“Pelvic Pain” – with Dr. Rachel Barr

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Rachel Barr. Thank you so much for coming on to the “Healthful Woman Podcast.” I really appreciate it. 

 

Dr. Barr: Thanks for having me. I’m really honored to be here. 

 

Dr. Fox: It’s fantastic. And of course, you know, I’ve known you a long time. You are one of the trainees who came up through the program, and it’s just awesome to see you in practice and being really successful. And it’s just it brings a lot of pride to those old people like me. 

 

Dr. Barr: Thanks. Yeah, that’s right. Great to be here. 

 

Dr. Fox: We’re gonna be talking about pelvic pain today with Rachel. But let’s just start a little bit just so our listeners understand. Let us know how did you get into medicine and into gynecology? 

 

Dr. Barr: Yeah. So I’m from the Detroit suburbs. I went to University of Michigan, actually with your brother. Do you remember that? 

 

Dr. Fox: Yep. Brother David. Absolutely. Midwest, yo. 

 

Dr. Barr: Yeah, go Blue. I ended up in New York and went to SUNY Downstate for med school and then went to Mount Sinai, where I did my residency and my internship, my residency, and then I stayed there for a minimally invasive gynecologic surgery fellowship. And that fellowship really focuses on treating women surgically in a minimally invasive fashion, meaning small incisions and doing surgery to, sort of, lessen pain after surgery, and really, you know, to help women. And a lot of what I learned about there was pelvic pain, which is something that is somewhat difficult to treat. It can be tricky. And it’s not something that we learn a lot about as a resident, and I learned more as a fellow. And I continue to learn every day, you know, at work because there’s just always more to learn from the patients and from my colleagues, and I really, really love it. It’s a great field. 

 

Dr. Fox: Yep. Pelvic pain is tough. I’m curious. So how did you choose OB/GYN? And I don’t think I’ve ever asked you this. 

 

Dr. Barr: Yeah. I had a really close family friend growing up, who is actually my godfather, who was an OB/GYN and he is incredible. And even in high school, I would go and like see patients come in the office, who took me once to do a delivery in high school. I still have the scrubs. I have a picture of me holding my first baby. And that just really sparked an interest in me. I’ve always loved, sort of, women’s health from a social, sort of, political standpoint. In college, I volunteered at Planned Parenthood every single week. I really, really like it. I think there’s a really nice aspect of gynecology where you follow with women, sort of, throughout their life and help them with issues that really impact their quality of life, which I really enjoy. And I think that’s also where pelvic pain fits in. But, yeah, I decided not to do the obstetrics part. 

 

Dr. Fox: I was gonna ask you about that. You spent, you know, four years of residency. It’s give or take 50% obstetrics, 50% gynecology. And for the record, Rachel was a terrific resident and certainly could have done anything with your career, whether it’s obstetrics, gynecology, whatever. So, how did you decide, A, to go in the direction of gynecologic surgery, gynecology? And I’m also gonna ask you, how did you feel about giving up the obstetrics, the deliveries, the pregnancy, that whole aspect of it? 

 

Dr. Barr: So even in med school I knew I did not want to do obstetrics. I always enjoyed being on the labor floor and enjoyed being part of deliveries. I did not enjoy it at 3:00 in the morning. 

 

Dr. Fox: Some people agree with you on that. Yeah. 

 

Dr. Barr: Yeah. And I just felt like you have to have, like, such a passion for obstetrics to want to do it at all hours of the night and I just really felt like my passion was really for gynecology. I like that you get to see patients in the office. You get to operate. I really like doing procedures and operating. And so I really just have always felt more of a pull towards gynecology. So in terms of do I miss OB? Not at all. I, sort of, left fellowship where I did some attending call on the labor floor and never looked back. When I had my kids, I was happy to, sort of, be there and was happy to not be doing that myself as a physician. 

