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BackTable / OBGYN / Podcast / Transcript #15
Podcast Transcript: The Microbiome
with Dr. Ian Fields
In this episode, Dr. Ian Fields joins Dr. Mark Hoffman at the mic to discuss the role of the microbiome in obstetrical and gynecological conditions. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Microbiome in Urogynecology: Health & Homeostasis
(2) The Impact of the Microbiome on Disease & Novel Treatments in Gynecology
(3) Challenging the Sterility Myth: The Urinary Microbiome's Role in Gynecological Disorders
(4) Urinary Tract Disorders & How the Microbiome Influences Disease Process
(5) The Physician-Scientist in Modern Healthcare: Bridging Clinical Practice & Microbiome Research
(6) The Microbiome’s Role in Diverse Health Conditions & Changing Environments
(7) Uterine & Intraperitoneal Microbiomes in Female Reproductive Health
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[Dr. Mark Hoffman]
Hello and welcome to the BackTable OB-GYN podcast. Once again, this is Mark Hoffman, your host, and we have another great guest today, Dr. Ian Fields, who is an assistant professor of Obstetrics and Gynecology and the Associate Residency Program Director of OB-GYN at Oregon Health and Science University, and he is going to teach me all about the microbiome. Dr. Fields, welcome to the show.
[Dr. Ian Fields]
Hey, thanks, Mark. Thanks for having me. I'm excited to be here and excited to talk about one of my favorite topics.
[Dr. Mark Hoffman]
One of your favorite topics. Well, good because I know little to nothing about the microbiome, and I'm excited to learn about it. Ian's okay, we talked about this a little bit before the show, we like to make sure.
[Dr. Ian Fields]
Yes, absolutely. Yes, please call me Ian.
[Dr. Mark Hoffman]
Before we jump into the microbiome, tell our listeners about you, as much as you want to share about where you're from, how you got into this business of being a-- You're a gynecologist, correct? Female reproductive medicine, FPM, female pelvic medicine and reconstructive surgeon.
[Dr. Ian Fields]
There you go.
[Dr. Mark Hoffman]
I have to stop and think about it every time.
[Dr. Ian Fields]
It's going to be changing soon, anyway, so that's going to–
[Dr. Mark Hoffman]
Just to urogynecologist or something different?
[Dr. Ian Fields]
Yes, urogynecology and pelvic reconstructive surgery.
[Dr. Mark Hoffman]
Oh, good. They simplified it to something totally complicated.
[Dr. Ian Fields]
Urogynecology is fine, though. I think that just go with the thing that makes the most sense.
[Dr. Mark Hoffman]
Yes, [crosstalk] because they changed the journal title name, right?
[Dr. Ian Fields]
Yes, we did change the journal title name as well.
[Dr. Mark Hoffman]
Well, I'm a MIGS surgeon which, again, is redundant, but we need to fix that too, but that's maybe for another show. Tell our listeners about you and then we'll jump into the microbiome.
[Dr. Ian Fields]
Sure thing. Short story, I guess, I was born and raised in El Paso, Texas, and went to a super nerd high school. I left my original high school when I was 16 years old and did an accelerated program at the University of North Texas called the Texas Academy of Mathematics and Science-
[Dr. Mark Hoffman]
Oh, that's cool.
[Dr. Ian Fields]
-in Denton, Texas. Yes, it is pretty cool. I was thinking maybe medicine was in my future, and so I thought, "Hey, why didn't I get a two-year head start on this deal?"
Essentially, went to college when I was 16 years old, did my first two years of college there, and then essentially graduated high school with two years of college credit and could go wherever I wanted. My journey took me to Loyola University in Chicago where I finished my undergraduate degree.
I got a bachelor's in biology, graduated college when I was 20 years old, and truly had no idea what I wanted to do. The two years shaving off was-- it was great I guess, but I still had no clue where my life was going to take me. I had been really interested in basic science research as an undergrad and had dabbled in my summers and time off, but anyone who does basic science research knows that you really can't accomplish much in a short period of time.
I took a job as a research technologist at Northwestern University at their undergraduate campus in Evanston, and I ended up working there in a molecular and cell biology lab for five years-
[Dr. Mark Hoffman]
Wow.
[Dr. Ian Fields]
-which was way longer than what I had anticipated because I was trying to navigate whether I wanted to do basic science research or whether I was truly interested in clinical medicine.
[Dr. Mark Hoffman]
How'd you make that decision?
[Dr. Ian Fields]
It was tough. The job as a research technologist, my boss was wonderful. She really gave me the opportunity to dive headfirst into this stuff and to give me the opportunity to really be independent in the research that I was doing, and really gave me the opportunity to publish some work while I was there.
In the five-year time that I was there, published three studies all about mechanisms of cell polarity, perhaps way less interesting than the human microbiome but really gave me the opportunity to see what it would be like to have a career as a PhD, and I ended up applying both to MD and PhD programs, and I really missed the human interaction portion of things.
I think that, for me, medicine has always been about the ability to connect with people and the ability to be a part of people's stories and a part of their lives and giving them back quality of life, which is what I do now as a urogynecologist. I missed a lot of that and so decided medschool was going to be for me. I went to Loyola University Stritch School of Medicine to obtain my MD and then–
[Dr. Mark Hoffman]
Met some pretty good urogynecologists there, I bet.
[Dr. Ian Fields]
It's so interesting that you mentioned that, because as a medical student, that was certainly not what-- It was the only medical school I got into, and we can talk about my journey to and through medicine.
[Dr. Mark Hoffman]
I got into one med school too, and here we are.
[Dr. Ian Fields]
Yes, and see, it works. I feel like everything in life, all the struggles and all of the ups and downs have totally led me to exactly where I am today.
