Second Opinion on Endometriosis – Dr. Seckin Explains it in Detail

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(CHILD’S VOICE) There once was a time when we were truly free — free of worry… free of fear… far from doubt. That is strength. That is power. That is fearless. “Second Opinion” is funded by Blue Cross Blue Shield, which is committed to improving healthcare accessibility and supporting more affordable community clinics where care is limited. Blue Cross Blue Shield.

(ANNOUNCER) “Second Opinion” is produced in association with the University of Rochester Medical Center, Rochester, New York.

(DR PETER SALGO) This is “Second Opinion,” and I’m your host, DR Peter Salgo. Today we’re joined by special guest, Ruta Sankilis-Biteman. Ruta has had a long and frustrating health journey, a journey that has impacted everything in her life. She’s here to tell her story and find some answers.

(RUTA BITEMAN) In my late 20s, I would say, I had such bad pain one night that I passed out from it, and I ended up going to the E.R., and it turns out I had a cyst that had burst.

(DR LISA HARRIS) Mm-hmm. It was on your ovary?


(DR PETER SALGO) So you had a ruptured ovarian cyst. Thanks so much for being here, Ruta. I’m delighted you’re joining us and sharing your story with us, and I want to get right to work. So, first thing we’ve got to do is introduce you to our “Second Opinion” panel. They’ll be hearing your story, by the way, for the first time. There, DR Tamer Seckin from Lenox Hill Hospital, Northwell Health… and “Second Opinion” Primary Care Physician from Our Lady of Lourdes Memorial Hospital, DR Lisa Harris. Welcome to you both.

(DR LISA HARRIS)Thank you.

(DR PETER SALGO) Now, back to you, Ruta. I understand you were athletic, a gymnast while you were growing up. You had a pretty happy childhood, and then you began having odd pain.

(RUTA BITEMAN) Basically, it was cyclical pain.

(DR PETER SALGO) What does that mean — “cyclical pain”?

(RUTA BITEMAN) Period pain.

(DR PETER SALGO) Okay, just be clear about it.

(RUTA BITEMAN) A little more extreme than what I thought it should be.


(RUTA BITEMAN) Unusual pain in my side, below my belly button, burning, searing — pretty excruciating.

(DR PETER SALGO) Did you have pain with sexual intercourse?

(RUTA BITEMAN) Absolutely.

(DR PETER SALGO)Okay.Did you finally see a doctor about it?

(RUTA BITEMAN) I did — a few.

(DR PETER SALGO) And what did they tell you?

(DR LISA HARRIS) Can I just jump in with a quick question? How old were you with your first period?

(RUTA BITEMAN) I was 16.

(DR LISA HARRIS) And how long after your first period did you start noticing this pain, or was it with the very first one?

(RUTA BITEMAN) It was probably 18, 19.

(DR TAMER SECKIN) About two years into this.


(DR PETER SALGO) Why did you ask that question?

(DR LISA HARRIS) Because it’s important to know if this was related to the very first period or if this is something that developed along over time. It kind of helps with the differential.

(DR PETER SALGO) What about the doctors you saw? What did they say to you?

(RUTA BITEMAN) Nothing. Basically, it’s just part of being a woman and to take some Tylenol or whatever and just deal with it.

(DR PETER SALGO) And were these women or men?

(DR TAMER SECKIN) They didn’t ask you about your G.I. symptoms, anything like that?


(DR TAMER SECKIN) Like any discomfort, abdominal discomfort that happens — nausea, maybe throwing up at times, missing school?


(DR PETER SALGO) What else did these doctors tell you? Did they give you any medication? Did they give you any life suggestions? Anything?

(RUTA BITEMAN) No, at that point, they didn’t, and I would say — I got married at 22. A few years later, we started talking about having children, and the pain was continuing, and I was told to maybe take the pill to basically subside some of the symptoms I was having.

(DR PETER SALGO) Then, I understand at some point, you had really bad pain, even compared to the pain you’d been experiencing. What was that?

(RUTA BITEMAN) Yes. In my late 20s, I would say, I had such bad pain one night that I passed out from it, and I ended up going to the E.R., and it turns out I had a cyst that had burst.

(DR LISA HARRIS) Mm-hmm. That was on your ovary?