 

Dr. Fox: Now, in residency, obviously, you do get exposure and you do train in surgery, in minimally invasive surgery and gynecologic surgery. So, I’m curious, what would be the reasoning behind the fellowship, three extra years of training in minimally invasive surgery? 

 

Dr. Barr: Yeah. So my fellowship is actually only two years. 

 

Dr. Fox: Oh, yeah. Oh, my God. God, you’re so lucky. All right. 

 

Dr. Barr: Yeah. Yeah. But like you said, in training, you’re doing obstetrics half the time. And so you get a lot of exposure to gynecology and you do a lot of surgery. But you don’t necessarily get to do as much as I think someone necessarily needs to do, to do really complicated laparoscopic surgery. At least Sinai’s program, as a resident, you’re not really doing as much robotic surgery to the level that you would want to do it to be able to perform as an attending when you’re out in practice. And I just think the having the opportunity to really spend two years in the OR almost every day doing some relatively straightforward surgeries, but doing a lot of complicated surgeries really just increased my experience and my comfort level, and it made it possible for me to feel like I could do that in practice afterwards. 

 

Dr. Fox: And during the minimally invasive fellowship, so what percent of your time in the operating room is it laparoscopy or robotic surgery? Is it 100% of the time? Is it like 90% of the time? Is it 50%? I mean, how much is it compared to, sort of, traditional surgery where it’s either bigger incision in the belly or in gynecology vaginal surgery? 

 

Dr. Barr: Right. So I think it depends on where you train. I mean, certain programs just by nature of who you’re working with are more geared towards robotic surgery or laparoscopic surgery. Some are geared more towards vaginal surgery, which a lot of people would argue is, sort of, the first kind of minimally invasive surgery. It certainly is. At Sinai, we really had a good mix of robotic experience, laparoscopic experience, hysteroscopic experience, which is when you put a camera through the vagina into the cervix and look on the inside of the uterus. And then some open surgery as well. I mean, it’s important that you’re still comfortable doing laparotomies, doing open surgery so that in the case of where you might need to convert from a laparoscopic surgery to an open surgery, or sometimes I still do open surgery. I actually just did one yesterday. And there still are patients who come to see you who just, unfortunately, can’t have minimally invasive surgery. So you still want to be able to provide them with the care that they need. 

 

Dr. Fox: Right. And so now you’re practicing in New York. You’re at Maiden Lane Medical. And what’s your practice like now in terms of you like, how many days a week are you in the office versus the operating room? And what types of things are you treating? 

 

Dr. Barr: The practice I’m at is a women’s health practice. It’s mainly focused on gynecology and pelvic pain, but we also have a multi-specialty group. So we have primary care doctors and pelvic floor physical therapists, we have a pain management specialist, we have some neurologists, and really everyone is focused on women’s health. And then some of the doctors see men too, not the gynecologists, obviously. I spend about three-and-a-half to four days a week seeing patients in the office, and then I operate one to two days a week. We have an, actually, in-office surgery center, which is great. So we do minor cases right in the office, which is a really nice service that we can provide to patients because they don’t have to go all the way to the hospital to have something that really only takes like half an hour and you can do that right in the office. There’s a really wonderful group of physicians I’m really honored to get to work alongside and really learn from as I continue to treat women and treat women with pelvic pain. 

 

Dr. Fox: And so what are the conditions that women come to you specifically for? Is it a very wide range or are you focused on 5 to 10 things? 

 

Dr. Barr: So I actually practice a pretty wide range of gynecology, so I certainly see a lot of patients for pelvic pain and specifically chronic pelvic pain. I also see a lot of patients for bleeding abnormalities and fibroids. Endometriosis is a big part of my practice and adenomyosis, those kind of go along together. But I also see your, sort of, routine gynecology visits as well. So I see patients for annual exams and talking about preconception counseling, planning for pregnancy, contraception, abnormal pap smears. I do colposcopies and other biopsies, put in IUDs, infections, UTIs. So it’s really a great variety. I love what I do. I love that I get to do that every day. It’s great. 

