A Functional Medicine Approach To The Root Causes Of Endometriosis

Mark Hyman, MD

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Dr. Cindy Geyer: And there was a 2012 study, Mark, in women with endometriosis that found that when they went on a gluten-free diet, a significant proportion of them got improvement. Dr. Mark Hyman: Hey everyone, it's Dr. Mark. My main goal with diet is to use food as medicine. But even when we eat super well, most of us are missing out on certain essential nutrients. Our soils have become depleted and our digestive tracks just aren't working so great. They're compromised by stress and toxins, and they just can't absorb nutrients as efficiently as they should. And that's why I always use, and I recommend to my patients, a multivitamin and mineral as nutritional insurance. It covers the basics for all our day-to-day body functions, all the things that we need that our food might be missing. But there are so many products out there I wouldn't go near because they contain artificial fillers or inactive ingredients and you have to be pretty picky. 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Right now, Athletic Greens is offering my audience a full year supply of their Vitamin D3 K2 liquid formula free with your first purchase. Dr. Mark Hyman: Now these two nutrients are also so vital for a strong immune system, strong bones, and many of us are not getting enough of them. I use the Athletic Greens powder and their D3 K2 formula to make sure I get extra nutrients that compliment my diet. They're also going to give you five free travel packs as well. Just go to AthleticGreens.com/Hyman to get your free year supply of Vitamin D3 and K2 and five free travel packs with your first purchase. You'll get it delivered straight to your door and I promise you will feel the difference Athletic Greens can make in your daily wellness routine. Again, that's AthleticGreens.com/Hyman. Dr. Mark Hyman: Now, so many of my patients ask me how I managed to work multiple jobs, travel frequently, well, not so much anymore, and spend time with my family and still focus on my health. I know it can seem hard to eat well when you've got a lot going on, but the trick is to never let yourself get into a food emergency and to stay stocked up with the right things to support your goals. So recently I discovered Paleovalley beef sticks. I keep these beef sticks at home and at the office so I know that whenever I'm in a food emergency, I have a healthy and delicious option to keep me on track. Dr. Mark Hyman: It's no secret that I have high standards when it comes to what I put in my body and Paleovalley beef sticks checks all the boxes. They're gluten-free, grain-free, dairy-free, soy-free and non-GMO. Plus, they use 100% grass fed and grass finished beef, which not only adds to the flavorful taste, but it also means they're free of any harmful antibiotics or hormones that you'll find in most meat. With grass fed beef, you'll get more nutrients than you would with beef fed with grains, things like higher levels of Omega-3 fats that help reduce inflammation and more B vitamins and other antioxidants to support your body's converting food into energy. Dr. Mark Hyman: And also more of the fat-soluble vitamins that are beneficial for healthy heart. Plus instead of being processed with chemicals and other questionable ingredients, these beef sticks are naturally fermented, so you get gut-friendly probiotics with every bite. How cool is that? Right now, Paleovalley is offering my listeners 15% off your entire first order. Just go to Paleovalley.com/Hyman to check out all their clean paleo products and take advantage of this deal. That's Paleovalley.com/Hyman. I definitely recommend stocking up on the grass fed beef sticks to keep in your house and your car and in your office. It's one of my favorite tricks to staying healthy while on the go. All right, now let's get back to this week's episode of The Doctor's Farmacy. Dr. Mark Hyman: Welcome to The Doctor's Farmacy. I'm Dr. Mark Hyman. That's Farmacy with an F. A place for conversations that matter. And today, if you're a woman and you struggle with menstrual cramps, with infertility, with weird periods, with weird menstrual hormonal symptoms, this conversation is something you should pay close attention to because this problem is way more prevalent than we think and affects so many people and is so missed. And we're going to talk today about endometriosis and we have our special guest today for this week's special episode of House Call. It's Dr. Cindy Guyer, who I've known for decades, worked together at Canyon Ranch over 20 plus years ago. Dr. Mark Hyman: In fact, I hired her as one of the key doctors to help us build the whole functional medicine department, which is really the beginning of the story of how functional