Dr Louise Newson: [01:00:00] This podcast is great to listen to. I'm with a gynaecologist, Tony Chalhoub, who specialises in endometriosis, but I tell you what he also specialises in is listening to patients. And this is something that sadly, so many female patients are not listened to, they're not believed, they're not understood. So this is gonna make your heart warm listening to this. So enjoy it. So, Tony, this is great because this is you as a gynaecologist in my podcast studio. And it's interesting because I'm not a gynaecologist. I'm a GP, I'm general physician as well. I've done a lot of hospital medicine. And traditionally, hormone care, menopause is a gynoecological specialty. But I sort of challenge that because like the hormones get everywhere, don't they. It's not just gynaecology, is it?  [01:00:53][53.3]
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Tony Chalhoub: [01:00:53] Yeah, correct. I mean, Louise, thanks very much for inviting me. You know, it's really a pleasure to meet you, eventually put the real face to the name. No, you're doing fantastic work and I agree with you. As a general practitioner, to be honest, you're more familiar with the patient's co-morbidities, with the history. So really, it should sit with the general practitioner when it comes to hormone and hormone replacement therapy. And you have some specialists, also gynaecologists. A really nice thing about the obstetrics and gynaecology is it's multi-disciplinary within the same specialty. You find the hormone replacement therapy is like a niche within gynaecology. Unfortunately, we're not taught through our training.  [01:01:36][43.1]
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Dr Louise Newson: [01:01:36] No.  [01:01:36][0.0]
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Tony Chalhoub: [01:01:37] And it comes up, you become a consultant, somebody comes to you, and then all of a sudden, oh my God, what can I do? And either you scare the patient off their... About it, even if they don't have any co-morbidities, just because you're not familiar with, where really, in a sense, you need to refer them to somebody who understands, rather than trying to scare them off and put them off.   [01:02:02][24.9]
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Dr Louise Newson: [01:02:02] Well, this is the thing, and you know, your career has been really interesting and you've changed and learned, and I think in medicine, our learning doesn't end the day we become doctors or the day we choose our specialty. It's constantly evolving and also, we do have a responsibility to train and teach others as well, don't we? And so if you just talk a little bit about your career, because it's really interesting how much you've done.  [01:02:25][23.2]
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Tony Chalhoub: [01:02:26] Yes, thanks, Louise. So basically I did my training here and I'll give you a little background, why did I do, for example, obs and gynae, what attracted me. And some patients, they do ask this question being a male, sometimes I don't understand why they're asking the question, but then it rings a bell for me. I was the only doctor, you know, I'm Lebanese in origin. My wife, Sarah, is here, is  British and from Newcastle. So I came in as a house officer to the UK and I did my training throughout, up and down the country from Haywards Heath, Princess Royal Hospital all the way to Aberdeen.  [01:03:01][35.4]
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Dr Louise Newson: [01:03:02] Yes.  [01:03:02][0.0]
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Tony Chalhoub: [01:03:03] But you know, but I got my national train number in Newcastle and then straight away I got the consultant post in there. So that, to be honest, Louise, even though I was like a travelling trainee...  [01:03:14][11.7]
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Dr Louise Newson: [01:03:14] Yes  [01:03:14][0.0]
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Tony Chalhoub: [01:03:15] ...it opened my eyes to lots of good practices and not as good practices. And this is where you pick up the good and you keep and you learn not to do the things that you thought and you don't want to do. Then in Newcastle, I was very humbled, you know, came into a unit, big teaching hospital, has lots of, very specialist. Straight away, I was able to change the, the culture within where, for example, office gynaecology wasn't heard of then, to offer women like outpatient hysteroscopy as part of their choice. Equally, not everybody can have outpatient, so you don't force it on it. So we were the first to bring the anaesthetists down and offer conscious sedation hysteroscopy, for example, in the outpatient setting. So that gave the patient the choice, but equally the innovation to the trust. And that means patient can come in and have her procedure in the morning and go pick up her kids half an hour or an hour later. And that was originally meant to be for, like by default for endometrial ablation. And then that expanded, it became some, the poor women, they cannot even tolerate cervical smear. You don't want to put them to sleep, but at least they have this option and lots of other indications. Same time, I set up in Newcastle, an endometriosis centre. So we became