Recently, I interviewed Dr. Jessica Drummond, and we discuss her journey into women’s health, the complexities of endometriosis, its symptoms, the challenges in diagnosis and treatment, integrative management approaches, the relationship between endometriosis and thyroid health, why it’s crucial to find a skilled surgeon, non-surgical options for managing endometriosis and more.. If you would prefer to listen to the interview you can access it by Clicking Here.
Dr. Eric Osansky:
I am excited to chat with today’s guest, Dr. Jessica Drummond. We are going to talk about endometriosis. It should be a fascinating conversation. Let me dive into Dr. Jessica’s impressive bio here:
Dr. Jessica Drummond is the founder and CEO of the Integrative Women’s Health Institute. For over two decades, she has worked with women with complex chronic illnesses such as endometriosis, pelvic pain, painful bladder syndrome, and vulvodynia. She has educated practitioners in over 60 countries. She takes the root cause innovative approach to healing in collaboration with her clients and students. Welcome, Dr. Jessica.
Dr. Jessica Drummond:
Thank you so much for having me. It’s a pleasure to be here.
Dr. Eric:
It’s a pleasure to have you here as well. Looking forward to talking about endometriosis. Before you explain what endometriosis is, for those who are unfamiliar with it, let’s go a little bit deeper into your background. How did you start helping women with endometriosis as well as pelvic pain, painful bladder syndrome, all these complex chronic illnesses?
Dr. Jessica:
I became a physical therapist first. I graduated from physical therapy school back in 1999. I thought I would work in orthopedics and sports medicine, which I did.
Within the first year, I became really interested in women’s health specialty physical therapy, which at the time was a lot of focus on an orthopedic approach to things like athletes in pregnancy. I had one patient who had breast cancer surgery and then had shoulder issues. That evolved. Women’s health and pelvic physical therapists do that kind of work still. But we also did a lot of work around incontinence and pelvic organ prolapse and birth injuries, which are actually surprisingly similar to orthopedic injuries of intense athletics.
My most challenging patient population were those who had chronic pelvic pain. Back in that time, in the early 2000s, we didn’t have a lot of options for therapies. Many of our clients were either struggling with opioid addiction or had to have nerve stimulators surgically implanted. None of these things worked very well. Our physical therapy tools were also limited.
At that time, in 2003, my oldest daughter was born. I had what I understand now, being a functional medicine practitioner and clinical nutritionist, it was a reactivation of EBV. I had intense fatigue and what we used to call adrenal burnout. I was wiped out, which was surprising for me because I had been an active, athletic physical therapist. Now, I’m a new mom and trashed.
I learned the tools of clinical nutrition and functional nutrition. I eventually went back and got a doctorate in functional nutrition. I was board certified in health coaching. I really slowed my practice down to start looking at what could be some of the root causes of these chronic pain conditions. Since they’re also hormonally related, as I was working with women’s health and menstrual health, endometriosis has some of that menstrual, cyclical relationship to the pain.
If we could, from more of a nutritional, biochemistry standpoint, start to have more tools than just opioids and nerve stimulators and pelvic PT, which in some cases were helpful and some cases were harmful and in some cases were just not enough, that’s where I really began to sub-specialize in more complex chronic pain conditions.
Dr. Eric:
Thanks for sharing your background. Let’s dive into endometriosis. For those who are unfamiliar with it, what is it? How common is it?
Dr. Jessica:
It’s very common. The underlying cause of endometriosis is a combination of genetic predisposition, so 1/9 female fetuses are born with endometriosis cells pre-birth. We know that there is some genetic predisposition. Then there is usually some kind of immune dysregulating trigger. It’s a chronic inflammatory condition. In some cases, there are autoimmune markers that can be elevated. There are a lot of autoimmune comorbidities. Hashimoto’s, Celiac, things of that nature.
It’s common in people with uteruses. Roughly 1/9-1/10 of people with uteruses have it. The tissue that is similar to the tissue that lines the uterus, which is called the endometrium, grows outside of the uterus. By definition, this is a disease that is systemic. These lesions are often in the pelvic cavity, so around the ovaries, the fallopian tubes, the bowel, rectum, bladder. These lesions can also grow anywhere else.