(DR PETER SALGO) So you had a ruptured ovarian cyst. Did they investigate this pain that you passed out from? They give you tests? What’d they do?

(RUTA BITEMAN) Yeah, basically it was that conclusion — I had a cyst, and at that point, I thought, well, maybe I was free from all the pain that I had been having up until that point, and so I was referred to another doctor ’cause I had told them I wasn’t really happy with my situation on the physician side of things, and I did end up seeing somebody else and explained to her in great detail some of the symptoms, the pain, as well as bleeding in between.

(DR LISA HARRIS) That was another question I was going to ask you. So the pain, did it start before your period at all, a couple of days before, or was it just with the onset?


(DR LISA HARRIS) And that was intensifying?


(DR LISA HARRIS) And now you’re having bleeding in between periods.


(DR LISA HARRIS) And how long were your periods lasting?

(RUTA BITEMAN) Four or five days.

(DR LISA HARRIS) And had they increased or changed?

(RUTA BITEMAN) They changed.

(DR PETER SALGO) What did they tell you was wrong? They said something was wrong.

(RUTA BITEMAN) Well, after I saw the doctor that I was referred to, she ran a battery of tests because I had told her I wasn’t getting any relief, the pain was starting to come back. I really had a lot of faith in her because she was listening, and I could relate with her.

(DR PETER SALGO) Did she give you a diagnosis, finally?

(RUTA BITEMAN) She did. I got that phone call, and –

(DR PETER SALGO) And said what?

(RUTA BITEMAN) That I have endometriosis.

(DR PETER SALGO) Endometriosis. And I’m going to stop in just a moment and get some definitions here, but what did she tell you to do about it?

(RUTA BITEMAN) She said that my only course of action was a hysterectomy.

(DR PETER SALGO) All right, stop. She wanted you to take your uterus out, and you wanted children, and you didn’t want birth-control pills, and you were in pain. Let’s go back. Endometriosis. That’s a diagnosis, finally. What is endometriosis? Either of you can just jump at that one.

(DR TAMER SECKIN) Endometriosis is presence of the endometrial-like tissue.

(DR PETER SALGO) Okay, now the endometrium is the lining of the uterus.

(DR TAMER SECKIN) The lining of the uterus, that causes the menses, menstruation…


(DR TAMER SECKIN) …is displaced outside the uterus.

(DR PETER SALGO) So this tissue that swells, then sloughs off and bleeds with every period —

(DR TAMER SECKIN) Estrogen-sensitive inflammation, essentially.

(DR LISA HARRIS): Did she tell you where your endometrial tissue was?


(DR PETER SALGO) ‘Cause this tissue belongs inside your uterus. When it’s outside your uterus in places where it doesn’t belong, it can cause pain.

(DR TAMER SECKIN) Exactly. It is dislocated off to the offside of the uterus, and the body strives to kick it out, eliminate it.

(DR PETER SALGO) So it causes inflammation and scar tissue, and you brought some pictures. What are we looking at over here? Just describe it.

(DR TAMER SECKIN) This is called the peritoneum — very shiny, beautiful texture.

(DR PETER SALGO) That’s the lining inside your abdomen.

(DR TAMER SECKIN) The lining of the inside of our abdomen, where the bowels move freely and move the content all the way down. It’s clear, smooth, with no problem. Just behind the uterus, this is where the tube and ovary — When we lift tube and ovary, this is what we see there.

(DR PETER SALGO) And that blue color is not natural. That’s dye that’s been injected.

(DR TAMER SECKIN) I use this in my procedures to bring the texture of the peritoneum.

(DR PETER SALGO) So now the next picture shows what?

(DR TAMER SECKIN) The next picture —

(DR PETER SALGO) Look at the difference.

(DR TAMER SECKIN) You see the difference — the earliest scar-tissue formation, defects on the peritoneum, and way up there at 1 o’clock, there’s a main lesion, but there’s more lesions here we can’t really see. Under a microscope, you can see.

(DR PETER SALGO) And I think we have one more picture.

(DR TAMER SECKIN) That holes have — This is more advanced form of the peritoneal destruction with inflammation.


(DR TAMER SECKIN) One more picture.

(DR PETER SALGO) And one more picture.

