Hello everyone and welcome back. I have a super special guest with me today for reasons that I will explain in just a second.

But first I want to welcome Megan Wasson to the podcast.

Megan Wasson (00:13)

Thank you so much for having me, Ginger. It is a pleasure to be here with you today.

Ginger Garner PT, DPT (00:18)

the first thing that I want to point out too is Dr. Megan Wasson, I wanted to say this, that is you’re an osteopath. Cue the sprinkles and the sparkles and the fairy dust and the unicorns and the rainbows and all that stuff running by in the background. If you’re not watching, you just missed all that on YouTube, so sorry. But I have a special place in my heart for osteopaths and…

Megan Wasson (00:28)

I am, I am.

Ginger Garner PT, DPT (00:46)

I think it’s because I wish that I could still have time in my life to go back and also do that on top of other things. But I just really love osteopaths. You guys are a really special group. so I got a little sidetracked, y’all. But I wanted to say that first. That’s the first special reason that I am excited that you’re here.

Megan Wasson (01:07)

Well, thank you so much. And similarly, I love pelvic floor physical therapists because I feel like it brings the osteopathic world and the medical world together with viscerostomatic reflexes. And we can talk about all of that if you want to. But yeah, there’s a lot of what I do that has roots in osteopathic medicine.

Ginger Garner PT, DPT (01:17)

Yeah.

Yeah.

Yeah, yeah, I just, it’s very synergistic. And when I talk to my other friends and colleagues who are osteopaths, we have like wishes back and forth, like, I wish I had time to do this and I don’t have enough time to do hands-on. And then I’m like, but I wish that we could do this, you know? But okay, so first I want to ⁓ brag on you a little bit. So y’all give me a listen for this fantastic bio. Here we go.

Dr. Megan Wasson is chair of the Department of Medical and Surgical Gynecology at Mayo Clinic in Arizona. She is also a professor of obstetrics and gynecology at the Mayo Clinic College of Medicine and Science and was also awarded the Outstanding Emerging Educator Award in 2020. She completed her fellowship in MIGS at Mayo in Arizona. She is a fellow of the American College of

obstetricians and gynecologists and a fellow of the American College of Surgeons. She is actively involved in multiple national and international medical societies and committees, including International Federation of Gynecology and Obstetrics, Minimal Access Surgery Committee, Immediate Pass Chair, et cetera, et cetera, all of these amazing things. ⁓ Not to mention that she’s got a ton of peer-reviewed publications. I’ll get to that in just a second. She was recently named as the incoming division director

for, is it, how do you say F, Figo? I was gonna say Figo, I’m like, oh, I don’t know, let me ask. Division of Benign Surgery. She is obviously a sought after speaker on gynecology, but also robotics, endometriosis, and MIGS, and has completed over 200 invited lectures. Back to that number of papers that she has, over 70 peer-reviewed publications and multiple book chapters, because it sounds like you have lots of spare time.

Megan Wasson (02:55)

Feed up, feed up.

Of course, of course.

Ginger Garner PT, DPT (03:23)

⁓ Obviously

her clinical interests include endometriosis and chronic pelvic pain ⁓ and robotic and minimally invasive gynecologic surgery. So welcome Dr. Wasson.

Megan Wasson (03:36)

⁓ thank you so much. yeah, when you put it all together, I don’t know how I have the hours in the day to get that done. But yeah, I’m very proud of what I’ve been able to accomplish. So thank you.

Ginger Garner PT, DPT (03:45)

Mm-hmm.

Yeah, I think, let’s see, and you were mentioning, is it your oldest is going into kindergarten? Yeah.

Megan Wasson (03:55)

into kindergarten this year. Yeah, yeah.

So I have a five-year-old and a three-year-old.

Ginger Garner PT, DPT (04:00)

my gosh. That is the real busy. When you get done with your day job, the other way full-time job, 24-7 job, which is ⁓ amazing and exhausting. And we have emphasized this time and again on the podcast that being a surgeon,

Megan Wasson (04:03)

keeping me busy.

My other full-time job, yes, yes.

I’m under a statement.

Ginger Garner PT, DPT (04:24)

And at being a mother and a female is a particularly unique and challenging situation. So we never just gloss over that and just pretend like, yeah, you can just do all these things and, you know, and be a mom. It’s incredibly hard. So I’m sure we’ll touch on a little bit of that too, because ⁓ every woman who’s a mother who is working in some professional capacity that is beyond parenting, which parenting, by the way, is probably the hardest job of all of that.

is really a superhero in her own right. So I just want to say that first.

Megan Wasson (04:58)

Thank you. And I couldn’t agree more. Like when I think about the women that I serve and the patients I take care of, they are all superheroes in their own right and trying to juggle everything and then add health concerns on top of it. Like women are powerful and we need to support them in every single way possible.

Ginger Garner PT, DPT (05:17)

Yeah, yeah, definitely celebrate that. Okay, so that brings me to my first topic, which gets me all fired up immediately. And that is the topic of menopause and endo, perimenopause, and even postpartum and endo, because postpartum can present so much like perimenopause until a mom’s done breastfeeding or whatnot. And so you end up spinning a great

deal of ⁓ years and decades and time of your life with this giant hormonal roller coaster that really until Menopause Society published that paper last year was not even being discussed really. Just kind of swept under the rug like, just let it happen. Whatever happens, happens.

⁓ Turns out there’s so many negative health impacts from ignoring this transition. And so I wanted to get your insight. We could ⁓ bounce these things back and forth and talk about how do you see endometriosis symptoms evolving during perimenopause and menopause.

Megan Wasson (06:31)

my gosh, I love this topic for so many reasons. ⁓ First, surgical menopause. I’m gonna touch on that really quick just so we don’t forget to mention that historically and even still today, there’s a lot of OB-GYNs who believe firmly that removing the ovaries, inducing surgical menopause is a way to cure endometriosis. And we know that’s not the case. There are many women that I care for who have gone through surgical menopause.

Ginger Garner PT, DPT (06:40)

Yeah.