accredited to 2012 until I left in 2024 November in Newcastle. And as part of my role, also I was deputy lead for gynaeoncology unit. So we had the one stop postmenopausal bleeding clinic or what we call the rapid access clinic or cancer wait clinic where any patient presenting with anything suspicious of cancer. So you diagnose them and if they turn out to be high grade endometrial, for example, you refer them to Gateshead. If low grade, I used to operate on them locally. And that also with that you'll have lots of other indications like breakthrough bleeding. Women on hormone replacement therapy, postmenopausally or premenopausally, lichen sclerosis, all these things. And then, foward to 2014, I started the robotic assisted surgery. I was one of the innovators on the complex benign, because robotic assisted surgeries is another form of laparoscopy. So it's nothing really exciting, other than ergonomically a better position. And then the instruments evolved to allow you to do much more minimally invasive where laparoscopy is fantastic and was gold standard for anything gynaecologic. However, you reach a point where it becomes a bit difficult or challenging or also even challenging to teach. For example, myectomies, you know, fibromas, leiomyomas, so they're quite common. It's the most common benign growth mass on the women's womb, yet again another like the HRT, I was the only one up in the north east who offered the service to poor patients where others used to scare them, oh no, if you have a fibroid removed, you're going to bleed to death, have a hysterectomy or live with it. You know, and again, because unfortunately, same with menopause and hormone replacement therapy, pre-menopause and menopause, we haven't been taught, you know, it's not like essential. [01:06:59][223.5]
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Dr Louise Newson: [01:06:59] I mean, it's so interesting, isn't it because there's so much, I did a podcast earlier with a medical student and there's very little training as an undergraduate about hormone treatments, what they are, what they do, and even what hormones, progesterone, estradiol, testosterone do in the body. And then as GPs, no training, gynaecologists, there's very little training and it really varies. And I feel sorry for gynaecologists actually, because you know, you are trained as a surgeon, you do the most amazing laparoscopic surgery, robotic surgery, all of this. But then because people don't know about hormones, they often still get referred to the gynaecologist for advice. And so the advice, the treatment can really vary between different gynaecologists. But then the other thing that I think about a lot is bleeding is a really common symptom. It's a really common side effect of hormone treatment, and it usually settles with time. And women who take combination, so estradiol, progesterone, the continuous progesterone, their risk of endometrial cancer is lower than not taking anything. But the problem is if they're over the age of 50, then they always get fast-tracked into a query cancer two-week referral. And so the clinics are flooded with people who really are not very high-risk for getting cancer. And often when I take a good history from them, they've been on holiday, They've forgotten to take their progesterone for a few days. They've also had, I don't know, a urinary tract infection and the bleeding is actually from the wee not from their vagina. Their patch didn't stick on very well and then they had some bleeding. So it's not going to be suspected cancer, but they are just fast tracked into this. So a lot of the hospitals are really flooded with women who shouldn't really be needing two-week referrals, should they?  [01:08:53][114.2]
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Tony Chalhoub: [01:08:54] Correct, I agree with you and that also put the fear of God in these poor women.  [01:08:57][3.7]
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Dr Louise Newson: [01:08:57] Of course it does, because they get letters saying suspected cancer.  [01:08:59][2.2]
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Tony Chalhoub: [01:08:59] At least one in ten will be cancer and you have to be seen and then as part of setting up a post-menopausal bleeding clinic where patients they come in, if the endometrial thickness, in order to fast track them, not delay their cancer waiting pathway, we offer hysteroscopy for endometrial thickening. However, you find some of these patients, they had a hysterectomy before, still they are here for potential endometrial cancer which is crazy and some patients like you mentioned rightly so they might have lichen sclerosis that led to a little bit of itching.  [01:09:32][33.3]
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Dr Louise Newson: [01:09:32] Precisely.  [01:09:32][0.0]
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Tony Chalhoub: [01:09:33] So a little bit of blood on the underwear. Oh my God, you have cancer.  [01:09:36][3.2]