(DR TAMER SECKIN) And this is how it is. These are grape leaves, like early lesions. Every month these will break and bleed.

(DR PETER SALGO) And hurt.

(DR TAMER SECKIN) And hurt. Underneath, there are blood vessels that feeds these lesions with nerves. Every time it bleeds, the body perceives it, and generally a fatigue feeling, messy feeling, never feeling right, generalized pelvic pain, constipation — you name it. These are covering the bowels, bladder, all multiple organs, and nerves in the pelvis.

(DR PETER SALGO) But I heard you say something very important. It covers the bowel, covers the bladder — can be in

many different places.


(DR PETER SALGO) Just removing her uterus isn’t going to fix this.

(DR LISA HARRIS) It’s not going to fix the problem — not at all.

(DR PETER SALGO) So, she’s had a tough time, and part of her tough time is because she got some crummy advice, and I think that’s because doctors don’t really appreciate this disease. What’s the doctor’s responsibility here?

(DR TAMER SECKIN) Well, you’re not alone Like you, so many women, millions — How about 10 million in America? — major cause of pelvic pain, major cause of infertility and hysterectomy, many unnecessary surgeries. So in this context, early diagnosis, early detection, and proper management is important, and doctors, mothers, we all have responsibility towards public health.

(DR LISA HARRIS) I wanted to throw in there, that means that medical education needs to begin with medical school, because this is implications for pediatrics — not just family practice and obstetrics and gynecology, because in peds is when we are starting to see with the onset of your period, and if pediatricians are not recognizing the symptoms to refer early, diagnose early, you’ll suffer unnecessarily.

(DR PETER SALGO) Wrong therapy, wrong concept of the disease. You didn’t do that.

(RUTA BITEMAN) Oh, I did not.

(DR PETER SALGO) Oh, good for you.

(DR LISA HARRIS) And she did not recommend birth-control pills, or were you already on the pill?

(RUTA BITEMAN) At that point, I was already on the pill just to try to alleviate —

(DR LISA HARRIS) Some of the pain?


(DR PETER SALGO) So, instead of having this surgery, which, as it turns out, wouldn’t have worked, what did you decide to do?

(RUTA BITEMAN) I turned my dismay into — It just turned into anger, and I didn’t know what endometriosis was. I had never really heard about it. I started reading, educating myself, empowering myself, got really healthy, changed my lifestyle.

(DR TAMER SECKIN) Did you have leg pain with periods radiating to your leg or back?



(RUTA BITEMAN) Radiating to my back, for sure.

(DR TAMER SECKIN) Very important.

(DR PETER SALGO) What else happened in your life as you went along this way, empowering yourself?

(RUTA BITEMAN) Well, I had put the idea of getting pregnant out of my mind and focused on just myself, and next thing you know, I was pregnant, so… [ Laughs ]

(DR PETER SALGO) So, you’re pregnant, endometriosis — you didn’t have the hysterectomy.


(DR PETER SALGO) You weren’t on the birth-control pills. It’s kind of a shock, I’ll bet.

(RUTA BITEMAN) It was a pleasant shock.

(DR PETER SALGO) With that pleasant shock, we’re gonna stay right where we are and take a very brief break. We got a lot more ground to cover, but first here’s this week’s “Myth or Medicine.”

(ANNOUNCER) Endometriosis can be a chronic condition that can cause severe pain before and during menstruation. Since menopause is defined as the absence of menstrual periods, does this mean menopause can cure endometriosis? Is this myth or medicine?

(DR AMY BENJAMIN) Menopause cures endometriosis. That’s mostly myth, and I’m going to tell you why. My name is Amy Benjamin. I’m an Assistant Professor at the University of Rochester Medical Center specializing in minimally invasive gynecologic surgery and chronic pelvic pain. Menopause occurs when women stop ovulating and their ovaries stop making estrogen. When that occurs, they stop having periods. So if they have endometriosis, they will stop having pain related to periods. Additionally, without estrogen, the endometriosis will no longer continue to grow, however, it will not necessarily go away. In particular, if women have deep lesions from endometriosis, or cysts on their ovaries from endometriosis, these will not typically resolve on their own. Many women who have endometriosis that causes chronic pelvic pain have other causes for their chronic pelvic pain, and these will not necessarily improve or resolve once they go through menopause. And that’s medicine.

