interview with an endometriosis specialist par ...

INTERVIEW WITH AN ENDOMETRIOSIS SPECIALIST PAR EXELLENCE ROBERT R. FRANKLIN, M.D. Interviewed by Mary Lou Ballweg, President/Executive Director, Endometriosis Association Editor's note: One of the most revered and renowned endometriosis specialists in the world is Dr. Robert Franklin, Baylor College of Medicine, Houston, Texas. Dr. Franklin, now 77 years old, is still active teaching fellows and medical students, advising, and lecturing. Dr. Franklin became most famous for his phenomenal surgical skills but there is a side of him that patients treasure just as much: his empathy, caring, and gentleness. I've known Dr. Franklin for many years and he has always encouraged the efforts of the Endometriosis Association, even early on when others did not yet understand or appreciate what we were doing. Dr. Franklin has been an Advisor to the Endometriosis Association since 1992. I have always been impressed with him and my appreciation for him continues to grow as I have seen him able to transcend from a surgical perspective to a whole body perspective on endometriosis. This interview was conducted the morning after a speech and book event in Houston, Texas. Many of Dr. Franklin's fellows and patients attended. Dr. Franklin will be honored with the first ever Endometriosis Association Lifetime Achievement Award at our 25th Anniversary Conference, October 7-8, 2005 in Milwaukee. You'll see why as you read this interview. Indeed, without the groundbreaking work of Dr. Franklin ( and Baylor College of Medicine ) in the 60s and 70s, the Association would have had an almost insurmountable task getting off the ground in the 80s.

Mary Lou Ballweg: How did you get interested in endometriosis? Dr. Robert Franklin: My interest in endometriosis began during my residency and started with one patient, age 29, who had severe endometriosis and was in severe pain and who had multiple operations with no relief. Does this sound familiar? Finally when she had one ovary left she was labeled a neurotic, even though the pathology—the endometrial implants—were still present. These were the days when it was felt that hysterectomy and bilateral salpingo-oophorectomy were a cure, only to leave the implants. Unfortunately, this is still a concept which some propose today. The implants should be removed so that the patient can have adequate estrogen replacement. I knew there had to be another way, a better way. One way was to diagnose this disease earlier, while it was still possible to remove the implants. At that time endoscopy was in its infancy. A group of physicians in New York, headed by Dr. Decker, was performing a procedure called culdoscopy. One of our young physicians brought the technique back to the University of Pennsylvania. The procedure required the patient be in the knee-chest position. The culdoscope trocar entered the cul-de-sac under local or spinal anesthesia. The technique offered a safe, rapid way of making the diagnosis. The cause of a woman's pelvic pain could be diagnosed before she had a completely frozen pelvis. I brought this technique to Houston and to Baylor. It was popular because a diagnosis could be made without a laparotomy with a safe, easy technique. My time at Baylor started in 1959. ML: In 1959? You were already doing endoscopy? Wow! Dr. F: Yes, but it was not without its drawbacks. The nurses and the anesthetists did not like the knee-chest position nor, as you can imagine, did most of the patients. But it allowed us an approach to the pelvis and the ability to make a definitive diagnosis. Some phyicians, Dr. Ed Diamond in New Jersey and Dr. Guiterrez Nahar in Mexico City, carried this technique further by doing operative procedures using this approach. But for the most part in this country, after the diagnosis was made and if definitive surgery was needed, it was converted to a laparotomy. Through my experience, my mind was changed forever that these

