓ then it could in fact be endo. Welcome.

Dr. Madhu Bagaria (03:03)

Thank you. And thank you for that introduction. I will just open the floor by saying that, endometriosis associates pain, but endometriosis also affects sexual health, which is like a whisper nobody wants to talk about. It brings shame and guilt. And it’s one of the concerns which is very, very just superficially touched.

Dr. Ginger Garner PT, DPT (03:27)

Yeah, oh gosh, you just like said it perfectly. What do you feel as from your vantage point as a surgeon, what do you feel like is most misunderstood probably about how endometriosis impacts sexual health? Because you, I mean, you said it so perfectly, it is just a whisper, it’s things people don’t talk about. what do you, what is your…

What is your take on that?

Dr. Madhu Bagaria (03:58)

I mean, there are many ways as when endometriosis can affect sexual health. And one of them is the dyspareunia which is painful intercourse. ⁓ And intercourse is a part of intimacy and it’s a part of which affects the sexual health and mental well-being of people. It’s a relationship thing, right? And it does affect intimacy for women. It does create a lot of fear and anxiety for them. ⁓ It is a lot of emotional strain and when they…

it makes them feel inadequate. Like when women feels that they can’t satisfy their partner because of XYZ and because women are the natural givers of the society, they feel very inadequate. They take it upon themselves that it is in their head when they go to the gynecologist office. It’s a very hard topic to talk about. Like not everybody is, it’s like they’re not, they don’t want to talk about it loud and clear because it’s a very.

very private thing which people hesitate to talk about unless it is broached down and they are told, okay, let’s use lubrication or use different positions or just relax your pelvis. And when there’s a reason for the pelvis, like there’s a reason why they are having actually this painful intercourse and we don’t address that reason and just tell them to do all these things, which supposedly they already have tried because all of them have friends, they all go on social media. I’m sure they are.

tried and then they go to the physician and instead of digging into the problems, we instead of making them feel comfortable, if we make them feel dismissed on this, it really brings them again an invalidation, thinks that it’s in their head, there’s a fault in their body, there’s a fault in their anatomy, you know, and they don’t want to talk about it and they just silently suffer.

Dr. Ginger Garner PT, DPT (05:47)

Yeah, it’s, you know, even when patients come in and they know they have that problem and they know that, you know, you’re an expert in this field, there’s still such a stigma around sexual health that they even then they don’t want to bring up that information. And I know that happens when a patient comes and sits down in my office as a pelvic, you know, as a pelvic health PT and they’re still thinking, here’s what I hear a lot. And I know you hear the same thing.

this is TMI, this is too much information or this isn’t something that feels relevant. I know you’re just trying to get at some other core problem. So what questions or, you know, yellow flags, red flags, et cetera, how do you approach having that conversation with them to kind of normalize that, hey, you can talk about sexual health. You can talk about the particular, you know, pain that you’re having. ⁓

how do you go about approaching that to make them feel comfortable with that, to kind of bring those walls down so they know, ⁓ I can talk about this?

Dr. Madhu Bagaria (06:54)

I mean, for me, ⁓ having a clear communication, it’s always a part of my thing in the back of my mind when I talk to my patients, to always talk to them about sexual health, how was intercourse for you, how has it been going, or when you started having painful intercourse, how long that has been going on, is it increasing, what positions have you tried, have you tried physical therapy, what was the assessment? So I try to dig into the history as much as possible. I also try to sometimes to touch on the…

mental health as well a little bit about them or how is their relationship with your partner and most of the time believe or not it’s totally okay. We cannot just blame you don’t have a good relationship with your partner that’s why you’re feeling that you know and one thing which we also need to discuss is how the partners feel when their wife or their significant other is going through this pain because they support their significant other in many ways and they also undergo a lot of emotional trauma when they see their loved ones going through this right. ⁓

Dr. Ginger Garner PT, DPT (07:36)

you

Dr. Madhu Bagaria (07:53)

So I usually, and if there’s significant others there, I also ask them to pitch in or is she missing something because sometimes women are hesitant to talk. So sometimes their partner will talk about, she isn’t too much brain, so she cringes. You try to get into the insights. I obviously, in the back of my mind, I’m thinking of endometriosis. I’m also thinking in terms of ⁓ whether they have pelvic floor dysfunction, which is a very important topic as well. And then also like,

trying to relate it, like if they have any pain during bowel movements, urination, those things, because pelvic floor health is a part of your sexual health. And all these things are interrelated. Unfortunately, talk about peeing, pooping, and having sex is very much, it’s not that often talked about. So I try to incorporate that in my conversation. ⁓

Dr. Ginger Garner PT, DPT (08:42)

Yeah.

Dr. Madhu Bagaria (08:48)

try to normalize it as much as possible for them so that they can open up. And it’s very important to make that environment to feel safe where they can talk about it for these symptoms.

Dr. Ginger Garner PT, DPT (09:00)

Yeah. And I think, you

know, once, once that they also hear, hey, this is an environment where you can, you can talk about those three big things, peeing, pooping, and sex, right? That all of the structures anatomically are so close together. And, and I’m sure that’s part of, it’s something that I think that as the listener, you’d want to hear too, that

anatomically and physiologically, all of these things have lie in such close proximity to each other, naturally they’re going to be impacted, including digestion. So that is kind of a good segue into the next question, which is, you know, what you see in surgery that impacts sexual health. So you’re in the OR, you know, anatomical patterns or kind of how lesions are distributed, et cetera.