(ANNOUNCER) Not sure if it’s myth or medicine? Connect with us online. We’ll get to work and get you a second opinion.

(DR PETER SALGO) And we’re back with RUTA BITEMAN. Thank you for staying with us. You’ve got endometriosis. You were ignored for a while, then basically told to have a hysterectomy, which wouldn’t have worked. Then you got pregnant despite all the warnings, and so that was a shock, huh?


(DR PETER SALGO) Pleasant one.

(RUTA BITEMAN) Very pleasant.

(DR PETER SALGO) Before we go into that, I just want to ask a quick question because I know our viewers are wondering about this. There’s all of this tissue which belongs inside the uterus that’s outside the uterus. Does it get there during the course of your life? Does something move it around or were you born with this problem? Do we know this?

(DR TAMER SECKIN) Well, that’s one of the biggest dilemmas, but we have an idea where that comes from.

(DR PETER SALGO) Where does it come from?

(DR TAMER SECKIN) It probably comes from the menstruation regurgitating backwards. It’s reverse cell trafficking. Instead of going through the main door, they are going to the fire escape in the back.

(DR PETER SALGO) So some of the cells escape, and they set up shop elsewhere where they don’t belong.

(DR TAMER SECKIN) Exactly. Some of them escape there and get implanted there. The body accepts it. Somehow they fool the body.

(DR PETER SALGO) All right. While you were pregnant, what happened to your symptoms?

(RUTA BITEMAN) Oh, I felt great.

(DR PETER SALGO) And the reason for that is she wasn’t cyclic, right? So these cells that were elsewhere in your abdomen, they weren’t getting any signals to get bigger, get smaller, bleed and hurt.



(DR TAMER SECKIN) But I wanted to ask you a very important question.

(DR PETER SALGO) Go ahead.

(DR TAMER SECKIN) Did you grow distrust to doctors? Is this one of the reasons you didn’t want to go because they will tell you something you wouldn’t like?

(RUTA BITEMAN) Absolutely.

(DR TAMER SECKIN) And your experience was bad with doctors before?


(DR LISA HARRIS) I think the unfortunate part is that you had a trusting relationship with a doctor who then gave you some bad advice, so — the one that said your only course of action is “X,” “Y,” “Z,” and I think in patients developing those types of relationships, if you have a good relationship, and we tell you something off, come back and tell us — “You know, that didn’t make sense to me. I don’t understand that, and I don’t really believe that answer. Can you give me more information or what else — there has to be something else out there.”


(DR LISA HARRIS) And maybe you could have repaired that relationship at that point.

(DR PETER SALGO) Let’s go a little fast-forward. Baby okay?


(DR PETER SALGO) Congratulations.

(RUTA BITEMAN) Thank you.

(DR PETER SALGO) That’s wonderful. After you delivered, and you started your menses again, what happened to your endometriosis symptoms?

(RUTA BITEMAN) I would say the first year or two, it was — I didn’t notice any symptoms, and then it started kicking back in.

(DR PETER SALGO) Okay. So let’s talk just a little shop here, if we can, about endometriosis. Women who have it find the pain unbearable for one reason or another, don’t respond well to medication. Is there a cure for endometriosis? Can you make it go away forever?

(DR TAMER SECKIN) Another dilemma in endometriosis. “Cure” is not the word we like to use. However, with endo, we’re likely to use “highly treatable disease.” Endo’s treatable disease.

(DR PETER SALGO) Well, how do you treat it?

(DR TAMER SECKIN) Unfortunately, you have to treat it — you have to diagnose probably early, and the treatment is by seeing it and by removing the disease in its earliest forms.

(DR PETER SALGO) Let me clarify what you just said. When in doubt, cut it out. It’s a surgical approach that you say.

(DR TAMER SECKIN) Absolutely.

(DR PETER SALGO) There are no drugs to make it go away? You can damp it down.

(DR TAMER SECKIN) It is one of the most misdiagnosed disease and —

(DR PETER SALGO) Why is that?

(DR TAMER SECKIN) Well, it comes with the dilemma. The topic is around the period. There’s misconceptions about periods. Like she named it a curse, which is a great way of naming it, but it’s considered to be normal to have pain, and she’s probably looked at someone who’s making up, trying to find excuse other things in your life while you’re growing up. It’s the common things that the kids face, and they don’t want to talk about it.

