Hi everyone! For the launch of our new podcast, Hormones and Hellfire, we knew we wanted to tackle one of the most misunderstood conditions in women's health: endometriosis.

We're thrilled to have kicked off our first episode with Dr. Kimberly Kho, a nationally recognized expert in obstetrics and gynecology and faculty member at UT Southwestern since 2009. She's dedicated to breaking the stigma around women's health and helping patients find real solutions to problems they've often been told to just live with.

In this episode, we’re diving into what even endometriosis is in the first place, common treatment options, debunking myths circulating on social media, and discussing what it really means to live with this condition. If you or anyone you know has ever felt confused or dismissed about endometriosis, this conversation is for you.

Three Key Takeaways from Our Conversation

1. You Don't Have to Suffer in Silence

Whether you're 20, 45, or 60, if endometriosis is impacting your quality of life, you deserve treatment. Maybe you're missing days at work, or avoiding intimacy with your partner, or spending 30 anxious minutes in the bathroom because of pain. Whatever your experience looks like, you have permission to call it unacceptable.

Dr. Kho emphasized that everyone's pain tolerance and quality of life needs are different. Part of her role (and ours at Gliss!) as a physician is to help patients articulate their suffering and validate that they can ask for better. Ignoring the problem won't make it better and can actually make things worse over time. There are real solutions that can help you feel better, whether that's medication, surgery or lifestyle changes.

2. Endometriosis Creates a "Frozen Pelvis"

Dr. Kho used the ocean as a metaphor of what a healthy pelvis should look like. Your organs should move freely, like you're snorkeling in clean waters with sea anemones gently swaying their fingers — that's what your fimbria should be doing. Everything should slide smoothly over everything else, like a thriving aquarium.

Endometriosis disrupts this balance. The inflammatory disease causes organs to become stuck to each other over time, creating what doctors call a "frozen pelvis." It's like a dead, calcified coral reef instead of a living ecosystem. Surgical treatment for endometriosis involves not just removing the endometriosis tissue itself, but also the scar tissue around it, and then carefully restoring the anatomy so everything can move freely again.

3. Menopause Doesn't Always End Endometriosis

If a doctor has ever told you to "just wait till menopause" for your endometriosis to go away, that advice isn't entirely accurate. While endometriosis is an estrogen dependent disease that grows in response to the estrogen in your body, the condition is more complex than that. The endometriosis lesions themselves can actually produce their own hormones, acting as their own little factories. This means that even after menopause, when your body's estrogen production drops, endometriosis doesn't always resolve itself.

Listen to the Full Episode

Ready to dive deeper into this conversation? We cover so much more in the full episode, including treatment options, the role of diet and lifestyle, and answers to common questions about endometriosis.

Listen to Episode 1 on Spotify | Listen to Episode 1 on YouTube 

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Read the Full Transcript Below

Host: So endometriosis, let's just start about how common it is. It's a condition that impacts, a benign gynecologic condition, that impacts up to one in ten women or girls even. So once you start menstruating, you are a potential person who could have endometriosis.

Dr. Kho: And what it is, is it's a chronic condition that's caused by tissue that's like your endometrial tissue. So your endometrial tissue is the tissue that lines your uterus and that you bleed out every month when you don't get pregnant. So that's where it should be.

It should be in the lining of the endometriosis when those types of cells, not exactly those cells, but those types of cells end up outside the uterus. Frequently, it ends up in the pelvis. So on the uterus, on the lining of the pelvis, that looks like it's called pelvic peritoneum.

Down in there is your bowel, your bladder, your ureters, your ovaries, your fallopian tubes. So endometriosis can implant in that area. And then it can actually be found more rarely, more uncommonly, but common enough, anywhere in the body. And what endometriosis does is that that tissue is not supposed to be there. It's not respecting its places, you know, its anatomic locations. So your body is mad about it.

And it causes scarring and inflammation and bands of tissue that shouldn't be there called adhesions, because your body is saying, I don't want these endometriotic lesions here. That's how it goes on to cause pain. So endometriotic lesions themselves can cause pain, and we can talk a little bit more about that and what they do. And then the scarring that happens as a result of the inflammation around the lesions.

Host: I like it. Can I just say, I had a really rare case where you were saying outside the body that I had a 15-16 year old many years ago, who every time she had a period, she had nosebleeds.

Dr. Kho: Yeah. Catomedial nosebleeds. Wild, huh? 

Host: And then we had to get her to pretty much put on a calendar because we couldn't figure it out. ENT saw her, everybody saw her. PCP was giving her those sprays that can vasoconstrict and then it just never worked. And then finally it was like birth control. That was it. Continuous birth control.

So just pertaining, because this is about menopause, what does endometriosis end in menopause? One would hope it would.

Dr. Kho: That's such a good question I get all the time. Unfortunately, I can't say it always does. Most of the time, symptoms do abate or get better because endometriosis is an estrogen dependent disease, meaning it grows in response to the estrogen in your body. But, and this is how tricky and mean the disease is, the actual lesions are their own factories for hormones.

And that's why we can't say, and if you've heard it or you've had a doctor tell you, oh, just wait till menopause, it'll go away. That's false news.

Host: So is it wrong if I used to say, or I still say that with age, it does get better. Like 55, it's not going to be as bad as when you're already 35. 

Dr. Kho: So there is some truth to that. You're not entirely wrong. But you're not right. 

About 5% of women with endometriosis are likely to have ongoing symptoms or even worsening symptoms because they get placed on HRT. And we see a lot of symptoms show up in perimenopause, I find.

I think that women are more intolerable of this and be like, there's just so much going on. You're finally, I mean, you've been suffering for decades, but finally you're like, what is going on? And it's that hormonal chaos that's happening that can actually make endometriosis seem worse.

I think I sometimes find patients who are like, everything was fine. And then I hit my late thirties and forties and those, even outside of the bleeding, the pain and those bloating symptoms are worse because it's not cyclic. It's not, it's just chaos.

