Health Committee on Nov. 29th, 2023

[Dr. Elaine Jolly]

Yes, you can certainly have endometriosis after that.

Having children is good, because the hormones of pregnancy help allay the situation. You may have an asymptomatic situation if you're lucky enough to get pregnant.

Of course, you can have endometriosis in your forties. The good thing about menopause.... It doesn't often start after menopause. It's the continuation when it gets severe. It causes the menopausal situation. Then it's very hard to treat the menopause because of the endometriosis. The key years are 20 to 30. That's where you have most of your endometriosis.

We would have diagnosed you. You should have come.

[Voices]

Oh, oh!

[Anna Roberts, Conservative, King—Vaughan, ON]

I am going to share something personal with you. I lost five children, and it wasn't diagnosed. After God blessed me and gave me two healthy children, that's when it was diagnosed, and they attributed it to being part of the miscarriages, but that's enough about me.

[Dr. Elaine Jolly]

I'm not sure about that.

[Anna Roberts, Conservative, King—Vaughan, ON]

I just think it's important.... Let's be totally frank here, and no offence to the gentlemen in the room, but if it weren't for us, they wouldn't be here. I'm just saying.

You mentioned a lack of education. I think we also need to bring that into the curriculum in schools to make them aware.

You mentioned the lack of doctors. I met with doctors, just a few months ago, who came from all over the world. Some of them had as much as 20 years' experience in all different areas of medicine, and they're driving cabs. They've passed their boards, but they're driving cabs. I met one doctor who really shocked me when he said that he taught at the University of Toronto, but he's not allowed to practise in this country.

When I hear about the situations we have with endometriosis and with the lack of health care for women, I question what we are doing as a government that we're not able to ensure we can get those doctors practising so that we don't have those wait times and so that we can do a better job. How can we change that system? What ideas can you bring to this committee to help us understand that?

[Dr. Elaine Jolly]

There is progress being made in Ontario to fast-track individuals so that they don't have to drive cabs and don't have to wait, if they have the training and if they pass the medical exams, because the council of medicine must have Canadian participation. However, many of those people do. They pass the exams. They have study sessions.

There's a piece missing to direct them. That is a provincial matter. We must have somebody, an ombudsman, who can fast-track the areas we need doctors in. It's very obvious, when you look at their CVs, what the situation is.

The fast-tracking has started, not with immigration but within the system. Once you pass your exams, then where can you go and how much do you have to train? We're very specific, and so it should be. We can't allow every doctor in, but we can allow in the ones who have trained and the ones who are good. That requires some assistance or an appointee at the provincial level who can direct them, or a committee that directs them.

[Anna Roberts, Conservative, King—Vaughan, ON]

Do you not agree that we have to do a better job of assessing the individuals who come here? Some doctors I met have 20 years' experience in their home countries. A couple were from the U.S., a couple were from Dubai, India and all over. They come here, pass the boards, and then they are told they can't practise. I shake my head, and I think to myself that I have constituents who can't even find a family physician, and therefore, they're struggling through their medical situations. They have to go to either the hospital or a walk-in clinic, and it could be a different doctor—

[The Chair, Liberal, Sean Casey]

Mrs. Roberts, I'm sorry, but that's your time.

[Anna Roberts, Conservative, King—Vaughan, ON]

They got six minutes, and I only got five.

[The Chair, Liberal, Sean Casey]

Yes, that's right. A couple of your colleagues farther down are only going to get two and a half.

[Anna Roberts, Conservative, King—Vaughan, ON]

Oh, I'm sorry. Thank you.

[The Chair, Liberal, Sean Casey]

Ms. Vandenbeld, go ahead for five minutes, please.

[Anita Vandenbeld, Liberal, Ottawa West—Nepean, ON]

Thank you very much, Mr. Chair.

I'd like to direct my questions to Dr. Mattatall.

Fiona, it's nice to see you again in this context.