(DR LISA HARRIS) I’d like to ask you a question. So, wouldn’t you think that some physicians would have prescribed oral contraceptives just to try to dampen some of the symptoms?

(DR TAMER SECKIN) Absolutely. And one of the things is, usually it comes with other symptoms that’s overlooked — usually G.I. symptoms.

(DR PETER SALGO) But the logic is — I think with Lisa, if I may interpret what she’s asking for our audience. If you can stop the cycling, as happened during your pregnancy, then these cells don’t get big and rupture and bleed, and then the pain goes away.

(DR TAMER SECKIN) It’s not about, really, surgery right away. It’s timely intervention when it’s necessary. However, birth-control pills in the form of controlling the period, the amount of it and making them regular and make the in somewhat containing the endometriosis in a cage.

(DR PETER SALGO) Can you surgically get every last cell that’s causing her trouble? Can you get it all out?

(DR TAMER SECKIN) Well, this is where the technical difficulty of endometrial surgery is. It’s very difficult to get every cell microscopically, but, in general, doctors or surgeons who are trained, particularly for endometriosis, they can see the lesions in its more occult, more atypical form.

(DR PETER SALGO) So you can reduce the burden, the total cell burden?

(DR TAMER SECKIN) Exactly. Usually lesions are described as pigmented lesion. However, maybe the majority of the lesions, maybe over 90 are non-pigmented. They come in atypical forms in every color, and they’re occult and they’re very hidden, and they hide in the most discreet corners of the pelvis. You really have to lift every stone to find it.

(DR PETER SALGO) This sounds like painstaking, frustrating surgery.

(DR TAMER SECKIN) Absolutely. A good endometrial surgery does not last less than three hours.

(DR PETER SALGO) At least three hours.

(DR TAMER SECKIN) Two to three hours at least.

(DR PETER SALGO) Did you have surgery?

(RUTA BITEMAN) No, I did not.

(DR PETER SALGO) So, what was offered you in terms of control of your symptoms going forward?

(RUTA BITEMAN) The pill, basically.

(DR PETER SALGO) And what did you say to that?

(RUTA BITEMAN) I didn’t really have a choice at that point — either bear with it and try to get pregnant, or it seemed to go hand in hand, or take a pill.

(DR PETER SALGO) Okay. And, so, are you on the pill now?

(RUTA BITEMAN) I am no longer on the pill. I took it for many, many years, and was concerned about taking it for so long, gave myself a break, and the pain came back, so I went another route and went with an I.U.D.

(DR PETER SALGO) Okay — an I.U.D.


(DR PETER SALGO) How are you feeling right now with the I.U.D.?

(RUTA BITEMAN) I think, for me, it’s really worked out. It’s controlled.

(DR PETER SALGO) So you didn’t have surgery. Someone like him didn’t go and take all the cells out.


(DR PETER SALGO) But by controlling the cycling, you controlled your symptoms.


(DR PETER SALGO) Is that good enough?

(DR LISA HARRIS) Well, that sounds, to me, like the ultimate thing to do would be to have surgery followed by hormonal therapy to try to control it, and I think that the problems that many of us don’t know that there are surgeons like Tamer that are able to do this type of surgery.

(DR TAMER SECKIN) But it’s interesting. Your symptoms somewhat diminished, but you also said you had painful intimacy.


(DR TAMER SECKIN) Did they get better? Or did you have any bowel symptoms like constipation, painful bowel movement, or your back pain did not disappear?

(RUTA BITEMAN) The back pain, I did have that — yes.

(DR TAMER SECKIN) So you, at present, don’t have any symptoms because of the I.U.D.?

(RUTA BITEMAN) Very minor. It’s definitely subsided.

(DR TAMER SECKIN) Wonderful.

(DR PETER SALGO) So, again, my question, why do anything more at this point? Would you do anything more?

(DR TAMER SECKIN) Unless there’s a strong history of ovarian cancer in the family, I wouldn’t do anything more. I would be checked by sonograms routinely to make sure that there’s no growing of the lesion or somewhat developing constipation. I think your — not every endometriosis progresses.