medicine got really popular. We were out there just on the front edge, trying to figure it out and we did it together and it was so much fun. And we have come a long way since then. Cindy is triple board certified in internal medicine, integrative medicine, and lifestyle medicine. She served as a medical director at Canyon Ranch for decades, and it's just one of the most external doctors and people I know. And we're so thrilled and glad to have her here now joining us at the UltraWellness Center, where I begged her to come work for me for 15 years, but she refused, but now she's here. I made her an offer she couldn't refuse. So welcome, Cindy. Dr. Cindy Geyer: Thank you. I'm so excited to be here, Mark. Dr. Mark Hyman: It's really great. So let's talk about this topic, endometriosis. And you might be thinking, oh, this is doesn't apply to me, I don't know. But I bet you or someone might have experienced some issue with this and the challenge with traditional medicine is endometriosis, it's really a struggle to get it under control. And with functional medicine, we really found that there are ways to really help resolve this for people. So let's talk about what are the common symptoms of this, how common is it and what is the traditional approach to this? Dr. Cindy Geyer: Sure. It's interesting. We still don't know all of the factors that come together to lead to endometriosis, but what it is, a condition is when cells that normally line the uterus somehow get into the abdominal cavity. We think maybe it's retrograde menstruation and then they set up residence there and they create this ongoing cycle of growth and inflammation and scarring that can lead to heavy, painful periods, pain with intercourse, infertility. And it's number one, very difficult to diagnose. It often goes years before it's diagnosed. It's estimated to affect as many as 10% of American women. But if you look at- Dr. Mark Hyman: That's millions of people. Dr. Cindy Geyer: That is millions of people. And if you look at women who have chronic pelvic pain, it's 70%. So that's huge. So a significant cause of reduced quality of life and chronic pain and difficult to diagnose. Dr. Mark Hyman: Basically the idea is that your uterine lining gets out of where it's supposed to be and starts depositing itself on your kidneys and your bladder and your intestines and your lining of your sort of abdomen. All those places that shouldn't be. And so then when you're having your period or all of a sudden, you're having a period in your kidney or your period in your bladder, or a period in your intestine- Dr. Cindy Geyer: And there's no place for it to go. Dr. Mark Hyman: And also blood in the abdomen is really irritating. Dr. Cindy Geyer: Very irritating. Dr. Mark Hyman: And painful. Dr. Cindy Geyer: Yes. Yes. And it turns out that those ectopic or implants of endometrial tissue that are outside the uterus, they develop their own ability to produce estrogen and propagate the cycle. So even though we don't know all of the factors that cause it in the beginning, what we do know is that chronic inflammation creates an environment where it continues to grow and continues to scar and continues to be a problem. Dr. Mark Hyman: So that irritation just creates a lot of inflammation in the abdomen and it can scar things, which leads to the whole infertility issue. Dr. Cindy Geyer: Absolutely. Dr. Mark Hyman: Some women who struggle with getting pregnant and have it. And I learned in medical school that it was sort of a mechanical thing that. Oh somehow the blood from the period blood got through the fallopian tubes and back out into the abdomen and squirted and landed in places, started growing. But it turns out it's way more than that. Dr. Cindy Geyer: Right. So that still may play a role, but it also may be that once those sites are there, they can be dormant and not cause a problem. But if there's coincidental inflammation, then it feeds the process and accelerates the process. So that's really where we focus a lot of our efforts, is figuring out where the inflammation is coming from and how we change the environment so that those implants can either shrink or go away. Dr. Mark Hyman: So kind of, we silo things in medicine. It's hormonal, it's immune. Turns out that endometriosis is both. And in fact, it's seen by some, as an autoimmune disease. Dr. Cindy Geyer: Yeah. Dr. Mark Hyman: Which changes how I think about it. Dr. Cindy Geyer: Absolutely. Dr. Mark Hyman: And how I treat it. Dr. Cindy Geyer: Absolutely. In the traditional treatment, so often, it's hard to diagnose. It's usually diagnosed by a laparoscopy. But the traditional treatment is to do surgery, to get rid of the scar tissue and remove those implants and hormonal therapies to kind of keep them from growing and developing. But unfortunately it tends to come back if we