[Dr. Mark Hoffman]
Well, that's a huge part of why I wanted to do a show like this. Every time I sit down with somebody who-- and I won't name names so I don't get in trouble, but like these medical luminaries of people we put on pedestals and people I admire, people like you that I think a lot of us go, "Well, man, how did they get there? They must have just been born and created this brilliant, talented, whatever." Every single time without fail, there's, "Oh, yes, this was not how I planned," or, "This was not what I was going to do and I met this one person who changed my life or whatever."
There's always more to the story. To me, that's a huge part of what kept me going when I was struggling at certain parts of my career or in med school, or whatever, you meet someone who goes, "Yes, you want me to tell you about struggle?" You go, "Oh, okay, well, this person's pretty great." No, I think there's a lot of those stories. You are at Loyola and you were going there just to become a urogynecologist, I'm sure.
[Dr. Ian Fields]
I actually went to med school thinking I was going to be a pediatrician. I had done all of my life–
[Dr. Mark Hoffman]
I did too.
[Dr. Ian Fields]
I did all my volunteer work at the Children's Hospital in Chicago, the Lu Children's Hospital, and I loved it. I was like, this is totally what I want to do with my life. Med school taught me differently.
Loyola was great. I really do think med school's tough. I think it was a really like formative time in my life, but I will say the people that I met at Loyola, the teachers that I had, the physicians I worked with, I would 100% do it all over again if I had to, just because Loyola was just amazing; and not just because I did get the chance to work with some of the biggest names in Urogynecology.
[Dr. Mark Hoffman]
Who was there when you were there?
[Dr. Ian Fields]
Kim Kenton was there, Beth Miller, Linda Brubaker.
[Dr. Mark Hoffman]
I interviewed for a MIGS job there and they took Linda Yang, which was a much better choice than me, because she'd been out for a little bit. She's outstanding.
[Dr. Ian Fields]
Oh, yes. I worked with her as a medical student and now she's at Northwestern-
[Dr. Mark Hoffman]
That's right.
[Dr. Ian Fields]
-right now, which is where Kim Kenton went off too.
[Dr. Mark Hoffman]
That's right. Maggie Mueller was one of my junior residents-
[Dr. Ian Fields]
Oh, how cool.
[Dr. Mark Hoffman]
-because I did residency at the University of Chicago, and so I think-- Was her fellowship at Loyola and then moved to Northwestern? Is that what happened?
[Dr. Ian Fields]
Correct. I worked with Maggie Mueller as a medical student and then again as a fellow because I ended up going to Northwestern for my obstetrics and gynecology residency, and had no idea that Kim Kenton was going there and got to work with and learned from her. I kept an open mind. I'm, interestingly enough, not one of the urogynecologist who's a super obstetrics downer. I loved obstetrics, I still think it's fascinating.
[Dr. Mark Hoffman]
I liked OB. I didn't do MIGS because I hated obstetrics. I'm with you. I wanted to be a good surgeon. I also didn't know how that was going to happen in the time, and that's again, a whole other podcast too, and how we train our OB-GYNs out there surgically. Yes, it was either MFM or MIGS for me. I liked obstetrics, but I just like pain more.
[Dr. Ian Fields]
Those are two very different fields? [laughs]
[Dr. Mark Hoffman]
Yes and no. If you're curious about it, like we like women's health, we like OB-GYN.
[Dr. Ian Fields]
Exactly.
[Dr. Mark Hoffman]
There's a lot of interesting stuff in this specialty for sure.
[Dr. Ian Fields]
I won the Forceps award as a senior resident which I don't know if I should admit that on this podcast.
[Dr. Mark Hoffman]
It's all your fault, all that prolapse.
[Dr. Ian Fields]
I do have the award hanging in my academic office here at OHSU. I think it's important. I think my viewpoint, I approach things very differently having that foundation. I really do think as a urogynecologist, having that OB background is super helpful. Because I know you can come at it through the urology way, but I just think we have such a different perspective on things because we have a really great working knowledge of how things happen in labor delivery and all the sequelae afterwards.
I wasn't an obstetrics hater, and I really struggled with the fact that I thought I was going to be a generalist. I really, really enjoyed the intricacy of surgery and pelvic reconstructive surgery, and the ability to give people back their quality of life; the onc part of things, tugged at my heartstrings a little too much, and I'm a little too emotional for that.
[Dr. Mark Hoffman]
I had the exact same experience. That's funny. I was like, "Oh, you should be an oncologist." I'm like, "I'm not, maybe emotionally mature enough to give what I think patients deserve and then also share that with the other people in my life."
[Dr. Ian Fields]
Exactly.
[Dr. Mark Hoffman]
Some people are just better at it. Just knowing myself, I felt like maybe there's not enough of me for this job.
[Dr. Ian Fields]
Absolutely, I totally agree. When it came time to apply for fellowship, I applied all over and then ended up out here in Portland, Oregon at OHSU, and was lucky enough to weasel my way onto a faculty position when I graduated in 2020, and even luckier to be able to weasel my way onto the residency leadership team, which is probably one of my favorite parts of the job that I get to do.
[Dr. Mark Hoffman]
That's awesome. When I came to Kentucky 10 years ago, there was no division that I could go into. It was very much like, "Yes." I could have stayed in Ann Arbor, which I love more than anything. I did undergrad there, but I wanted to build a program-
[Dr. Ian Fields]
Yes, awesome.
[Dr. Mark Hoffman]
-but to create the job that you want and when you've gone somewhere, you just find the things you love and over time you can create the position that you want, even if it may not be the one you were hired into. That's great. How do you like Portland?
[Dr. Ian Fields]
I love it. Portland is definitely a slower pace of life than Chicago for sure. I lived in Chicago for 15 years prior to coming out here. The winters are much more bearable, although people that live in Portland will complain about it nonstop. I just say, "Go spend a winter in Chicago and then come back and tell me this winter's not bearable." It's beautiful. There's tons to do. Like I said, people are great. It's a slower pace of life and I truly do love my job and the people that I work with here. I think that's the thing that has really kept me here.