(DR PETER SALGO) Mm-hmm. Okay. Now, you have in front of you two of the pre-eminent physicians in America. This is your shot to ask for a second opinion — any question you’ve got. Fire away.

(RUTA BITEMAN) [ Sighs ] Oh. So many questions.


(RUTA BITEMAN) [ Chuckles ] Is there any idea where it really comes from? I mean, the backflow you mentioned of that endometrial –

(DR TAMER SECKIN) Well, that’s one of the theories.


(DR TAMER SECKIN) However, every woman have backflow. The caveat is when this backflow really happens. Not every backflow happens in the same period. We are suspecting today this backflow probably happens during birth of young girls. It’s sudden withdrawal of the maternal hormones. We know that 6% of the newborns we can observe like a mini period in newborns, and that is one area. The other time is before the real period starts, there is a time from the breast development until the period starts. There is action continues on the uterus. There could be backflow then. However, I have to also warn, it’s not only backflow. There is genetic predisposition, the uterine configuration anomalies like double uteruses, or occult septums, or [Indistinct] of the uterus, and, more importantly, there is people may be born with it, too, genetically, so that’s also valid. It’s called [Indistinct] — the way it is structured. So, but most likely, the disease is associated with the periods. I believe in that theory a little bit more, but I respect the other theories, yeah.

(DR PETER SALGO) I’m gonna leave with one question for you. Knowing what you know now, having been through what you’ve been through, what advice do you have for women who are experiencing these symptoms?

(RUTA BITEMAN) Oh. I would say, first of all, follow your instinct, your gut. If you’re not getting all the answers that you need, just keep looking for them, educate yourself. That’s empowering in itself, and talk to other women. I have learned from just doing this interview show here today that so many people do not know yet what it is and don’t know that their lives, or how their lives are affected by it with family and friends and so forth.

(DR PETER SALGO) Well, thank you so much for being here. Panel, thank you, of course, for joining us, as well. And I want to thank you, of course, for your insight into this case, and to end today’s show, here’s this week’s “Second Opinion 5.”

(DR JORGE CARRILLO) Hello. I’m DR Jorge Carrillo, and I’m going to tell you five things about endometriosis. First, endometriosis is a benign condition that usually affects reproductive-age women in which the inside tissue of the uterus is implanted outside the uterus. This brings inflammation to the surrounding organs when menses occur. It frequently occurs next to the ovaries, the fallopian tubes, outside the uterus, even sometimes will affect bowel or bladder. Second, endometriosis can be asymptomatic, but usually you will experience very painful periods. You may also have pain with intercourse or infertility. Long-term, this condition is a very frequent cause of chronic pelvic pain. Next, a doctor will usually start treatment based on clinical suspicion, but the diagnosis is surgical. We do a laparoscopy and take samples of the tissue that seems abnormal. Fourth, you can help the discomfort by using NSAIDs like Ibuprofen. The real question is, are you planning to conceive any time soon? If the answer is yes, the goal is to make this happen spontaneously, with medications, or with the help of an infertility doctor. If the answer is no, the goal is to stop your periods, and this we can do with birth-control pills, injections, or implants, for example. And lastly, indications for surgery are to confirm the diagnosis if we can’t control symptoms with medications, if we identify an ovarian cyst, if there is infertility, or if we suspect involvement of organs like bowel or bladder. Depending on goals for future fertility, we do a laparoscopy with removal of lesions versus a hysterectomy. A hysterectomy is not always the answer since you could have other chronic pelvic pain conditions. And that’s your “Second Opinion 5.”

(DR PETER SALGO) Thank you so much for watching, and remember, you can get more second opinions and patient stories on our website at You can continue the conversation on Facebook and Twitter, where we are live every day with health news. I’m DR Peter Salgo, and I’ll see you next time for another “Second Opinion.”

(CHILD’S VOICE) There once was a time when we were truly free — free of worry… free of fear… far from doubt. That is strength. That is power. That is fearless. “Second Opinion” is funded by Blue Cross Blue Shield, which is committed to improving healthcare accessibility and supporting more affordable community clinics where care is limited. Blue Cross Blue Shield.

(ANNOUNCER) “Second Opinion” is produced in conjunction with U.R. Medicine, part of University of Rochester Medical Center, Rochester, New York.

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