 

Dr. Fox: Awesome. So let’s focus on pelvic pain. And you mentioned before that you specified chronic pelvic pain. So what do you mean by chronic pelvic pain versus, I guess, maybe acute pelvic pain? 

 

Dr. Barr: So chronic pelvic pain is pain that’s been present for six months or more. When we think about acute pelvic pain, it’s something that has been present for less than six months, but really, we’re thinking more like something that is sudden and onset, has been around for a few hours to maybe a few weeks. And that’s something different. That’s where hopefully the patient will come to you soon after their symptoms start and you’re really thinking about things like is the patient pregnant? Is this an ectopic pregnancy? Does she have a cyst? the cyst, if it’s there, is it something called torsion? Is there an infection? And that’s something different than chronic pelvic pain. 

 

So chronic pelvic pain tends to be more based on inflammation. Sometimes too, sources of chronic pelvic pain have to really do more with the nerves of your pelvis and your vagina and the vulva. And a lot of times what we see are patients who really, unfortunately, been suffering for quite a long time, so sometimes years, and haven’t really found an answer yet as to why they’re in so much pain and why it is not getting better. 

 

Dr. Fox: Who do people normally see when they have a pelvic pain? I mean, why would they come to, let’s say, a gynecologist versus an internist or gastroenterologist or a general surgeon? Is it, sort of, everyone dabbles in this a little bit or is it that they’re getting a lot of opinions and they don’t really know what it is and then suddenly they find you? Or how does that work? 

 

Dr. Barr: Yeah, I think it depends. I mean, there is a lot of overlap in these symptoms with GI, with their gastroenterologist. And so a lot of times my patients will have already seen a gastroenterologist and either won’t have found a clear diagnosis or their gastroenterologist will say, “Well, I think you have something going on that’s gastrointestinal, but maybe there’s also something else going on with your pelvis. Maybe you should see a gynecologist and see if they think there’s endometriosis or something else.” Oftentimes patients will see a primary care doctor or even just a more general gynecologist who maybe doesn’t specialize in pelvic pain. 

 

The patients I tend to see are patients where they’ve seen a lot of other people often and have not come up with a great solution to their pain. Or some patients haven’t seen anyone else and they just google us and see that we do pelvic pain and come to us as, sort of, a first opinion. Either way, more than happy to see them and, sort of, focus on what’s going on. 

 

Dr. Fox: Yeah, in my experience, pelvic pain is something that’s very hard, obviously, for the patients, for the women who are in pain, but frequently for the doctors and whether they’re gynecologists or, you know, from another field of medicine because it’s often difficult to figure out what’s going on. And even if you know what’s going on, exactly how to treat it, like are you trying to treat the pain part of it or are you trying to treat the cause of the pain? And then you, sort of, get into different realms. Like, pain specialists will treat pain, but they’re not getting at the cause of the pain. And gynecologists tend to try to get to the cause of the pain. And sometimes there’s confusion over who’s really treating here. 

 

And I think a lot of people just have very difficult times working in this environment. For the patients, it’s hard for them because they’re frustrated because no one gives them a straight answer. And for the doctors, it’s not that it’s frustrating, it’s just difficult to, sort of, get to what’s going on and to find a solution. And so have you found that in your practice, since you guys focus a lot on pelvic pain, that maybe it’s a little more comprehensive, or it’s easier, or there’s more experience in it, that patients maybe find solutions or answers more readily than they would elsewhere? 

 

Dr. Barr: I’d like to think so. But I think part of the reason for that is because we…my boss has really developed such an incredible group of providers here. And really when you’re treating chronic pain in general, but chronic pelvic pain, you really want to take, like, a multispecialty approach to treating patients because it’s not just about the gynecologic approach, but it really is about the pain management and the physical therapy aspect. I send so many of my patients for physical therapy and, frankly, pelvic floor physical therapy is something I was not familiar with when I did, sort of, residency training because it’s just not something that I really saw a lot of and it didn’t necessarily have anyone who’s doing a lot of pelvic pain. So it’s such an integral part of treating a lot of pelvic pain. And you had an excellent pelvic physical therapy podcast with Rivki Chudnoff. 