[Dr. Mark Hoffman]
It's a huge part of it.
[Dr. Ian Fields]
It really is.
[Dr. Mark Hoffman]
I'm all for work is work and family is family, but I genuinely can say the thing about my job that brings me the most joy, I love taking care of patients. I love surgery, but when I've got my team and my people that are all rowing the boat in the same direction and are happy to see me when I come there, that makes all the other stuff easy. It makes everything else.
It's hard enough being a doctor. It's hard enough doing what we do. Being a nurse it's hard. I'd been an MA, but then we have a team that we're all helping each other out. That is the most valuable currency in this job, I think.
[Dr. Ian Fields]
Yes, that's the thing that I tell the trainees that I work with the most is like, good people and the team that you work with, it's truly worth its weight and gold. If you can find it, you should stick with it.
[Dr. Mark Hoffman]
Never let it go.
[Dr. Mark Hoffman]
Yes. Before we get a microbiome pizza, are you a deep-dish pizza person? I could never get into it. It's like Lasagna.
[Dr. Ian Fields]
I have my favorite when I go back to Chicago, it's lumalnatis all the way. I won't hear anything otherwise, but in the day-to-day, no, I think it's, one to two pieces and then you're sitting in a food coma the rest of the night.
[Dr. Mark Hoffman]
Yes, and don't make plans after that.
[Dr. Ian Fields]
No. No plans after deep-dish pizza. I like it at a time and place that's appropriate, but it's not something I miss deeply.
[Dr. Mark Hoffman]
It should not replace all pizzas.
[Dr. Ian Fields]
No, no, no, no. I guess I wouldn't be a true Chicagoan then, but that's okay.
[Dr. Mark Hoffman]
Forno Rosso was the place I went to most recently in Chicago that was like wood-fired pizza.
[Dr. Ian Fields]
Oh, yes.
[Dr. Mark Hoffman]
Which on Randolph is so good. It's [crosstalk] dish.
[Dr. Ian Fields]
So good. Chicago in general has amazing food.
[Dr. Mark Hoffman]
I do miss that. My wife is in a bigger city, and so the thing about Lexington, she's not as big a fan of. We have some good restaurants here. It's getting much better, but it's not the big city.
[Dr. Ian Fields]
Not quite a big city.
(1) The Microbiome in Urogynecology: Health & Homeostasis
[Dr. Mark Hoffman]
No, and she reminds me it's not too infrequently that this is not a big city. The microbiome, talk to me about just for like-- Of course, I know all about it, but for our listeners who may not know everything there is to know about the microbiome, just a general overview of what it is generally. And then we'll work our way towards how that applies to what we do as OBGYNs and what you do as an urogynecologist.
[Dr. Ian Fields]
Yes. You can think about the microbiome as all of the things outside of our cells that make up our human body. There's like trillions of cells that make up the human body, but there's some studies even suggest up to three times more organisms that are living all throughout your body on your skin, in your gut, in your mouth, in your GU tract, everywhere that make up what's called the microbiome.
It's comprised of everything else aside from what makes you use cell-wise; so bacteria, viruses, fungi, all types of things that help us function. That may play a role in how we as humans maintain states of health. Also, interestingly enough, have large impacts in the pathophysiology or the development of disease states too.
There's been a lot of research done over the last 10, 20 years as it relates to the microbiome. If people are interested, I encourage them to always start with the Human Microbiome project, which was a large NIH study that really was like, how do we function in states of health? It took all these healthy individuals, looked at the microbiome in five different sites of the body. The nose, the mouth, the skin, the gut, and the vagina. It was essentially studying how do we as healthy people-- what comprises our microbiome?
[Dr. Mark Hoffman]
We will put a link to this in our show notes. When is this from, or when did this project start or is it an ongoing project? Is it like a book?
[Dr. Ian Fields]
It started, I want to say, either the early 2000s is when it all started and things have trickled out since then. It's one of a number of large microbiome studies, but yes, you can absolutely look it up. The NIH Human Microbiome Project.
[Dr. Mark Hoffman]
That's fascinating. We grew up hand-washing. We had three boys. A white kitchen, white floors, white chairs. My mom was in the kitchen with her yellow rubber gloves, everything got scrubbed, no pets in the house. Like was, "Was it too clean, was there too much cleaning going on in our house?" Other people they say having a dog as a kid growing up, it allows you to know your immune system works better. It sounds like it's not just the microbiome, the bugs, but also how our immune system responds to that. It seems like it's just a constant interplay. Is that right?
[Dr. Ian Fields]
Yes. Or like in concert with it. I think it's kind of a little bit of a symbiotic relationship there too. The bacteria needs some of the things that we give it. We need some of the things that the bacteria give us. It's how we function together. This inter-play and inter-connectedness that potentially allow us to maintain this homeostasis and when things go awry, that's how we get to certain things that we as physicians may see clinically.
(2) The Impact of the Microbiome on Disease & Novel Treatments in Gynecology
[Dr. Mark Hoffman]
What are examples of situations where-- Because I think most people think bacteria means infection. There's some bacteria we don't want, let's get rid of bacteria. Especially in gynecology, if there's a discharge, give me antibiotics to treat it. Well, there's a lot of normal activity in the vagina. There's bacteria, fungus, if we hit one, the other can have an opportunity to overgrow.
That's one where we see the microbiome maybe more frequently in our clinics, but what are examples of some big situations where the microbiome can impact or be related to disease processes?
[Dr. Ian Fields]
I think one of the things that fascinated me the most when I was in medical school was studying and learning about clostridium infections in the gut. We hear about C. diff after antibiotics. There's a very large amount of work that was really done with the gut microbiome; is perhaps one of the most studied microbial niches.
C. diff happens typically after patients are treated with antibiotics for some other infection that antibiotics have some collateral damage elsewhere in the body. The gut is a big place that gets that collateral damage. At that point, you potentially develop this clostridium difficile infection.