I think of it as a benign cancer. These lesions can grow through the diaphragm, on the lung. They can be a cause of collapsed lung. They can grow in joints. There have been case studies of endometriosis lesions on the knee, inside of the nose. It really can be anywhere.
The original theory was that there was a retrograde menstruation that pushed cells out of the uterus in the wrong direction during the menstrual cycle. Things would get inflamed from there. We know that’s not true because we know these cells can be there from birth, but they are similar as the lining of the uterus.
One important thing to note about that is because by definition, these lesions, little growths that are like cancer but not cancerous, they have their own hormone supply. They create their own blood supply. They hijack the immune system to sustain themselves. They are by definition outside of the uterus. Hysterectomy is not a treatment for endometriosis.
There is a sister condition, if you will, called adenomyosis, which is similar types of lesions on the uterine muscle, so inside the uterus. That could in some cases be treated, and the current standard of care is it could be treated by hysterectomy. Endometriosis is not treated by hysterectomy.
Dr. Eric:
From what I understand, based on your explanation, endometriosis itself is not an autoimmune condition, but it’s common for it to be present in other autoimmune conditions. You mentioned Hashimoto’s and Celiac.
Dr. Jessica:
We don’t really know for sure whether or not endometriosis is autoimmune. It’s absolutely inflammatory. It does have some features of autoimmune diseases. It’s a combination of a disease state that is autoimmune. In some cases, maybe all cases, chronic inflammatory, and genetic.
Dr. Eric:
Okay. Is it something that’s commonly misdiagnosed, where a woman will be having it for many years before someone finally hopefully is able to diagnose it?
Dr. Jessica:
Yeah. The standard delay of diagnosis is 12 years. For most women, it presents in prepuberty, around 8-12 years old, as gut issues, digestive issues, bloating, what’s known as endo belly in the endometriosis world but is really SIBO or SIFO, an overgrowth of bad microbes in the small intestine. The menstrual pain can present and be irregular early on. At any time, too. It’s not always cyclical pain.
Some key red flags are those digestive issues, fatigue, and intense menstrual pain or intense pelvic pain outside of menstruation. Because this disease is systemic, there could also be pain or other symptoms pretty much anywhere in the body.
Ideally, the time for diagnosis would be roughly middle school, maybe early high school. Unfortunately, it’s a surgical diagnosis at this point. We don’t have any easy blood markers. It doesn’t always show up on imaging. The only way to diagnose it truly is with a skilled orthoscopic surgery, which is another reason why often the complete diagnosis can be delayed. It is even possible to be diagnosed in perimenopause, menopause, or beyond. It gets complicated because each case can present differently.
Yes, unfortunately, often women are misdiagnosed with things like IBS or SIBO without underlying the endometriosis driver or menstrual pain. They’re often just brushed off and given hormonal birth control to try to quiet the symptoms, but it’s difficult to get good, early diagnosis of endo, even now.
That number from the start of my career 25 years ago has only declined three years. It used to be 15 years to diagnosis; now it’s 12.
Dr. Eric:
It’s still a long time. I didn’t know the relationship between endometriosis and SIBO. If someone gets diagnosed with SIBO and has underlying endometriosis, that person might take rifaximin or herbal antimicrobials, which might temporarily help, but it’s not going to resolve the SIBO unless the endometriosis is resolved, correct?
Dr. Jessica:
Yeah. That is really challenging. Like I said, it’s known as endo belly in the endometriosis community because you’re exactly right. The SIBO or SIFO could be treated either from an integrative or a more conventional perspective.
Imagine if you have little lesions growing on and anywhere around the small or large intestine. You’re going to have motility issues. You’re going to have little pockets where the fungal or bacterial overgrowth can thrive. That can always remain, even if those lesions are surgically removed because sometimes, you then have little areas of adhesions or inflammation.