 

Dr. Fox: Hey, thanks for the plug. 

 

Dr. Barr: Yeah, which was great. I listened to that and I was like, “This is spot on.” It was wonderful. And just from listening to her speak, it sounds like her patients are so lucky to have her as a therapist, physical therapist. 

 

Dr. Fox: There’s some people who are specialists in certain things where you know that they’re the kind of person that many people before they saw that person and after they saw that person, it’s like a change in their life just based on what you do. And it’s rarely…I don’t know, there’s some fields just like whatever, people go through them, but someone like that, it’s life-changing if you find that person. 

 

Dr. Barr: It can be hard for physicians to treat and, sort of, manage patients with pelvic pain because pain is subjective, right? It’s not like there’s a test where you can go, “Okay, I’m going to order this.” And that tells me that you’re having pain or not having pain. And then it can be very vague, I shouldn’t say vague, but there can be a lot of symptom overlap. So it can be hard to, sort of, tease apart why you’re having pain. And when I talk about pelvic pain, we’re thinking about pain that is, sort of, typically situated in your lower pelvis or lower than your belly button, but it can be higher up also. Sometimes it’s associated with your period and sometimes it’s not. Pain during sex is a huge component of chronic pelvic pain and is, unfortunately, fairly common and really debilitating for patients and frustrating. 

 

And there’s a huge also, sort of, neurological component to pelvic pain. And this is really where our pain management specialist comes in. Because what happens is, is when you have chronic pain, you have something called centralized sensitization to pain where you actually…there’s a change in your brain where your nerves actually become more sensitive to, sort of, normal touch and normal sensations and it’s interpreted as pain even though what might be happening is not actually painful. And then this becomes a cyclic process that just worsens and worsens until you’re able to treat them and both treat, sort of, the neuropathic pain aspect of things and then actually get to the root of where the pain is coming from and treat that as well. So it can be a challenge. Yeah. 

 

Dr. Fox: Just in general, what’s kind of like the laundry list of things that commonly cause pelvic pain? So the patients who come into your office and ultimately you figure out what it is, what are, like, the top five things that typically you diagnose them with? 

 

Dr. Barr: Yeah, so endometriosis and, sort of, adenomyosis are probably the most common things that are going to cause chronic pelvic pain. Fibroids sometimes as well can cause that, although maybe not quite as often typically think of that as chronic pelvic pain. They’ve, sort of, categorized that in their own category of fibroids, but they often can cause pain. Something that I see a lot is what we call pelvic floor dysfunction or pelvic floor muscle spasm is another term that we use. And this is often secondary to whatever else is causing their pain but can be a really significant source of pain. And it basically happens when the muscles of your pelvic floor and your vagina can spasm. They get really tense. And when that happens, you can feel, sort of, sharp, stabbing, burning pain, worse during sex, worse during a pelvic exam, very uncomfortable. And then also vulvodynia, which is where you have, sort of, hypersensitivity to the nerves of the vulva, which is the outside of the vagina, the labia, and the perineum, and the groin, and this also can contribute to a significant source of pain. 

 

Dr. Fox: Wow. And then how many people do you see, or when they come for pelvic pain and they’re seeing a gynecologist, would you say ultimately, “You know what? I don’t think it’s gynecologic. I think it’s your intestines or I think you have something in your hip or something in your pelvic bones or in your spine.” Does that happen at all? And then you say, you know, “Maybe you should be seeing a different specialist?” 