I thought we treat it with antibiotics, but one of the other ways that we can treat this is by doing fecal transplants, which I thought was just the most out there thing that I learned. I was like, "Wait a second, you're telling me that they're taking stool from healthy people and placing it in somebody's gut?" I just thought that is so bizarre, but fascinating at the same time to me that somebody had thought about this.
[Dr. Mark Hoffman]
No, I think every time anyone hears that for the first time, there's always that like, "Oh, come on." Then people want to learn more about, "Wait, I'm sorry, did you say transplant? Who's the donor, who's got the best stool out there?"
[Dr. Ian Fields]
How do we decide that?
[Dr. Mark Hoffman]
We got to bring in this guy again because his patients are doing great. How does one maintain a kind of feces that is desirable for transplant? My goodness. This is a whole other thing that none of us know anything about. Clearly, there's a lot out there we don't know.
[Dr. Ian Fields]
Right. I think that that was something that blew my mind as a student that this is something that was happening.
[Dr. Mark Hoffman]
Was your basic science research in the microbiome or what was--
[Dr. Ian Fields]
It was not. I studied mechanisms of cell polarity and polarized epithelial cells with broad implications for renal cancers. I worked with kidney cell lines and did lots of like, "Okay, how do cells decide that they're going to grow in the way that they do?" Once we learn baseline, how they function, then we would knock out functions of certain proteins that we were studying to see how that had an impact on these mechanisms of how cells grow the way that they do.
(3) Challenging the Sterility Myth: The Urinary Microbiome's Role in Gynecological Disorders
[Dr. Mark Hoffman]
Not a direct line, but as an English major, I'm definitely thinking, "Okay, this, this is all way above my pay grade." Clearly an advanced level of understanding of cell biology, which allows you to be far more in tune with what's going on in the microbiome.
In gynecology, what do we know? What are the areas of work that's being done and what's the future hold for our better understanding of the microbiome?
[Dr. Ian Fields]
That is a great question. Most of the work in terms of what we see clinically as gynecologists, urogynecologist is the shift in homeostasis that happens with the healthy bacteria that live inside the vagina that lead to things like bacterial vaginosis. I think that's probably the most studied condition in terms of how it relates to the microbiome in our world, but as a urogynecologist, I have specific interest in urinary tract disorders like incontinence, both stress incontinence, urgency urinary incontinence, recurrent urinary tract infections and conditions like interstitial cystitis and painful bladder and all have implications in terms of studies that have linked alterations in the microbiome, in the bladder to those different conditions.
It's really funny because going back to this, a lot of this work about the urinary microbiome also came out of Loyola University, which just again, so interesting that my life has taken me down this path and I have so much crosstalk and interplay with the people that have done this research, although I have not worked on it there myself.
[Dr. Mark Hoffman]
In recurrent UTI, I was trying to think about in preparing for the show today, like things that I would've thought would be impacted by the microbiome within the urinary tract specifically, but pelvic organ prolapse-- Is that what you said? Or things like interstitial cystitis, which as a pelvic pain person, I see a lot.
The other conditions you're mentioning too, I wouldn't have thought the microbiome would play as much of a role. Can you talk about the ways that the microbiome could or does, or could potentially impact those different disease processes?
[Dr. Ian Fields]
We'll backtrack just a little bit here because the first thing we have to realize is we have to challenge this dogma that the urine or bladder is sterile.
[Dr. Mark Hoffman]
Yes. Lots of Twitter chatter, I think by some experts like you about whether or not people should be thinking it's sterile. I won't go any maybe further than that.
[Dr. Ian Fields]
Yes. There's a lot that you can get into on Twitter in terms of weird practices that they relate to medicine. This was like a hot topic, I want to say, a couple of months ago when Ashley Winter, who is a urologist, tweeted that urine was not sterile. You would've thought this is like flat earther territory again. People are just attacking her saying like, "This is so dumb. Of course, you're in a sterile, how would you get a bladder infection if urine is not sterile to begin with?" It takes so much of you to sit back and say, "This is potentially not worth my fight right now in this forum, specifically."
[Dr. Mark Hoffman]
"How much time do I have? How much energy do I have left-
[Dr. Ian Fields]
Correct.
[Dr. Mark Hoffman]
-for this conversation?" The answer is, probably not enough.
[Dr. Ian Fields]
Yes, most of the time the answer is not enough to engage. Although, I did jump in and participate here and there, I was like, "I don't really want to get into this and I don't really want to bring out the troll."
[Dr. Mark Hoffman]
Mute notifications.
[Dr. Ian Fields]
Yes, mute notifications on this thread. No more, please. She tweeted that urine was not sterile. I think we know this at this point in time. I think we have really good evidence and a lot of that work again, came out of work that was done by microbiologists immunologists at Loyola University; Alan Wolf and Paul Schreckenberger well as Linda Brubaker when she was at Loyola, had done all this work to really challenge this dogma that the bladder is a sterile environment, because the bladder was not included in the human microbiome project. The vagina was, but the bladder was not.
It's plausible. We as gynecologists know, and I think this is like such an interesting quote from Alan Wolf when he talks about the work that he's done, says, "It was ludicrous to me when I found out that medical students were learning that the bladder was sterile because the female urethra is just like a day trip for E. coli." It's really doesn't take much for-- It's three to four centimeters. E. coli is, of course, going to be able to climb in there. That's how we get these infections. That's how UTIs manifest is typically because of things like that, and E. coli motility.
He thought, "There's got to be a way that we can study the bladder and figure out whether or not urine is sterile." One of the first studies he did was looking at voided specimens, super pubic aspirate and urethral catheterized specimens to determine whether or not there was bacteria present.