Do you often see, and I know this is a loaded question because things are so close, right? But for the listener, what would you see in surgery that would kind of clue you into know, gosh, that’s probably gonna correlate with some problems with, know, dyspheronia or painful intercourse, which by the way, may not even get as far as penetrative, you know, sex. It could just be even sitting down and putting pants on, which is obviously gonna.

you know, prevent someone from even having any desire whatsoever. So what do you see in the OR?

Dr. Madhu Bagaria (10:27)

Yeah, before I touch them, also say that one of other ways how people feel more comfortable in talking about it is when they’re telling you the symptoms and you explain them with a pelvic model. And I’m like a huge fan because when they see the things, how things are in the pelvis and when you tell them this is the reason why you’re having this, they open up more and more because they see value in telling their symptoms because we are connecting the puzzles and we’re connecting the dots. So it’s no longer in the head. ⁓

there’s a reason for every symptom they’re having that makes them feel very, like very validated and they feel like they’re in the right place. ⁓ Coming back to the question about what do I see in the OR on an everyday basis? ⁓ Most of my patients when I take in the OR and when they have dyspareunia which is painful intercourse, and on my exam, during the office, like I always do an ultrasound and I do the slight test.

Dr. Ginger Garner PT, DPT (11:05)

Yeah, very heard, very seen.

Dr. Madhu Bagaria (11:27)

and also look for ⁓ things like over an endometrioma, possible frozen pelvis, and those things as well. Even then, if I don’t see, the most common causes, which I do see in the operating room, is you have a ligament called as utro-sacral ligament, which connects your uterus to the back of the sacrum, so in the back. So when people have this back pain with sexual intercourse,

or when they feel this pulling sensation that’s mostly related to the utero sacral ligament, the lesions on the utero sacral ligament. And understand that when you have lesions on these ligaments or the space between the rectum and the vagina, which is supposed to move very freely, so they should glide, but when there’s a lesion and they become stiff and when you have intercourse, those tissues are being moved. They’re supposed to glide, but when they get fixed, then you feel the sensation because obviously these lesions are

in a weighted by nerves. So when you’re irritating them, you feel the pain. The other common things which I do see is retroverted or a fixed uterus, which means the uterus is kind of fixed, pulled up by adhesions and scarring. And when you’re trying to have intercourse like this, you’re hitting a ball. And again, this tissue is not gliding. So that could be a cause. When you have frozen pelvis, which are not kissing ovaries, I’m sure most of my listeners are very familiar with kissing ovaries over and endometriomas.

So when these tissues are stuck on the back of the uterus and they’re kind of stuck there, and when you, this is the area at the back of the uterus where you, at the back of the cervix and the vagina where most of the action is happening when you’re having intercourse. So if there’s, it’s a concrete cement and you’re trying to have intercourse and the tissues are not moving, you feel the pain. When there’s inflammation, your vaginal walls at all become very fibrotic. Sometimes you have vaginal endometriosis too.

So all these areas can get affected and can cause pain while you’re having sexual intercourse. Having said that, this is like one of the anatomical things which I see. So there’s definitely something wrong with anatomy there which is causing pain. The other things which could be is a hypertonic pulmonary flow. And that is one of your specialty. ⁓ I tell my patients always, I always check them for hypertonicity or tender points in the pulmonary flow before I take them for surgery.

because I always feel that pelvic floor PT is my best friend. With years of inflammation, with years of chronic cycle of pain, the slightest movement from your pelvis rewires your brain. The slightest inflammation can rewire your brain and that can cause a lot of pain hypersensitivity to your brain and that can cause a…

when we talk about central sensitization and everything. it’s very, these things can also play an important role. Or the trigger point in the pelvic floor muscles can be very important part of your cause of the pain. So I do usually assess my patients for it. And if needed, I do trigger point injections to release those muscles. And also like working with physical therapist.

Dr. Ginger Garner PT, DPT (14:33)

Yeah, you you said something ⁓ that we often end up talking about in both worlds, in the surgical worlds, in the therapy world alike, and that is central sensitization. then there’s, I tell my, I describe it to my patients as almost like a brain smudging. Our brains are very smart, but it’s also very difficult for it to pinpoint over time where pain is actually coming from. If they, the longer pain goes on, the brain kind of smudges it and it can kind of spread.

Dr. Madhu Bagaria (14:54)

Thank you.

Dr. Ginger Garner PT, DPT (15:02)

But I think the other important point about that is because the structures are so close together, so the somatic experience we have, the visceral proximity of organs, can you talk a little bit about how you talk to patients depending on where lesions are, location, depth, or amount of fibrosis? Even if, for example,

there wasn’t vaginal endometriosis or anything in the bladder and that was clear. What if it was just not just, it’s never just bowel endo, but what if it was only bowel endometriosis? How do you go about talking to patients? Because what I see a lot is when they’ll come in, sit down, talk about, well, there was, it was only bowel on the endo. And so therefore I shouldn’t have problems in the pelvic floor, right? So how do you talk to them about this? Cause I think it’s something the listener,

would be very curious about, it’s certainly questions I get all the time from patients, how can they still have pelvic floor dysfunction, dyspareunia, painful intercourse, supposedly, what if it was thoracic endometriosis or bowel endometriosis?