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Dr Louise Newson: [01:09:36] Then people worry and in medicine, you know, I'm sure you were taught the same, most of the diagnosis is in the history and it's difficult when you're busy and you've got lots of patients, but sometimes taking a bit of time to take a history, you don't have to need your, I mean, when I as a GP for many years, we didn't have two week referrals. It wasn't there. So we had to prioritise, is this urgent or is it not, how much can we do ourselves? Take a really good history. You might try something, if it helps, fine, and if it doesn't, you try something else, and then you might speak to one of your mates who's a consultant gynaecologist, and say, what do you think? Oh, that sounds like we need to be seeing them, in they go, whereas now it's a bit more tick box, really, have they had bleeding, yes or no? Are they this age, yes, or no? Off they go. And there are some guidelines that came out with HRT to say, one of the things you could do is stop the HRT, and if the bleeding settles, you know it's related to HRT. Now, I've seen a lot of women whose symptoms have come straight back, especially their mental health symptoms, and it doesn't feel the right thing to stop an evidence-based treatment because it's still not helpful, is it?  [01:10:44][68.2]
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Tony Chalhoub: [01:10:45] Correct and I agree with you and for many reasons one because they fast-track they're gonna get a diagnosis very quickly.  [01:10:50][4.9]
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Dr Louise Newson: [01:10:50] Yes. [01:10:50][0.0]
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Tony Chalhoub: [01:10:51] And continuing on hormone replacement therapy for another two weeks or four weeks is not going to worsen than their prognosis. They're not going to get cancer. I agree would you Louise and that's why I say, you know I follow you on Instagram and I see you do fantastic work because the patients, I mean you have to be a patient to realise. I remember you know, I'm not a bear, but my wife sometimes, you know, she shaved my back a little bit and then one day she told me oh Tony you have this thing on your back, it wasn't there before. Make the story short that triggered going to a GP. Again, I'm sitting I cannot see the thing you know more looking at a photo and then blew it up and the GP started the terminology irregular borders and blah blah blah referring me to the melanoma clinic.  [01:11:40][49.1]
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Dr Louise Newson: [01:11:40] Oh gosh.  [01:11:41][0.0]
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Tony Chalhoub: [01:11:44] Then, long beforehand, I lost a very close friend, a colleague of mine, to pancreatic cancer. He passed away within six weeks.  [01:11:50][6.0]
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Dr Louise Newson: [01:11:50] Oh gosh.  [01:11:51][0.6]
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Tony Chalhoub: [01:11:52] At the age of 54. So all these things start playing in the back of your mind. I go to the melanoma clinic, another person, all of a sudden I have like, you know, like you go and you watch the movies in the States, how they start taking pictures of you. They brought behind me pictures and then I remember the clinical nurse specialist, she said, oh, we could take a little biopsy or we could remove it. I said, please remove it, how big is it? And then for two days, we got the surgery really within 48 hours. Those 48 hours, a million things went in my head. You start thinking about your kids. So really, like you said, Louise, education or educating us about being in the place of a patient that you'll see how it could affect you. And these poor women, not only they've been asked to stop hormone replacement therapy, some of them, they got recurrent bleeding and then what would you do. And that bleeding could be because they're so dry and they need a little bit of estrogen. So that will put them off sex for the rest of their life. Because every time they have intercourse, oh my God, go to the two weeks wait. So it's really crazy.  [01:12:57][65.5]
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Dr Louise Newson: [01:12:57] It's severely worrying, and I think it is a hard time. There was a study that I read recently looking at urologists, and a lot of them are so scared to prescribe vaginal hormones because in the insert, it says risk of clot stroke, heart disease. I mean, it's completely wrong. But if people are not being updated, if the computer systems are linked with the wrong warnings, are scaring people, then they were saying that they are scared to prescribe vaginal hormones and they haven't got the right education. So then they're putting women's symptoms are continuing or they're too scared to ask the questions because then the women might want treatment and they don't know how to prescribe. So it's a really difficult time and I think things are changing because women are getting it and women are understanding it often quicker than healthcare professionals. And a few months ago, someone I trained with actually phoned me up and he's a cancer surgeon. And he said, Louise, what do you think you're doing? He said, I'm really cross. I said, what'd you mean? He said because women now are asking for hormone treatments after having cancer and it's outrageous. I said oh, is it? Is it really outrageous? Surely they can have a choice. And he says, well it's making our clinics really busy because the women won't stop asking questions and