He did this. Basically, you can do this through a series of sequencing what you know is there based on the bacteria that you would expect. You sequence what's called part of the 16S ribosomal RNA, there's like variable regions that are pretty consistent throughout like evolutionarily that you can find in sequence even if bacteria-- to see if bacteria are there. He essentially was able to show that, "Yes, there is a large community of bacteria that lives in the bladder in healthy patients and healthy subjects."
[Dr. Mark Hoffman]
It makes me think about, because I'm a big fan of science and space travel and those things; how do you know if you go to Mars if there's life if you've touched all this equipment and you send it there? That's a huge part of that whole science of studying whether or not there is evidence of life in places where we didn't expect it.
It sounds actually very similar because if you're going through a catheterized sample or going through the skin into the bladder, you could potentially be bringing things in. That's where you have to have people who know what they're doing, who understand what to expect and compare it, but I can see how it would be. That would be really challenging work to do, because to get into the bladder to see if there's bacteria, you were going through all these bacteria rich microbiomes to get there.
[Dr. Ian Fields]
That's why this midstream voided specimen that we use to figure out if a patient has a UTI is catching all of this skin from the vulva and the vagina, so we can't know for sure.
[Dr. Mark Hoffman]
I feel like every urine culture I get is–
[Dr. Ian Fields]
Polymicrobial.
[Dr. Mark Hoffman]
Polymicrobial.
[Dr. Ian Fields]
I feel like that's what you're going for, polymicrobial.
[Dr. Mark Hoffman]
Yes. Thank you.
[Dr. Ian Fields]
Polymicrobial.
[Dr. Mark Hoffman]
Polymicrobial. Yes. It's like–
[Dr. Ian Fields]
"What do I do with that?"
[Dr. Mark Hoffman]
Nothing is what I've been usually doing with it. It's everywhere. How do you know what's what? That sounds really challenging.
[Dr. Ian Fields]
It is. He then took that a step further, because you can say, "Okay, great you have presence of bacteria that are there based on these genetic sequencing that you've done. That means you could have dead bacteria that were anywhere. How do you know that these bacteria are alive and they're healthy?" He was like, "All right, well, let's just take this a step further."
He challenged the standard urine culture. Basically, took a cohort of patients who were healthy controls and patients with urinary incontinence and had their urine plated under standard aerobic conditions at 35 degrees Celsius, grew for 24 hours. Did it grow or did it not? Then took those same samples and grew them under a variety of different conditions, different culture mediums, anaerobic conditions, different temperatures, longer periods of time, and was able to show that over 90% of people who had been a part of this study, you could cultivate bacteria that way from the bladder, which was just this huge paradigm shift.
[Dr. Mark Hoffman]
Who's the one doing the work? Whose work you're referencing, and when was all this research done?
[Dr. Ian Fields]
This was done back in 2012 and 2014. This is the team at Loyola University, the two PIs on the study, Alan Wolf and Paul Schreckenberger.
[Dr. Mark Hoffman]
That's pretty recent, though.
[Dr. Ian Fields]
It is.
[Dr. Mark Hoffman]
In the scheme of medical research, things like basic stuff we know about the human body, 10 years is not that long.
[Dr. Ian Fields]
I remember being at the American Urogynecologic Society meeting at the time when these papers were presented, and my mind was blown. I was like, "This is so far beyond anything that I could comprehend as a student, as a resident." It just was mind-blowing to me.
[Dr. Mark Hoffman]
Was it taught in med school prior to this that urine was sterile? Was that like--
[Dr. Ian Fields]
I think so. [laughs]
[Dr. Mark Hoffman]
I'm like trying to be cool. I know stuff, I'm like, "Maybe thought urine was sterile too." I've been out of training for 10 years and I don't deal with the urinary tract. At least I try not to deal with it very often in my job.
[Dr. Ian Fields]
If we can avoid it, yes. [laughs]
[Dr. Mark Hoffman]
If we can avoid it, right. I'm trying to sound like I know what I'm talking about. I feel like that's what we were taught. It was sterile.
[Dr. Ian Fields]
I believe so. Despite me being at Loyola, I'm pretty sure that's what I was taught. Alan Wolfe was one of my microbiology teachers, so I hope he doesn't come after me after this. I'm pretty sure at that. I was in medical school around 2009, 2010 is when I would've been learning.
[Dr. Mark Hoffman]
Well, if you used a textbook, it was probably written in the '80s, anyway. The thing is, this information typically happens or progresses pretty slowly or at least it's delivered pretty slowly. This is a big thing to think about. All the things that we don't know about, that you're talking about, especially interstitial cystitis or painful platter syndrome that we see a lot in our endometriosis patients, recurrent UTIs. At some point you just go, "I don't know what to do with that."
Can you talk a little bit about specific diseases? We had to back up. Did you get caught up enough? I don't want to--
[Dr. Ian Fields]
No, that's-- I feel like we're caught up enough to where we should be.
[Dr. Mark Hoffman]
Okay, good. I feel like I understand more now, so I appreciate that.
[Dr. Ian Fields]
Yes, good. I'm glad. We've at least established that urine not sterile.
[Dr. Mark Hoffman]
Not sterile.
[Dr. Ian Fields]
Right.
[Dr. Mark Hoffman]
I'm sure we'll turn off our notifications when people hear this one too.
[Dr. Ian Fields]
Oh, goodness.
(4) Urinary Tract Disorders & How the Microbiome Influences Disease Process
[Dr. Mark Hoffman]
What are ways that we think the microbiome is impacting disease processes and the urinary tracts of our patients?
[Dr. Ian Fields]
A lot of work has really been done specifically in urinary incontinence, so both the types of incontinence that I see as a urogynecologist, stress incontinence, which is leakage of urine that happens with activities like cough, laugh, sneeze, exercise, things like that, and urgency urinary incontinence, which is really a lot well less understood how that happens.
I think we can see how stress incontinence happens typically because of pregnancy, childbirth, you lose support of the urethra, therefore, activities that increase intra-abdominal pressure like cough, laugh, and sneeze could potentially lead to loss of urine involuntarily.