don't address the underlying autoimmune inflammation and the environment. Dr. Mark Hyman: Yeah. So the treatments like they open your tummy or they laparoscope and they burn all the spots, they hope they don't come back. They don't go, why are the spots coming in the first place? Let's just not putting out. It's like building the boat while there's a hole in it instead of fixing the hole. Which is pretty much, and hormone therapies can be effective, but they're pretty nasty and they shut off your hormones and they turn you into kind of a menopausal woman. In some ways. It's not fun. I feel bad that we have all this stuff causing these hormonal issues. But I kind of have, I don't know what your religious or spiritual beliefs are, but I definitely think there was some higher intelligence that helped create us and that nature is designed to work, not malfunction. Dr. Mark Hyman: All natures and it can get screwed up and out of balance. And so functional medicine is really about where did we get out of balance? And how is it that 10% of women, how is it that 70% of women with pain? How does it, there's there's some causes. So what, from a functional medicine perspective, from a nutritional medicines, we don't know the cause you just got this thing, take these drugs, let's cut it out. What, from your perspective and a functional medicine perspective, what are the root causes of endometriosis? Dr. Cindy Geyer: I think we should touch a little bit on the ones that we probably can't do as much about. There is a genetic component. There's no one gene, but there is a genetic component to it. It's more common in first degree relatives of women who've had endometriosis. There also seems to be an epigenetic component. In other words, the intrauterine environment, when a baby was developing, can also influence her future risk of endometriosis. The strongest link there has been exposure to endocrine disrupting chemicals like dioxins or PCBs or phthalates or bisphenol A. So those intrauterine exposures may also play a role. Dr. Mark Hyman: And those names, phthalates, dioxin, PCBs, bisphenol A, these sound like weird chemicals. They are everywhere, in everything. In every plastic. And everybody has these things in them and more or less. And so they really do act like hormones. They call them xenobiotics or xenoestrogens and they're super nasty. And they're often synergistic and they're often not just additive, but they're multiplied them. In other words, one and one isn't two it can be 10 or 100. And so these compounds are everywhere and then some women are particularly susceptible to them and some can be toxifying. And we don't really think about that when you go to your gynecologist, go, well, let's look at your toxic load and let's figure out how to detoxify you and help your hormones work better. They don't do that. Dr. Mark Hyman: That's what we do in functional medicine. And it's so satisfying because we get to see people really get help where often they can't. So family history is true. I want to sort of just kind of loop back to something you said, because it's a little bit abstract for people, this whole idea of epigenetics and what you were referring to was what happens to your genes as you were entering the world in utero, and then even after, how your genes can be effected by your environment. And ways that affect their expression, it doesn't change the code, but it changes the, which one are red or not red, and that can affect your function. Dr. Cindy Geyer: Yeah. And I think that's actually, it's a message of hope for many of us, that your DNA is not necessarily your destiny, that these switches, and it's often by a process called methylation, the genes that you come into the world with, they can be switched on or off, depending on the environment that they've been exposed to. Not just in utero, but after you're born and the way you live. And to me, that's really the message of hope that these lifestyle choices, like the foods we feed and the things we're ourselves and the things we expose ourselves to and how we live our lives, have the ability to reprogram our DNA in a way. Dr. Mark Hyman: Yeah. And in a way, it kind of can be really mind blowing. I mean, if your mom loves KFC, eating KFC while she's pregnant, you're probably going to like KFC. And if your mom's eating broccoli and grass fed beef, you're probably going to like that. And it really conditions your needs. Then we see this all the time in the data and literature, so really important to early life, but also all our exposures over our whole life. Dr. Cindy Geyer: And I think where a lot of the data now in terms of endometriosis and making it worse, is really connected to the health of the gut microbiome and the intestinal lining. For example, they found higher levels of bacterial endotoxin and lipopolysaccharide