women were neurotics. The pathology was there and could be seen. The problem was to determine the best approach to diagnose and treat this condition. ML: So you were really the person who got Baylor into endometriosis. I always wondered where that started. I should have figured it was you. Dr. F: Yes, I had the patients, but Drs. Buttram, Malinak, and Wheeler came to write extensively on the subject. I was always so busy that I kept my writing to a minimum. ML: So it's actually around 1959-early 60s that Baylor, because of you and then Dr. Buttram, began to really develop this expertise and interest in endometriosis, and started telling people that this was more serious than they'd thought. Dr. F: It was a joint effort. Drs. Buttram and Malinak wrote more about endometriosis than I did. We were close friends and colleagues. Often we attended local and national meetings together discussing our thoughts. Of course, we were learning from many around the country. The American Fertility Society was the place where most of the discussion on endometriosis took place. People like David Olive [M.D., Association Advisor, University of Wisconsin-Madison Medical School], David Redwine [M.D., Association Advisor and Lifetime Member; Director, Endometriosis Institute of Oregon], and Richard Marrs [M.D., California Fertility Partners, Lifetime Member, Los Angeles, CA] came through our department either as students or residents. We became closely associated with the Nezhat brothers [Association Advisors and Lifetime Members Camran Nezhat, M.D., Professor of Clinical Ob/Gyn, Stanford University, CA; Ceana Nezhat, M.D., Atlanta, GA; and Farr Nezhat, M.D., New York, NY] all who, I believe, have an excellent approach to this disease. They led the way in laparoscopic surgery. (Continued on page 4)

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ENDO EXPERT (Continued from page 3) ML: Deborah Metzger [M.D., Ph.D., Association Advisor, Los Altos, CA] too, right? Dr. F: Yes, Dr. Metzger. It is difficult to know how much influence that I have had on young doctors, but it has always been my feeling that the most important learning occurs in the early years when the mind is still open. The most difficult thing in the world is to change a mind which is already made up. ML: You really have trained a lot of wonderful doctors!

Dr. F: Yes, I have helped to train some wonderful doctors. ML: A lot of your patients have come from Latin America.

Dr. F: Yes, it looks like where air pollution is prevalent, endometriosis follows. It is why I have felt we saw so much endometriosis. Our area is in the midst of a large petrochemical complex. I have followed the Endometriosis Association theories and writings about dioxin and its connection with endometriosis. This disease is probably multifactorial, but pollution looks to me to be an important player. ML: I've seen the same thing in Asia—lots of pollution, lots

of endometriosis. What about your experience with difference races? Dr. F: There have been many myths regarding endometriosis, most of which have been shown to be completely untrue. One of these was that endometriosis did not occur in black people. The most obvious answer to this question was that it was not looked for in that population, that their pain was caused by pelvic inflammation (PID). Unfortunately, the PID mentality is still prevalent in our ERs because in most medical schools where students are taught, the patients are poor and often poor historians. The patient presents with pelvic pain. They are given antibiotics and their symptoms get better. Therefore, they must have had infection-right? Wrong. Endometriosis symptoms also get better and worse with time. Endometriosis is diagnosed by an astute physician who asks the right questions and is thinking about the disease. ML: Exactly. We had black women with endo in our group at our very first meetings! Dr. F: Also there's the myth that endometriosis is a "career woman's disease." In my opinion, in some women at least, endometriosis is a generalized disease, affecting not just the reproductive, but also the nervous system, the immune system, the genitourinary and gastrointestinal systems and especially the reproductive system. They present as would anyone with a chronic inadequately handled disease. They are "hyper" anxious and often depressed. They are diagnosed as neurotics because they have symptoms in multiple systems. The patients who spoke out were the intelligent vocal ones and these happened to be the career women. They were simply better able to verbalize their symptoms. The anxious presentation that these women show is the presentation of somebody dealing with pain or discomfort or not feeling well on a daily basis. When you sit down and present yourself to a doctor and when you present that picture, he immediately makes an assumption that this is a nervous woman and that's wrong. It's the symptoms causing the anxiousness, not the other way around. ML: Did you see the movie years ago called "The Doctor" with

William Hurt, where he made all of his young residents be patients Endometriosis Association Newsletter Volume 25, No. 5-6 4

first to give them a sense of what it was like, how nervous it made them, and how different their perspective was, being a patient? Dr. F: I didn't see it, but it's a good idea. Like when my wife was sick—it was a different story. ML: The movie is about this young hotshot surgeon—not a gyn—who is really arrogant. He treats the patients horribly; treats the staff horribly; treats the other doctors arrogantly. And then he develops throat cancer and so the tables are turned and he sees how cold much of the whole medical system can be, and he turns it around. It's a very good movie, based on a true story.