And like I said, the lesions themselves. So in the menopause, even when the ovarian function goes to sleep, mostly the lesions themselves can just keep on churning out the hormones that stimulate their growth. It's a terrible disease.

Host: So menopause is not a cure for endometriosis. And if women are struggling with that or suffering from the symptoms in the perimenopause and even beyond that, this is still something that needs to be addressed.

Dr. Kho: I could keep going, but often I think it's the sequel. It's like the chicken and the egg. And we see this regardless of age, you know, adolescence to like thirties and forties into the menopause.

What we find is that endometriosis is like an egg. Or the chicken that laid the egg. I don't know. But you then have pain and symptoms and the scarring and the bloating and the ongoing pelvic pain that we can dive into really over time and just years and years of living that way. It's the dysfunction that really can manifest as women get older.

Host: Talk to us about general endometriosis treatments that you are offering at your clinic or that people should be considering.

Dr. Kho: So endometriosis from a treatment perspective really should be personalized, but I think there are many things that can be done at the get-go to help manage symptoms. So if you're a mom of a teenager —I know this patient whose daughter is struggling with endometriosis — and you just have a pediatrician right now, starting with birth control pills is a great way to keep us going. It's what we call our first line of treatment. And what I generally recommend is a three to four month trial of that. 

If you've tried nothing before, you're having painful periods, you or your daughter or anybody else, you know. And just let's go back to those painful periods. Pain during periods is actually super common, but being debilitated, not being able to do activities, missing sports activities, your aerobics class, work, you know, feeling like you have to call in or even like call in late, any of those things you should seek help. We do not need to suck up that kind of discomfort and that kind of pain. 

And let's call it what it is. It's pain. But we've, I think so many people have normalized that that's normal. And you've done that to yourself because how would you know different since you've had your periods, it's been like that. And probably your mom and your sister and your best friend and your roommate in college have all experienced it. You know, who doesn't have a bottle of naproxen or, you know, a leaf and a heating pad for your periods.

So we are just socialized to learn that that's normal, but I'm saying it's not. And there are really simple, straightforward initial treatments like birth control pills. And what I recommend is birth control pills continuously. So even if you're not sexually active and thinking about using it for contraception, we're using this for the treatment of pelvic pain during your periods.

We call that dysmenorrhea or even period pain, pain outside of your period. And the reason that I like for us to use it continuously, meaning skip the sugar pills or those like white pills at the bottom of your pack is because we're trying to keep a steady state of the hormones, right?

The endometriosis lesions and endometriosis symptoms are responding to the cyclic normal changes that our bodies were created to do so we can get pregnant. And when we're not using it for reproduction, those cycles go up and down. And the birth control pills try to override that and give us steady states.

Host: And this is the same thing that we would do in perimenopause.

Dr. Kho: Exactly. This is exactly what we would do in the perimenopause. We use birth control pills frequently to manage so many gynecologic conditions that have nothing to do with the actual birth control part.

And then there are other things that I like to use, because a lot of women are sensitive to the estrogen components of birth control pills. And you might ask, why do I give estrogen birth control pills, combined oral birth control pills or COC (combined oral contraceptives are made of estrogen and progesterone) at a steady state through the month?

Why are we giving estrogen to something that's an estrogen dependent disease? It's really to get the steady state of it. But a lot of women have side effects from the estrogen or maybe are not good candidates for it because of a history of uncontrolled blood pressure or a history of even severe things like a stroke or other conditions that maybe make them not good candidates for estrogen. Actually, my favorite medication is just progesterone.

Host: And that's one hormone that you take all the time every day. Do you have a favorite one?

Dr. Kho: I do. It's called norethindrone acetate or Agestin. And I find that that's very, very well tolerated. I would say that like some pediatricians, you know, family meds who don't do this like I do every day, may be more comfortable starting birth control pills because that's a hormone they write a lot. This is a little bit more niche, I guess, but it shouldn't be.

And it's a great medication and generally very well tolerated with much fewer contraindications. And cheap.

Host: And cheap, super cheap.

Dr. Kho: Yeah, exactly. I think that's important when we're like, everyone's about to lose their health insurance. Yes. And you're paying out of pocket for things like thinking about the costs. And the goal is actually, you know, to have this steady state and one added benefit of it is that sometimes your periods really lighten or they may even go away because you've got this steady state of hormones. And I know that can be scary to some women like, oh, I just need to know that I've had my period.

Host: So I know I'm not pregnant.

Dr. Kho: But actually, it's a very effective form of birth control if you take it more or less around the same time every day. And you can always just take a pregnancy test.

Host: Okay, so going back to that, you were talking about side effects of birth control. We hear it so often. I don't want to take it because it makes me anxious, lowers my mood, and lowers my libido. So in those counseling sessions where you're talking about endometriosis, and the benefits, but also these cons, people will quit. I mean, they'll just quit, come back flaring in pain. What do you say to those patients? 

Dr. Kho: So I think kind of addressing those concerns before we even get started is really important. Sometimes I think we all in the healthcare world tend to just diagnose something, that's where we're trying to get. And then you're like, oh, here's the treatment. And you throw it at the patient, like, see you later. See you in three months, right? Let me know how it goes. What you don't see is that the patient has tried this for, you know, four weeks, trying to be a good patient. And they're like, this stinks, you know. My boobs hurt, I feel bloated, my skin is different, you know.

I would say early on, and I tell my patients this, if this isn't working for you, message me. I mean, we live in 2025, right? Like, you can message your doctors where available. I'd rather know what's not working.

And because we have so many different formulations, and dosages, and different kinds of combinations of these pills up our sleeves, but you just are getting one of them. Or even like, if you're very sensitive to one hormone, maybe we just need to adjust the dose a little, like start at half a tab.

And there's so many ways we can do that instead of just giving up on it. But I also start with like, what are the main problems? I think an important part of the visit is what are we really trying to address? What are the things that brought you to pay for the valet, pay for your parking ticket, you know, to come and talk about this today? Or in your case, hop online, right? And get the kids a snack and be like, I need a moment to myself to talk to my doctors.