Dr. Madhu Bagaria (16:14)

First of all, pelvic floor dysfunction is not always only endometriosis. You can have pelvic floor dysfunction even if you don’t have endometriosis. Right. Correct. Because you use your pelvic floor for sitting, pooping, peeing, standing, your work, your singing. Yeah, you use it for everything. Secondly, there other things which can also cause and increase ⁓ pain symptoms.

Dr. Ginger Garner PT, DPT (16:25)

Unfortunately, yeah.

singing.

Dr. Madhu Bagaria (16:43)

which may not be related to endo, it could be your congested pelvic floor muscles, vessels. And when you have endometriosis in your bowels, you definitely can have issues of constipation or diarrhea. That means you’re trying to strain yourself and use your pelvic floor muscle in order to get things out. And endometriosis is an inflammatory state. Yes, you still have endometriosis there, but sometimes you can have inflamed tissues everywhere, right? And that can cause inflammation of your pelvic floor muscles too.

these tissues can get cramped up. So you don’t need just endometriosis to bring a tissue in a cramped up state. It can also be related to other secondary factors about your posture, ⁓ how you’re sitting or things like, ⁓ you have constipation and you’re constantly straining and those things can also cause it. ⁓ There are other things which can happen like pudendal nerve irritation, which can happen.

with childbirth and things like that that can also irritate your pelvic floor muscles. ⁓ So we need to understand that many causes of it. And ⁓ just because you have a bowel endometriosis, when we have endometriosis, unfortunately, we signal every symptom of ours to endometriosis when they can be two things which can be coexisting together. So I often bring it together. Like pain is multifactorial. We have to peel the different layers of the onions, so one layer at a time.

It’s possible that endometriosis is causing inflammation and that the muscles is kind of stretched up. And yes, we remove the disease, but excision doesn’t solve everything. You have to work in retraining your muscles and your mind map, the pain map, which is there. We have to break that cycle. And with proper excision surgery, where the inside three factor is gone, but we still need to retrain and rehabilitate the pelvic floor muscles as well.

Dr. Ginger Garner PT, DPT (18:33)

Yeah, I often…

Dr. Madhu Bagaria (18:34)

⁓

I tell people that going to pelvic floor therapy is not a waste of your time. It’s just retraining and then it’s like a lifelong work for yourself, know, ⁓ which you could do at home.

Dr. Ginger Garner PT, DPT (18:42)

Yeah.

Yeah, yeah, I often will ⁓ tell patients that ⁓ it would be nice if when we had excision surgery, when they had excision surgery, that your brain and your body just got the memo that it was all cleaned up now. But sadly, they don’t. So I also often have to kind of… ⁓

will validate ⁓ patient concerns like, well, I had surgery and I had this decrease in pain, but I still have pain with A, B or C. And that’s where we just, have to work to press the reset button on the nervous system or the tissues or whatever it is to let them know that in fact, excision surgery was done, things are better and that retraining needs to be done.

Dr. Madhu Bagaria (19:35)

Yeah, yeah, and

use that time period because surgery itself is going to cramp up the tissue. Use that window like when the tissues are fully free from inflammation to further work on the nervous system on the pelvic floor muscles. And that gives you the best results.

Dr. Ginger Garner PT, DPT (19:49)

Yeah.

Yeah, it’s a great timeframe to do that. ⁓ Early intervention with excision and rehab are always critical. So what kind of, ⁓ and ⁓ one thing that we didn’t touch on, we’ll get to this in just a second. So ⁓ listeners hang on, we’re gonna talk about hormones and how they influence pelvic floor function, et cetera, and what can be done if you have endo, especially to support sexual health, because that’s pretty important.

We’ll circle back in a second to that. What post kind of findings like, and if you have to go back in again, or if someone had ablation and now you’re doing excision, you’re doing the correct thing for the first time for this person, what do you see in terms of like adhesions, ⁓ nerve entrapment, et cetera, that patients were either not informed about or…

you have to inform them about afterwards that you see that obviously could impact sexual and overall health.

Dr. Madhu Bagaria (20:51)

I feel like if the patients have prior ablation surgery or prior incomplete, most often, or sometimes even if they had surgery, sometimes we encounter fibrosis. With ablation, if you have not gotten to the root, let’s say it’s a deep endometriosis, sometimes it can be deeper than what you think. It’s like the tip of the iceberg, right? So unless you remove the inciting factor completely, it’s going to keep…

producing that inflammatory areas around which can continue to affect women, the pelvis also because inflammation affects everything, right? It affects the bowels, the bladder function, and it can affect the pelvic floor muscles as well, which we never talk about. So unless you remove that areas, ⁓ it is going to be there. Or sometimes when there are atypical lesions and nobody has even thought about looking into every nook and corner because usually when we talk about beneath the

cervix, it is like a hidden crater. You really have to go close in with your camera to look for those areas and if you just look at from the distance, you will not see it. It’s like going in one of the nooks and corners of your house to detect some dirt, you know. So you have to be very mindful of doing that, that you actually go in and look and actually identify the lesions which is there because some of them can be atypical as well. So these lesions can be missed and these can cause recurrent symptoms for that woman.