Dr. F: One of the most difficult things to do in this era of HMO medi- cine, where time seems always to be so short, is to listen to the patient. It has been said that if you listen, the patient will tell you what is wrong. It really does not take a lot more time, simply undi- vided attention. And make sure they ask all the questions they want to ask. In several studies of our patients, the right diagnosis was made in over 80% of our patients at the initial visit using mainly the history and pelvic exam. "One of the most difficult things to do in this era of HMO medicine, where time seems always to be so short, is to listen to the patient. It has been said that if you listen, the patient will tell you what is wrong." ML: I'm glad that you chose clinical work rather than purely aca-

demic. Dr. F: Charlie Flowers, who was my mentor, was the chairman of the department at Baylor when I was trying to decide which role I should take, the academic versus the clinical. While on a hunting trip in Canada, after several evenings at the campfire, he told me that my best talents lay in treating patients one-on-one. I could be a teacher by offering to teach students and residents how to relate to patients, which is most important if you are to be an excellent healer. I have young doctors with me all the time. They're here doing the patient interviews and learn to ask specific questions. I show them how easy it is to diagnose endometriosis by pelvic exam. The patient should be awake so she can respond. You have to take your time, touch slowly, and be extremely gentle. When the areas of en dometriosis are touched, the patient will respond. You have to be aware of these responses. ML: Well, your fellows [doctors in advanced training] hold you in

the highest esteem. Last night I met many of them. The fact that they came last night—I was delighted! I didn't know they were there until afterwards. They were all introducing themselves and talking about how they were your fellows and how much they had learned from you and what a great honor it has been to work with you. Listening to patients Dr. F: Our approach to the treatment of endometriosis is to teach the patient to be self-sufficient and that's where the real success is. Learning to live with a chronic disease, learning to live and conquer it in different ways. A lot of times they don't really want you to say, "Oh, you've got irritable bowel. Good-bye." Learning to live with the allergies, the G.I. disturbances, are a part of the treatment of patients with endometriosis. It is not simply operate, remove disease, and send them on their way. Those doctors I call "scopers." (Continued on page 5) 4

ENDO EXPERT (Continued from page 4) ML: I appreciated so much what you said last night. A number of people there obviously had extremely severe disease—many, many surgeries—and trying to figure out if they should just have another surgery and you helped them, I think, understand that they need to take charge. Do whole body approaches, look at another approach. You said don't keep doing surgery over and over and over, which means a lot coming from a surgeon. "Our approach to the treatment of endometriosis is to teach the patient to be self-sufficient and that' s where the real success is." Dr. F: If something doesn't work, don't keep doing it! Twentyone laparoscopies—I mean some of these girls have had 21 laparoscopies! Maybe they're helped for six months to a year and then another laparoscopy! Isn't that crazy?

Dr. F: The same thing is true for labor. My patients with endometriosis say labor is much less painful than the pain from endometriosis. And labor pain can be severe. ML: Exactly. I didn't even know that I was in transition when I was in labor. It was so easy compared to what I had been through. And on top of it, I got a baby afterwards. Dr. F: Well, you got a reward. ML: Yes, a wonderful, wonderful reward! Dr. F: You don't get a reward for having this pain from endometriosis. The patient who is having severe menstrual cramps, "killer cramps," who is undergoing a laparoscopic exam, receives a presacral neurectomy in our hands with amazing relief of pain.

