Dr. Karen Tang (3:26)

It was maybe, like, around, like, when Covid happened that I first heard about it, because there were women who were protesting the statue in Central Park. There was a statue of J. Marion Sims. And that was the first time I actually had ever heard that story. For those who don't know, J. Marion Sims was literally. He was called the father of gynecology. And he was very famous for developing techniques for surgical repair of vesicovaginal fistulas, which can happen because of childbirth. And what most of us didn't know is that he actually had experimented on enslaved women, that he had practiced his techniques on unnecessary slave women. The actual number is unknown, but there were three women, Betsy, Anarcha and Lucy, who. We actually know their names, but there were many more who were unnamed. And I had. It was quite shameful. I could not believe that I did not know this story. And like Dr. Malone was saying, we have instruments named after him. They're called Sims retractors. The speculum that we use nowadays for pap smears is actually developed by him. I couldn't believe this. I thought this was a rumor. When I was researching my book, I actually found the whole scanned copy of his journals where he literally wrote about. He bent a spoon. He literally bent, like, a pewter spoon so he could retract and look inside the vagina. So all of this is just stranger than, you know, like, you would think it be, like, fiction, but it's actually the harsh and terrible reality of our field. And I think the fact that it's taking us so long to acknowledge and even know that this existed, I think is part of the reason that there's so much embedded, you know, like, racism, misogyny into the history of our field that we didn't even recognize. And it sort of infiltrates the way that we see patients. The lack of research, you know, how different women, black women, are viewed in terms of their perceptions of pain. Like, it really is quite foundational, right?

Dr. Sharon Malone (5:22)

And even just the notion that it took until like the 1840s before gynecology, even as a field of study, was something that anyone was ever interested in. I think that was probably his biggest contribution was like, oh, women need somebody to look at their women parts. You know, that in and of itself was revolutionary.

Dr. Karen Tang (5:42)

That's why I felt it was important for the book to start with a history chapter. You know, I think I made the point to my editors. I was like, I feel like I can't just like launch into medical facts without giving like a groundwork. Because, you know, the. It's not just about like lab values and hormone levels. It's about like human beings. So, you know, it was really something that I felt very strongly about to kind of center it and give this, you know, this context. And also as I was writing, like each of the different sections in the history chapter, I kind of draw back an association to how things happen now. So, for instance, you know, the. A lot of women with endometriosis, which is a very common condition that causes chronic pelvic pain, are told still today to get pregnant to treat their endometriosis. And the reason that that rumor exists is because people may temporarily feel better in pregnancy, like because of hormone changes, but it's obviously not like a long term fix. The crazy thing is that women have been told some variation of that to get pregnant to fix their health problems for all of human history. So it's like all the way back to ancient Greek and Egyptian times and ancient Roman times, we were like, well, is there something wrong with your health? Just get pregnant. It means your body's starving for pregnancy. Or that's going to be the answ.

Dr. Sharon Malone (6:59)

Please tell this story about the wandering womb.

Dr. Karen Tang (7:01)

The wandering womb. So yeah, literally, I've never heard of it. Isn't that funny? I love this story. So, yeah, ancient Greek, Roman, Egyptian times, they literally thought your uterus moved around your body and that it was like almost like an animal, like seeking things, seeking sex, seeking pleasurable things, seeking pregnancy. And so they actually would treat people by, you know, tempting the uterus with things that they thought they would like. Like, say like you, you should have sex. Like if you are unmarried, the reason you're having health issues, more sex. Or literally they would hold up sweet things to like the pelvic area to say, like tempt the uterus to come back to where it's supposed to be. And even, you know, like Plato, like one of these, like these, you know, foundational, like philosophers. He's like, you know, this, this founding father of philosophy. Like, there's literally quotes about him saying like the wandering womb and how it affects like women. And it's, it's just wild. It sounds so ridiculous. But like, this literally was like for, you know, hundreds of years, something that people actually thought like these actual, you know, health specialists thought was what was happening with the body.