the consultations are longer. So he was worried that the consultations were being too long, and in my mind, like I don't know what it's like to have cancer, but women still get benefits from hormone treatments regardless of their cancer. So for their bones, their heart, their brain, all their systems can improve and their symptoms as well, obviously. And so he was so cross. He ended up putting down the phone and I really respected him as a medical student. So I was quite surprised. But you know, women, I see a lot of women and I hear from a lot women through my social media. But women who've had cervical cancer, who have been told, you absolutely can't have hormone treatments. And these women are quite young often, so they've had a total hysterectomy, everything's been removed. And then often chemotherapy, sometimes depending on the cancer, they might've had radiotherapy. So you've got a lot to deal with, and then they've got no hormones.  [01:15:08][130.8]
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Tony Chalhoub: [01:15:08] Especially the disease, the human papilloma virus disease, it's nothing...  [01:15:12][3.5]
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Dr Louise Newson: [01:15:12] It's not related to hormones is it?  [01:15:13][1.4]
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Tony Chalhoub: [01:15:14] No, but equally Louise, I used to counsel patients and, you know, ignorance is really harmful for us and for the patient, because the evidence even in endometrial cancer, certainly low-grade endometrial cancer, if somebody is below the age of 50, the longevity is increased with keeping their ovaries. I know there is, and the ovaries produce a lot more hormone than the HRT that you've given them.  [01:15:41][27.0]
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Dr Louise Newson: [01:15:41] Absolutely.  [01:15:41][0.0]
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Tony Chalhoub: [01:15:41] For that reason, for the cardiovascular, for the bone density, but also for, these are young women below the age of 40, sometimes, you know, they're 50. They get endometrial cancer and then what we do, we keep their ovaries, you now, we'll biopsy them, because you have maybe nearly 5%, they have synchronous ovarian, and if the biopsy is normal, then you don't have to remove the ovary for that particular reason, but like I just mentioned, ignorance unfortunately.  [01:16:09][27.7]
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Dr Louise Newson: [01:16:10] Absolutely. And also there is uncertainty. We don't know because no-one's done the studies, there'll never be randomised control studies looking at people. And even if there were, your patient is not the same as the patient in the studies. And I saw someone recently who'd had breast cancer 12 years ago, and she had been told she can never have hormones, ever. But she's now got osteoporosis. She's got raised blood pressure. She has given up her job because she can't think properly. And she said, I've spoken to all my family. I have spoken to my GP, I just want to try some hormones. And if they help the way I feel, then I'll probably continue, but I just want to try them. You know, I don't drink, I didn't smoke, I exercise. So it's like, well, that's your choice, really. And that's fine.  [01:16:54][44.6]
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Dr Louise Newson: [01:16:57] Before we continue, I'd like to tell you about Newson Clinic, the sponsor of this podcast. I founded Newson clinic to improve access to expert evidence-based hormone health for women. My clinic makes this podcast possible, allowing us to continue sharing free education and information to help women better understand their hormones and health. To learn more about Newson Clinic or book an appointment, visit www.newsonhealth.co.uk. This link is also in the show notes.  [01:17:28][30.8]
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Dr Louise Newson: [01:17:31] I think it's really awful when I see people who have been devoid of all their hormones, but it's interesting. I'm 56, so I had a hysterectomy when I was about 48 and I decided to keep my ovaries and my consultant really wanted to take my ovaries out and I was already taking hormone treatment then, but I said well I, they're probably producing hormones that I don't even know about and I just don't see the point of them coming out. And he said, well, okay, well, when you're 55, come back and I'll do a laparoscopic bilateral oophorectomy so take out both your ovaries and then when I was 55 my husband said are you going back to see him? And I said no like why would I like would you take your testicles off so you don't get testicular cancer and he sort of crossed his legs and went oh well no you're probably right but it feels a bit weird doesn't it to just... [01:18:17][46.0]
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Tony Chalhoub: [01:18:18] Especially if you don't have any family history or risk of any breast or ovarian cancer, to remove it, like you said, we don't just start chopping people's arm and legs off. Especially nowadays we're doing things minimally invasive. In the past they used to do midline open surgery. One would say, oh my God, if something happened with your ovaries, it's going to be a nightmare to go in. Nowadays... [01:18:39][20.6]