Also removing the disease at the entirety. When I go in, most of the time I do see disease in the rectovaginal space or in the rectum or in the utro-sacral ligaments, which is not removed. The person who’s operating on you should be well adept not to be afraid of the balance because when they’re working around the rectovaginal space, it’s very easy to damage or to cause injury, thermal injury, which is a heat injury, or to cause any injury down there.

And this is what general OBGYNs are usually afraid of, so they don’t touch those areas or they just superficially ablated, so without removing the disease in those areas. So the surgeon who’s operating, they should be comfortable operating near the bowels. So that’s one thing.

Dr. Ginger Garner PT, DPT (23:04)

Yeah, that’s a

great question because later on I was going to ask about questions to ask your surgeon. I just hate to have to say that it’s what you just said is everybody should listen to this again because I get too many patients. That’s what I was saying. I really have to hate to say that the truth is and the reality is, unfortunately, most of the patients I have that

sit down and they’ve been to someone else, they’ve been to a GYN who said, yeah, sure, I can do surgery, but they’re talking about ablation or they’re talking about very superficial excision where they did not investigate that area of uterus, sacral ligaments, the rectovaginal space, and now they need surgery again. Or ⁓ because I’ve had multiple patients where they are actually told you’re inoperable and they absolutely were not inoperable. ⁓

Can you speak a little bit more about that? Because I don’t think patients get educated on that. And if they go to a GYN and the GYN says, oh, I can do surgery, they just just do it.

Dr. Madhu Bagaria (24:10)

Yeah, it’s a trust thing, right? Like because you have a long relationship with the OB-GYN and also the GYN, they also need to understand that certain surgeries are not in the scope. If you

Like, let’s say if I have a cancer patient, even early stage endometrial cancer, which just needs a simple hysterectomy without needs for going for lymph node, which any general OBGYNs can do it. But the moment they heard, they hear the word cancer, it becomes like a medical legal thing and they don’t want to touch it. Even if it’s like a complex hyperplasia with atypia, which doesn’t have, which is not actually cancer, but they move it to the OBGYN because all the standard things they have instructed the OBGYNs to do that.

Right? Because it’s a survival issue. It’s like life, like five years survival. When it comes to endometriosis, because it’s not a cancer, it affects the quality of life, but it doesn’t affect the survival, right? So people, they just operate on them thinking that they can operate on them because ultimately sexual health or the pain thing is not something which is measurable.

It’s not a measurable tool, These women goes from the mental health is not like they work on, okay, how many patients, like what is the quality of life of women? Nobody cares about it. So if this becomes like, okay, this is beyond my scope, when the people start thinking about it, that this is beyond my scope, I should not be touching because I’m affecting the quality of life for this young woman.

who’s going crazy thinking about things, or maybe I can refer to a specialist just like the way I refer my patients to the GYN  I think that will solve most of the problems. So education and awareness is the key. And because we have such a good relationship with the GYN, we trust them, right? Because we trust their education. And so it needs education on both the patient aspect and from the GYN aspect as well because…

From a doctor’s perspective, I also think they’re trying to do their best for their patients, but they don’t know their limitations themselves. They don’t know because they’ve never been exposed. They think endometriosis is GYN thing and I can do it, not realizing that they need to undergo special training for it.

So they are trying to do their best for their patient because they also, I’m not saying they’re wrong, but it’s just a lack of awareness from both ends. So education awareness is the key and I’m sure that the  care one day will reach to the level where it will be just a specialist care.

Dr. Ginger Garner PT, DPT (26:40)

And it’s horribly

sad, especially with the statistics we have on the incidence of it being one in nine women, and endo is still not treated like specialty care. It’s treated like some simple, know, GYN hysterectomy issue. And there are too many patients. had a patient this year sat down, and it was a mother-daughter situation where no one had screened ⁓ the daughter for endo and the surgeon was suggesting a rather ⁓

invasive procedure, it actually turned out to be endo and the procedure wasn’t necessary at all. The surgery wasn’t necessary at all. But the reason I say that is because the mom sat down and said, ⁓ when I said, does anyone in your family have endo? There really has a lot of signs and symptoms and presentation of it. And the mom raised her hand and then she immediately said, ⁓ but it’s okay, I had a hysterectomy.

Dr. Madhu Bagaria (27:37)

No, it’s not okay. It’s not okay.

Dr. Ginger Garner PT, DPT (27:38)

It’s not, I said, well, how are you feeling? And she said,

⁓ I still have the same pain. Yeah.

Dr. Madhu Bagaria (27:44)

Yeah, it’s not okay.

Yeah, we don’t need to normalize pain and we need to normalize the good things, right? Like sex should not be painful or it’s not, your pain should not be painful. Like yes, it can be painful to some extent, but not to the point it cripples you.

Dr. Ginger Garner PT, DPT (27:53)

Yeah.

Yeah, yeah.

And that’s where the trauma, the gaslighting, whether it’s overt or accidental or whatever, the end result on the patient’s still the same. And then you get delayed diagnosis. Or in the case of someone having an ablation, which is not the gold standard ⁓ surgical intervention for endometriosis, it ends up making a mess for the actual experts, the excision experts. They get to you and tell me a little bit then about

how much harder it can be or the outcomes can be not as good if they’ve had ablation because it makes your job harder. And it could mean that they lose more tissue because of what happened with ablation.

Dr. Madhu Bagaria (28:44)

Correct. I will say that when you have like the first surgery, like when you do, like when the tissue is untouched, if you go and remove the tissue, it’s always better because you had the right planes and there’s not much stickiness of the tissues to each other and it makes the surgery easier.