Dr. Sharon Malone (8:06)

Right. Because every, they thought that everything that women somehow it was always just shrouded in equal parts mystery and shame. You know, they kind of went hand in hand about why we behaved. And I think that, you know, historically people just threw their hands in the air and go, oh, women, they're so complicated.

Dr. Karen Tang (8:24)

Why even both Crazy. Yeah.

Dr. Sharon Malone (8:26)

Come up with something crazy. And then now we have subspecialties in GYN and some of which are really of a relatively recent vintage. And I want you to just go through because people don't understand what the difference, like what do the different subspecialties do?

Dr. Karen Tang (8:44)

Yes. And this is so exciting for me to talk about because I don't think anybody has ever asked that in an interview. You know, we jump right into like the specific issues and, and topics. And like a lot of people don't realize that there are these subspecialties for people who, who need more specialized care. So Minlane base of GYN surgery is for the surgical management of things like endometriosis, fibroids, cysts, and it sort of is related to pelvic pain because so many of those conditions cause pain that are specialty also trains in the diagnosis and management of complex pelvic pain. So we work very closely with pelvic floor physical therapists and the urogynecologists who specialize in the bladder and the pelvic floor and bladder function and support of the pelvic organs. There's cancer, so there's GYN oncologists, there are ob high risk OB specialists called maternal fetal medicine. So there are all these different subspecialties that really kind of dive into more of the specialization. So I think a lot of the struggle that sometimes the average patient goes through in trying to get the care that they need is that they may only ever depending on where they live. You know, if you're more remote area only have access to just, you know, not just but like to general OBGYN and not to some of these like uber subspecialists. And it's very hard. Like, you know, just like primary care where primary care doctors are absolute heroes because they're trying to handle so much. And I feel exactly the same way about rural OB GYNs, because they're literally doing the jobs of like 10 different doctors. But that's very difficult. And it's hard for the doctors, it's hard for the patients sometimes if they're really kind of, you know, have a very complicated situation medically and it's hard to kind of get that super specialized care. So I think it's really important. It's important to talk about the system because I think a lot of people's disappointments with our field, their bad experiences sometimes is because of this difficulty getting the exact knowledge base and specialization that they need.

Dr. Sharon Malone (10:41)

Right. And then the, and then the, the. The whole field of reproductive endocrinology has changed. And because again, when, believe it or not, when I started, IVF was relatively new and they did a lot of the endocrinology type stuff that, you know, pcos and things like that that they. Endometriosis that they don't do anymore, that's like, oh, no, that goes to somebody else. That's now in your wheelhouse now.

Dr. Karen Tang (11:08)

Absolutely. So that's a big difference. So again, I started my residency in 2005, and back then the endometriosis and fibroid specialists were the fertility doctors because again, they were doing these surgeries and managing patients who. Those conditions were affecting the patient's fertility. Over time, it's changed very much because a lot of fertility doctors now, they are primarily, you know, managing infertility on the level of, you know, IUI or IVF cycles, egg freezing, et cetera. And now there's many more. So migs is now actually the most competitive specialty, which again, like, back when I started, nobody even knew what it was. Like, what is that? And now it's become much more popular, especially topics like endometriosis have really been on the forefront of a lot of, like, social media discussions and things like that.

Dr. Sharon Malone (11:54)

I want to get to what you do and this minimally invasive gynecologic surgery. Do you say migs? What do you say?

Dr. Karen Tang (12:02)

Yeah, we abbreviate it. Migs.

Dr. Sharon Malone (12:04)

Okay.

Dr. Karen Tang (12:04)

But nobody knows what that is, so you end up having to say the whole long crazy name.