What motivated you? And I always put that in my note, so that two or three visits down the line, or even a year down the line, we go back to what brought us here in the first place. And sometimes we've already addressed those, right? But then we're dealing with other side effects or other issues.

Host: You told me that you started doing that, and I did. And it's so helpful, just addressing like, what is your primary goal? Because you forget where you started so easily, when you start feeling better.

Dr. Kho: That's exactly right.

Host: It's that line in medical school, the chief complaint.

Dr. Kho: Yeah, that's right. That is the highlight. We forget to write it.

Host: It's so easy to just forget how bad it was. Like I couldn't have sex. And now you're just having hot flashes, which is great.

Dr. Kho: Exactly. Great. We won. And let's keep on moving. We won that point.

Host: Right. A hundred percent. Because patients do feel better.

Dr. Kho: Most of these, a lot of these, like very frequently, these initial treatments can really be effective. But to your point, we just give up, you know? And I've been there myself. Like I'm like, this is not working for me. Peace, you know? And then I just continue to suck it up and struggle with the symptoms.

Host: Now on telemedicine, they have a copy of our notes, the AI chat. Sometimes we'll record it. They get a copy. And then the thing I tell them to do is write a journal. Like on that day, whatever post-it note or whatever they, I don't choose. I always use post-it notes. But on your calendar, I want you to write the three symptoms that are bothering you and rank them from zero to 10. And if you come and see me in six weeks, eight weeks, and that is an improvement.

Host: We have set the goal so they don't forget in an objective way. But I have to remind them of that because sometimes they come back with new side effects or whatever I'm giving. And like, okay, well, remember, we hit the three. It just comes with a side effect.

Host: Totally. I love the number scale.

Dr. Kho: Right, right. It's objective.

Host: You know, we're talking about birth control? Nextelis. It's a very popular one that OBGYNs are now starting to use. Do you find for endometriosis and perimenopause, it's better compared to the other ones?

Dr. Kho: You know, I see a lot of patients who start with me before that process. They're starting to go through the perimenopause. And then I meet a lot of women who are in it when we meet to discuss whatever issues they're having around endometriosis. And Nextelis is a really, a newer drug. And I think it's great and really promising, especially sort of the hormones that are in it that are a little bit different from traditional combined oral birth control. It's a contraceptive with estrogen and progesterone, but just different kinds of estrogen and progesterone. And I think the promise is very good. It's a probably more natural kind of estrogen. I call it plant-based.

Host: Plant-based. Right, right.

Dr. Kho: But I actually have found such good success with the initial treatments that we've been discussing. I usually start there and then if those aren't working, then that's something that I'll suggest after. But that's because I'm just an old fogey who knows what I do, right? And it works and it sets it right.

Host: What is your favorite birth control? Like what is your go-to? I know they're probably different for different things, but.

Dr. Kho: Yeah. So for a combined oral contraceptive, I use just low estrogen. And there's, again, so many generics that can be so affordable. And it's monophasic, meaning it's not like these crazy different levels that we're trying to mimic birth control, like your regular cycles.

Host: That was very trendy.

Dr. Kho: That's a new thing.

Host: It's coming back. TikTok is saying that you should do triphasics because it mimics your real cycle.

Dr. Kho: I'm not on TikTok. That's how old I am.

But triphasics were really trendy when we were training, when I was needing a lot of birth control. So I think we've moved away from that because you don't need it. And then you end up with some higher doses for periods of time. But I like low estrogen, which has, again, so many generics that can be so affordable. And it's monophasics, and it's just so easy to dose and take. I love it.

Host: Okay. I know this is probably more than most people want to know, but I want everyone to know this because I feel like it's important: the surgical management. So you decide that for whatever reason, pills are not working. And I feel like this is the next step that people really need to understand because it's not that everyone can do this. Surgical management of endo, which is to get it done well and to have good results, you need someone that does this. And that's why I'm so happy you're here in Hawaii.

Dr. Kho: That is really such an important and nuanced question. I think OBGYN teaching is evolving because the data is evolving. But endometriosis can only actually be diagnosed at this point in time. I think there's so much more compelling literature that's developing around imaging that really like 99% of the likelihood you have endometriosis, right? But the gold standard of diagnosis is having tissue of endometriosis. And you can only do that during surgery. And we traditionally do that through laparoscopy or what was called keyhole surgery.

It's a very minimally invasive surgery, small tiny holes in your belly, but we have to get in your belly and you need to go to sleep to do that. So you don't move. It's generally a surgery.

And when I was taught, you know, diagnostic laparoscopy, which is just a peek and look and diagnose it was a thing, right? Like a very common thing, but a peek and shriek or just look at it and say, oh, it looks like you have an endo. We'll put you on birth control pills for the rest of your life, right? You know, a subspecialty has emerged in the past 20 odd years called minimally invasive surgery, GYN surgery, MIGS, or complex benign gynecologic surgery or complex benign gynecology, excuse me. And there are hundreds of people who are trained in just this and more and general OBGYNs who actually appropriately get this training, right? Where it's not just a peek and shriek, but you're actually treating too.

So you're doing two things, diagnosing and then treating. And what is treatment? Treatment is excising, not just burning or ablating the disease because you want to get to the root of the disease and then restoring the anatomy. So it's restorative too. You know? And it's putting everything back where it belongs because things can get really stuck and adherent to each other through this inflammatory disease and thereby kind of restoring the function.

Because what happens is that all your organs can ultimately over time, like get stuck to each other. We call that a frozen pelvis. Like I always like to tell my patients, especially in Hawaii, because everybody loves to be in the water, you know, our organs should float like we're in the ocean and snorkeling, right? It shouldn't be a dead reef where everything is calcified, right? And stuck. You want little sea anemone moving their little fingers. Those are like your fimbria. You want organs sliding over each other.