ML: Sometimes they don't even have that! Sometimes they'll be "Green" cervix in young girls back in pain right away or two months later. You know, you can Dr. F: In another vein, I would like to talk about the young teenalmost get cynical and wonder if somebody's just using them. ager who starts her period early. In these young women, the cervix is "green." It is firm, not fully developed, rigid. Dr. F: Well, when the patient comes in and she feels so bad and her mother is sitting there with them saying "Take it all out, she is hav- ML: So the flow is obstructed? ing too much pain ...." 16 years old and they're in so much pain. Dr. F: It is my feeling they have an obstructed flow. This is one of And these are the very patients that need to be looked at carefully, the reasons why I started using oral contraceptives on these young listened to carefully, shown there are other ways women beginning in 1970. I noticed that the to get rid of pain like diet (which we talked about cervix softened, the flow was reduced and most last night a lot). This is where Dr. [John] Mathias had relief of their pain. Those that did not get has helped me a lot. His approach to these young relief had deeper, more established lesions. women is phenomenal—so much so that I use These required removal. So by the use of oral him with most of my patients before I do contraceptives, I was able to give relief to many surgery. The cure is more like management. without having to do surgery. ML: It's wonderful to hear you say that because you're such an eminent surgeon. Maybe it will help people wake up and realize that there is more to treating this disease than just having surgery. Dr. F: Well, it's absolutely true that many of these women have a generalized condition, and the generalized condition is affecting their whole body and making them feel terrible. I think something's happened to the immune system and immunity is how cancer is prevented. Their immune system is overwhelmed. ML: Very much so—a little bit like a wound-up toy soldier that's gone crazy! Dr. F: In any one day, I'll see four or five patients with endo and at least one or two of them will have migraine headaches, fibromyalgia—that type of picture. And to think I have trouble convincing people that it's a real disease. It's a real disease! ML: It's all too real! Dr. F: It's an absolutely real disease! ML: A lot of our members who have had bad endometriosis, as well as cancer, time and again I hear them state that the endometriois far and away worse than the pain they had with cancer. On top of that, people took them seriously with the cancer, and family, friends, employers were respectful, careful, and helpful. Whereas with the endometriosis, they were in far worse pain, often couldn't get pain relief, and nobody even thought it was important.

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ML: You talked to me about this idea before about the green cervix, the softening of the cervix, and it seems like such a very smart idea. Have you published it anywhere? How can we get that idea out there? Because we are now dealing with 8-9 year old girls and their futures look terrible if something isn't done for them. Adenomyosis Dr. F: Having done a few million pelvic exams, the cervix of a woman is softer. The cervix of these young girls is like an unripe plum. It is very, very firm. I think this also may well be when the adenomyosis starts. If the route back through the uterine portion of the fallopian tubes is open, then they get retrograde flow and may go on to develop external endometriosis. On the other hand, if for some reason there is "spasm" and this route of overflow is not operant, then they develop adenomyosis. Menstrual blood and endometrium are forced into the myometrium. How many patients do we see at 20 to 25 with a tender, irregular boggy uterus with all of the symptoms of endometriosis and with no endometriosis, or only a small amount of endometriosis externally. I have followed enough of these women to realize that adenomyosis is there at these times and is not a disease of just 40 or 50-year old women. Almost every study I've ever seen says it's a 20 or 30% incidence of adenomyosis with endometriosis, especially with severe endometriosis. I think it's at least that much. It is diagnosed in the older age women because that is when hysterectomies are done. The younger women have had to put up with these symptoms. (Continued on page 6) 5