Sometimes, a combination of really skillful integrative therapy for SIBO and SIFO, including bowel function and gut microbiome, and skilled excision surgery, which is the robotic surgery that removes those lesions from the root, then you can sometimes eradicate endo belly, but it can be difficult.
We often have to manage it with things like pelvic or visceral physical therapy, rotational movements, breathwork, things that help with motility, like ginger and artichoke. Then a kind of occasional, maybe quarterly or semi-annually support with those antimicrobial herbs. A lot of times, it won’t stick because there’s that structural change to the gut.
Dr. Eric:
Makes sense. There is some train of thought. Maybe that’s not the case currently, but I’ll let you share your thoughts. Endometriosis, being an estrogen dominance condition, problems with estrogen metabolism could be a factor or even the main factor in the development of endometriosis. What are your thoughts on that?
Dr. Jessica:
In 2018, we had a great study out of Belgium that showed that endometriosis lesions, about ¼ of them had estrogen upregulation in the receptors. ¼ had progesterone upregulation. ¼ had both. ¼ had neither. The challenge is that multiple kinds of these lesions could be in the same person.
Yes, some endometriosis lesions are “fed” by estrogen in the same way that you can have an estrogen-provoked breast cancer. Only about ¼ of those. It makes sense as to why some women do well with estrogen suppressive therapies. Anything from GNRH agonists to hormonal birth control to an integrative or functional approach to support reducing estrogen, better metabolizing estrogen.
But that’s not really the driver of the condition. It’s part of the condition. In some cases, it’s actually progesterone that is the problem. In some cases, both. In some cases, neither.
I really think of endometriosis as more of a structural immune disorder than hormonal. Depending on the age of the patient, usually if we can optimize the gut microbiome in the immune system, the hormones- We want them to be in balance for the whole system.
We have started having interesting conversations about endometriosis and perimenopause and menopause. The original thought was absolutely avoid giving these women hormone therapies. But there should be an individualized conversation around using hormone therapies if women have significant menopausal symptoms because they’re not always going to exacerbate the endometriosis. Even if they do, there is a cost benefit analysis of that. As you and I know, we do things like support the liver, support the gut microbiome, support bowel function, support the detox pathways. It’s not necessarily problematic to the endo.
It’s not 100% of the time that estrogen suppression or even support of estrogen metabolism will help with endometriosis. It’s about 25% of the time. Same thing with adding hormones. Sometimes, that’s appropriate; sometimes, it will really exacerbate the symptoms.
Unfortunately, there is no quick test for that. If any given person’s lesions have that histology is after taking the lesions out, after surgery and doing histology on them, but by then, it doesn’t matter because the lesions are out. We have to do this from a trial and error perspective.
Dr. Eric:
That’s interesting. You said 25% involves progesterone upregulation. In those cases, at least in some of those cases, giving progesterone might actually exacerbate. Like you said, if you’re taking a whole body approach, if someone is only given progesterone, maybe that might be problematic. If you give them progesterone and are doing other things like supporting the liver and the gut microbiome, then maybe not.
I’m sure you’re familiar with the DUTCH test. A few years ago, with the different metabolites, I recall during one of their lectures, they were saying that endometriosis is commonly characterized by elevated 16 hydroxy metabolites. Based on what you said, maybe in some people, that’s a pattern. If someone has perfectly normal metabolites, or if they have elevated 4 hydroxy, and their 16 hydroxy looks fine, you can’t use that to rule out endometriosis.
Dr. Jessica:
Absolutely not. It’s not a diagnostic test. I would say I see both. Sometimes, I see people with perfectly normal estrogen metabolism. I actually would say that I more commonly see 4 hydroxy estrogen because it’s an inflammatory condition. Both of those, elevated 16 or elevated 4 could be problematic.
For me, looking at a DUTCH test in women with endometriosis, the most important and first thing I will look at is the cortisol curve. It’s very difficult to help them heal in an environment of autonomic dysregulation. Optimizing nervous system regulation really helps with everything else.