If you had a prior surgery, like each, when we say like, whenever it’s a dictum, like repeated surgery does causes more inflammation, more fibrosis, and the organs kind of stick together. And when it happens.

the surgery becomes harder. And there are increased chances of having injury to the bowel, bladder, or ureter because we are working close to that areas. We’re trying to remove the stickiness of the tissue. And in that, when we’re trying to do it, the planes is not good. So they don’t separate. They kind of stick together. And we’re trying to find a plane. So inadvertently, we can damage those places. So it does make it harder recovery a little bit.

when the tissues are very sticky around the ureter and trying to remove it from there, sometimes the ureter can be nicked or cut and then you have to do some additional procedures and things like that. ⁓ I have also seen like people who are in Orlyssa, they usually have a stickier tissue, the tissue’s a little more stickier even if they never had a surgery. It’s just an experience I’ve seen with Orlyssa as well. But any kind of previous surgery it does, because in the process of healing your body, ⁓

Dr. Ginger Garner PT, DPT (30:04)

Interesting. Yeah.

Dr. Madhu Bagaria (30:12)

does undergo some fibrosis, that’s a normal process of healing. But if the endometriosis has not been removed, then again, that inflammatory process is kind of doubled up because you’re healing from the surgery and then those tissues are still there. And endometriosis can also cause, if it’s extensive or it’s deep, it can also cause scarring and adhesions. So it’s kind of combined effect which happens, which makes surgery harder. Not inoperable, but a little harder.

Dr. Ginger Garner PT, DPT (30:40)

Yeah, so it’s always good to go straight to the source ⁓ first. And if that’s a message I could just shout from a rooftop for everyone to hear it is, please, please, please seek out experts in excision surgery and ⁓ do your homework. And I think one of the good questions to then ask, ⁓ questions to ask your surgeon, gosh, we could come up with a bunch, but one is how do they handle, you know,

Dr. Madhu Bagaria (30:50)

Sure.

Dr. Ginger Garner PT, DPT (31:10)

what do they call, interpret as surgery? There are resources we put in the show notes many times like Nancy’s Nook is one of those where you can look up surgeons who have been vetted, but still you have to do your homework beyond that. So what do you think some of the most practical questions are for patients to ask surgeons just to identify whether or not they should be doing surgery and to put it bluntly on you?

Dr. Madhu Bagaria (31:35)

So ⁓ if you’re going to regular GYN, ⁓ usually the first question will be like, how many cases do you specialize in endometriosis or what is your training background? Have you worked with endometriosis specialists before? ⁓ Or even if you’re just straight out residency, because let’s say at Mayo Clinic when I was there.

The students, the medical students, they are exposed to endometriosis because when they’re rotating in GYN, they’re exposed to it. So what’s your exposure in your residency with respect to endometriosis? Or what has been your training background? Do you, like how many cases of surgery do you do? Are you comfortable operating near the bowels? Because typically, as I remember, when I was a resident, my attending would be like, don’t touch the bowel, don’t touch the bowel. We have to get in general surgeons. So how comfortable are you with?

touching the bowel or the bladder, working near the ureter, or opening their spaces, which requires interventions in the pelvis.

⁓ What’s your complication rates? How many cases of endometriosis you do in a month or in a week? Typically, a high vol endometriosis surgeons will be doing at least six to seven surgeries in a week. So those are the things which you need to ask about. And like, how do you have a team if you need to come in? Like if you need to call in somebody in ⁓ in the OR, do you really have somebody who is working with you as a specialist? Like let’s say if I need a rectal excision, do you have somebody who can do with it? Can someone help with diaphragmatic injury?

or do you do it or do you have someone in your team who can do it? So those are good questions to vet and also to read their views, right? EndoWorld is a very small community and the patients to make sure that they help the endo warriors each other along so they leave the reviews and things like that. So that can speak also volume and I feel the patient voice matters more than the surgeon’s voice and these for building the trust because when they see the endo warrior.

getting good reviews for that surgeon, you know that those surgeons are good.

Dr. Ginger Garner PT, DPT (33:32)

Yeah,

yeah. And I love that you call on the phrase endo warrior. I love that ⁓ because these women have been through so much and they’ve had to persist even in midst of dismissal ⁓ that it becomes a whole mental health journey in addition to the crippling effects of what the disease can do. So in your opinion, would you say that

High quality excision surgery then is going to give them the best possible outcome for sexual health.

Dr. Madhu Bagaria (34:04)

Definitely, but this surgery should be combined. Just having surgery is not the solution, especially if you’re suffering from years and years of ⁓ nervous system sensitivity as well as pelvic floor spasm. You do need to combine it with pelvic floor therapy as well as ⁓ the nervous system retraining as well.

Dr. Ginger Garner PT, DPT (34:07)

Yeah.

Yeah, definitely so. What kind of things do you do in surgery that directly protect sexual function? I mean, every excision is going to be nerve sparing, et cetera, mapping and things like that. But as the listener, that might be a scary thing for them. my gosh, I’m going to have surgery. How do I know I’m going to have sexual function when I come out? Can you tell me a little bit about some of the technical aspects of what you do to ensure preservation of that?