[Dr. Mark Hoffman]
That seems more of a functional thing. When you said you thought the microbiome had a role with stress incontinence, I was like, "I thought we understood that, because it was pelvic floor stuff and now you're saying there's like more to the story.
[Dr. Ian Fields]
There is, there is. When we think of stress incontinence specifically, a lot of the work has been done about response to surgery, and there was this large trial that was just presented and published I believe in the GREY Journal within the last year or so showing that the presence of different bacteria in the bladder at the time of surgery or before surgery could predict somebody's response to mid-urethral sling surgery. It was down to a couple different genera of bacteria that when present may potentially lead somebody to not respond as well to mid-urethral sling surgery.
[Dr. Mark Hoffman]
That seems crazy.
[Dr. Ian Fields]
We don't know why that is yet. It's just fascinating to me, especially on the flip side of things when we look at urge incontinence, we don't know why people get it. The hardest thing for me to say is people always want to know, "Well, why do I have urge incontinence? When I get the urge to go to the bathroom, why can't I make it to the toilet on time?"
The answer is we really don't know. The prevailing theory is that it's a way that the nerves in your body communicate with your bladder muscle. I always tell people the way we are designed to urinate is one of the most neurologically complex things that we do as humans, but we just don't think about it.
[Dr. Mark Hoffman]
A neurosurgeon that I worked with as a med student, that was his thesis, he just showed me a map of the micturition pathway and I was like, "That seems terribly complicated," but you got to know it's there, but you don't want to pee just yet and you got to be allowed to pee but you also got a control not peeing. It's just all of these things going back and forth between your brain and your bladder and your pelvic floor muscles all in concert. It's a miracle any of us are walking around dry, honestly.
[Dr. Ian Fields]
That's very true. Again, it's always a thorn in the side of the fellows that we train that learning that pathway and committing it to memory is really, really difficult. It's I think, one of the hardest things that we learn as fellows. There's a huge body of work showing that there are disturbances in the urinary microbiome, tangible disturbances that are linked to urge incontinence. I think that's one of the largest bodies of work that we have, is to show that alterations in that urinary microbiome may be more profound in somebody that has urge incontinence versus somebody that doesn't.
[Dr. Mark Hoffman]
It's fascinating. I'm just thinking about endometriosis. There's all this stuff we don't know. I just finished reading the Andromeda Strain. I don't know if you've ever read that before.
[Dr. Ian Fields]
Gosh, maybe when I was in middle school, I think.
[Dr. Mark Hoffman]
Well, I'm a little delayed. Well, no, we were at a used bookstore with my son and I was like, "Oh, I never-
[Dr. Ian Fields]
That's a great book.
[Dr. Mark Hoffman]
-read that." It's great, but how do you look for things you don't know even where to begin? I'm trying to think of other examples of that. Heartburn is one of those things we just assumed, but then turns out there's a bacteria involved that shouldn't be there. Is that more of an infection versus microbiome? Or is that a disturbance to the microbiome? What's the difference? Is that an example of--
[Dr. Ian Fields]
Yes, I think that's probably more an example of an infectious process that needs to be treated with antibiotics versus-- We don't fully understand. Just because these bacteria are there, I think this is the link that we're still waiting to uncover, which is why there's so much work to be done in this arena, because just because we know the bacteria are there people are like, "Well, so what? What does that mean now? How do we use this information?"
[Dr. Mark Hoffman]
Which of those bacteria are supposed to be there? Which of those bacteria may be causing the problem? Or which lack of what bacteria is allowing this problem to happen? It seems like there's a lot left to learn and a lot more to understand. As a basic scientist, how much of your job now is actually involving basic science research, any of it?
[Dr. Ian Fields]
None of it at this point in time. I did a lot more-- None yet, none yet. This was the focus of my fellowship thesis project, was the microbiome.
[Dr. Mark Hoffman]
Did you do basic science research in fellowship as well or just working with basic scientists?
[Dr. Ian Fields]
I was mostly working with basic scientists, although I did spend some time in the lab. There was a component of the project that I wanted to-- I wanted to do a basic science component in conjunction to the microbiome piece, but wasn't able to get that off the ground. Unfortunately, the collaborator who I worked with unexpectedly passed away during the time that I was in my fellowship, and so didn't get the chance to fully delve into that work like I had wanted to.
[Dr. Mark Hoffman]
Yes, and so when you go to a new place-- and that's unfortunate, but when you go to a new place, then you got to meet everybody again. Again, we talked about how people end up where they are, you just bump into somebody and go, "Oh hey?" Then it turns out your career goes sideways from there, a totally different direction. The challenge of being a basic-- Is it frustrating you at all, or is it something you want to keep doing? Because I am not a basic scientist. I math science in high school and I got to college and I was like, "I think I've done enough math."
(5) The Physician-Scientist in Modern Healthcare: Bridging Clinical Practice & Microbiome Research
[Dr. Mark Hoffman]
I'm terrible at reading books. I was really bad at writing and so I figured I'll become an English major just to learn how to write and learn how to read more critically. I was glad I did it. I wasn't good at it but I never felt comfortable in the lab. I never felt like that was something I understood well, but for someone like you, clearly, that's your wheelhouse.
As a physician now, we always think about the physician-scientist model. I think we hear a lot about it that it's going away. It's just RVUs and clinical productivities, and academic demands. There's just not an opportunity to do that in the same way that there was. Do you feel like that's true? Do you feel like opportunities out there for physicians like you who are clearly good at doing that stuff, like to continue doing that and also be a busy surgeon?
[Dr. Ian Fields]
Oh, 100%. I think that there's absolutely room for people like that. For me, on my career trajectory, I see more in the education arena with the work that I do with the residency program and the work that I do with medical students. I think my brain is hardwired as a basic scientist to think about a lot of these things.