It should look like an aquarium in there, like a healthy aquarium, not a sad, calcified, dead coral reef or something that's been like glue has been poured over. And that's a lot of the work that we do surgically. Excising the tissue and then removing not just the endometriosis, but the scar around it and then putting everything back and letting the body heal.

And sometimes we have to put things in there to help the body heal in a more natural way. And some people might say, well, you know, you might meet a doctor who is like, well, you've already had surgery, more surgery causes more scarring. I think on the right, that is not untrue. Surgery itself causes scarring. If we touch something, it can cause scarring. But with microsurgical techniques and really delicate tissue handling and in the hands of people who really know what they're doing and do this all the time, we really can restore anatomy, restore function of the bowel, bladder, decrease pain, and give sort of a new start.

Because endometriosis is a disease, like we keep saying, it's a chronic disease, you can't cure it, but you can definitely make it much more livable. And I think that if you have severe enough disease, or most patients, you know, who end up needing surgery, because, okay, they've gotten to like 50% better with birth control pills, but they're still hurting. That means there's something inflammatory going on in their pelvis that is hostile and angry. And we need to address that. So yeah, so that is really a lot of what we do and specialists in endometriosis do.

And I'm just going to address the issue of burning and ablation, because I feel like that's like a hot topic on maybe Instagram and social media. You know, I think that that was a really common way to treat endometriosis, because we didn't have the surgical devices, and the advanced technologies, and maybe even the skill sets to really work around these critical anatomic structures like your bowel and your bladder. But in 2025, just like you can just hop on telehealth to visit with your doctors, we can do that, like our technology has evolved so much that we now have skilled surgeons all over, you just have to find them who know how to use that to their best advantage to help patients.

Dr. Kho: And I feel like the other thing that I want to sort of like harp on is that I feel like not even last week, I had someone that came in and was like, I don't want to see an OBGYN in a person because they're going to tell me I need a hysterectomy. And I was like, that's actually not true. And I feel like you just need a different person. So yeah, she's going to win your way.

I think, you know, older thinking was that hysterectomies were the cure for endometriosis. It would stop the backflow of, you know, menstrual blood and effluent and tissue back. And we actually know that that's not true. Endometriosis is a disease outside the uterus, by definition. So removing the uterus isn't going to cure the endo.

But I will say a hysterectomy actually can be really beneficial for women who need it because so many things happen on top of each other simultaneously or at the same time. Right. And there's a condition that I feel like is even more underdiagnosed and undertreated and underrecognized than endometriosis. And it's called adenomyosis. And they are like mean cousins that hang out together. And there's so much overlap between those conditions.

And I will tell you, hysterectomy for patients with both of those conditions or just adenomyosis itself is life changing. So, you know, don't shy away from seeking care. And if you're not getting the answers that you want, though, keep looking for the people who are going to give you those options.

Dr. Kho: But the more that I think women come to their appointments informed about what their options are, then the more they can advocate for themselves.

Host: Exactly. Well, speaking of surgery, how about non-surgery, like all these new medications. Alyssa, you know, using them particularly for our audience, which is 35, 40 plus. What are your thoughts on that?

I am so glad that we've had funding for science to advance these treatments because it was decades that we were just borrowing other medications like birth control pills to treat a lot of the very common conditions that women experience.

Alyssa is in a class of drugs called GnRH antagonists. So what they do, antagonist means like, what they do is they stop or block the activity of hormones at the highest level. So it's not blocking the hormones of the estrogen and progesterone at the ovarian level, but at the brain level. And they block the signal so that your body stops producing that.

We've had some drugs that are similar, agonists called Lupron, which some women may have experienced and hated, you know. So Elegolix is an antagonist.

The end is that they end up working in a similar way, but mechanistically they work differently. But I think it's a good option. I don't prescribe it a lot because I think that by the time patients are good candidates for it, they probably need surgical management. And then I don't need to put them on such a heavy hitter afterwards.

Host: I see it's a heavy hitter because it comes with it from side effects. Like we were saying, it turns off the brain level signals to produce those hormones.

Dr. Kho: So it's basically inducing menopause, like real menopause. Like I am in the process of slowly going into menopause and it's not graceful at all. But if someone just turned the lights off and blocked that, I think I'd be a lot more uncomfortable and those symptoms can be quite bothersome.

So we do give add back, like some little level of hormone replacement, if you will, to make those more tolerable. I think it's a good option for women who may not be good surgical candidates because they're very ill or their life can't afford that at this moment, who have tried those first line treatments that we went over, birth control pills, norepinephrine.

Even in Europe and Canada and not America, they use a drug called divinogest, which is really effective. If those haven't worked for her, then this is a good option if surgical management isn't, or if we need to bridge you to get other conditions better, you know, other medical conditions and get you to surgery, which I think is really the gold standard treatment. Because it's pretty expensive.

Host: It is very expensive and that's the issue. And we really can't be on it for a long term. So there are two dosings and one is the longest you can be on it is really two years.

Dr. Kho: So yeah, it's not a cure.

Host: Right. Speaking of other non-surgical, I get this question all the time. What can I eat?

Dr. Kho: Great question. I just made a flyer for my patients. I actually think because endometriosis and chronic pelvic pain are all tied together, it overlaps with irritable bowel syndromes. I mean, it's a whole body disease. I always say that our pelvis or our body is not a one bedroom. It's not like a four-bedroom or five-bedroom house. It's a one-bedroom studio there. So everything's hanging out, right? I have teenage boys. If they toot and fart, I can smell it in the same room. I can't just close the door. So that inflammation, whatever's happening in that environment, is going to impact potentially the rest of everything that's in there.

And that's your bowels, that's your bladder. And a diet, a low inflammation diet can really help women manage symptoms. I generally recommend a Mediterranean diet, which is known to be low inflammation, and a low FODMAP diet, which FODMAP is like an acronym for these carbohydrates that our body breaks down. And what we want to do is eat foods that won't hang out in our guts for a long time and ferment. So these are more easily digestible foods.