Thank

Megan Wasson (06:59)

have been castrated are now not having any of their natural hormones but are still struggling and suffering because of endometriosis because the disease has not been removed. So we need to stop this notion that endometriosis is an issue with the ovaries. It’s not an ovarian problem. Yes, endometriosis responds to the ovaries but you have to treat endometriosis at its core. And so thank you for bringing up this topic. I think it’s incredibly important to make sure that we…

minimize the number of ovaries that we are removing unnecessarily because it really doesn’t help. And it just causes a whole host of other issues that you were alluding to with that long-term impact on overall health. We’re increasing risks for dementia, heart disease, osteoporosis by removing ovaries when we’re not even helping with the primary issue to start with. So this is so incredibly important.

Ginger Garner PT, DPT (07:33)

Yes.

Mm-hmm.

Yeah, so listeners, my gosh, this is so important. So Megan, if you could drop this truth bomb for us because this is going to find its way out to a bunch of listeners who really, really need to hear it. So just drop that truth bomb for us one more time on ovaries and endo

Megan Wasson (08:08)

Okay,

removing the ovaries does not cure endometriosis. Endometriosis responds to the ovaries, but endometriosis is not a problem with the ovaries. We need to stop taking out ovaries unnecessarily.

Ginger Garner PT, DPT (08:22)

Mic drop. Okay, all right, that’s it. I know I need a little thing, you know, so can drop it. Okay, perfect. ⁓ That’s a huge thing. I mean, I look back in my family history and it’s not just family history. It’s all of the patients that I see who’s the mothers of the young girls that I have in my office. And I see in my office are raising their hands when I’m screening.

Megan Wasson (08:23)

Done.

Ginger Garner PT, DPT (08:48)

them for endo because they’re coming in for other issues and I’m screaming screening the for endo and then asking the question, do you have, you sure there’s no family history of endo? And usually their moms are there with them or someone else and they’re raising their hand and they’re saying, ⁓ but I had a hysterectomy.

Yeah.

Megan Wasson (09:07)

Yeah, no, you’re absolutely right. And, I think that also gets to the normalization of symptoms that happens across our society that, you know, if mom has been experiencing painful periods and having issues with her menstrual cycle and has been told by her physicians and providers, well, that’s normal. Well, then when her teenager starts having menstrual cycles and is really struggling, she doesn’t know any different. And so she again normalizes it and it just is

Ginger Garner PT, DPT (09:17)

Yeah.

Megan Wasson (09:34)

perpetuating thing that we need to break the cycle and really ensure that if patients are having issues, if women are having issues, that we are intervening sooner rather than

Ginger Garner PT, DPT (09:45)

Yeah, and I think the thing that’s heartbreaking to me that I feel and see is because I’ve had this situation happen, and I’m thinking of three specific cases with that exact same scenario in the last few, just in the last six weeks really, ⁓ is to also, for those of you listening, if you’re the mom in this situation of your young daughter is, please don’t blame yourself because

This was, that was normalized. This pathological stuff that was happening to you was normalized by the generation prior to that and prior to that. That is just part of the social and cultural conditioning that we’re talking about having to break. But we also don’t want you to, you know, I don’t want anyone to ever feel bad like, ⁓ I have failed my daughter. No, no, no, we’re gonna stop the generational curse with podcasts like this and others that will say, hey, it’s okay.

Megan Wasson (10:39)

We have.

Ginger Garner PT, DPT (10:41)

if your symptoms were normalized when they should never have been normalized, but now we can change it for the future. And that’s like a hopeful message.

Megan Wasson (10:47)

Yeah, my gosh.

Yeah, I love that. I love that so much. We do the best we can with the information and the knowledge we have at that precise moment. And we can’t go back. We can only move forward. And so doing better for future generations is really what is essential. I love that so much,

Ginger Garner PT, DPT (11:03)

Yeah.

Yeah, yeah. So how can, that you have seen, because there are so many symptoms, menopausal symptoms, when I screen for perimenopause, there’s like 30 symptoms, right? So it’s not like we can just rattle those off. Well, maybe we could, but because there’s typical ones, but you know, in your experience, which is so incredibly valuable, can…

Megan Wasson (11:15)

Okay.

Ginger Garner PT, DPT (11:32)

Can you describe how you have seen endometriosis remain active or even worsen with like the perimenopause to postmenopause transition?

Megan Wasson (11:39)

Yeah.

Yeah. So with perimenopause, the ovaries are intermittently turning on and turning off. So the brain is sending chemicals to the ovaries to tell the ovaries to produce estrogen and progesterone. But as the ovaries age, they respond to that signaling less and less. But then when they do respond, they tend to surge and you get a huge increase in estrogen and progesterone. Well, with that significant surge of hormones, in turn, you get a surge in endometriosis related symptoms.

So it’s not uncommon to have this waxing and waning of, I feel really good. I’m having hot flashes, but my pelvic pain is much better. And then all of sudden my hot flashes go away, but now my pelvic pain is miserable and all of my endometriosis symptoms are flaring up. That is a very common story that we hear in the perimenopausal transition. And again, it’s because those hormones are surging back and forth between really high levels, really low levels.

and the body is just trying to figure out what to do with all of that change. Add to that the aromatase that endometriosis has that converts testosterone into natural estrogen. And in Scottsdale, we’ve had a significant increase in the amount of patients who are actually prescribed testosterone to assist with the perimenopausal transition. Well, that testosterone, endometriosis converts it into estrogen. So then we’re actually feeding the problem inadvertently by trying to treat some symptoms.

Ginger Garner PT, DPT (12:42)

Mm-hmm.

Megan Wasson (13:02)

And so you end up with this circuitous issue and we’re just making things worse instead of better. So it ends up being this challenge of, well, are we going to treat the menopausal symptoms, the hot flashes, the difficulty sleeping, the mood swings, or are we going to treat the endometriosis and how do we treat both of them at the same time?

Ginger Garner PT, DPT (13:22)

Isn’t that a very special hell?

Megan Wasson (13:27)

Yes, perimenopause is not for the weak of heart. It is not. It is not.