ENDO EXPERT (Continued from page 5) ML: Yes, I think so too. What about better diagnostics for adenomyosis and endo? Dr. F: Our best tool is still pelvic exam and clinical experience. Ultrasound and MRIs offer some value. It takes someone who has a special interest. ML: Exactly. Well, we've noticed a pattern and, of course it's been well documented in our literature, that girls are starting puberty and their periods younger and younger and younger. Someone needs to put that observation together with this green cervix observation be- cause that really would help explain...like the 13-year old who was there last night at our book event who already had endo at nine and she's in such trouble already. Dr. F: I think those girls may have endometriosis before they have periods. Because a lot of them have a lot of pain ... ML: GI symptoms too ... Dr. F: A lot of GI symptoms especially, so I see them with Dr. Mathias. Or they are referred by him. He sees them as GI problems and we see them as they get a little bit older as endometriosis prob- lems along with the GI disturbances. One of the things that happens with girls that are operated on for endometriosis that don't get bet- ter and actually get worse is that the bowel may well be a major problem. It seems to me like the way to treat those patients is to not operate on them first. Dr. Luis Paez, who is one of my residents down in Mexico now, is not operating on them. He's having them go on the low-glycemic diet first. He's proactive in promoting Dr. Mathias' regime. ML: Oh, that's wonderful! He just finished the translation of our second book [The Endometriosis Sourcebook ] into Spanish. Dr. F: He's a fabulous guy—really, really smart. He's one of the smartest fellows we've ever had here. It Takes a Team

Dr. F: The hardest patient in the world to treat is a teenager. Because they simply won't comply. Sometimes they'll let you examine them because they're having such bad cramps, but being on a diet that has any kind of restriction is very difficult for them. Understanding the problem is very difficult for them. And that's what takes a whole unit of specialists and hopefully, counselors. Ancillary people are necessary in treatment, especially in teenagers. Biofeedback procedures are extremely useful. The Endometriosis Association has an important role here. ML: They need peer support. Someone to talk to in their own age group. Dr. F: That's what your group is doing that is so important—just like AA—which is what makes Alcoholics Anonymous so successful—talking to a peer support group is what makes this successful. This is a chronic condition. You may be able to clear up the endometriosis symptoms with surgery, but it is a lifestyle change you have to do for your whole lifetime. ML: Right. Which is exactly what people don't want to hear. Dr. F: They don't want to hear it—they want a magic pill or "I want to be cut—take it out."

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ML: If only it were that simple! Dr. F: And, unfortunately, everybody fell into that realm and it's one of the reasons for all of the lawsuits. Doctors were thought of as gods and they can do all this stuff—and surgical techniques did improve unbelievably—I mean, it's so much better than it was, but there's only so much that you can do. And the surgeon can do so much and if that's the only thing he's going to do, then he does this woman a disservice because she needs further care and she needs more complete care. To be successful in treating their condition, you need to treat the whole person. It often takes a team. "To be successful in treating their condition, you need to treat the whole person. It often takes a team. "

ML: Yes. Of course our biggest problem really is that this disease was identified strictly as a gynecologic disease and defined that way and it's really hard to get people out of that thinking. Dr. F: Absolutely. Even in the fields of gastroenterology, urology, and gynecology, there's separation. I always meld them together. These patients fall through the cracks. If these people go to their gastroenterologist, they get one treatment— they get an irritable bowel diagnosis—and they forget that there's other things in there that might be causing this. These women often have a very tight bladder neck or spastic one, so they have difficulty urinating, you know, the whole bit. My hope is that places like Vanderbilt [the Association's multidisciplinary research team at Vanderbilt University School of Medicine supported by our Millennium Campaign for the Cure] will show that a team effort is necessary to treat these patients. You really need a team! You need people that have different knowledge in all the areas to see people and to help them. Surgery and Adhesion Prevention Dr. F: I really feel people that are really good with the surgery ought to be the ones doing it because you have to be very careful, you have to be able to take your time, you have to use every technique you can think of to prevent adhesions. Adhesions are a horrible result of a lot of surgeries at this time. You have to have knowledge of how far to go with one technique and not another, and if you don't want to do that, then you shouldn't be doing endometriosis surgery. ML: What are some of the most important things for adhesion prevention? Dr. F: Surgery itself is one of the causes of adhesions. Therefore, if this condition can be treated medically, then it should be. Secondly, the laparoscopic techniques in proper hands are associated with a marked decrease in adhesion formation. When a laparotomy is necessary, microsurgical principles are to be adhered to. There are certain adjuvants to be used in adhesion prevention, such as Interceed, Hyscon which are helpful, but none are as important as technique. At laparoscopy, the most important thing that I know is take your time. What happens with laparoscopy is that somebody else has a case scheduled right after you and he's on your backyou can't let that happen! Whatever is necessary to do in a timely fashion with this patient has to be done. (Continued on page 7) 6