But there are so many, it’s so great. You can literally just Google “low inflammation diet”, and from a reputable source, there are entire diets. And I have really found that that can be a really great adjunct to helping people manage that. And that is something that you can use for your life, right? It's not a drug that you need to stop with side effects.

And the benefits of those diets are profound, like from a cardiac, like a longevity standpoint, a life standpoint, there's nothing bad about those diets. And that's what the obesity medicine people recommend is. So I mean you'd be hitting two very common perimenopause symptoms all at once.

Host: Totally. Well, a common question I also get is how long do I have to be on this diet before I see the effects?

Dr. Kho: Yeah, so I think that some women who may have sensitivities to things like gluten, they see it pretty quickly, you know? And there is a lot of overlap with that. But you know, I would, you know, and it's like how religious are you gonna be, you know, about it? How book compliant are you gonna be with it? You know, you need to live your life, right?

Dr. Kho: But I would say, you know, really committing to it for a few weeks should help.

Host: So patients who are getting close to menopause and their doctors or OB-GYN's like, “hey, you need surgery, you need surgery.” And they just, how, you know, some of them are like, I don't want surgery. How do you recommend surgery less and less so the closer they get to menopause?

Dr. Kho: Yeah, I see what the question is. Okay. It's a question I get asked often, right? Yeah, they're like, their pain is increasing. Yeah. And they're like, okay, if I could just get to 50, how long do I really have to wait to get to surgery? Or do I, or can I get to 50 and decide, okay, now I'm gonna try? Right. I'm gonna try to sell this.

I think that's a real, real-world question. Yeah. I mean, who has time for surgery, right? Like we're driving our kids to school and doing everything, right? Like living our lives. I really think it's about how bothered you are by your symptoms. And everybody's gonna be different.

But I want to tell women, and I think it's so important for people to know, that you don't need to suffer, right? Like if you're 45 and having, missing a few days of just life, even if it's not calling in sick, but not being your best version of yourself and getting to that, you know, yoga class that you usually want to do.

If that is impacting your life in that way, and it's bothering you, or you can't be intimate with your partner in that way, and you're losing that part of yourself, or you get anxious about going to the bathroom when you're at work because you know it's gonna hurt, and take like 30 minutes to be able to sit again, you don't have to live that way.

And I think when I really get into the details and the weeds with my patients, you really help them articulate like the suffering, their experience. Then I say like, it's time, right? Like you can tell me when it's time, you know? But, and everyone's pain level tolerance and quality of life tolerance is different, but what I think so much of what I get to do is validate that like, you can call that pain, and you can call that unacceptable.

You can do that at 50, at 60, at 20, at any time, and that you can feel better. I mean, I think that's the other side of it, that there are real things that can make you feel better. And it may be medicine, it may be surgery, it may be a combination of those, and it may be diet, it may be pelvic floor physical therapy, because you've lived with all this pain for so long now, that your musculoskeletal system around that is firing in a dysfunctional way.

And I also tell patients that if we don't address this, it can become worse. Right.

Host: Well, I always think menopause could be 10 years.

Dr. Kho: That's right. You could go, you could think that you're two years away, and then what if it's really five years? That's right, because the average is like 51, but like, what about all the other people on the curve?

So, I have to say, I was like, I don't know, nobody has a crystal ball, it's going to be something. And how long can you wait? And you're not even guaranteed, right? That it's going to get better, like we were saying, right? The postmenopausal, you could be that 5% of women who are gonna have ongoing pain or worsening, and then it's complicated by getting started on HRT, right, which can make symptoms flare.

That's another thing, and then I know so many of your patients are perimenopausal or postmenopausal. One thing I would tell women is if they have an endometrioma, that means a ball of endometriosis on their ovary, they're at an increased risk, and this is not to instill fear, but of developing ovarian cancer. And that may be something you really do want to address in your perimenopause, and certainly in your postmenopause.

So, you know, on an absolute scale, I don't want to scare anybody, endometriosis does increase your risk of ovarian cancer, which is like a very scary kind of malignancy, a cancer to have, because we don't really know how to early diagnose it, we don't have like mammograms for it, you know, like screening tools. And it does, but that's about going from like 1% to 2 to 3%, you know, so on an absolute level, most women with endometriosis who are aging are not gonna develop ovarian cancer, but it's not nothing, and it certainly does increase your risk of it.

Dr. Kho: So, symptoms at that age should not be ignored. Right.

Host: Back to menopause, perimenopause, transitioning from OCPs to HRT. Yeah. We have a lot of patients who are all endometriosis, and or have it, they've been controlled really well, but their symptoms now for the birth control are just not being alleviated by that. So, they want to move over to it. Do you have advice for that, whether the progesterone should be higher? Because I know, I've learned that micronized progesterone at even like 100, 200, it's not enough. And then, does it matter how much estrogen?

Dr. Kho: I do follow the principle of using the lowest dose that suits your symptoms, that treats your symptoms. Estrogen, we can say, can be a miracle growth for endometriosis. So, we're trying to find the dose that is lowest to manage your symptoms, but you have to manage the symptoms, right? And it's a balance. It's really a teeter-totter of a balance of symptoms, but yes, we know that starting hormone replacement therapy can make symptoms flare, especially in women who have actually gone through more like natural menopause, without hormones on board, and then are starting to need something, and they're like, oh, the pain I had when I was 30 is back, right? I see that a lot.

And then, as far as your progesterone question, I think, you know, prometrium is a very common progesterone balance to the yin and yang of estrogen and progesterone in the married menopause. And that's really, I think, I really, I definitely, everyone needs to be on progesterone, let's just put it that way, who has had some amount of like more severe symptoms or endometriosis, severe endometriosis.

So, even if your ovaries are gone, let's just say you had them removed from endometriosis surgery for other reasons, traditionally the teaching has been, if you don't have ovaries, you don't need to be on the progesterone, because it's really just to protect the uterus.

Every one of my patients with endometriosis who is in that situation, who I'm giving hormone therapy, menopausal hormone therapy to, I put on a progesterone. And sometimes it'll be just prometrium, or sometimes, depending on the severity of the disease, I'll go back to that norsyndrome. Yeah, and generally probably don't need the higher levels, so I'll do like a half a tab of that.