It's helpful sometimes in the clinical setting to be able to break it down for patients who want more answers to what they're doing. I prescribe vaginal estrogen all the time in my clinic. You can ask any medical student or resident; that's one of the things that I want them to take away from their time with me no matter how short or long they rotate in my clinic, is that vaginal estrogen is safe and it's effective, especially when we think about things like recurrent UTI and genitourinary syndrome of menopause.
It's one of those things where patients ask me, "Well, how does this work?" I'm like, "Oh well this works--" We know already that vaginal estrogen works to increase collagen production in the cells that line the vagina and it increases thickness, and that thickness increase lubrication which helps dryness and helps decrease the ability of bacteria to climb up and be mobile and get into the bladder. It also has the added effect that vaginal estrogen we know now completely changes the microbiome of the vagina and the bladder.
We talk a lot about good bacteria in the vagina like lactobacillus. I think everyone knows-- Hopefully, many people know, lactobacillus is always thought of as a good bacteria. We know based on a lot of the work that we've done that when you treat somebody that has gone through menopause with vaginal estrogen therapy, you can bring back in lactobacillus to dominate their microbiome, so they thus have a less diverse microbiome because it's dominated by lactobacillus.
We know that lactobacillus makes the environment in the vagina more acidic and therefore makes it harder for these Uropathogens we think of, like E. coli and Klebsiella to grow and therefore cause problems.
That's a frequent thing that I talk about in my clinic because my patients want to know how this is going to work. I say, "How do I know this? It's because I've studied it myself." I think it gives credence a little bit to the therapies that we're using to let people know that like, "No, I'm not just BSing you on this. I know how this works and I do think it's going to benefit you.
That's a really long-winded answer to your pretty simple question. Yes, I think there's a lot of room for physician-scientists and I think there are many in my field. I was just lucky enough to work with one of the PhDs in our department, Dr. Lisa Karstens, who's done a lot of this work here at OHSU. Her interest in the microbiome and my clinical work just linked up beautifully to be able to do that fellowship project.
If I had more time and more energy, that's always the currency that I need more of that I can't seem to find. I would love to continue to do a lot of that work here. I think there's absolutely a way for people to do that if that's really where their interest lies.
[Dr. Mark Hoffman]
Very earlier in your career and to have done that much in your career at this time is always super impressive. I'm sure you'll find an opportunity at some point to follow those things that you're curious about. Which I say again and again, I think curiosity is by far the most powerful force, at least it certainly is for me.
Passion wears out, curiosity is what keeps you up at night and gets you up in the morning to try to read something, find something out. Being curious, sounds like you're a very curious person.
The vaginal estrogen thing, again, it's funny how social media can make such an impact among providers, not even patients. That's one of the things I watch those conversations happen on Twitter and people like, "Hey, by the way, now I use it every day." There's patients across the country being treated with vaginal estrogen because of what they read on social media and the power of that particular platform to educate people and to educate physicians.
We're supposed to know it all already, that's what med school's for. Except that you and I both know that we learn a certain amount of things and things change and you got to keep learning and it's exhausting and the medicine changes
[Dr. Ian Fields]
There's only so much that stays in your noggin. Some of that stuff just leaves at some point.
[Dr. Mark Hoffman]
Also, some of the stuff that stays is no longer practiced anymore. That's why I keep certain apps on my phone with algorithms. I'm like, "They could change it tomorrow, and if I commit it to memory, I've now committed the wrong algorithm to memory, I might as well just know what resources I can trust to be up to date. The CDC website for management of STIs." They're updating that. They're the ones who will know if I need to do something differently. If I try to memorize it, it may not be--
[Dr. Ian Fields]
May not be correct.
[Dr. Mark Hoffman]
May not be right.
(6) The Microbiome’s Role in Diverse Health Conditions & Changing Environments
[Dr. Mark Hoffman]
What are other areas where the microbiome is-- where people looking at it in other disease processes? What are other areas where you think maybe we wouldn't expect the microbiome to be impacting our patients in a way?
[Dr. Ian Fields]
As it relates to us as OBGYN?
[Dr. Mark Hoffman]
Or just at all. Again, I'm fascinated by this idea that there's all these different populations of organisms living everywhere that we're just barely chipping into the surface of this stuff.
[Dr. Ian Fields]
I think it's just all of it. It's fascinating. Preterm birth has been linked to changes in the microbiome. Like I said, interstitial cystitis, painful bladder urinary incontinence, bacterial vaginosis, even the difference in the neonate microbiome versus when somebody is born via spontaneous vaginal birth or C-section. They're colonized immediately with different bacteria and that colonization potentially can lead to different things like asthma, allergies, things like that that you just don't think of.
Like inflammatory bowel disease, heart disease. I was at a talk the other day about links between the microbiome and childhood epilepsy because of the way that a gut bacteria can metabolize certain foods in the diet that create these byproducts that can trigger an epileptic state in the brain.
[Dr. Mark Hoffman]
That's crazy. It's overwhelming. Truthfully though, it's like, "I give up. It's too much. All right. Nature, you win." There's just too much out there. It is overwhelming I think to think about all those possible ways that it's all impacted.
I'm in eastern Kentucky, certainly an area that is underserved. I think about environmental impact. We have people we work with here looking at some of the environmental impacts of living in areas where they've done significant amounts of mining or those kinds of things. We think about the toxic potential.
[Dr. Mark Hoffman]
I imagine the microbiome is significantly impacted by diet or other environmental aspects. How does the environment impact microbiomes in a way? Is it shifting? Is it something that's changing with diet and those things?
[Dr. Ian Fields]
I think a lot of work has shown that it does. People can have different microbiomes based on where they live.
[Dr. Mark Hoffman]
Moving could change your microbiome?