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Dr Louise Newson: [01:18:39] It's very different now, isn't it? [01:18:40][1.5]
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Tony Chalhoub: [01:18:40] It's very easy to go back, you know, and remove, and at least you owe it to the patient to discuss the risks and the benefits, if any.  [01:18:48][8.2]
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Dr Louise Newson: [01:18:49] Yes, I mean, if I had a strong family history, or I had BRCA gene, I would sit down and have a different conversation. And it's a choice thing, you know, absolutely. But to just sort of take them out regardless, which is what happened, you know, more and people now I think are changing and thinking, which is good. [01:19:05][16.3]
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Tony Chalhoub: [01:19:06] I think so. I mean, thanks to these podcasts and then now patient awareness, you know, it's fantastic. Especially the evidence, even in endometrial cancer, the benefit is to keep your ovaries, let alone at age 48, they want to remove your ovaries for, I presume, you know, a benign disease, it's...  [01:19:23][17.4]
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Dr Louise Newson: [01:19:23] It doesn't make sense really does it? No. But it's also interesting. So I was at a conference in America earlier this year and someone was talking about the guidelines and pathways for POI, premature ovarian insufficiency. So this is women under the age of 40 and we know it's common it's about 3-4% of women and as you know without those hormones there's all these health risks. But they were talking about if women who were under the age of forty had a surgical menopause and so they had their womb removed with their ovaries, then they would only need estrogen. So I got the microphone at the end and I said to the speaker, look, we know that our ovaries also make progesterone and testosterone. So why would you not give all three hormones back? Why is it the decision just for estrogen? So she said to me, Louise, that's because that's what the guidelines say. And everyone in the audience liked gasped. Then she said, next question, please. And that was me being just... But I'm one of those doctors, for many years, only gave estrogen to women who had a hysterectomy because I said, which is partly true, you haven't got a womb so you don't need progesterone for your womb. But then over the years I've realised progestorone affects every cell in the body and it's very beneficial. So now if people have had a hysterectomy, we talk to them about progesterone and testosterone as well, especially if their ovaries have been removed too. But it's a changing conversation, isn't it? [01:20:48][84.7]
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Tony Chalhoub: [01:20:48] Yes, because like I said, we talk to patients and then you talk to patients, that's the important thing. You're right and progesterone nowadays, you have bioidentical progesterone.  [01:21:00][11.4]
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Dr Louise Newson: [01:21:00] Exactly, it's very different to the synthetic.  [01:21:02][1.8]
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Tony Chalhoub: [01:21:02] Very different. We're not worried about breast cancer anymore. Come back to women, that poor patient you were talking about, who had a mastectomy, I suppose, you know, the lady with the breast cancer. If you remove the glands, the whole breast, you also the risk going from... nearly nonexistent, you for her to recur. So no, the nice thing is we need to educate ourselves more. Certainly, I feel the Royal College of Obs and Gynae now through having a president who's a gynaecologist, the last president and the current president, they're looking more into not only the surgical pathways where to, because it's scary, even as a gynaecologist to become a first-year consultant, all you have to be signed off to complete your training, to be able to do open self-injecting, removing a fallopian tube for ectopic pregnancy, not even laparoscopically. So these things has to go within our core curricula. Same with the research. So just so people become a little bit more savvy to go and research and study the guidelines. And you find lots of guidelines based on very flimsy research. So if you start microscoping the evidence, you'll find either a lax or it's not very good evidence. [01:22:31][89.0]
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Dr Louise Newson: [01:22:34] It's not very robust is it. I was trying to find a study, I've tried many times to show that estradiol causes endometrial cancer. We've known for decades since the 1970s that the pregnant horse urine, the Premarin, is associated with a small, it's only small, instance of endometrial cancer. We know ethanylestradiol, which is the synthetic estrogen in contraceptives, is associated with a small risk of cancer. But estradiol on its own, I can't find. And whenever I read guidelines to say, give progesterone because of the risk of unopposed estrogen with cancer, I can't still, what they refer to is not about estradiol, it's about older types of estrogen. And so like for me, language is really important, but also showing people lack of evidence is also really