ENDO EXPERT (Continued from page 6) Becoming a Good Endo Surgeon ML: That's wonderful. Why is it so difficult to become a really good endometriosis surgeon? Dr. F: It takes a lot of experience, it takes a lot of knowledge of the anatomy, it takes a lot of experience of how far to go and how far to push for resection. You don't learn endometriosis surgery going to a threeday course in laparoscopy. You learn laparoscopy training with somebody who absolutely wants perfection. ML: How do we help women understand that the average gynecologist really is not in a good position to devote himself/herself to being an endo specialist? There really are a lot of pressures on physicians from managed care to time constraints, expectations too high by patients sometimes .... Dr. F: The case load ... The one that's doing a lot of deliveries and is trying to do surgeries too—it's very difficult for him because he's got a woman in labor upstairs and trying to do a case downstairs. ML: So should obstetrics and gynecology be separated? Dr. F: Well, I think routine gynecology can be done by obstetricians. I think, though, when you get into the surgical specialties of this type, like oncology, endometriosis is a specialty. Actually, endo is often harder surgery than oncology surgery. ML: I think all of the top endometriosis surgeons have found the same thing—that other surgeons have come to them to learn some of the interesting techniques that have evolved in our field over the last 15 years. Dr. F: I think in our field we talked a lot about laparoscopy and also a lot about surgical techniques to prevent adhesions. Surgeons, in general, have always accepted adhesions as something that just happens. We have to operate on a woman who wants to have a baby and we have to have results. We have to prevent adhesions. I think we have more push to learn to prevent adhesions. ML: I'm wondering how you developed your outstanding surgical expertise. Dr. F: Well, I'm obsessive compulsive. Most nights, especially when I first started surgery, I would lie there at night seeing how I could have done it better. Sleeping 4, 5, hours a night—I don't know if it makes you a better surgeon, but it does make you think about what you did that you can improve on. And then I worked with a lot of young doctors and when you teach, you learn. A lot of students have good ideas, and if you listen to them, they're willing to let you know their ideas. And a lot of times you pick up things. Like I learned a great deal from David Olive [M.D.]. David Olive had really good statistical expertise when he became a doctor and he's used that to become an expert in his field. He's very bright, very energetic, and I think a really good teacher. ML: And we're lucky because we have him in Wisconsin now! Dr. F: Oh, I didn't know that. ML: He's at the University of Wisconsin Medical School in Madison. He helped me launch our new book in Wisconsin at a couple of our book events. Dr. F: He's great. Endometriosis Association Newsletter Volume 25, No. 5-6

ML: He was one of the first people, maybe the first, to say

when you look at the studies on endometriosis, particularly the medical therapies, they don't add up. So I kept inviting him to speak at our meetings because the women need to hear that. Endometriosis Is an Epidemic ML: Bob, you've been at this over 40 years. Besides the changes in surgery that you've mentioned before—and surgery has really improved greatly—what are some of the other big changes you've seen, in terms of endometriosis? Dr. F: I think it's more common. Everybody says we're diagnosing it more. Well, patients tended to present with this type of pain picture before. Something is happening. It's an epidemic. Somebody says 10% or 5% of the population. In the southwest Texas area, it's got to be more like 30 or 40%. Then I hear people saying they see endometriosis in women who have not had symptoms that had their tubes tied after babies—well, who knows what this patient has gone through. Patients with endometriosis tend not to give you symptoms. They have been taught that this is something that's normal for them. As a matter of fact, the best interview you can do is one with her husband. She'll say, "Oh, I have a little cramping." He'll say, "It puts you to bed!" If you just listen to her, you would get the wrong idea of how much discomfort she was having because they tend to minimize it because of the fact that they have had trouble being believed. Especially nurses—they're afraid everything is psychological. And the nurses, a lot of times, seem to have the worst endometriosis and I'm not sure it's not something that drives them into nursing care just to try and answer some of their own problems and to realize that people hurt like this, someone's got to be able to help them. But you see a lot of endometriosis in nurses. "...the best interview you can do is one with her husband. She'll say, 'Oh, I have a little cramping.' He'll say, 'It puts you to bed!' I f you just listen to her, you would get the wrong idea of how much discomfort she was having because they tend to minimize it because of the fact that they have had trouble being believed."