But it really is, that's where you want to be seeing someone who knows how to deal with endometriosis and manage those symptoms. Because I think you're trying to optimize two things, right? The symptoms of the menopause, and then not, yeah, trying to limit the recurrence. But we know that women on hormonal menopausal therapy can re-flare, or endometriosis can recur.

And you know what? What's so mean about this disease? You don't even need to be on menopausal hormone therapy for endometriosis to worsen or flare in the menopause. So there's like no real winners. So I think finding a partner who's gonna help you, like a physician, a health care team, that's gonna partner with you through that.

Host: My fave, fibroids. Tell me what they are, and why do people care?

Dr. Kho: So fibroids, and I came from Texas, people call them fireballs in my uterus. We're all from Texas roots, no way.

But fibroids are a super common condition among all people with a uterus. So about 70 to 80 percent of women, if we look for them, will find fibroids. They are quote-unquote benign, so non-cancerous conditions of the uterus, where tissue grows in really paw-like formation in the wall and muscle of the uterus.

And it's not actually, it's not the same tissue that makes up the myometrium or the wall of the uterus. It's another tissue, and they can grow from the size of little pieces of rice to the size of a very large prize-winning watermelon. And they're ubiquitous, they're everywhere if we look for them.

But only about a third of women are actually symptomatic from it. And symptoms of fibroids can be, and you imagine, like pelvic pressure, pain, pain with intercourse, even subtle things like having to go to the bathroom a lot, like to pee, or to defecate, or having a hard time passing stools, whether that be painful defecation, or feeling constipated, because you just, if you think of your pelvis like a fruit bowl, there's just so much room for the naturally occurring things that are in there. If you add a watermelon, yeah, an orange, a strawberry, a watermelon, you know, depending on the location, they can cause that. And then they can cause bleeding. And we also know that fibroids, depending on their location, can impact fertility as well.

Host: Is HRT going to make fibroids grow?

Dr. Kho: Yeah, such a good question. I get that a lot, I'm sure you guys do. HRT can make fibroids grow. It's an estrogen and progesterone dependent condition, just the drugs and medicines that we give for hormone replacement therapy.

So yes, the answer is yes. And I think the times that we're thinking about supplementing hormones, are also a time when fibroids can grow, in the perimenopause. Because just like we were talking about before, you know, it's like the chaos of the hormonal cycles. There's no beautiful rhythm to your estrogen and progesterone, it's just flaring and then nothing. And we see a lot of fibroid growth, our symptoms start emerging around the perimenopause. Around the time we're thinking of giving hormones, all the things just sort of layered on top of it, to just really make those symptoms manifest.

Host: Well, you know, the one I see the most is fatigue. Because they're bleeding a lot, they're anemic, they get this cyclical fatigue, and then they also perimenopause. 

I feel like that question should be like a screening question for women above like 35. Are you feeling fatigued?

Dr. Kho: Well, the iron deficiency causes so many other symptoms. The anxiety, the palpitations, which copy my perimenopause, the restless leg syndrome at night, and the insomnia. You feel this kind of it's all wrapped in, so you have to then make sure that it's not one versus the other, or both.

Host: Yeah, yeah, absolutely. Will HRT make my bleeding worse?

Dr. Kho: That's a very common one too. So, it can. HRT is at a different level of dosing than birth control pills, which are actually like a treatment, oddly enough, for fibroids. Because they're trying to kind of stabilize the endometrium. That's not the goal of the endometrium, is the lining that bleeds. And if you have a fibroid sticking there, or bleeding on it, that can cause heavy prolonged bleeding, bleeding between periods, bleeding after intercourse. It's just a mechanical thing that's disrupting that lining. And that's not necessarily the goal of hormone replacement therapy levels of hormones.

So yes, you can see, like when you didn't maybe have those symptoms, irregular bleeding and spotting, you know. Or like I even have patients who like to play tennis, or athletes, and they're like, I bleed every time I play, you know. And that usually indicates a specific location of a fibroid being disruptive.

Host: So yeah, sometimes it can manifest as irregular bleeding. Do you think so for really heavy bleeding, the matter of Agestin versus micronized progestin matters?

Dr. Kho: Yeah. Because I think the dose is too low. Yeah, I think it does. I think also we need to get to the heart of the matter of why they're bleeding. Any bleeding in menopause needs investigation. Like a hundred percent.

So this is actually like, I think a really important take-home message. Don't just chalk it up to the fibroid I knew was there when someone told me I had a fibroid when I was pregnant 20 years ago. Any bleeding in the menopause needs to be evaluated, and the evaluation means make sure it's not cancer. I cannot underline that enough. I myself have had a good friend who was on hormone replacement therapy, menopausal hormone therapy, and they just kept adjusting the dosage without further looking into why she might be bleeding. And lo and behold, she had cancer. It had been tinkering with the hormone, the medication management for two years.

Host: No, and I think that that's especially important in these, including our patients who are getting online care, where it is very easy to sort of like potentially slip through and not realize like that it's been two years, or if you've been on a platform that just does reviews of intake.

Dr. Kho: Yeah, and it's refilling the prescription. And you, so I think women need to know. Any irregular bleeding in the menopause, whether you're tinkering with your hormones or not, it's not to make you afraid, but to make you aware that that deserves an in-person evaluation.

And that evaluation does not need to be scary or intimidating, it often just starts with a pelvic ultrasound to look, what they're doing is looking to see are there fibroids or even like a polyp, and then measuring the lining of the uterus. So, and it could be cancer of the uterus, like the lining of the uterus, things that can also manifest and get kind of crowded out by all these other management options is rarer things, but really terrible things like fallopian tube cancers, or peritoneal cancers, those are really things that you wanna try to get a diagnosis of sooner than later, because it's such a morbid condition. So, 100%, if you are on any platform or not seeing a gynecologist, and just getting your refills, or not seeing a doctor, and getting refills from some other place, using your sister's, cousin's, friend's meds to get you through, bleeding in the menopause is not normal, ever.