We do know that some particularly anti-inflammatory, antioxidant supplements, things like quercetin and resveratrol and curcumin in the right people can be very helpful. In many women with endometriosis, especially those who have significant pain with their condition. Not everyone does. Some people have very silent endometriosis until they struggle with fertility or until they hit perimenopause or menopause. Different things can trigger the disease in different people.
For me, I think more about the immune system than the hormone system. Thinking about how all of these systems interact, the nervous system, the immune system, digestive function, then the gut microbiome.
Dr. Eric:
You said silent endometriosis, so you can’t just go by symptoms. When it comes to symptoms, you mentioned SIBO, like GI symptoms, bloating, gas, pretty common. Pelvic pain. Would you say those are the two most common symptoms, the pelvic pain and GI symptoms?
Dr. Jessica:
Yeah. GI symptoms, pelvic pain, menstrual pain. If a period is taking a woman or girl out of work or sports, if you have to be in bed one day a month, that’s a big red flag. If you need pain medication every single month, that’s a big red flag.
It’s genetic. If a person’s mother struggled with endometriosis or infertility or pelvic pain or menstrual pain, a lot of times, the older generation of women weren’t appropriately diagnosed, especially if they were able to have children. Look for those red flags of women in the family either not being able to have children or having really painful periods.
That is where it can become a bit of a gaslighting situation. You have a nine-year-old girl who has really painful periods. Every woman in her family is like, “This is just how it is for us. It’s fine. You’ll be fine.” Painful periods.
Painful sex. Especially pain with deep penetration. It’s common that’s deeper in the cervix and the connection posteriorly by the rectum. That’s a very common place for endometriosis to grow. Painful sex with penetrative sex is a big red flag.
Also, with the menstrual pain, it’s beyond pain. It can also be diaphoresis, like sweating, dizziness. POTS or any kind of dysautonomia is common with endometriosis.
There are two sets of what we call terrible triplets, common comorbidities in endometriosis. One set is bladder pain, so endometriosis with painful bladder symptoms. It’s not just pain, it could be urgency, frequency, things like that. It is common for endometriosis to grow on or around the bladder. Then vulvodynia, so pain at the very opening of the vulva. That is one set.
The other set is endometriosis with mast cell activation syndrome (MCAS), so a lot of histamine issues, redness, heat, feeling allergic to everything. Can’t tolerate a lot of foods. Hives is really common. Plus dysautonomia, which might mean you have been dizzy your whole life. You’re a person who can’t skip breakfast, or you’re feeling like you’re about to pass out. Purely diagnosed POTS or another form of dysautonomia. Hypermobility. If you’re double jointed or you went into dance or gymnastics because you’re very flexible, that’s a big red flag for that kind of constellation of presentations. MCAS or histamine issues, dysautonomia, and hypermobility.
Dr. Eric:
Sounds like it could be pretty complex, which falls into your bio, dealing with complex conditions. It’s not just endometriosis itself, but MCAS is pretty complex.
Dr. Jessica:
Most people with endometriosis have a lot of these things, not just painful periods.
Dr. Eric:
It’s not a two- or three-month process as far as getting their health back. Some of these people might take in excess of a year to get their life back?
Dr. Jessica:
Yeah, I would say in an ideal situation, we have about three months to get the body strengthened in terms of nervous system regulation, good digestive function, calm some of the inflammation, balance the immune system.
Then they would have skilled excision surgery, with someone who specializes in endometriosis and is just really skilled at finding those lesions and cutting them out from the root robotically. Then it’s about a six-week to six-month acute recovery from the surgery and about 6-24 months for full recovery back to all activities, no more fatigue, much less pain, fertility more optimized.
There is a window of opportunity post-op where the immune system is more balanced from an autoimmune standpoint, where fertility improves significantly. There are these windows of opportunity, depending on what the person’s goal is. Are they experiencing pain? Are they experiencing fertility issues? Are they most stressed by their digestive problems? What are their key problem areas? Then we can set up a plan that helps prepare for and recover from surgery.
Now, not everyone has to have surgery or chooses to have surgery. It is an elective surgery. The vast majority of the time, endometriosis is not life-threatening. There are some rare cases where it is, such as when it’s growing on the lung or things like that. The vast majority of the time, it’s not life-threatening, but it is dramatically quality of life-threatening, as you can imagine.