important because I think sometimes, and I've written books on evidence-based medicine, so I'm used to really unpicking the data. But when you're a busy clinician, you just read the top line. It's like reading the headlines, isn't it? And so then you also learn by rote. So if someone tells you estrogen causes cancer, you go, oh, okay, therefore it must do. But then someone like me will say, well, hang on, what do you mean by estrogens? Do you mean estradiol, estriol, estrone or a synthetic estrogen because they're all very different metabolically. And then people say, well, fat cells produce estrogen, people who are overweight have more risk of cancer, but then our fat cells produced all sorts of inflammatory cytokines as well. So then you have to be, and it's fine to say, I don't know, I think in medicine and I'm sure for you as a surgeon, just to sometimes to say no, an operation won't cure you or no, this treatment might not help or I don't know whether it will help or not. I think that's fine with our patients as well, isn't it?  [01:24:29][115.1]
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Tony Chalhoub: [01:24:30] You're right, it's very important to be honest and to be upfront, and then and not to be intimidated because patients are now very savvy. They come up sometimes with or some things you haven't heard of. Not necessarily in the obs and gynae, but they come in and tell you about, say, some comorbidity you haven't, you know. So you do a very quick search, and you'll be able to find out with them, or they'll educate you these days. So it's very important to be upfront, and patients will pick up. If they go to somebody, and normally the defence mechanism, if you don't know something about a patient, you shut them down, you'll start talking over them. But patients nowadays, they're through. And some of them, they come and apologise and oh, sorry, but I've looked this up on the net or whatever, I say no, it's good on you because it's very important.  [01:25:21][51.9]
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Dr Louise Newson: [01:25:21] I think it's great. I totally agree. And I think what's really sad is there's a lot of medical gaslighting, there's a lot of people who are not being believed with their symptoms. And I'm sure you hear a lot stories of women with endometriosis where they're told it's in their heads and because they can't do a blood test or a scan that's going to show the endometriosis. But I was always taught, and I'm sure you were, that you have to believe your patients. You listen to them and you believe them. And even if they've got symptoms that don't really fit into a diagnostic pattern, they're still having those, they're real symptoms just because we can't see them if they're pain or, you know, it's different. Like when you have a rash, I can show you what it looks like, but if it's something internal or I get a sensation, we still have to believe our patients, don't we? [01:26:13][52.4]
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Tony Chalhoub: [01:26:13] Definitely, and then so many times, Louise, you know, patients, I'll go to them. So I get patients referred for return surgery or I get patients referred for second opinion, especially when it comes to endometriosis, who have been depressed, you now, literally, and they put on antidepressant because nobody believed them. And then ultrasound scan is normal, MRI scan is normal. Or it's in your head or you have irritable bowel syndrome, which again, it could if symptoms flare up around menstruation. But then I'll go in, in the recovery to just tell the patient, oh, you had endo and they start crying. [01:26:50][37.0]
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Dr Louise Newson: [01:26:51] So relieved.  [01:26:51][0.2]
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Tony Chalhoub: [01:26:52] Oh my God, crying with the relief that all these years, oh, doctor, oh, I thought, you know, I'm going to waste your time, you feel... [01:26:59][7.8]
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Dr Louise Newson: [01:26:59] It's very validating, isn't it?  [01:27:01][2.2]
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Tony Chalhoub: [01:27:01] It's validating, but the evidence is there, Louise, and thank God they changed the guideline two years ago now, November, because poor patients, they're waiting eight to nine years before they get diagnosis, because not only seeing the GP, seeing also the gynaecologist and sometimes specialist who know your ultrasound scan, your MRI scan. We know there's no correlation between the staging or amount of disease and degree of pain, and that's why endometriosis per se. It's the silent kidney killer in some women. Some women, they come into you to be sterilised because they had their three children or so. You put the laparoscope and then you feel, oh my God, stage four endo and this lady didn't have pain. Where others, they're rolling in pain.  [01:27:44][43.8]
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Dr Louise Newson: [01:27:45] And they've got very little. [01:27:45][0.2]
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Tony Chalhoub: [01:27:46] You know, very little, but when you treat it, it improves their symptoms. So no, we need to listen to patients. And me having four sisters, I was brought up to listen my sisters.  [01:27:56][9.8]