Dr. Madhu Bagaria (34:35)

and

First of all, restoration of anatomy, which means you’re trying to free up the organs. When you have a fixed pelvis, definitely that’s going to hurt. I mean, can’t even think, like imagine how much it hurts usually when things are like stuck. So restoring the anatomy, moving the tissues, respecting the tissues, Respecting the ovaries because women do need their ovaries for their hormones and for their sexual function because a lot of them depends on that as well. Like how well your ovaries are preserved when you’re younger or not. respecting your ovaries

reproductive organs ⁓ and then making sure that all the tissues we removed, we do a dedicated work there in respecting every tissues and removing them and to prevent adhesions like let’s say lot of inflammation and all those tissues we have removed, we also use an anti-adhesive barrier which is called an amniofix which helps to prevent adhesion. So we do our job in making sure that the surgery is technically, you you do proper hemostasis which means less less bleeds.

less touching of tissues, respecting your tissues, proper restoration anatomy and on the top of that we do sometimes amniofix which is preventing adhesions. ⁓

Removing the disease in an entirety, like your first surgery is always the best surgery, so try not to leave any disease. Just because it’s four hours in the surgery doesn’t mean that you have to rush to the surgery. You still have to be committed to the patient, thinking about the patient goal. ⁓ And you should always have that in mind. This is a young patient, has some goals in the life, and we need to fulfill that goal. And they have come to you with all those, you can’t take the trust lightly, you have to think about that as well.

when you’re doing the surgery.

Dr. Ginger Garner PT, DPT (36:36)

Yeah.

So it becomes, I think that whether or not the listener, whether or not you have endometriosis or you think that you do, or you love somebody that does, ⁓ hearing words like deep infiltrating endometriosis, especially in the area of the uter sacral ligaments and the rectivaginal area can be very scary for people. ⁓ How do you move forward then when

when addressing that if they’ve heard staging of endo and different things, which we know doesn’t correlate to pain or symptoms, but how do you talk to them about that? And then I have a kind of a little follow-up question after that.

Dr. Madhu Bagaria (37:07)

Thanks.

For the deep infiltrating endometriosis on uterocycle, I mean, typically I tell them that it’s a deep endometriosis, yes, but it is easily removable.

like you preserve your nerves, you’re around that because uterus sacral also has a lot of nerve and when you’re working around it, you just have to see your tissue planes, right? And it’s very doable, very easily removed. That’s the least of your problems. Like it can easily be done. And plus when you have deep endometriosis, you have to look in those nook and corners around the rectum, the, in front of the vagina or in front of the rectum. So you have to make sure that you ensure the complete removal of the disease.

look

all around as well. And you should not forget that there’s also nerve, that area specifically, the utero sacral area region. They have very tiny nerves which you have to respect. Like you don’t touch the tissue, it doesn’t need to be touched. You don’t want to damage those nerves because that affects yours.

Dr. Ginger Garner PT, DPT (38:02)

Yeah.

Dr. Madhu Bagaria (38:18)

bladder health as well, like how well you can empty your bladder and some people can develop issues of bladder emptying or bowel having issues with the bowel movements and all because we are damaging those nerves. Some nerve damage is inevitable, but you have to respect the nerves and you have to respect the proper tissue planes. And I my patients, very doable and it’s not a thing to be fear about.

Dr. Ginger Garner PT, DPT (38:39)

That’s awesome. It’s a great message of hope. And then I think that, the follow-up would be from that

if they are doing their therapy, if they’re going to pelvic floor physical therapy, that all the little lingering issues that will hang around like pelvic floor hypotonicity or tender points, trigger points, guarding, ⁓ obturator internus involvement, and dyspareunia can then overwhelmingly be worked through, you know, after that in their recovery.

Dr. Madhu Bagaria (39:09)

Yeah, and sometimes during surgery, I also do the trigger point injection with Botox as well. ⁓

because you know when you are in pain because after surgery if you work so close with these pelvic floor muscles usually they start feeling more crampiness. So sometimes I give them the vaginal suppositories to help with that and I also do the pelvic floor Botox or trigger point injection with lidocaine because if they are in pain they’re not going to go to physical therapy because you know so it can be an adjunct and the reason why all these things helps us that when you’re doing the Botox you’re trying to break that pain cycle

so

at least three months they are out of pain and they’re working with a PT then if it comes back then you again do it so by six seven months or 18 months the pain cycle the hyper excitability of the nodes have calmed down and it can really help them I think. The other thing is Vegas now training you know like reading those things because

Dr. Ginger Garner PT, DPT (40:03)

Hmm.

Dr. Madhu Bagaria (40:06)

endometriosis when you’re in pain, always in a state of fight and flight. So only way you can retrain it is by increasing your vagus nerve stimulation.

Dr. Ginger Garner PT, DPT (40:14)

Yeah, I find that when I’m working with patients, I use ultrasound imaging in my practice so that even early, early on when we don’t have to do anything invasive or internal, we can use external trans abdominal imaging to visualize the bladder of the base, teach them those vagus nerve retraining techniques so they can get kind of get a grip on managing the nervous system, resetting the nervous system very early on through

all the vagal techniques that you can do. And that’s very empowering to them too, because they can see it in real time what’s happening, ⁓ how they’re breathing, how they’re ⁓ recruiting an abdominal wall or not recruiting the abdominal wall to help them accelerate recovery. That brings me to another question too, because in sexual health, we’ve talked a lot about anatomy and physiology, preserving the anatomy.

restoring the physiology with a combination of surgery and rehab. But then there’s systems-based issues like, of course, ⁓ as a therapist, I’m always concerned about ⁓ levels of inflammation and I’ll track those things and help work with them on all the lifestyle pieces, the sleep, the nutrition, stress management, movement, everything we know that is great to be anti-inflammatory. ⁓ But then we’ve got the hormone piece.