Dr. Sharon Malone (12:08)

Okay, so for everybody here, minimally invasive gynecologic. Gynecologic surgery, we're going to say migs from now on. Just as the mouth. Exactly what is the difference in approach, minimally invasive versus traditional surgery? And I'll just tell you. Traditional surgery is, oh, you're having a hysterectomy, you go in, you have an incision, doctors go in they put their hands on, and they remove your uterus or whatever it is that they're going in there to do your fibroids. That's traditional, what we call laparotomies, which is an open procedure. Now, tell our viewers and listeners what the difference is. What is a minimally invasive gynecologic? Because we're doing the same procedures, but what's your technique that's different?

Dr. Karen Tang (12:50)

Exactly. So the name kind of gives a little bit of the hint away. So when we think about laparotomies or what we call, like you said, open procedures, people think of it as, like, the bikini cut incisions or C section incisions. It's a big incision across, like, your lower abdomen for GYN surgeries to do things like hysterectomies, fibroid surgeries, cyst removal, et cetera, as you can imagine. And those of you who have been through these surgeries know it's a lot to recover from. It's a big incision, and it can be painful. It can really limit your activity, your ability to kind of, like, walk around and exercise and do the things you want to do in your life. So minimally invasive GYN surgery is basically using techniques that have much smaller incisions, that have less pain, risk of hernias, which are, like, weaknesses in the strength layers of your body, and less blood loss, and there's less risk of scarring. It basically just gets you back to your life faster with less pain, less risk of bleeding and infections and things like that.

Dr. Sharon Malone (13:49)

A lot of it is outpatient.

Dr. Karen Tang (13:51)

Yes. And I actually do all of my hysterectomies outpatient, which means that you don't have to stay in the hospital in terms of, like, the experience. You know, pretty much everybody who would have a choice would say, yes, I would rather have. Have the version that, you know, less painful, less of a recovery, gets me back to what I need to do. Like you were saying, there are obviously lots of situations, medically, where you would need to do the big incision either because something like the uterus is just way too large. It would take forever to complete the surgery with the tiny, tiny incisions. Like, like you said, you have to get a huge uterus out of the body, even if you, you know, detach everything with a tiny incision. So it's. It would make sense to make, like, four teeny incisions and then make, like, a decision this big just to, you know, cut the whole thing up.

Dr. Sharon Malone (14:34)

Right. Because when you add them all up, it'd be the size of a regular lab. Right. You may have done it the other way. So tell me, what types of procedures, what surgeries are appropriate for minimally invasive gynecologic surgery. So hysterectomies, what else?

Dr. Karen Tang (14:52)

Yeah, so hysterectomies, which is just to clarify. Cause a lot of people are confused, actually, about what that means. It just means taking out your uterus. A lot of people hear the word hysterectomy, and they think it means taking out your ovaries and dropping your hormones or causing menopause. So just to kind of say right up front, hysterectomy is just taking out your uterus, including usually the cervix, which is the opening, the fallopian tubes. They're all attached together. And also, we mentioned a couple of times, endometriosis, which is probably one of the most common causes of chronic pelvic pain. Really, really painful periods, pain with sex, inflammation, bowel problems, bladder problems, get worse with your periods and endometriosis diagnosed and removed surgically. Meaning that it doesn't tend to show up on imaging studies unless it's more advanced. Which, if you imagine, like, you know, with the incision, like a C section incision, you had to put your whole head into the incision, like, you could still barely see. So that is actually one of the few surgeries that, like, you know, pretty much all endometriosis surgeries are done laparoscopically. It's almost impossible to really do a good job with a big incision where you can't see that closely. But surgeries for fibroids, which, you know, can include things like hysterectomies, but also surgeries called myome, which are where you cut the fibroids out of the body. And then ovarian cyst again. Most ovarian cysts can be taken out laparoscopically. Even if they're pretty big, you can still drain the fluid out and do the surgery. And then a lot of G1 cancer surgeries are done laparoscopically, too. So unless there is a big, big tumor where you'd be afraid of, you know, you can't cut it because it could spread the cancer. Uterine cancers, almost all of them are done laparoscopically because the cancer is contained inside the uterus. You take out the uterus, the ovaries, and do lymph node deceptic sections, all laparoscopically. So that's been a big change.