I just want to pick up on something you said that, frankly, is a bit shocking. You mentioned that we track wait times for things like hip surgeries, but not for gynecological procedures. Then you also mentioned something about surgeries done on women being reimbursed less than surgeries done on men, if I heard you correctly. It just begs the question: Why is this happening?

You talked about performance indicators. If we're not tracking or measuring this, what is the issue now in terms of data? Are there barriers to getting this data? Is there anything the federal government could do to improve both of those situations?

[Dr. Fiona Mattatall]

Thank you, Anita. What a nice treat to see you.

I think it is historical gender equality. It's 2023 and it's time for that to be called out.

The issue with data is that we do not have it. I went online today to see what my wait time is for hysterectomies here in Calgary compared with other colleagues, and the data is blank. It is not there. Without asking the question, we don't have the answer.

The suggestion I have is to make a push to the provincial ministries of health to quantify this, to prioritize gendered procedures and ask the question.

Hopefully members of the committee have time to take a look at that excellent Canadian study that did look at the cost per surgery and what physicians and surgeons are paid for surgery. When you look across the country, surgery for endometriosis is not paid well.

To the last point, we can bring in more surgeons for endometriosis—excellent surgeons from outside of Canada—but without operating room time and access, it does not change the wait times for patients, so bringing in more physicians can't be stand-alone.

[Anita Vandenbeld, Liberal, Ottawa West—Nepean, ON]

Those are excellent suggestions. I appreciate that very much.

My next question is for Dr. Jolly.

I am an Ottawa MP, so I know very well the incredible value of the women's health centre and the work you do.

I want to pick up on what you said about centres of excellence. You talked about sea to sea and how big a country we are.

As a federal government, how we would be able to support the establishment and ongoing support for these kinds of centres of excellence?

[Dr. Elaine Jolly]

They're so important. They are training centres as well. They are training physicians at all levels and training in medical schools.

What happens is, it's a wonderful surgery. The residents love it and they want to take extra time because it's like “wow” surgery. Menopause is...not so much. Everybody has menopause. It's a difference.

What is a centre of excellence? Well, it is something or some place that is run by or operated by experts in endometriosis. Surgical experience is the first thing that happens. Medical treatment for endometriosis is quite exciting. It's not perfect, but it can certainly get you through without surgery. You have the option, as a woman, to try. Surgery is really still the last resort, unless there's a big ovarian cyst or the typical chocolate cyst.

It's very important to have the education at all levels— in the medical school curriculum and the nursing. We had fantastic nurses who were certified and credentialed, for example, in menopause. There are nurses, probably in your institution, Dr. Zakhari, who help with the patients and they are taught about endometriosis. They go to endometriosis meetings. They are part of the research. The whole team comes together. It's multidisciplinary.

The other thing is that it should be associated with a university with regard to the education. Remember that we're not talking about 100 of these. We're talking about one in every medical school. We have 16 medical schools and I understand there are three more on the way.

Each one of these should be mandated and there should be funding for this. It's a centre of excellence, so there should be an endowed chair. The endowed chair can be someone who has excellence in leading this, but also has funding to do research. That research may $100,000, $200,000 or $300,000, but that chair is endowed. That is very important.

[The Chair, Liberal, Sean Casey]

Thank you Dr. Jolly.

[Dr. Elaine Jolly]

There's other stuff, too.

[The Chair, Liberal, Sean Casey]

Thank you.

Ms. Larouche, you have the floor for two and a half minutes.

[Andréanne Larouche, Bloc, Shefford, QC]

Thank you, Mr. Chair.

I would like to go back to something. It was you, Dr. Nguyen and Dr. Zakhari, who talked about funding.

Something could be done with regard to research. Moreover, the World Health Organization, or WHO, has recognized that not enough research is being done and that there a many knowledge gaps in certain areas, particularly for the development of potentially less invasive diagnostic methods, especially treatments that would not prevent women from becoming pregnant. In many cases, that is a dramatic outcome of endometriosis treatments.