Host: Right.

Dr. Kho: And it might be very simple, and it might just be your vagina's dry, right? So let's figure that out and distinguish. Our rule for telemedicine is three months, because if they had regular bleeding and then we start them on medication and have irregular bleeding, it's very likely the medication. But if, in three months, we have made something or mucked up something that has caused irregular bleeding, they gotta go be seen. Yeah, I think that that's fair. Not to make a mountain out of a molehill, but to have an endpoint to check in, you know? 

Host: We went on a deep end to Reddit and into YouTube to see what patients are seeing for, if you type in perimenopause or menopause with fibroids. There's chiropractors and other people who are not pelvic pain OBGYNs who comment on things that you can do non-surgically, natural remedies for fibroids and for menopause. There's one particular one about vitamin D. It’s this idea that if you take enough of it, very, very high doses, more than normal that you would get from Costco or from Target, that you could shrink your fibroid while treating your symptoms for menopause. 

Dr. Kho: So the things about some of these social media influencers and health influencers that gets me is that it's halfway maybe right. It's not totally not based in science, but those recommendations are not based in science, right?

There is a pathophysiology that's right. So vitamin D, let's go just specifically that, but I think this is like a lesson from about all health influencing and where you're consuming that information from. Vitamin D, there is growing evidence that vitamin D can address, can help treat fibroids, okay? There is a group out of Chicago, they used to be in the South, Ayman Al-Hendi and his team, who's doing a lot of molecular level and even clinical level work around green tea extract and vitamin D. 

I totally get that people want natural things, and they exist, but we need to do it from an evidence-based level and I think the evidence is still building. But yes, vitamin D, let's just start with the fact that most women are vitamin D deficient, like 90% of women who are African-American descent actually are, and everyone else is vitamin D deficient, like 50% of the rest of us.

So checking vitamin D levels is really important. If you're vitamin D deficient, replace that. But also taking super physiologic levels can be harmful, potentially, and super, super physiologic is really potentially harmful. Like vitamin E, remember that whole thing? Everybody was saying, you could live longer, but you live way shorter. But vitamin D does look like, it does, on a molecular level, address the fibroid growth from, and like it helps with cell death. So yes, in some early clinical trials, you can actually get some fibroid reductions, like pretty impressive, like 30, 40% fibroid size reduction. 

But I do check patients' vitamin D levels and do recommend vitamin D replacement if they need it, in kind of like the 4,000 unit. So I think that, and then just because I brought it up, green tea extract too. Like you're not gonna drink enough green tea to shrink your fibroids. But there's also mechanistic, like biologic plausibility about what they do. It induces apoptosis, it addresses the blood growth, the blood vessel growth that allows for fibroids to happen.

So there is really some truth to those recommendations. But I think we're still really drilling down on what the right dosages are, to balance the side effects, to make this a standard of care recommendation. When I talk to patients, I do share that information about what the clinical trials, early clinical trials are beginning to show. But as far as taking tons and tons of this, we also don't know, on the flip side, what the side effects will be. 

Host: Do you think that the smaller, earlier fibroids may be better than those who are way bigger?

Dr. Kho: Yeah, yeah, I do. Because I feel like that's what the studies kind of imply, right? Yes, yes, the earlier, as a preventative. And I think that's when we've talked about these in our kind of scientific fibroid sort of forums, it's those that we're trying to address. Like could we use these potentially as supplements to prevent growth, significant growth, so that we're keeping them at the level that they're minimally symptomatic, if not at all, right? If you've got a giant fibroid, This isn't gonna be the same. This isn't gonna be the treatment.

And I think we're looking at other treatments like radiofrequency ablation, like the minimally invasive treatments that are more surgical, with that same thing in mind. I think we're, our thinking about this disease and this condition has evolved in that everyone used to just get a hysterectomy, right? Just take it out, right? Who needs that organ? 

Well, we know that that's not necessarily appropriate, not desired, that there may be likely like long-term health side effects, to even just taking out the uterus without the ovaries. We can talk about that at another time, but thinking more about what going from that extreme to just taking out the fibroids and addressing, to now addressing it from a preventative level, addressing the fibroids that may not be symptomatic, but we know, because we know what will happen.

Maybe not in you specifically, because we haven't, you're 20, and we haven't seen you at 50, but we know from every woman around you, likely this will grow. So, what are the things we can do to prevent that? 

Host: You know, the chiropractor is so convincing.

Dr. Kho: Oh my God. Right, even though I was like, wait a second, he is right. Because you mentioned African-Americans, and right, they have a lower vitamin D because they have higher melanin. But I just wanted to say that it could be multiple other causes, like their muscle tissue has other, maybe receptors or things that stimulate fibroid growth, and it's not just that. 

Host: A hundred percent. Oh, totally, totally, yes.

Dr. Kho: And there's work being done on that. You know, how does vitamin D impact the receptors? And you're exactly right, or the growth factors that make this grow. For a disease that impacts 70 to 80% of women, we know shockingly little about this. And so, unfortunately in 2025, we are still at the moment, right, where we're still trying to figure it out. Like from how do fibroids grow? What makes them grow? How do we develop medications or supplements or things that encounter in nature already to treat them? But that is also an opportunity for a lot of shillers, like people who want to step in and make a buck, you know?

So, and I'm sure you guys will talk about this too, right? I would discourage people from getting healthcare information from people who are really trying to just sell you something, you know?

Host: I know that we are going long, but I do, I feel like we have such an opportunity right now to like have an expert on fibroids. And like, I feel like what Hawaii in general is missing is like this sortof like the gap between doing nothing and hysterectomy and myomectomy. I feel like this is,there's this large vacuum that is partly just because Hawaii is so far from everyone. So I feel like I'm really excited for everyone in Hawaii, and I keep talking about this, but I feel like there's a lot of, if you don't mind just going through some like very high-level interventions.