Ginger Garner PT, DPT (13:30)

And

then you throw endo into it and you’re like, if you’re the person experiencing it, you’re like, what did I do karmically to deserve this horrible combination of existing on the planet? But the good thing is there are a lot of interventions. There are things that don’t have to be invasive to be so pervasive into your whole life and then just be all consuming. Because when you think about,

when we internalize somatically, when you were saying, you’re describing the cycle and the circular notion of it, I’m having compassion, somatic response to, my gosh, that’s awful to be stuck in that. So I think the next question that listeners probably intuitively have is, my gosh, what about hormonal treatments? What’s safe? What’s effective when someone has, they’re going through menopause and they have endometriosis?

Megan Wasson (14:27)

Yeah, and there is not a right size fits all. It truly is individualized to each person. So if patients have not had surgery, if we know that they have a significant endometriosis disease burden, then we would want to be using both estrogen and progesterone for those patients for hormonal support, regardless of if they’ve had a hysterectomy or not. So speaking to that woman that you mentioned that had had a hysterectomy as her cure for endometriosis, if she still has endometriosis in her pelvis,

Ginger Garner PT, DPT (14:33)

Mm-hmm.

Mm.

Megan Wasson (14:55)

that is going to be an estrogen dominant state and she’s going to need progesterone to help stabilize that. So that’s a very key learning point for individuals that regardless of a uterus or not, if someone has significant endometriosis, the deep infiltrating disease, we need to be giving progesterone to counteract that estrogen stimulation. But truly doing anything from a hormonal perspective with estrogen and progesterone to give that stabilization of the ovaries and stop this

Ginger Garner PT, DPT (15:15)

Yeah, I think.

Megan Wasson (15:25)

surge and drop and surge and drop that happens with estrogen progesterone levels is really what’s going to help improve quality of life, not just from a hormone perspective with menopausal symptoms, the hot flashes, the brain fog, but also help with the pelvic pain that comes with that surge as well.

Ginger Garner PT, DPT (15:42)

Yeah, there’s so many musculoskeletal symptoms that can be helped. In fact, many of the conditions that someone would end up in my office, say for pelvic PT, ⁓ are going to be assisted by that hormone therapy. And in many cases, like if someone had prolapse on top of this stuff, talk about a special hell, that’s a whole other thing.

to add a pelvic organ prolapse on top of it, they may absolutely need that support in order to be able to maintain the integrity of the vaginal tissue to support like a pessary or something like that should they need it.

Megan Wasson (16:18)

Yeah, exactly, exactly.

Vaginal estrogen is not the enemy. I hear that a lot from women who have had endometriosis and been told, getting back to the surgical menopause, take out your ovaries, never use estrogen because you’ll just feed the disease. That’s not the case at all. Our bodies need estrogen to be successful and thrive. so estrogen is not the enemy. We just need to work with our hormones to make sure we’re optimizing things for our bodies.

Ginger Garner PT, DPT (16:33)

Mm-hmm.

Yes. That’s

another truth bomb, you guys, by the way. That’s very, it’s very good talking about this because ⁓ at some point with endo, you’re going to have this conversation. And so the point of our conversation is to dispel a bunch of those myths that you couldn’t use vaginal estrogen. I mean, we know that, that it’s not absorbed systemically. It’s going to act locally. And if you have, ⁓

painful bladder syndrome, interstitial cystitis, if you have urinary incontinence leakage, if you have painful intercourse, all of these things that would typically be treated in pelvic PT are very much dependent on the support of vaginal estrogen in that area. Yeah.

Megan Wasson (17:29)

Yeah, yeah,

no, absolutely. And to just put this in perspective for people, there have been a lot of studies even looking at patients who have breast cancer that is estrogen receptor dominant. So is being fed by estrogen. And for even those patients with breast cancer, vaginal estrogen is safe, it’s effective, we can utilize it. So vaginal estrogen is amazing, and we should not be afraid to utilize it if it helps with the pelvic floor and all of those host of issues that you described.

Ginger Garner PT, DPT (17:40)

Mm-hmm.

Yeah, yeah, that’s just a massive win to see that because I mean, I’m sure you and I both alike have those patients who do have those multiple things. They also have a breast cancer diagnosis on top of these things, which is devastating, but very hopeful to know that vaginal estrogen can be safe for them as well. Yeah. Let’s talk a little bit about surgical menopause versus natural menopause because surgical menopause I think is its own

Megan Wasson (18:18)

Yeah, absolutely.

Ginger Garner PT, DPT (18:29)

its own horse, you know? It’s its own kind of apocalyptic horse, I think, sometimes. Because natural menopause already has its challenge, but then when you’re going through a surgical menopause, how would you say that that presents differently? in terms of impacting endometriosis differently, and their symptoms, what they would feel.

Megan Wasson (18:50)

Yes.

So surgical menopause is literally a light switch. You go into the operating room and you’re feeling whatever endometriosis symptoms that you’re having or whatever other gynecologic issues that were prompting you to go into surgical menopause. You walk out of the OR and suddenly your ovaries are gone and you no longer have estrogen or progesterone in your body. The metabolism of estrogen and progesterone is very, very fast. So as soon as the ovaries are gone,

your body is going to feel it. There are patients who wake up in the recovery room and immediately are having those significant hot flashes. And because it’s a light switch, there’s no transition period, there’s no natural adoption to those symptoms that people are having. And so they feel all of those waves of symptoms immediately. And it can be very important to manage it effectively in the short term. So that way we’re not allowing those symptoms to get away from us.

From a endometriosis perspective, the thought that, again, doing surgical menopause is immediately going to make the endometriosis symptoms go away is not accurate either. And so not only are we not helping the pelvic pain symptoms, but then we’re adding the quality of life issues with the hot flashes, the difficulty sleeping, the brain fog, all of the other whole host of quality of life issues, we’re trading one problem for another problem. And so…

if we’re doing surgical menopause, if it’s someone who is supposed to be premenopausal, so someone in their 40s that were doing like risk reduction for BRCA mutation or Lynch syndrome that were intentionally doing surgical menopause to reduce their risk for cancer in the future, we immediately put that patient on estrogen. I am not an advocate for surgical menopause for endometriosis. So I’m intentionally not talking about surgical menopause for endometriosis.

Ginger Garner PT, DPT (20:38)

Yeah.