When possible, at least having an assessment by a skilled endometriosis excision surgeon is a good part of the healing experience. Not everyone has to or chooses to have surgery. It depends on a lot of factors.
Dr. Eric:
Okay. Let’s say someone does choose to go through the surgery. You mentioned the first three months, you’re doing things to support the body, the gut microbiome, the autonomic nervous system. Trying to do things to optimize their health. If you do that, and then they get the surgery after that, you’re still doing things to optimize their health.
I think you said it’s six months post-recovery. Is there still a risk of the lesions coming back? It does depend on the skill of the practitioner, which is why you said you want to make sure they choose someone who knows what they’re doing.
Dr. Jessica:
Yeah, it depends a lot on the surgeon. Even the best surgeons will tell you that sometimes, the lesions come back. Either they missed something, or something grew back. It’s hard to say.
I’ll say that surgical techniques have dramatically improved. When I was first doing this back in the early 2000s, it was very common for people to have 16-20 surgeries, almost a surgery every year for their entire child-bearing years. Now, I would say that the majority of people have 1-2 surgeries max in a lifetime. Sometimes, three, depending on the complexity of the recovery or if there were multiple organ systems involved, or if a general surgeon needed to be called in. It’s much more common to only need one good surgery in a lifetime.
Depending on where a person lives, that can be challenging to access. In the United States, almost all of the surgeries are out of network. There is not good billing support. Because of how complicated these surgeries are, it’s very difficult to get them covered by insurance. In the United States, they can be very expensive.
Outside of the United States, there can be long delays to accessing them. In Canada or the UK, where there is socialized medicine. There are challenges with surgery no matter which country you’re living in.
It’s still worth trying to hold out for a skilled surgeon because another non-skilled surgeon can set you up for needing more surgeries.
Dr. Eric:
Makes sense. Even if someone has to wait a little longer to see a skilled surgeon, it’s probably better because seeing one that is not as skilled, maybe you’ll get some relief, but there is a greater likelihood that you’ll need multiple surgeries. With a skilled surgeon, still no guarantee that you won’t need another surgery, but less likelihood that you will. Makes sense.
I know you said a lot of these women have autonomic nervous system dysregulation. MCAS, hypermobility. I assume some don’t have all that going on. It’s still not a simple case of endometriosis. I guess, if they’re not having the autonomic dysregulation and MCAS, is it not as long of a journey in most cases? Is it still something where you can expect a similar process? I guess the process would be similar, but the duration.
Dr. Jessica:
Yeah, the recovery would be easier. It’s interesting: I was just talking on my podcast to one of the top endo surgeons. Her episode is coming out in July or August of this year [2024]. We both noticed, since almost everyone has been infected with COVID at this point, almost everyone I’ve talked to, if not everyone, with endometriosis in the last four years post-COVID infection do have all three of those things as well.
It may be that we are dealing with a new environment now where there is a large pathogen overload. I’m not sure what we’re dealing with now when it comes to endometriosis, but I have very rarely met a simple case in the last few years.
Now, that also could be because the work that I do is pretty specialized. Same with her. We often see the most complicated of cases. It is hard to say.
If I was working in a hospital based pelvic rehab practice, there may be occasions where we find a “simpler” case of endometriosis. Let’s say there are very visible lesions. They’re in the common places. A person has a skilled surgeon. They’re eating an anti-inflammatory diet. They’re doing a lot of stress management. They already have a healthy heart rate variability. They exercise. Their cycles become more regulated. Maybe they’re younger, they’re only in their 20s or early 30s.
Absolutely, we can see a more simple, complete recovery, which could look like six months or so, just with some pelvic floor downregulation. If that person is already doing a lot to take care of their gut microbiome and balance their immune system, and they’re already a meditator or something like that, then yes, there is a wide range of complexity.
As I said, there are people who do have silent endometriosis who don’t even know they have it until they struggle with fertility. There absolutely could be people with no symptoms of endometriosis who maybe aren’t interested in having children. You can have the genetic predisposition and also not express endometriosis.