Dr. Kho: Yeah, yeah. So fibroids, like endometriosis, like really everything that is new, you know? Like we might see, I may see a fibroid patient every, you know, every visit. You're the one with the fibroids, right? And having the symptoms. Care needs to be customized, but that also means having available all of the treatment options that are FDA-approved, and maybe even a good understanding of the non-FDA-approved treatments that could be really effective.

And for all of that, knowing what the advantages and disadvantages are, being able to articulate that and discuss that with a patient and marrying that with the goals of the person sitting in front of you. The person sitting in front of you is not for fibroids. It's a human being, right? Who has a job and a life and needs to figure out what's gonna work for them, right? 

I get a lot of consults, actually, for patients who got a sonogram for something else or got a CT scan in the ER because they were getting rolled up for appendicitis, and they're like, I have a fibroid. Well, we go through all the questions that we've asked, and if the answer is no, then we don't necessarily need to do anything about it, right? But if the answer is yes and it's bothersome, then we need to start moving up the chain of treatments, you know? And it's kind of like a step stair, like a staircase, right? The ground level is nothing. If you are having symptoms, you know, there's medication management. 

Host: Some of the medications treat just the symptoms, okay?

Dr. Kho: Some of the treatments can, for a while, shrink the fibroids. And then we have interventions that are not, I would say, surgeries, like uterine artery embolization or otherwise known as uterine fibroid embolization, highly effective treatment that does not require you to lose your uterus and actually doesn't even require you to go to surgery, right? Great treatment. We're working with a group where I'm beginning to meet some of those folks who do that.

Those are called interventional radiologists, not gynecologists, and are working to build a team. What we want to create here for Hawaii and the region is a multidisciplinary fibroid program. So we're really thinking about all of the options for each patient and presenting them to her. And then if bleeding is the bothersome thing and you have a little fibroid, like we talked about this patient who was in the menopause that's kind of sticking into the cavity, maybe we just need to shave down that fibroid, right? Or if you've got a few in the muscle but you're not feeling bulky but it's really annoying in the perimenopause and you're having heavier periods, you could even do something called an endometrial ablation.

That technology has evolved and that's burning or freezing the lining of the uterus so it doesn't regrow and you actually have normal periods or lighter periods and some women actually, the periods go away.

Host: And this freezing one is totally different from the older burning ones, which I think is important in Hawaii for people to realize. In the mainland, it's pretty well established.

Dr. Kho: Yeah, there can be side effects to the heat which can itself cause scarring inside the uterus, yes. So there are a lot of ways to address that. And then up the chain a little bit more is radiofrequency ablation and it's not science fiction, it's like when we send heat into the uterus and we can do that incisionless through the cervix and the vagina or laparoscopically from above, depending on where those fibroids are and those fibroids will shrink by 40 to 50, 60%, okay?

Host: And they will stay shrinked, right?

Dr. Kho: Yes. So I feel like a lot of women don't want parts of themselves removed and I think some people just kind of shirked at that and said, well, then live with it, you know? I'm offering you a removal surgery, you know, and that's it and the conversation would end. There are so many technologies and treatments out there to meet people where they are, okay? And most of these, you are going to sleep in your own home that night, you know? Unfortunately, you know, you can get your kids to put the dishes away in the morning. 

Those are called radiofrequency ablations. The devices that women might hear about are called Sonata and Excessa and we're offering that and we're putting that all together in a program. And then finally, there's myomectomy, which is a removal surgery, but it's a removal surgery of just the fibroids and keeping your uterus and we kind of reconstruct the uterus and we used to kind of only offer that in the past to women who still wanted babies. My nodal point has changed. Do you want to keep your uterus, you know? And a lot of people won't offer that in perimenopausal or postmenopausal women. I think with appropriate counseling, if that's what a woman wants, she wants to keep her uterus, but make it better, you know? And take away the thing that's bothering her, then I think that can be very reasonable with the right workup. And then finally, hysterectomy. And we can do that through small incisions or no incision.

Host: I love it. We have made you talk so much. No, it's obviously like the stuff I love to talk about. We’re just so grateful that you're here. 

Dr. Kho: I feel like a part of this is exposure, right? Like if you're a resident and you don't even like it, you read about something and don't understand that people are doing this. Or that like, this is how you manage endo in someone. Like if you don't, you never have been exposed to it, it is all just like what is passed down.

Host: And then it impacts the whole community, right?

Dr. Kho: Cause that's all you ever offer. I mean, you wouldn't get to see the fruits of your labor, Teresa, but like doing that, we did the same thing with Migs. Like, you know, by the time I left, like every graduate of our program knew what you could really do. And that's the majority of doctors in Texas, right? Of OBGYNs. We did that, you know? And we're already changing the conversation. 

Host: Okay, so we have a little thing where we wrap up every episode with a few personalized questions. What is something you wish someone had told you about perimenopause? Because even as an OBGYN, we knew a lot to be dangerous. Yes.

Dr. Kho: I wish someone had told me about the whole bodiness of it. You know, I think I thought about it as hot flashes and thinking about my bone health. It's all the things we counsel patients about, right? But it is doing something to your metabolism, your body structure, the body mechanics, you know, your skin, your hair, your energy, your mood. It is every single part of you. And I think I underestimated the impact of that, even though like, you know, we're OBGYNs.

Host: Yeah. We kind of knew it, but we kind of didn't.

Dr. Kho: No, it's totally different to experience it. Yeah. It has changed my counseling dramatically. I feel like that comes with phases in our life, like breastfeeding and having pregnancy, right?

Host: One as a resident before. What was I telling people? It was terrible, terrible. I apologize to all of them. And you know what I'm excited about, actually, is that there are so many women physicians in this field who are actually experiencing it. So I think a lot of the changes that are happening and the advocacy is coming from within, because we ask ourselves, how would I want to be treated?

Dr. Kho: Right? Like, how would I want my best friends to be counseled? And it's not being told it's horrible and go on. Just exercise, walk a little bit more. Yeah. It'll just go on.

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