Megan Wasson (20:40)

But it

would be the same premise that if I have a patient who comes to me who has surgical menopause related to endometriosis and is really struggling, doing the hormone replacement is going to be incredibly important. And it’s also important to recognize that if they are premenopausal age for a time, so in their 40s, 30s, even 20s, I’ve unfortunately seen that individuals are surgically menopausal, the amount of hormones that they need are not the same as someone who’s in their 50s.

They need to have a higher therapeutic level of estrogen in their system, not just to control menopausal symptoms, but to protect their brain, to protect their bones, to protect their heart from all of the negative morbidity that comes with being menopausal at the age of 20.

Ginger Garner PT, DPT (21:18)

Yeah.

Mm-hmm, yeah, yes. I’m just thinking back to those ⁓ young women that I have had in their 20s already having gone through surgical menopause for endo and adenomyosis. ⁓ And it’s what moves me to keep doing things like this so that ⁓ there are these…

consistent stream of hopeful messages that even if you have endo, even if you have adenomyosis on top of that, even if you do have these other things, you can still thrive. Yeah.

Megan Wasson (21:56)

Yeah, no,

absolutely, absolutely. There is no reason to take out ovaries in a 20-year-old for treatment of endo or adeno. There are so many things that we can do to optimize pelvic pain. you know, seeing the patients who have had surgical menopause and are still struggling and now have this whole other host of issues that we have to tackle and deal with, it’s heartbreaking. And we need to do better. We can do better that we need to stop blaming the ovaries for everything.

Ginger Garner PT, DPT (22:05)

Yeah.

Yeah.

⁓

Megan Wasson (22:25)

You know, I always say, like,

let’s step back. Let’s think about if this were a male condition. Would we ever consider doing an orchiectomy on a male, removing the testicles? Like, that’s insanity. No one would consider that. But we remove ovaries in women all the time without giving it a second thought. And we need to do better.

Ginger Garner PT, DPT (22:37)

Mm-hmm. Mm-hmm.

Yeah, that you’ve just like read my mind because the next question was going to be to talk a little bit about the horse historical precedent here, like why menopause has been overlooked in patients with a history of endo and even without it’s just been overlooked without it, but and vice versa. And then we get into, you know, historically what has happened. So ⁓ what’s your take on that? You know, why menopause has been overlooked?

Megan Wasson (23:10)

Yeah, I mean, I think that number one, women just suck it up and deal with it a lot that we don’t complain. We show up and we do what we have to do as moms, as wives, as professionals. And we don’t complain if we’re having significant impact on our quality of life, especially if someone tells us that it’s normal and that it’s really not that big of a deal. Then, OK, fine, I’m going to make sure that it’s not that big of a deal. But then we compound that with

Ginger Garner PT, DPT (23:15)

Yeah.

Mm.

Megan Wasson (23:37)

just research dollars in general and the lack of funding for women’s health and the lack of research that’s been done in women’s health, that we look at these huge studies that have investigated things like diabetes and hypertension, and they’re predominantly males in that study, in that cohort. And we don’t acknowledge and recognize the impact of gynecologic hormones on life and the impact of health for women as a whole. And that’s where we are doing better.

Government has given more funding towards women’s health and researching women’s health issues. But until we really start to dig into menopause, which is half of a woman’s lifetime, we’re not going to make any significant headway. We need to get away from thinking that women are solely, our sole purpose is producing babies and offspring and really recognize that even beyond fertility, there’s a lot of value and we need to optimize our entire lives, not just the fertility time.

Ginger Garner PT, DPT (24:17)

Mm-hmm.

All

Right, exactly. if you think about going back to what you said about the number of years that a woman will spend most of her adulthood, really, in menopause, not in a fertility window, that we’ve historically kind of discarded women after that and only looked at their value based on their fertility. And I know with…

in a couple of the episodes previously, we’ve talked about the damage that can be done just to a woman’s self-worth and confidence if she’s only offered endo treatment or care based on her want for fertility, you know, ⁓ is so dangerous. the misconceptions about endo and menopause, I end up saying endo and meno all the time.

are so incredible because of that massive range of time that is spent there. And you’re right, I think women have been conditioned to suck it up. We have conditioned ourselves, so in a way, the gaslighting then ends up resting with us because we just gaslight ourselves and say, we’re supposed to live without or in pain or with this pain. But the origins of it,

Megan Wasson (25:51)

Yeah.

Yeah.

Ginger Garner PT, DPT (25:56)

do start with the neglect of women’s health historically. The origins of it ⁓ do rest firmly in medical misogyny or patriarchy of the label hysteria and the crazy stuff that ⁓ went with that. You could probably trace that all the way back to women speaking their mind and ending up being burned at the stake, which is like funny not funny, right? It’s never funny, but it is.

Megan Wasson (26:09)

Mm-hmm.

Right, right.

Ginger Garner PT, DPT (26:24)

⁓ a stark reminder of how little time that we’ve had in history with any attention being paid to women at all. ⁓

Megan Wasson (26:34)

Yeah, no,

you are 100 % correct. And one of the other things that I just want to highlight from the menopausal perspective is a lot of women feel better with menopause when it comes to endometriosis because they’re not having that surge in estrogen. So having a lower estrogen level, they feel better. They might not feel great, but they’re not having that significant surge in symptoms every month. And so they say, okay, well, this is good enough. Well,

It might be good enough, but imagine how good things could be if we actually adequately treated the disease and improved everything surrounding this condition. And so again, it’s that conditioning of, if it’s not going to kill me, I can just deal with it and move on. But we need to get away from that and really focus on quality of life should not be minimized. Quality of life is incredibly important.

Ginger Garner PT, DPT (27:06)

Yeah.

Mm-hmm.

Megan Wasson (27:23)

And if quality of life is not at the level that someone wants it to be and is negatively impacting their day to day, that’s where we need to do better, regardless of if they’re trying to get pregnant, if they’re not able to get pregnant, if they’re menopausal. It doesn’t matter where someone is in their time frame. Quality of life is incredibly important for every single person, every single day.