What are your thoughts on such research and the need to invest in research related to such treatments?

[Dr. Dong Bach Nguyen]

Thank you for the question.

I absolutely agree with what you're mentioning.

When patients come to see us and we give them a diagnosis of endometriosis, one of the first things they ask is why they have endometriosis. There we are all looking at them and trying to give an answer when we really don't know why. We have many theories why this disease is occurring, and it's probably a combination of all, but we don't exactly know the perfect pathogenesis, nor do we find perfect DNA or genetic answers for patients. I think, from the get-go, research needs to tackle that. When we know the origin and exact cause, that would also help us develop research in developing medications or targeted medications toward endometriosis. Currently, all medications treating endometriosis are hormonal-based, because we know that this condition is a hormone-dependent disease. Invariably, if we do advance research more, we will be able to find ways of treating endometriosis better.

We always talk about three areas or barriers to care: number one is awareness, number two is diagnosis and number three is treatment. In diagnosis as well, currently we're relying heavily on imaging, on MRIs—ultrasound mainly, if not MRIs. Now, laparoscopy is really used mostly to treat endometriosis, but if we can find diagnostic methods that are less invasive, then even the people in the remote areas can have access to these and have a quicker diagnosis.

[Dr. Andrew Zakhari]

What I would like to add, too, which has not been mentioned before, is that we talk about ultrasound used to diagnose endometriosis, but it's actually quite a difficult thing to do in the community, because it requires a specific skill set with ultrasound. It's much easier to diagnose a gallstone by ultrasound, because you see the stone. With endometriosis, you may see a chocolate cyst, but you may not, so negative scans are often not negative.

At our centre, we often are repeating ultrasounds ourselves, and we're getting outside MRIs reread by our radiologists. These are duplicate amounts of work. They're not remunerated fairly either. We're often asking radiologists at our meetings if they would mind taking a look at an MRI, which has already been reported, but the report is not accurate. There's no standardization of ultrasound reporting in Canada that I'm aware of, or in Quebec for sure, so lots of ultrasound reports we get will just say that there is a normal uterus present, but they lack all the signs that we look for for endometriosis. We have to repeat a lot of work, which is another barrier for patients.

[The Chair, Liberal, Sean Casey]

Thank you.

We have Ms. Mathyssen, please, for two and a half minutes.

[Lindsay Mathyssen, NDP, London—Fanshawe, ON]

Dr. Mattatall, you had mentioned in many of your recommendations the need for coverage for prescriptions and medications. As someone who has pushed really hard on the idea of pharmacare and the government providing pharmacare, I'd love to hear more about that. In addition, I think you also mentioned that that include, of course, the specifics around contraception.

I've just put a motion forward in the House that calls for that universal access to contraception as well, and that the federal government provide that, much like we see in B.C.

Maybe you can talk about some of the positives of that and the need for that.

[Dr. Fiona Mattatall]

Thank you for the question.

The arenas around contraceptives and endometriosis do overlap. Sometimes oral contraceptive pills or the Mirena progesterone IUD are adjuncts that can be used to treat pain with endometriosis and to control bleeding that can be associated with it as well.

The standard and approved medical treatments for endometriosis are expensive medications. I have many patients who do not get coverage for these medications. Whether it's through plans at work or our Blue Cross here in Alberta, these will not cover our approved medications for endometriosis. Also, we really struggle with off-label treatment with other medications for it. We've talked a lot about surgical access and barriers there, but there are significant medical barriers to endometriosis to get pain under control—and it's not just pain. It's about preventing that disease from getting worse over time and trying to prevent that chronic pain state.

As Dr. Jolly mentioned earlier, getting that diagnosis early for that younger patient, and getting them on a medication to prevent some of the later complications from endometriosis will ultimately save our health care system money.