 

Dr. Barr: Sure. Yeah. I mean, it happens. I don’t think this is easy to say it’s definitely not gynecologic in origin just by maybe their initial visit. And you certainly want to get imaging. Sometimes, depending on how long the pain has been going on, it would make sense to do even a laparoscopy and look for signs of endometriosis if that, sort of, fits what they’re telling you. But oftentimes, too, I mean, this can be something with their hip, with their back. Do lots of hip MRIs, send patients to orthopedics because all of those things are also interrelated as well. 

 

Dr. Fox: Right. And how often is it something where just it actually ends up being something very, very simple but no one found it? So, for example, they have like two little adhesions or pieces of scar tissue in their belly from a prior surgery and then you go on and snip them and then they’re great forever. It’s something that turns out to be very, very straightforward. Does that happen a lot or is that pretty rare? 

 

Dr. Barr: I would say it’s not as common, but sometimes it could be like they have a cyst that just hasn’t been diagnosed and worked up yet. And you take the cyst out and their pain gets better, although that’s more for acute issues. It’s not that treatment is necessarily always a challenge. Sometimes treatment is that straightforward where you just have to diagnose the right thing and treat it appropriately and they get better. And most of our patients really do get better. The issue is that it takes time. And this is I think what Rivki was talking about on your podcast, more like it’s a marathon, not a sprint. So it does take time and effort to help pelvic pain often get better. And I wish it was as simple as take a course of antibiotics and you’ll feel better. But unfortunately, it does take longer than that often. 

 

Dr. Fox: And how do you evaluate women who come into your office for their initial evaluation? What is it you’re doing to try to understand what it is causing their pain and what you might be able to do to help them? How does that go? 

 

Dr. Barr: At this office, one of the things I love about it is we actually have visits set aside for almost an hour for new patients for pelvic pain, and we have them complete a really comprehensive questionnaire that asks all sorts of details about the different kinds of pain they have, where they feel the pain, when they have that pain in terms of their cycle, their menstrual cycle, any other associated symptoms that they have, like back pain, groin pain, pain with lifting, we get into the sexual function and pain with sex and bleeding and all sorts of things. Then I do a really comprehensive what I call pelvic pain exam. So unlike your, sort of, standard exam that you might be familiar with, if you go and get an annual, you do an exam where the doctor puts a speculum in and does a pap smear and maybe does a bimanual exam, this is really head to toe. 

 

So I would start by looking at the patient, seeing if they look like they’re uncomfortable or in distress. Can they not sit down because it’s too uncomfortable to sit because they’re having that much burning of their vulva? Or can they not lay down because there’s something going on with their back or their pelvis? And then you do a really thorough exam with their back and their abdomen assessing their, sort of, internal structures and their muscles, their hips, and then I do a pelvic exam. And the pelvic exam focuses on what are the nerves of the vulva and, sort of, the introitus, the entrance to the vagina. And you do that by taking a Q-tip and gently pressing and seeing if this provokes any symptoms of burning, or a sharp pain, or maybe it doesn’t produce any pain. 

 

And then you examine the muscles with a gentle finger and understand if they feel tender or spastic at all and if the patient has good, sort of, muscle awareness. And then you do a speculum exam and feel, you know, the uterus, and if it’s enlarged, if it has good mobility, if it feels like it’s stuck to, sort of, the back of the pelvis, which might imply that there’s scarring from endometriosis, and then a rectal vaginal exam. So you do a rectal exam and a vaginal exam at the same time. And again, this lets you really feel the back of the pelvis and assess if there’s nodules, if there’s tenderness, and how free the organs feel relative to one another. 

 

Dr. Fox: And at this point, is it common that you know what’s going on with them or it’s common that you’re, like, still not sure what’s happening? I mean after you’ve done that thorough history and exam, sort of, one of the tenants of medicine is that basically, you’re going to find out, you know, 80% of what’s going on in your history and another, you know, 10% to 15% on your exam and then the tests are, sort of, like just a very minor component. But is it the same with pelvic pain or is it a little more challenging? 