Ginger Garner PT, DPT (27:43)

Yeah, I think that from the 40,000 foot view, if you take the cliche, if mama ain’t happy, ain’t nobody happy, imagine a world where even for the expense alone, but looking at quality of life, but also the enormous amount of expense that goes into a woman’s end of life care if she’s incontinent, if she has dementia, if she has heart disease,

all of these things that we know, estrogen suppression and deprivation actually contribute to. Imagine a world where we actually appropriately treat menopause and endometriosis at the same time, where we don’t have the number one reason women are admitted into nursing homes is incontinence. that alone, that would make a lot of people happy. So if mama’s happy, like, you know, everybody be happy because…

We wouldn’t have these long-term admissions and sharp declines in quality of life. I think about so many family histories where all the women in their family have passed from complications from dementia. It’s just, and heart disease and metabolic syndrome and diabetes are all kind of on top of that. It’s incredibly hopeful, but it’s also incredibly sad to look back at the loss of quality of life of family members, the women who didn’t have to suffer like that.

Megan Wasson (29:10)

Well, your point is exactly that. They did not have to suffer. As a medical community, we have failed them and have not provided them with the treatment they need and deserve. And in turn, we’re causing this whole host of health issues that people aren’t even recognizing that has happened. And so that’s where I am very hopeful. I agree with you. The Menopause Society is doing amazing work to raise awareness and understanding of the importance of menopausal transition and treatment of menopause.

Ginger Garner PT, DPT (29:15)

Yeah.

Mm-hmm.

Megan Wasson (29:39)

but there’s still so much work to do.

Ginger Garner PT, DPT (29:41)

Yeah, yeah, absolutely. ⁓ And so you highlighted really some of the most important misconceptions about the relationship between endo and menopause, which is that it will just completely get better, right? Because I think a lot of women are told, you have endo? just wait. It’s going to get better later. Well, I’m one of those that it didn’t, right? It absolutely didn’t. It got exponentially worse and…

So you think going through that ⁓ moment of perimenopause, like all the surging that you were talking about, well, that makes sense why symptomology would potentially get worse for some ⁓ before it gets better. So I think my next question is related to, because obviously we’re talking, there’s a larger conversation at Menopause Society and throughout their…

People are writing books on it. I mean, it’s like all over the place now, which is good. Instead of just calling it, you know, instead of saying, it’s just menopause or it’s just aging. How can patients with endometriosis advocate for themselves when they come up against that, that kind of, that old archaic attitude of, it’s just menopause or it’s just aging.

Megan Wasson (30:59)

Yeah, no, that’s a really great question. And it honestly gets to endometriosis in itself, right? Like if you’re going to a provider and you’re having to educate your provider on endometriosis and teach them what the disease is, that’s probably not the provider that’s going to be best for you. Like I appreciate that providers are open to learning and wanting to learn, but at the same time, as a patient, you should be able to go to someone and have that expertise given to you rather than having to share it with your provider. And so my first

Ginger Garner PT, DPT (31:11)

Yeah.

Megan Wasson (31:28)

recommendation is if you’re having to share that menopause is not just suck it up and deal with it, that we should be managing it, try and find a different provider to be perfectly honest. On the NAMS website, the National American Menopause Society, there’s a provider finder button that will allow you to find individuals who are certified in menopause care and they have to go through a rigorous test. They do a lot of study to make sure they are experts when it comes to menopause.

Ginger Garner PT, DPT (31:34)

Thank

Yeah.

Mm-hmm.

Megan Wasson (31:58)

OB-GYNs have classically been who we look to for menopausal management, but there’s a growing field of women’s health internal medicine, which I actually love. I am very fortunate that I have a very large department of women’s health internal medicine here at Mayo Clinic. And they build the expertise of not only female health and hormones, but the entire medical system as well. So they understand heart disease, diabetes.

everything that’s happening in the body as a whole as we age, but then they add it to hormones. And so you’re able to get this expertise for everything. And so I would seek out a women’s health internal medicine provider as well. They’re phenomenal, phenomenal expertise.

Ginger Garner PT, DPT (32:41)

Yeah, yeah. And the other thing I love about the NAMS registry is that there’s such a wide scope of practitioners who can sit for the exam and study and pass that. it could be PT, it could be nurse practitioner, it could be PA, obviously MD, DO, but then there are other providers who can be literate in menopause too. Maybe it is from a nutrition.

or dietitian perspective that they really want to focus on nutrition for menopause. So that is exciting to me that you can build a team that’s all menopause literate for you for the future, whereas just a decade ago, none of this was really available to us. It’s exciting.

Megan Wasson (33:25)

Yeah, yeah, exactly,

exactly. We are much stronger together and you can’t have just one person on your team. You really do need that multidisciplinary approach to make sure that we’re optimizing things all around the board. So yes, I agree. I love NAMs for that perspective.

Ginger Garner PT, DPT (33:42)

Yeah, it’s fantastic. I love the interdisciplinary education that’s going on too, because then that allows us to, ⁓ and your providers, so for listeners, you want providers, a team that can actually refer across disciplines to each other. And I don’t think that we’ve had nearly enough of that in the past. And so I’m hopeful that this generation, the next generation will look entirely different for care for women in endo than it does right now.

Megan Wasson (34:10)

green.

Ginger Garner PT, DPT (34:11)

And that’s better for mental health, which is probably one of the most important things to talk about because there’s so much, there’s so much, I think that’s kind of a whole sentence, surrounding mental health and identity and trauma and endometriosis. And I’d just love for you to just share some personal experience stories about how you see menopause and endometriosis impacting

mental health because with all of the known gaslighting that’s happened, sometimes it’s overt, sometimes it’s misunderstood. Wherever it came from, it has the same impact on women, which is to negatively impact mental health and create ⁓ trauma inside a system that you’re supposed to go to for sanctuary and safety. It creates that institutional betrayal or trauma, if you will. So how have you seen menopause and endo impacting mental health?

Megan Wasson (35:09)

Yeah, no, that’s a great point. And I love this question. So immediately my mind goes to sexual health because that unfortunately is something that causes a lot of trauma, a lot of gaslighting. we hear endometriosis, premenopausal endometriosis patients say all the time, well, my provider just said, have a glass of wine and that’ll help. It’s horrific. It’s horrific. But then couple that with, well, it’ll be better with menopause.

Ginger Garner PT, DPT (35:16)

Hmm.

yeah.