That is a very hot topic now with the FDA removing the black box warning for vaginal estrogen, which is really important. ⁓ Those are things that I think before were like an afterthought or are not really considered ⁓ outside the space. Now in the endo world, yes, we’re always talking about this stuff, but for patients, they might think, ⁓ surgery and a little smattering of PT or whatever, and then I’ll be good to go.

But depending on age, what they’re going through, a lot of times I’ll come, know, someone, let’s say someone comes in from, you know, for pelvic floor PT, post-op, and I noticed the tissues, volvulavaginal tissues, they’re not doing well. ⁓ There’s a fragility there. They’ve got ⁓ other issues. Pelvic floor is weak and not functioning very well. That’s when we start considering things like, you know, low dose, you vaginal estrogen, et cetera. So,

In your practice, tell me about, well, there’s the whole inflammation piece, but hormones. ⁓ People are also worried, I can’t do vaginal estrogen. I had endo, et cetera. How do you approach that conversation ⁓ overall? And then I get another piece of that question, but let’s go there first.

Dr. Madhu Bagaria (42:57)

First of all, I always empower women that ⁓ people get IVF cycles also after endometriosis surgery. So I tell them, like you have undergone a surgery, all your tissues are removed. ⁓ There’s no reason, like yes, you can have some recurrence, but the recurrence chances if you look at the literature is 40%. So there’s a 60 % chance that you may not have endometriosis, especially in people who have minimal disease.

Dr. Ginger Garner PT, DPT (43:05)

Yeah.

Dr. Madhu Bagaria (43:26)

or they have superficial disease, right? The people we are worried about is basically ⁓ like who have deep endometriosis or they have like stage four, like bad disease, like bad inflammatory disease, a little thing that you may have a higher chance of recurrence depending on your age and where you are, right? So I always empower the women that…

you definitely can have hormone therapy if you want to. I don’t push hormone therapy for everybody, but again, it’s coming to the point where you find that tissues are not good or they have been on loop around for most of their life, they have been suppressed.

Even when you are on continuous birth control pills, I’ve seen those women also have bad vaginal, like they’re very vaginal dryness. And these people will definitely, definitely benefit from doing the vaginal estrogen. And I do empower them to use it because again, it’s a quality of life issues. just, you see those, that vagina is just not there. You feel the sensation of being dry. You feel the dryness during sexual intercourse. You feel that constant irritation to go to the bathroom to pee.

Dr. Ginger Garner PT, DPT (44:08)

Definitely.

Dr. Madhu Bagaria (44:30)

So you cannot ignore it. Like if your face is dry, you always have that itchy feeling in your face. You want to put some moisturizer. So the vaginal estrogen is like a moisturizer for your vagina and you have the control. Like if you want to use some day once a week, if you’re not comfortable, just use it once a week. You don’t have to use every day, but at least give a little support to your vagina. So I’m not opposed to that at all. And I will encourage women to do that.

Dr. Ginger Garner PT, DPT (44:56)

Yeah, it’s so important. find, and then the literature supports use of vaginal estrogen for all kinds of reasons, bulking of the tissues, tissue integrity, quality ⁓ for intercourse, but also with ⁓ bladder function as well. Pelvic floor is going to also be stronger, more ⁓ receptive. In terms of sexual health and function, there’s an increased sensitivity because

A lot of women will come in and go, I don’t feel a thing. I don’t have any desire and the structure. They don’t look the same. It’s, you know, it’s fragile. I even get attempted bleeding thing. It feels like things are tearing, et cetera. And all those reasons are, of course, why someone would want to ⁓ use vaginal estrogen. But it’s really great to have this conversation to just dispel that myth that if someone has had endo, you can’t use that, which is not necessarily true.

Dr. Madhu Bagaria (45:30)

Yeah.

they

definitely can use it and it’s very important that they use it if they need it.

Dr. Ginger Garner PT, DPT (45:58)

Yeah.

Well, we have talked about a lot. We’ve talked about nerve conditions like neuropathic contributions, vagal pathways, and just to break off for just a second on sexual health. This was a study done a long time ago, 2005, 2010, on spinal cord injury, women with spinal cord injury, when they learned that the upper segment of the vaginal canal has a vagus nerve connection.

that is not the spinal nerves, which was really cool. I remember reading that study when it came out going, my gosh, this is fantastic, which means that for sexual health, you’ve got this plus. We wanna preserve all the neural pathways, but if we also are working on the nervous system and pain management, that working on the vagus nerve can also actually improve ⁓ sexual health too.

Dr. Madhu Bagaria (46:49)

Yeah, vagus

nerve, I think the left side just goes to the gastric, so doesn’t reach the pelvis. But vagus nerve is your cranial nerve. So it’s a nerve which arises from your brain and it goes all the way down to the pelvis. If you can stimulate your vagus nerve, which can be just swimming, hiking, going in nature, it releases those happy hormones and it relaxes you. So it’s a very important nerve in our body.