 

Dr. Barr: I’d say most of the time, even before I’ve done a physical, I know what I’m looking for on the physical exam just by the things that the patient’s telling me are bothering her, and the physical exam I’m really just using to, sort of, confirm those findings. But, sure, some of the time, it’s not clear. Some of the time you do an exam and everything is fine. And you’re like, “I’m not really sure.” And then at that point, imaging is really helpful. Sometimes a trial of different medications might be helpful. The other component that I actually haven’t touched on yet but is really important is that there’s a big correlation between depression and anxiety and pelvic pain, like chronic pain in general. And that’s not to say that the pain is in the patient’s head. I actually cringe when patients tell me like, “Oh, this other doctor told me it’s all in my head.” That’s just so unfair because pain is real. 

 

But we know that there’s overlap. And we know that patients who have pain often have higher rates of depression and anxiety and treating one helps the other and vice versa. And many antidepressants actually treat pain. So it is really important to focus on their mental health and make sure that they’re getting appropriate care for any mental health concerns that might be coming up. It’s actually part of the intake we do is depression and anxiety questionnaires, and just really making sure that that aspect of their care is not being ignored. 

 

Dr. Fox: It’s not that necessarily A causes B, right? It’s both ways, meaning someone who has, you know, mental health challenges might have a heightened sensation to pain or might manifest sometimes as pain. And the flip side, someone who has a lot of pain, it may distress them and cause anxiety and depression. And they play off each other in both directions. And frequently, you’ll see them together. But, again, it’s not that you know necessarily which one came first. And they generally just, you know, happen together, and treating one tends to help the other. I think that’s really important. Obviously, you can, sort of, make the parts of the pain go away, but if they’re not well, they’re not well. It doesn’t really matter. 

 

Dr. Barr: Exactly. 

 

Dr. Fox: Excellent. And so when you said imaging, is that normally things like ultrasound, MRI, is anything, sort of, more out of the ordinary you guys ever do? 

 

Dr. Barr: I mean, usually we start with a pelvic ultrasound or an MRI. That’s the mainstay of imaging. I mean every so often you need to get something else, like maybe sometimes a hip MRI or looking at the back, but that’s the main things before we would do maybe some kind of surgical imaging, so to speak, a laparoscopy or… 

 

Dr. Fox: Right. Yeah, I was going to ask you about that because people don’t think of that as imaging, they think of it as surgery. But as we know from training, a lot of surgery is called diagnostic meaning diagnostic laparoscopy, diagnostic hysteroscopy. Meaning we’re doing an operation to diagnose, not to treat. I mean, you might be able to treat potentially, but you’re really doing it to get a really good look. And what conditions might that be helpful for, for you to go and say, “Listen, I’m going to give you anesthesia and put a camera in your belly to take a look? So it’s a big deal, but it’s important because I might find or treat…” what? 

 

Dr. Fox: So endometriosis would be the biggest thing and certainly if on their imaging may have a mass that’s a cyst or a cyst consisting of endometriosis, which we call an endometrioma. If they have fibroids. If they have obvious endometriosis in other parts of their pelvis. But if their imaging is normal and they still have signs that sound like endometriosis, I typically would at that point, and we’ve talked about medical management and they’ve either chosen not to do it or it hasn’t worked, then surgery makes sense. And you’re doing a diagnostic laparoscopy but I always go in and at least take out biopsies of anywhere where you would typically find endometriosis because that helps with their diagnosis. And you really go into the plan to hopefully give them some form of treatment and not just a diagnosis. 

 

Dr. Fox: Right. And so what are the options for treatment for pelvic pain? It’s obviously very wide based on what they have. But if you could break it down maybe into nonsurgical versus surgical just so someone might get a sense of what are the potential treatments that you might recommend. 