in the menstrual fluid and the peritoneal fluid inside the belly of women who have endometriosis, which is suggesting that gut bacteria are somehow making their way into the uterus and into that peritoneal lining. And we know that that is a big contributor to ongoing smoldering inflammation. Dr. Mark Hyman: Okay, this is mindblowing. Here's what you just said, just for those listening, because it was a lot to take in. The products of bad bacteria, they're like bacterial toxins, called LPs or polysaccharides. These things get absorbed through a damaged gut and they somehow end up in the menstrual fluid, wow. So your guts talking to your uterus. That is just mind blowing. And so when you see a traditional doctor, you're not thinking about all these interconnections and the body as a system. They're like, oh, you have no ectopic uterine tissue and we better cut it out or give you drugs that turn off the hormones. Not, gee, why is this happening? And is it inflammatory and is it toxic? Where's it coming from? And when you start thinking about autoimmune disease, you start to ask a different set of questions, which is, what's pissing off the immune system? Dr. Mark Hyman: And it's a short list. It's toxins, allergens, microbes, and imbalances in the gut flora, poor diet, stress and how those interact with our genes. And so it really, you have to go down that path of investigation. And in traditional medicine, they'll look at your labs. They'll look at your hormones and look at maybe an endoscopy or they'll look at a CT scan or an MRI of your belly, trying to get a sense of what's going on, but they don't really don't look at these other pieces. So tell us, what is your approach when someone comes in and struggling with endometriosis, from that lens of everything is connected? What do you tend to think about, what are your diagnostic tests you do, and what do you tend to sort of begin to advise people and to unwind this process? Dr. Cindy Geyer: First, we're going to do an in-depth history. We want to know somebody's family history. If we can figure out what they might've been exposed to, that's great. But we also want to know where they could be potentially having ongoing exposures to these endocrine disrupting chemicals that we mentioned before. They're personal care products, foods, whether they're eating organic or not, and targeting, let's at least reduce the burden. We will probably measure hormone levels, even though estrogen metabolites to see how efficiently somebody can process the estrogens that they're already making. As long as we keep in mind, that what we see in the blood may not necessarily tell us what's going on inside the belly. I certainly want to know somebody's health of their gut microbiome and health of the intestinal barrier, because I think those are really critical. And I'm going to want to look at their inflammatory markers. What's their C-reactive protein? Dr. Cindy Geyer: There's another molecule that's emerged as a predictor and a driver of the scarring and inflammation called galectin-3. And it's a lectin that's part of the immune system and it seems to fuel cellular growth and inflammation and scarring. And it's been implicated in many fibrotic conditions like interstitial pulmonary fibrosis, congestive heart failure and endometriosis. The reason it's important to identify galectin-3, interestingly, there are some drugs being developed that target it, but modified citrus pectin blocks the activity of galectin-3. So there might be a time at a place to even bring in a food supplement that could potentially slow down the fibrosis. Dr. Cindy Geyer: When you mentioned autoimmune conditions, we know that that gut lining is such a critical component. Anybody with an autoimmune condition, number one, we want to look at the health of their gut, because 70% of your antibody producing cells actually line the wall of the gut. So it's kind of a Canary in the coal mine. We also want to identify whether there's a gluten issue. Anybody with an autoimmune condition, there's statistically speaking, a higher prevalence of gluten related disorders, because we know that in people who are gluten sensitivity or celiac disease, eating a meal with gluten causes a disruption in the health of that gut lighting. And there was a 2012 study, Mark, in women with endometriosis that found that when they went on a gluten-free diet, a significant proportion of them got improvement. Dr. Mark Hyman: What do you know? Dr. Cindy Geyer: What do you know. Yet another condition. Dr. Mark Hyman: Yes. We knew. We've known for 30 years. Yeah. I mean, it's such a simple strategy for approaching people's health, using functional medicine. It's really about, okay, what are the things that could be pissing off your body and what does your body need to function better? That's why we call it functional