Dr. Ginger Garner PT, DPT (47:01)

Yeah. Yeah.

Dr. Madhu Bagaria (47:18)

to just get access there from the vagina that is really.

Dr. Ginger Garner PT, DPT (47:22)

It is amazing.

And I realized now that I just was thinking about the study, but I didn’t fully explain the study. The study was about women with ⁓ complete spinal cord injury, so paraplegic, so can’t feel anything from the waist down. And so what the researchers were investigating is everyone assumed, they couldn’t have any sexual function or pleasure because they can’t feel anything. When in fact, because the upper portion of the vaginal canal is innervated,

or has a pathway from the vagus nerve that in fact they actually could reach. They could have pleasure, they could have an orgasm, they could reach that. Yeah, yeah, exactly. So that was a really cool study and it means that you don’t have to be spinal cord injured in order to use that physiology to your advantage, which is one of the things that of course your pelvic floor PT would work with you on. But it’s great to be empowered with those little tidbits of anatomy.

Dr. Madhu Bagaria (47:59)

There’s still a connection there, right?

Dr. Ginger Garner PT, DPT (48:20)

that let you know that your physiology, you can still feel normal and have the sexual health you want, thanks to the cranial nerves. Yeah. So what, a couple of concluding questions. Where do you see future pathways going? What research do you wish existed already? mean, of course, there’s a ton of, yeah, there’s a ton of, that’s a big question, but what makes you hopeful for the future about?

Dr. Madhu Bagaria (48:29)

Yeah.

Dr. Ginger Garner PT, DPT (48:50)

endometriosis and sexual health in general.

Dr. Madhu Bagaria (48:55)

think the biggest thing is now is that we are trying to do tissue typing for endometriosis. So understanding the epigenetics and understanding the genes and doing a targeted therapy. So it’s being treated just like a cancer case. Like we going many folds ahead in terms of cancer case. I’m not saying endometriosis is cancer. Please don’t take that message. What I’m trying to understand is that people are now trying to dive into the physiology and why this disease happens so that we can do a targeted therapy for those.

There’s a lot of AI coming into view where more and more surgeons will get equipped to recognizing the danger areas and they will be able to perform the surgery. So it will not be inaccessible care, hopefully in future because right now the biggest thing is also accessibility to care, right? So that is something. And with the social media and the ripple, I think people are finding the right care. ⁓

Physical therapy is not a sign of weakness. feel like now women are more and more the pregnant women, postpartum women. They’re recognizing that pelvic floor health is a functional, is a health for them and they need to work on it. Be in the pregnancy postpartum because people can have vaginal or pelvic pain years after the vaginal delivery because of post-seps and these things, you know. So these things, the education and awareness is coming to play. I’m very happy to see that. And just how women are supporting women, trying to be

vocal, trying to talk about the issues which are never talked about, trying to empower the little girls about talking about endometriosis. This is a huge win for us.

Dr. Ginger Garner PT, DPT (50:30)

Yeah,

definitely. So I’m really excited about the future and mapping as well. ⁓ So what would you say, ⁓ what do you want patients to know about advocating for themselves in both ⁓ surgical and sexual health realms? ⁓ Just like to take some of that stigma away if you could, what do you want them to know?

Dr. Madhu Bagaria (50:56)

One thing is that your sexual health is actually of important health. It’s not something which can be just voodooed away. It’s not just for reproduction or having fertility. It needs to be taken into account even though if you’re not trying to have any kids. It’s very, very important that your sexual health is addressed. So you need to find the right specialist who understands it.

And who also has the training to evaluate your pelvic floor muscles, just not for endometriosis, but they should also be able to recognize that there are trigger point areas in your pelvis and you can benefit from it. ⁓ Sexual health is not a luxury. It’s an essential part of your life. So advocate for yourself for it and don’t shy away from talking about it. And as a mother, I would talk to my daughter about sexual health growing up. So it’s important that we educate

our younger generations about it by talking openly about it as well.

Dr. Ginger Garner PT, DPT (51:56)

Yeah, that’s perfect. I love that. Speaking of finding an expert, where can everyone find you?

Dr. Madhu Bagaria (52:04)

⁓ So I’m ⁓ if you google my name you can find it. I’m also on Instagram. I also have a YouTube channel. So just my name my ⁓ Instagram is ⁓ at the rate of D O C T O R Bagaria, so ⁓ that’s where on Instagram you can message me or Even the YouTube you can message me. I also recently opened a TikTok just like ⁓ It’s called Bagaria . endometriosis so

Dr. Ginger Garner PT, DPT (52:27)

my gosh.

You’re amazing. I

don’t know how you do it all.

Dr. Madhu Bagaria (52:37)

I just recently just opened, like I was never into TikTok. And then obviously, yeah, and also the SE, like if you Google my name, and Endometriosis Surgical Speciality International, there you’ll find me.

Dr. Ginger Garner PT, DPT (52:40)

Yeah. my gosh. Bless you for doing that.

Awesome. we, everyone listening,

you don’t have to like stop your car or your walk. We’re going to put these things in the show notes. So they’ll be hyperlinked on the blog, on YouTube and on wherever you get your podcasts.  thank you so much for being with us today. I just really value your work and it’s just, you’re incredible. Thank you.

Dr. Madhu Bagaria (53:12)

Thank you, Ginger. It was really nice to have you.