 

Dr. Barr: Sure. So for endometriosis, there are options for using hormones. The most common ones that we think of are birth control pills or hormonal IUDs. There are some other hormonal contraception options that work as well. A little bit less common but still have a role would be just to use progesterone on its own or GNRH agonist or antagonist. You know, if medical management, sort of, hasn’t optimized their pain, then surgery often is what’s next. Although pelvic floor physical therapy does often play a role in patients with endometriosis. So surgery would be done to look for and remove or treat endometriosis lesions. 

 

Maybe we should take a step back and actually explain what endometriosis is. Endometriosis is when you have the cells that normally line the uterus that you shed when you have a period every month end up in other parts of the body. And it can really end up almost anywhere else in the body. But most typically it’s found in the ovaries, or in the pelvis, maybe along the, sort of, outer surface of the GI tract. And so when it’s in these places, it responds to hormones as it normally would if it was in the uterus and this causes a lot of inflammation, which can result in a lot of extra cramping and sharp pain and discomfort, GI side effects, constipation, diarrhea, bloating, irregular bleeding sometimes can happen with endometriosis. And so by treating the lesions and taking out endometriosis and then giving hormones usually after that you, sort of, remove the endometriosis and suppress the endometriosis from growing back. And that really results in good, sort of, long-term care for the patients and treatment. 

 

Dr. Fox: And so in general, if someone’s coming to you for chronic pelvic pain and they’re walking in the door for the first time, they’ve had pain for years, it hasn’t really been treated, what would you say, sort of, statistically is going to happen with them, again, not immediately because it does take time, but let’s say a year or two later, like what percent chance is she going to be completely, like, cured, be better, and C, nothing helped? 

 

Dr. Barr: I would say about 50% or more of patients within 6 months are feeling significantly better, which doesn’t mean that the other 50% aren’t going to feel a little bit better. It’s probably some of them will feel a little bit better and some of them might take a little bit longer to really achieve feeling a lot better. But it also just really depends on what the cause of their pain is because endometriosis is different than maybe treating muscle spasm that might improve a little bit more readily with somebody who’s doing pelvic floor physical therapy a couple times a week. It really just depends. 

 

Dr. Fox: Okay, that’s fair. Are there any particular diagnoses that are the most challenging for patients in terms of getting better? Is endometriosis one of them? 

 

Dr. Barr: Yeah, it certainly is one of them, especially if you have severe and aggressive endometriosis and or just have a lot of scarring. So it can be a challenge, unfortunately, but you hope that you’re able to help them, help patients, and help them get better however you can. 

 

Dr. Fox: It must be tremendously rewarding to work, sort of, to specialize for women who are in pain because when they’re better, it’s like you’ve totally changed their lives, you’ve significantly improved their everyday experience. And that must be pretty good stuff when you’re able to do that for people. 

 

Dr. Barr: Yeah, it’s great. It’s so rewarding. I mean I just saw a patient today with vulvodynia. Came to me in so much pain two-and-a-half months ago where she couldn’t sit down, was in agony. And I gave her, sort of, a compound of topical medication. She used it every night, which is really, sort of, the standard first-line for vulvodynia in our practice. And she’s doing so much better. She can function. She has maybe a little bit of pain but nowhere near to the extent that she did before. And it was just great to see that. I mean, it’s such a change and it’s just like, “Great.” Now that makes you feel good and made her really happy too that she wasn’t suffering every day. 

 

Dr. Fox: Is there anything that you either predict is on the horizon or you would hope would be on the horizon to, sort of, improve care for women with pelvic pain, whether it’s a new therapy or a new diagnostic test that could be coming? 

 

Dr. Barr: I don’t know what’s actually on the horizon. But I’ll say that it would be great if we had an easier way to diagnose with certainty endometriosis. I mean, right now, it really…sort of, the standard is to have a tissue sample and you can make, sort of, a clinical diagnosis without doing surgery and getting that tissue sample. But it’d be great if there was a blood test where you could draw someone’s blood and say yes or no. And that would make life a lot easier. And it would be great if we had, sort of, more treatment options. There are more that are coming out all the time. But even more would be even better. 