Megan Wasson (35:37)

once you transition into menopause, the endometriosis is going to go away and your sexual health is going to be amazing. Well, okay, then we couple, have scarring at the uterus sacral ligaments. So penetration is still horrific that you’re literally tearing tissue every time you have penetration. And then we add on to that, that we have the genitourinary syndrome of menopause, vaginal atrophy, the lack of estrogen. No one will give estrogen because we might feed the endometriosis.

Ginger Garner PT, DPT (35:53)

Mm-hmm.

Mm-hmm.

Mm-hmm.

Megan Wasson (36:04)

So then we, again, we are not able to have enjoyable intercourse. And for a lot of women, that has significant toll on their mental health, that they really feel like it’s not contributing to their relationship with their partner. They feel like they’re failing their partner. And it adds to this huge sequelae of mental health impact that

not only have they been gaslit premenopausal, they were clinging onto this hope that, once I transition into menopause, I’m going to be great. Things are going to be much better. I just have to hang on. I just have to get there. Well, then I do that transition and nothing’s better. Things are actually worse and people still are not listening to me. And so we’re only able to cope with so much and we’re only able to tolerate so much. having that hope is so critical. And once you transition into menopause and that

hope starts to become less and less is really where the impact on the psyche can be very, very impactful.

Ginger Garner PT, DPT (37:03)

Yeah, yeah. How do you see, because there’s so many different routes. ⁓ You know, some people do well with talk therapy, but other people need EMDR or, you know, other types of, you know, evidence-based ways to negotiate this. Some need somatic-based therapies, like movement-based therapies. ⁓ But how have you seen, you know, helping patients navigate that grief or identity shift that can come with…

losing fertility, losing libido, losing energy during menopause, after years and decades of already battling endometriosis, what have you seen that has worked and helped?

Megan Wasson (37:42)

Yeah, so truly in the first thing, it seems very simple, but it’s just acknowledging and giving space to say, yes, I see you. Yes, I hear you. And yes, this is real. Like the amount of relief that just comes with not making people feel like they’ve done something wrong and that they’re making this up can be very, very impactful. But then in addition to that, building that multidisciplinary team that you were talking about. So.

will treat the menopause, have that women’s health internal medicine provider who has expertise in sexual health to work through the sexual cycle and work on libido and the vaginal health, but also couple that with our pain rehabilitation program who works on the cognitive behavioral therapy. Our physical therapists are involved in that program as well and really working on the way the brain processes, because if someone has been in pain and that pain is always associated with intercourse, no matter what you do,

you’re never going to be able to have that arousal and that natural sexual cycle because you’re constantly going to be thinking, this is going to hurt. And so why on earth would you want to be intimate because it’s going to hurt? And so that’s where the cognitive behavioral therapy can really help to break down that cycle as well as the sexual therapy. So it’s that multifaceted, multidisciplinary, like you were alluding to, there’s so many different ways that you can tackle it. And it really does need to be individualized. But the first step,

Ginger Garner PT, DPT (38:45)

hurt.

Mm-hmm.

Megan Wasson (39:06)

is acknowledging that the problem even exists.

Ginger Garner PT, DPT (39:09)

Yeah, wow, amen to that. ⁓ And the cool thing about ⁓ other therapies too, like the integrative approaches that are, and we’re talking about evidence-based approaches here, obviously, not like alternative approaches that don’t have any scientific support. So when we talk about those things that are well-supported in the scientific literature, things like CBT.

are also, NAMS also supports that for vasomotor, for hot flashes and night sweats. It’s not gonna cure it, but it does help, and it’s one thing you can throw in your toolbox. Having night sweats, great. Let’s also work on the trauma and the medical gas lighting and your vasomotor symptoms at the same time. So it’s kind of a win-win.

Megan Wasson (39:52)

Yeah, yeah. And I love that you mentioned that because a lot of patients, anytime I mentioned therapy or anything from a psychiatry psychotherapy perspective, they immediately think that I’m saying that their symptoms are not real, which is not the case at all. It’s just recognizing that the brain is incredibly powerful and the brain can either turn up the volume of symptoms or turn down the volume of symptoms. And so doing the cognitive behavioral therapy, doing EDM, it’s just turning down that volume to make it so that your body’s better able to cope and

Ginger Garner PT, DPT (40:04)

Right, right.

Megan Wasson (40:22)

state.

Ginger Garner PT, DPT (40:23)

Yeah, yeah. There are so many cool things. And the other thing is that in this whole bucket of cool things, right, of evidence-based and best evidence treatment modalities, there are going to be things that work for the individual. So for listeners, not everything’s going to work. Mindfulness-based stress reduction may not work for you, although there’s a ton of support in the literature. Maybe it’s going to be something like…

CBT instead of mindfulness-based. Maybe it’s not meditation, maybe it’s just simple ⁓ somatic exercises and yoga-based movement, that’s deep breathing. ⁓ For a lot of my patients, I will combine that stuff, because my background’s actually in yoga first, so I have this weird circuitous kind of route. So I will toss in the yoga for them, but then I’ll do real-time imaging on top of it so they can see what their respiratory diaphragm and their pelvic floor is doing.

if they can see how it’s getting inhibited by when they think of stressful things. I’m thinking of one particular story where I was imaging the bladder base and she started to talk about a stressful event and immediately the bladder base went up by like 14 millimeters. I was like, did you feel that? It was like earthquake, you know, was like, that’s a lot. It was like an earthquake in the clinic, right? And she was like, no, she was like, wait, ⁓ wait.

Megan Wasson (41:43)

Yeah.

Ginger Garner PT, DPT (41:47)

Okay, here it comes. She’s like, that’s the thing. That’s the feeling that I get that’s random. And I didn’t know where it came from. I was like, I think it’s being, you know, it’s being pushed by your stress. Not that she can’t manage stress. It, you know, wasn’t trying to say that it’s that her pelvic floor does what it wants without her permission, which doesn’t make it psychosomatic. It is not all in her head and yet.

Megan Wasson (42:08)

Right, right, right.