ML: I have seen that same pattern—people who went into nursing because of the struggles in coming to terms with their own health. And it does give them empathy. Dr. F: It sure does. Treating Teens with Endo ML: In your 45 years, you have seen so much endometriosis. You have helped so many people. Anything else you want to make sure people know? Dr. F: A patient, especially a teenager, who presents with severe disabling dysmenorrhea needs a work-up that includes the bowel function. Most people nowadays will put those girls on birth control pills. Birth control pills help a good number of them. When it doesn't help, it doesn't mean they've got established endometriosis. Patients that are on birth control pills, especially with progesterone-dominant birth control pills, often the bowel symptoms get worse. (Continued on page 8) 7

ENDO EXPERT (Continued from page 7) You've still got to think about other sources of the pain. And they're the hardest. You've got to be a magnet to get them to stay with you long enough to really help them. But those girls are the ones that are going to be seen with severe endometriosis later. The young lady who has nausea and vomiting with her menstrual period, who lies in the nurse's office and the nurse is saying she's just trying to get out of class, is developing severe endometriosis. And those girls deserve immediate attention and their mothers need to know that and they need to go to somebody that will do something about it. Unfortunately, because they're teenagers and they're emotional, it's all blamed on that. I think oral contraceptives are of value. I think reducing the number of menstrual periods per year is of value to young women, especially for those experiencing disabling dysmenorrhea. If their cramps are made better by that technique, that's the way to go. If there's no relief with oral contraceptives, the patient deserves a complete work-up. If the patient is not relieved of pain by diet and every other technique we can think of, even at age 16 they deserve a laparoscopy. Some have extensive, deep disease already.

ML: I wish we could clone you and get a couple thousand of you!

Thank you, Dr. Franklin!

ML: What parents often say to me is "I don't want my daughter

to have to go through surgery." I try to explain that it might be the least of her difficulties compared to what she's going to be going through. But it can be hard to get to a really skilled surgeon. Dr. F: The idea is to stop it, excise that disease if it's already penetrat-

ing deeply. They talked about burned-out endometriosis last night—that phrase always infuriates me—because if you look at those scar tissues, you'll find endometriosis in the middle of this area. That's active disease—it's just been scarred around. Knowing One's Skills Dr. F: The other thing that I find is that you can't do more than

you're capable of. Some laparoscopists are technically so able they can do extensive surgeries with the laparoscope. Others are not, and if you're not capable of doing it, then it's even better to do nothing and back off, or do minimal and back off and let someone do it who can. If it can be done through the laparoscope, it should be done through the laparoscope. If you're in or around the bowel, or if you 're in or around the ureter, it is sometimes very difficult to do the surgery with a laparoscope without doing damage. And then a laparotomy with microsurgery technique may be needed. We use a lot of Lupron. We try to use Lupron pre-op and post-op a lot of time. Especially if we operate on an ovary. We feel it is important to keep the ovary quiet until it has time to heal. Lupron does that well. If you allow that ovary to work in the next cycle, it's going to swell up. It's going to pull on the stitches and it's going to cause adhesions. ML: That makes so much sense. I've never heard anyone explain

that in that way before. Thank you. Dr. F: It's important. I think maintenance with oral contraceptives

is of value in these patients if they're not seeking children. These patients need to be seen at intervals, encouraged, making sure they are staying on their diet and their new lifestyle. Endometriosis Association Newsletter Volume 25, No. 5-6

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