medicine. There's not a long list, here's the things that are troublesome to humans and let's get rid of them. Toxins, allergens, microbes, stress. And one of the things the body means to thrive and function, the right food and nutrients, light, air, water, sleep, love, community, all those things. So I feel what you just unpacked was so critical to understand that if you are suffering from a hormonal disruption or some kind of hormonal condition ... This is true for anything, not just endometriosis, but particularly endometriosis, you have to think deeper. You have to peel back the layers and look at things you wouldn't look at. Dr. Mark Hyman: Yes, we look at hormones. We also look at hormones quite differently. We look at a 24 hour urine sample, for example, that looks at how estrogen is processed by the body and whether it's producing toxic molecules that are more likely to cause problems or not, and why? It could be because of environmental toxins that disrupt those pathways. It could be cause of full later B12 or B6 deficiencies that causes problems. It could be a lot of other things. So our job is to look at, not just at the regular hormones, but more sophisticated. And we look at the gut and the poop testing, which seems weird. But yes, we look at food allergies and sensitivity, gluten testing. We look at environmental toxins. We can do tests for a lot of things like docs and PCBs, phthalates. A lot of the BPA, a lot of these compounds, we can check in the urine and we can even look for things like heavy metals. Dr. Mark Hyman: And all of these things are so important to look at because when you miss them, you're just kind of trying to help people symptomatically get better and you're not really getting to the root cause. So I know you've done this and you've seen real changes in your patients and improvements. And I have patients who've had infertility, struggle with getting pregnant, chronic painful periods, just chronic pelvic pain. And you start to design an anti-inflammatory lifestyle, which is the basics, the usual lifestyle. Dr. Mark Hyman: But often an elimination diet and exercise, stress reduction, sleep, all that. But then you started doing any started doing you toxification and you do things to manipulate the hormone. So let's talk about this whole idea of how do we look at estrogen metabolism and how do we look at the detoxification of hormones and the role that plays in various hormonal conditions and what we can do about it? Because the thing is, it's one thing to just say, oh, you have this thing. It's another thing to say, oh, well, we know exactly how to modify these pathways and fix this dysfunction to get you feeling better. Dr. Cindy Geyer: Yeah. So this is a complicated one to unpack, but let's see if we can walk through it. So estradiol is the primary estrogen that your ovaries make. Your tissues can make another form of estrogen called estrone from conversion of testosterone and DHA. Those estrogens get processed by adding an OH group, a hydroxyl estrogen, and it can get attached at different positions. And the reason it's important is they have different levels of reactivity. There's something called a two hydroxy estrogens. There are four hydroxy estrogens, and there are 16 hydroxy estrogen. Dr. Mark Hyman: What do you mean? There's not such a thing as estrogen? They're all these different kinds of estrogens? Dr. Cindy Geyer: Yes. And they have different impacts. So which pathway we tend to go down with our metabolism is going to impact how it functions as our bodies. For example, we know that the four hydroxy estrogens, in particular, are potentially damaging to DNA. They're really reactive and they have much more of a damaging tissue response. There is a genetic piece to that, but lifestyle, again, plays a role with which pathway we tend to go down. After we make those hydroxy estrogens, we can either methalate them, adding a methyl group to it. We can glucuronidase them. So we can sulfate then. So there's other detox pathways [crosstalk 00:23:51] package them up. So they're not going to cause a problem anymore. But if somebody is not able to package them up, then you accumulate more of those reactive molecules and they cause a problem. So- Dr. Mark Hyman: They cause breast cancer, uterine cancer, cervical cancer. Dr. Cindy Geyer: Yes. It's not just about endometriosis. So what are some of the lifestyle factors that influence this? Well, interestingly, adding that methyl group that I mentioned, your stress hormones share an enzyme with those, they're called catechol estrogens. We have catacholamines, that's adrenaline. Yes. They need the same enzyme to be able to methalate and make them package them up so they can't be a problem anymore. That enzyme needs good B vitamins and magnesium to do its job. So now you're starting to look at