Ginger Garner PT, DPT (42:15)

retraining the brain is then how we bring it all down and you know in full circle again, but it’s so cool because it it it basically reinforces to them a you’re not crazy B there it is. We just saw it. It just happened. You know, it’s just like See if there was a mouse in your kitchen. ⁓ there it is. It just ran by you know, it’s like there’s the proof there it is We’re not just imagining high tone or you know, guessing that it might be something like that. You can actually see it

Megan Wasson (42:27)

Yep. Yep.

Yeah, yeah.

Ginger Garner PT, DPT (42:45)

And then it takes the self blame, you know, and everything off of them so that they can go, okay, breathing is actually important, which is how we ended up changing that particular patient’s experience was just tweaking the breathing a little bit and going, when you’re thinking about that, try this instead. And instead of getting a 14 millimeter jump in pelvic floor tone, you’re actually going to get like a 14 millimeter decrease, which is like a 30 point differential.

Megan Wasson (42:57)

Yeah.

Yeah.

Ginger Garner PT, DPT (43:14)

you know, of a stretch, you know, on the pelvic floor.

Megan Wasson (43:15)

my gosh, I love that. Yeah, that’s amazing.

Ginger Garner PT, DPT (43:18)

So, and then it’s proof for them. So, there’s just so many different ways that we can, ⁓ you know, usher patients towards usher our, you know, people, you know, towards taking back control, right? Like, and that really is what it’s all about. Instead of it being, you need to go to psych, right? It’s so much more than,

Megan Wasson (43:40)

Right.

Ginger Garner PT, DPT (43:44)

than that and not just that, you know, in and of itself. It’s not all in their head.

Megan Wasson (43:52)

Yeah, yeah, no, I love that. I love that you said it’s not just psych. Psych can have a very important role in minimizing the symptoms of endometriosis, menopause, pelvic pain, but it’s not the only part of the puzzle. But if we leave it out of the puzzle, if we don’t acknowledge the impact that our psyche has on our health as a whole, we’re doing ourselves a disservice. And so having that entire team around you, the village, to help manage these symptoms is really what’s critical.

Ginger Garner PT, DPT (43:58)

Mm-hmm.

Thank you.

Yeah, and the other thing is because we know endometriosis has a genetic component to it, so if your mother had it, we really have to take it seriously that you could have it. If you think about the epigenetic weight ⁓ of the historical trauma that women have suffered from, so you think if your mom had it and her grandmother or your great aunt or whatever had it, and we know that

epigenetically trauma is, you know, transferred across multiple generations, then that means you’re holding a really heavy weight in your body, somatically, and in your mind, and in your gut microbiome that was passed down to you that you had no control over, that now you’re still tasked with healing.

Megan Wasson (44:57)

Yeah. Yeah.

Yep. Yeah. You are 100 % correct. Yes.

Ginger Garner PT, DPT (45:14)

It’s pretty big burden. Yeah, exactly. So let’s talk about change. I mean, we’ve been talking about change the whole time, right? So we’ve listed some non-hormonal strategies and hormonal strategies, lifestyle modifications. First of all, not blaming yourself for growing up in a system that was oppressive and ⁓ suppressive for women to begin with. So now we talk about advocacy.

Megan Wasson (45:16)

Mic drop.

Ginger Garner PT, DPT (45:44)

What do you think needs to change? Let’s just talk about the ideal world. ⁓ I think of that movie Zootopia. Did you ever see that movie? Yeah, I was gonna say utopia, but then I thought Zootopia because hey, I’ve got three kids. So, all right. So in a Zootopia, ⁓ what do we need to change in the medical system? You have a unique, very powerful… ⁓

Megan Wasson (45:53)

Yeah, yeah, yeah, my kids love it.

Thank

Ginger Garner PT, DPT (46:12)

situation and position and unique view in that you’re in academics. You get to be involved where a lot of us are, we’re doing our best in clinical, but we don’t have the time or the opportunity or the privilege to be in academics and you do. So I think that you’re like a powerhouse to answer this question. What do we need to change in our medical education system and in our medical system to better support women going through endo and menopause?

Megan Wasson (46:26)

Yeah.

my gosh, that is such a big question. We have another hour, right Ginger? Yeah, so, you know, I am at a very unique institution. Not only am I at an academic institution that I’ll speak what the difference is with that, but Mayo Clinic really focuses on the three shields with education and research supporting clinical care. So the patient is the center of every single thing we do.

Ginger Garner PT, DPT (46:42)

Yeah, exactly.

Megan Wasson (47:06)

but we also recognize the importance of education and research to support that care that we do for the patient. And so in terms of like what needs to change in the medical community, what do we need to do better? Physicians need to understand and recognize this disease. And that’s one of the main things that I really focus on and why I do so many lectures and why I travel and spend a lot of time speaking to different groups of individuals. It’s not just speaking to the endometriosis surgeons and helping them to do

better surgery. I love that there are endometriosis surgeons out there and I love that community that we have, but that’s just the tip of the iceberg. We need more of us out there to be able to really break the cycle of this. And so educating primary care providers, family medicine, internal medicine, to understand the signs and symptoms of endometriosis, adding to that general OB-GYNs. We only know what we know and we don’t know what we don’t know.

During residency even, I was trained that endometriosis just has the powder burn appearance. And so I did not recognize the three quarters of lesions that do not have powder burn appearance. And so that’s the education system that we currently have. And so we need to retrain the OB-GYNs that are out there to be able to better recognize so that way we don’t have a diagnostic laparoscopy that comes back quote unquote negative. When I go in and see endometriosis,

Ginger Garner PT, DPT (48:16)

Yeah.

Mm-hmm.

Megan Wasson (48:33)

And I truly don’t fault the general OBGYN. They don’t know that they’re not adequately identifying this disease. And so it starts with educating medical students. I have med students with me in the OR all the time and showing them what this disease looks like, what the impact of this disease is. So that way, even if they’re going into emergency medicine, if someone comes in and says, I have endometriosis and I’m having severe pain.

Ginger Garner PT, DPT (48:34)

Mm-hmm.

Yeah.