[Dr. Ian Fields]
Yes. Moving could absolutely change your microbiome. That's like totally very well established that those things-- even in the day-to-day in your life can change your microbiome. Some studies have shown even women who, or I should say, people who menstruate can have different microbiomes based on the day in their menstrual cycle. I think that can come down to little things like that.
There's so much that can influence it. That absolutely like environment certainly can play a role in the establishment, maintenance disturbances in your microbiome. I think we're just beginning to scratch the surface on a lot of this.
[Dr. Mark Hoffman]
Forget who's got the best pizza. Now we have to figure out which city has the healthiest microbiome. That's, where you want to know, I'm going to move to--
[Dr. Ian Fields]
Hopefully it's a sunny place.
[laughter]
[Dr. Mark Hoffman]
Exactly. It is North Alaska.
[Dr. Ian Fields]
Great. It's not on a beach somewhere in Hawaii. No.
[Dr. Mark Hoffman]
You know, it won't be, it's going to be some place--
[Dr. Ian Fields]
It's going to be Alaska.
[Dr. Mark Hoffman]
It's going to be really dark and cold.
[Dr. Ian Fields]
Dark for two months of the year.
(7) Uterine & Intraperitoneal Microbiomes in Female Reproductive Health
[Dr. Mark Hoffman]
Exactly. It's fascinating. You've certainly sparked my curiosity and all this stuff and now I'm like-- It's one of those things that once you know a little bit about it, once you get the idea that, "Oh wait, this is probably impacting a lot of things." Again, I deal with fibroids, endometriosis, chronic pelvic pain, a lot of these disease process is where we tell patients, "We don't really know where this starts. We don't really know how this happens."
We now know, at least a new lead to try to figure this out. Does the microbiome-- Because the Fallopian tubes things leak out. We talk about retrograde menstruation. There's bacteria in the vagina, possibly in the uterus. Is the uterus of microbiome? I imagine probably.
[Dr. Ian Fields]
Yes, there must be. I don't know of any off the top of my head, but I imagine that there must be, given the fact that you can have endometritis. It certainly is plausible that you can have something that potentially helps maintain homeostasis in the uterus..
[Dr. Mark Hoffman]
If we're talking about the urethra and how E. coli can travel, that's a day trip. I think if the vagina has its own microbiome and the cervix is only six centimeters long on average and people are menstruating about every month. Clearly there's some connection between the uterus and the vagina. I would imagine there would have to be. All of a sudden now I'm thinking, "Well, then there must be connection with intraperitoneal cavity." Again, we think of the abdominal cavities being sterile. Is it there a microbiome there?
[Dr. Ian Fields]
You bring up a good point. Again, I don't know of anything off the top of my head that anybody that has studied like peritoneal fluid, that would be just if you have a resident or a fellow who's chomping at the bit for something. Again, like the microbiome in--
[Dr. Mark Hoffman]
Sounds like one of your residents as opposed to one of mine, you're the expert.
[Dr. Ian Fields]
I think that's so fascinating. Again we think, especially with the work that you do with endometriosis and fibroids, like it's woefully underfunded, woefully understudied because it's underfunded and there's so much that we have--
[Dr. Mark Hoffman]
It's not understood.
[Dr. Ian Fields]
Correct, we don't know.
[Dr. Mark Hoffman]
It is frustrating to tell patients, "I just don't know." My wife is not in medicine but she is brilliant and reads, anytime anything comes up, she's pulling out journal articles and I'm like, "Where did you find this?" She likes to know an answer and she does not like it when doctors say, "I don't know how this happened."
[Dr. Ian Fields]
I think it's the hardest thing that we do as physicians sometimes is telling people we don't know.
[Dr. Mark Hoffman]
No, and it's hard to do and I don't think we're taught to do that. I think I'm pretty good at it. I'm happy to be honest. It's transparency. I can't promise--
[Dr. Ian Fields]
Same.
[Dr. Mark Hoffman]
-anything but honesty and transparency to my patients. We don't know. It sounds like if these old models of how endometriosis or of how we think endometriosis started, let us basically know where. Maybe this is the next frontier. You've got my wheels spinning.
[Dr. Ian Fields]
You have my wheels spinning too. Now I'm thinking, I'm like, "Oh, endometriosis and peritoneal," I'm thinking peritoneal fluid. That can't be that-- not something that communicate. Again, you have my wheels turning as well.
[Dr. Mark Hoffman]
Your wheels spinning are much more likely to produce valuable research than mine. If we've gotten someone wheel spinning, that's good news.
[Dr. Ian Fields]
You're too kind.
[laughter]
[Dr. Mark Hoffman]
Listen, the good thing about this show is I get to bring on brilliant, thoughtful, intelligent experts and we get to let other people in on these little conversations that we have at a bar or coffee shop, and now everybody gets to listen in. These fun little conversations that we have, hopefully others will get their wheels spinning and maybe somebody will come up with an answer for us because I have no idea.
I'm so glad you were able to join us today. I know you're very busy. I know you have a lot going on. I also know that this is something that I know very little about and I'm super curious about and I think our listeners will also enjoy the opportunity to learn a little bit today. Thank you so much for joining us on BackTable OBGYN and hopefully we get to meet in real life at some point soon.
[Dr. Ian Fields]
Yes. Thank you so much for having me. It's a pleasure to talk about this stuff and get other people's wheel spinning and just to be a guest on your show. Thanks for thinking of me. Thanks for the invitation, and let's do this over a beer or coffee in real life at some point when we can meet face-to-face. All right?
[Dr. Mark Hoffman]
It's a deal. Wonderful. Awesome. Such a fun time. Thanks again and have a great holiday.
[Dr. Ian Fields]
You as well, [Dr. Mark Hoffman], you take care.
Podcast Contributors
Dr. Ian Fields
Dr. Ian Fields is a urogeyncologist and an assistant professor with OHSU School of Medicine in Portland, Oregon.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2023, February 23). Ep. 15 – The Microbiome [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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