this interconnectedness about how, okay, if somebody has a slow methylation enzyme and they have a lot of stress, that's putting a demand on that enzyme and they're eating a diet that's not meeting their needs for magnesium and B vitamins. That whole thing then drives production of those reactive estrogen molecules. Dr. Mark Hyman: So basically it can be genetically set up. You can be nutrient deficient. You could have all these exposures and stuff and that just drives these nasty estrogens. But the beautiful thing about the understanding it is you can actually fix them. Dr. Cindy Geyer: You can do something about it. Dr. Mark Hyman: You can actually give the B vitamins. You can get rid of the toxins. You can improve some of the pathways. You can, I mean, even food plays a huge role. When you look at sugar and starch that drives in the nasty estrogens. And if you eat more broccoli and soy and flax seeds, it helps improve the estrogens. Dr. Cindy Geyer: Absolutely. So we want to support those other pathways. The sulfation pathways, you think of all the smelly foods like the broccoli, but also garlic and onions in the allium family. Dr. Mark Hyman: We talked a little bit about this in the podcast before, that there is this phenomenon, estrogen imbalance in our population. It's basically too much estrogen in relation to progesterone. So maybe an absolute or relative difference. But we live in an estrogen dominant universe. I don't mean because there's more women than men. Because the very things that drive excess estrogen production in the body are the very things that are the dominant features of our society. High sugar and starch, alcohol, low fiber diet, stress, environmental toxins. These are just things that we all deal with, deficiencies in certain nutrients. And yet they're all correctable. Dr. Cindy Geyer: Yeah. And I think the big drivers we can measure, insulin and inflammation, this is an upregulation of estrogen production. Dr. Mark Hyman: Yeah. And obesity plays a huge role because your fat cells make estrogen too. And that's why men who are really overweight or eat a lot of starch and sugar have beer bellies, they'll get man boobs and they lose the hair on their chest, the hair on their legs. It's just a real estrogenation of men from the same phenomenon. So actually this is more of a hopeless story than most people think around endometriosis. Because if these are all diagnosable, underlying causes and there are ways to address them all, then it's not just, oh, I'm stuck with this and I got to take these drugs and have the surgeries and I won't have a baby. And I mean, I'm just amazed. Dr. Mark Hyman: I remember this one woman who had all these inflammatory issues, autoimmune issues, endometriosis. She was 26, 27 years old. Struggling with chronic painful periods and infertile or trying to have a baby and it was just mess. And we just kind of went through this approach that we just talked about and not only did all her autoimmune stuff go away and inflammation go away and our joints get better and her gut get better, but she got a baby. She got a baby. So I think there's hope for people out there. If you're struggling with any kind of hormonal disorder, the functional medicine approach is really effective in understanding the root causes of hormone imbalance, and then in treating them. Dr. Mark Hyman: Well, Cindy, it's been awesome having you on the podcast. The UltraWellness here in Lenox, Massachusetts. We see people from all over the world. We do virtual consults now as well. And we're able to diagnose these things, looking at these diagnostic tests, help people get better and use a combination of diet and lifestyle supplements and other features, detox, to help people get their systems rights. So if you've been listening to this podcast and you struggle with your hormones, tell us how you've dealt with it. We'd love to hear from you and leave a comment. It's always something that we really encourage, because we want to know what you're thinking. If you loved the podcast, anybody's struggling with this issue, please share with them on social media. Subscribe wherever you get your podcasts and we'll see you next time on The Doctor's Farmacy. Dr. Mark Hyman: Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you to all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter and in it, I share my favorite stuff from foods to supplements, to gadgets, to tools, to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else, I promise. And all you do is go to DrHyman.com/Picks to sign up. That's DrHyman.com/Picks, P I C K S, and sign up for the newsletter. And I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger, longer. Speaker 4: Hi everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner and can help you make changes, especially when it comes to your health.