Megan Wasson (49:02)

they don’t minimize those symptoms and say, okay, this is just a drug seeker, which is what I very commonly hear from my patients. And no, this patient is struggling, this patient is suffering, and we need to acknowledge that and hold space for that. So the medical system as a whole does need to continue to improve and do much better from an understanding and recognition of endometriosis, and then add to that the research component that I am…

Ginger Garner PT, DPT (49:04)

Yeah. Yep.

Mm-hmm.

Megan Wasson (49:29)

very, very fortunate that I have PhDs that I work with and I collaborate with. And so we’re working on treating the disease in ways that hopefully will not require surgery or make the surgeries better. understanding the immunologic response to endometriosis and how the immune system either up regulates or down regulates. We’re identifying different markers that allow drug targeted therapy. how do we get

Ginger Garner PT, DPT (49:47)

powerful.

Megan Wasson (49:56)

medications specifically to endometriosis, but not the rest of the cells in the body. And so my dream and my goal is that eventually I won’t operate because I won’t need to operate and that will have a much better handle on this disease. Will that happen in my career? I don’t know, but you know, it’s my pipe dream and perfect world and my utopia of what I would love the endometriosis community to be.

Ginger Garner PT, DPT (50:17)

Mm-hmm.

my gosh, yeah, all right. So now I’m like all watery eyed just hearing about that. As a clinician, as a daughter of someone with endo, as a person with endo, it’s just incredibly important that all providers learn how to screen ⁓ because we hear too many stories of

women coming in and being labeled as drug seekers. ⁓ And the stories just flood my heart. It’s not even just my mind. It’s they flood my heart with so much ⁓ both like empathy and also rage for what’s happening out there right now that these patients are in midlife now going through menopause and they’ve been dismissed for years. ⁓ So I think that if we could

screen everyone appropriately. That would be incredible. Look to have more, you know, compassion to women’s health issues instead of them not understanding and then blowing that off. And having well-meaning providers and really smart colleagues say, that’s not an endosymptom. When I was, know, if I’m talking about GI symptoms and they’re like, that’s not related. Okay, well.

Megan Wasson (51:26)

Yeah.

Yeah.

Ginger Garner PT, DPT (51:52)

Unfortunately, it is. ⁓ GI symptoms are very much related to endometriosis. And I think that comes from the misconception that for the listener, ⁓ your provider may think that endo is only a reproductive organ problem, right? And that it can’t be anywhere else. And of course, and what you said, Megan, early on, just hit the nail on the head. If you have to educate your provider about what endo is,

Megan Wasson (52:09)

Right.

Ginger Garner PT, DPT (52:19)

That’s probably not just a yellow. It’s a red flag and time to you know to move on So to that end we will put in the show notes ⁓ the NAMS website as well as other resources any other resources that that bubble up what when we are you know in when we’re in the thinking mode for post-production on this we will put in the show notes so that you don’t have to go searching for those on your own ⁓ I have one more question. I think and

Megan Wasson (52:22)

Yeah.

Ginger Garner PT, DPT (52:49)

gosh. All right, maybe two, we’ll see. Do you have, and you may not, so that’s fine. That’s where the possible two questions came from. Do you have like a patient story that just kind of shifted your thinking, like how you practice that maybe, you know, was the catalyst for sending you in this amazing direction that you’re in?

Megan Wasson (53:11)

Yeah, yeah. So there was a patient that came to see me from out of state. So she had seen her local provider multiple times for pelvic pain. And as I was gathering her history, she started with her pelvic pain journey many years ago. She had a diagnostic laparoscopy. They saw endometriosis, did a little bit of adhesiolysis. She improved, but then her pain came back.

So then she had another diagnostic laparoscopy where they did the hysterectomy because that’s going to cure your endometriosis. Her pain continued. So then she went back and had her ovaries removed because of course menopause is going to cure her endometriosis. She continued to have pain. So then they took her back to the operating room, removed her C-section scar because well maybe her abdominal wall was where her pain was coming from.

Ginger Garner PT, DPT (53:49)

Yeah.

no.

Hmm.

Megan Wasson (54:09)

continue to have pain. She ended up having nine laparoscopies for treatment of her pelvic pain in the span of three years.

Ginger Garner PT, DPT (54:18)

my goodness.

Megan Wasson (54:20)

By the time she came to me, not only was her endometriosis not treated, but her pelvic floor was a disaster. She had central sensitization of pain. Like all of these could have been prevented if we intervened with the correct surgery at the correct time, instead of sending her into this spiral cycle of inadequate treatment, inappropriate treatment, and ongoing pain. And so,

Ginger Garner PT, DPT (54:27)

Mm-hmm. Mm-hmm.

Mm-hmm. Yeah.

Megan Wasson (54:45)

It’s heartbreaking to know that these individuals are out there and I know that she’s not alone in her journey. And I think it gets back to me for why I spend so much time educating and why I value having my fellows in the OR with me and why I spend a lot of time making sure that we are having other providers go out there who can do this because I am only one individual and there are only so many hours in the day.

So I cannot take care of every single woman, every single individual who is having these symptoms. But if I build my little army and I have my fellow graduates, who I’m very proud of, are doing amazing things, that they’re my grandbabies and really taking care of patients that I’ve had a hand in taking care of. So that’s why education is so critical to prevent this story from happening because we can do better and we need to do better.

Ginger Garner PT, DPT (55:40)

Yeah, yeah. So for all of our women out there with ⁓ approaching menopause, what’s one thing that you, what’s the takeaway? What’s one thing you wish every woman with endo that’s approaching menopause knows?

Megan Wasson (55:54)

Don’t be afraid of hormones. Hormones are not the enemy. You can absolutely utilize hormones to transition into menopause with endometriosis. Just because you have endometriosis does not mean that you cannot use estrogen. It does not mean that estrogen is the enemy and you can treat menopausal symptoms while also treating endometriosis.

Ginger Garner PT, DPT (56:16)

⁓ yes, on the mic drop there. Boom. Thank you Dr. Megan Wasson for being with me today on the vocal pelvic floor. This has been incredible and I cannot wait until this hits the airwaves.

Megan Wasson (56:30)

well, thank you, Ginger. It has been a true pleasure. And similarly, I’m excited to get this out there and see what people think. So thank you so much for having me.

Ginger Garner PT, DPT (56:40)

Absolutely.