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Dr Louise Newson: [01:27:56] Yes.  [01:27:56][0.0]
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Tony Chalhoub: [01:27:57] You know, because people talk about negative laparoscopies, i.e. patients, they go in and you find nothing. Touch wood yet for me not to find anything because you listen to the patient like you said and the symptoms will be suggestive of endometriosis. And there's a list of symptoms being like pain during an intercourse, cyclical, anything, a cyclical what has started and then become chronic throughout the month. It depends because endometriosis is a multi- organ inflammatory condition that things are getting sticky now and affect many organs and we don't know the aetiology yet although there's so many theories. I have two patients and now male patients that they have endo. Where we heard about endometriosis in senior men who had for example prostate cancer and had to have estrogen or as part of their treatment. And you find they develop endo, so the theory then was, well maybe we all have these undifferentiated cells.  [01:29:00][63.6]
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Dr Louise Newson: [01:29:01] It's very interesting and they probably would have had a synthetic estrogen as well.  [01:29:05][4.0]
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Tony Chalhoub: [01:29:05] Correct, but that's also a theory, because then or maybe then these cells are through hormonal and influence differentiating now into something where one patient referred to me through the urologist who was having pain in his penis every time he had a wee. So he got tested for STI, sexually transmitted infections, for urine infections, nothing. Eventually, the GP referred the patient to a urologist. They did look with the telescope and then they found little area. They biopsied and he came back on the endometriosis within his penis. So anyway, so I saw him thinking he may have gynecomastia, he might be obese, he was... Nothing. So there's lots of things we don't know and lots of, like you suggested or you mentioned, Louise, lots of guidelines built up on things that maybe we don't know or we don't know enough but then becomes like oh my God you have to follow the guidelines.  [01:30:08][63.5]
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Dr Louise Newson: [01:30:10] Set in stone, yes. There's so much we need to do and I'm looking forward with trepidation but how the next few years are going to be because I think we're going to more patient-led, we're going to the more led hopefully by hormone treatments, more led just by inquisitive doctors which is the way it should be as well. So I'm really grateful you're coming. Before I end I always ask for three take-home tips. So three things that you're looking forward to when we're thinking about endometriosis in women, what are the three things that you would really like to see in your professional lifetime?  [01:30:41][31.0]
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Tony Chalhoub: [01:30:41] So from endometriosis, now we have, you mentioned EndoSure, EndoTest. Which now they get NICE guideline, they're looking at them positively, but unfortunately they still are self-funded, even the insurance doesn't cover them. And they're not cheap, one nearly £400, one £900. They're very sensitive and specific for the, but unfortunately, not unless we start looking at women's health as a strategy nationally to prioritise them for every prostate, for every four prostate, you got maybe one procedure for women. So now we're going increase my fear, the diagnosis, which is rightly so, shorten the period patient to get diagnosed, but they're still going be waiting for ages. So I'd like to see one, this diagnosis to treatment...  [01:31:32][50.3]
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Dr Louise Newson: [01:31:32] To make it quicker and easier.  [01:31:33][1.3]
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Tony Chalhoub: [01:31:36] Second, more patient awareness and more education and more podcasts, you know, so patients are equipped. They come and challenge the physicians, you know. And the third thing is the physicians to listen to their patients.  [01:31:47][10.8]
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Dr Louise Newson: [01:31:47] Oh, I love that.  [01:31:48][0.6]
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Tony Chalhoub: [01:31:49] Because once we listen to the patients, you make their journey easier and make our life easier as well.  [01:31:54][4.8]
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Dr Louise Newson: [01:31:54] Oh, I love it. Thank you so much, Tony for coming. It's been really great. Thank you.  [01:31:57][3.4]
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Tony Chalhoub: [01:31:58] Thanks very much Louise.  [01:31:59][1.0]
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Dr Louise Newson: [01:32:02] So just a quick one, it would be really great if you could follow or subscribe to this podcast. This will really help me reach more people with evidence-based information about hormones and their future health. And it also ensures that you'll never miss a future episode. Thank you.  [01:32:02][0.0]