 

Dr. Fox: Yeah, I mean, people ask me all the time during ultrasound if I can see their endometriosis. And I tell them like it’s microscopic. Unless you happen to have an endometrioma, like the cyst that forms from it, you can’t see it in ultrasound. And it’s really challenging for people because they’re like, “But I have so much pain.” And I was like, “Yeah, like you have a lot of pain, but I can’t see it. And so I can’t tell you if you have it, or where it is, or is it getting better, or is it getting worse.” And it’s the same thing for your CT scans and MRIs. And people find that very troubling that there’s this condition that hurts so much and affects them so much and we can’t see it. It’s tough. 

 

Dr. Barr: The extent of pain that women have with endometriosis doesn’t correlate with the extent of their disease. So a woman might have excruciating pelvic pain and you look inside and she has like three dots of endometriosis and someone else might not have any pelvic pain and do surgery for something completely unrelated and you find tons of endometriosis that you weren’t expecting because she had no symptoms of it. So it’s really a tricky disease in that sense. Hopefully, the scientists and the researchers come up with more diagnostic modalities and treatment modalities. 

 

Dr. Fox: Final question for you. So let’s say one of our listeners or a friend of one of our listeners has pelvic pain, it’s going on a long time. Her doctors can’t figure out what’s going on. Like, okay, so if she’s in New York, she can come and see you and all is well and good. But what if she’s not, right? Where can she go? How does she find someone like you or your practice that focuses on pelvic pain? Is every practice that says we treat pelvic pain gonna be equally good at it? Like, what are the signs that maybe people know what they’re doing? 

 

Dr. Barr: Any gynecologist should be able to at least do an initial assessment. I mean, gynecologists are still trained in diagnosing pelvic pain. And so I think if you’re somewhere where maybe there isn’t a pelvic pain specialist, certainly pay a visit your gynecologist and have them assess what’s going on. Otherwise, you can look for someone who is trained in minimally invasive gynecology fellowship or who maybe has done some extra training in pelvic pain. 

 

Dr. Fox: I think it’s hard. People don’t always know. And sometimes you end up bouncing around doctor to doctor. And again, like you said, I agree that you start with your gynecologist and many are really, really good at treating pelvic pain just from experience and knowledge and whatnot, but others are more challenged. And I would say it’s hard to give a blanket rule. But generally, I think if the doctor is listening to you and trying to figure it out and is not always set on one thing but is open to other possibilities and other treatments and is really working with you. And like you said, even in a specialty practice that focuses on something, it can take a long time because this is a complex problem for people that people should, sort of, be patient unless they think the doctor is blowing them off and not paying attention. I think that you have to, sort of, give it some time with your gynecologist or your pain specialist to let it work. 

 

Dr. Barr: Right. And another thing that I haven’t touched on as much but is really the component of pelvic pain that affects sexual function and a lot of women come to me with pain during sex and I think that’s something I just want your listeners to know that sex shouldn’t be painful and if you’re having pain during sex, you really should see your gynecologist and a lot of times it’s not just that you need to be better lubricated. It really is an issue of the nerves or the muscles are not functioning normally like they should and treatments for that really often revolve around physical therapy. So I guess if they are somewhere where they couldn’t find a gynecologist or someone who was, sort of, knowledgeable about pelvic pain, seeking out a pelvic floor physical therapist might be the next best thing to do so they could maybe start that treatment or have that aspect of an evaluation. 

 

Dr. Fox: Rachel, thank you so much for coming on the podcast. First of all, I love talking to you because I’ve known you for so long and it’s great to see where you are, and how well you’re doing, and how accomplished you are, and how smart you are. But we always knew it would be this way. We predicted it from day one. 

 

Dr. Barr: Thank you. It was really a pleasure. Thanks for having me. 

 

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthful.woman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@helpfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.