I had a patient in my practice last year who had an identical twin sister who did not have endometriosis. There is certainly a wide range of expression for sure.
Dr. Eric:
Similar with autoimmune conditions. You could have identical twins, one who has Hashimoto’s or another autoimmune condition, and the other twin is perfectly fine. Environment does play a big role.
For someone who chooses not to get the surgery, what other options do they usually look into? Could things like visceral manipulation help? It won’t get rid of the lesions completely, but maybe to get some relief. I imagine some people try acupuncture.
Dr. Jessica:
There are some nutrients to stabilize the lesions. Quercetin is helpful. Some of the other anti-inflammatories.
Doing a nutrient program to support gut microbiome and immune health and lower inflammation in combination with pelvic floor physical therapy, which does have really strong evidence to support its effectiveness for quality of life and pain management. Pelvic floor physical therapy, including visceral mobilization, including things like cardiosacral, which is helpful for nervous system regulation, all of that can manage, and in some cases, people don’t need surgery. I have seen that happen in some cases.
In other cases, their symptoms are managed enough that they choose not to have surgery. I had a patient probably eight or nine years ago who was about to have surgery. She decided she wanted to try to get pregnant first, which there is a cost benefit to getting pregnant pre- or post-surgery. She decided she wanted to try to get pregnant. She did get pregnant, and her symptoms were quieted. Sometimes, pregnancy, because of its impact on the immune system, can reduce the symptoms a bit temporarily.
She was pregnant. She nursed. She had that one child. She chose not to have any more children. She was going to have the surgery after that, but she felt, given everything she had done to get herself healthy, optimize her fertility, optimize her gut health, she did have some symptoms, but they felt manageable enough to her that she chose not to have the surgery. She had the one child that she wanted. Her quality of life was okay. She just continued to really take care of her health, and she was fine without surgery.
That may change in the future, but at this point, this is what her decision was. It worked well for her.
Dr. Eric:
That’s awesome. One of the questions I was going to ask is since most of the listeners have a thyroid or autoimmune thyroid condition, the relationship between endometriosis and thyroid health and thyroid autoimmunity.
You earlier mentioned Hashimoto’s being more common in those. That’s one potential relationship. Another one I could think about is gut issues are common. Part of that triad of autoimmunity is that increase in intestinal permeability, which SIBO can potentially lead to. That could potentially be a link between autoimmune conditions. I don’t know if you know any other relationships.
Dr. Jessica:
I agree with you. Commonly, autoimmune diseases tend to copresent. Endometriosis in many people does have autoimmune factors, things like elevated ANA in some people. Those are the kinds of markers we can measure declining post-surgery. I agree with what you’re saying. Some of these risk factors for both could contribute to people having both at the same time.
The other thing I would look at is what is their HPA axis? How much neuroinflammation are we dealing with? If they’re under either emotional stress, because it’s very stressful to live in chronic pain. In fact, we’re hosting a viewing of a new movie called Below the Belt, which is about people with endometriosis trying to navigate the healthcare system. You do the same kind of thing. Complex chronic illness, navigating the healthcare system is horrible. That in and of itself is very stressful, which can then impact the thyroid because you have the HPA axis out of whack.
You have the brain, where the HPT axis originates. Anything that causes neuroinflammation or emotional stress, which is a condition where at any moment, you can be in really intense pain, that is very stressful, especially when you go to the emergency room, and they say you’re fine or a drug seeker or whatever. That can certainly contribute to thyroid issues, just dealing with low grade or high grade chronic stress for 12 years.
Dr. Eric:
I see that in a lot of patients with dysregulation of the HPA axis. A good point about the neuroinflammation as well.
You covered a lot of information. Anything that I should have asked you that I didn’t ask you? Do you want to summarize anything before we wrap up?
Dr. Jessica:
I would say that if someone is struggling with pelvic pain, even if it’s not cyclical, even if it doesn’t seem to be related to your estrogen, especially if you also have digestive issues, because about 90% of people with endometriosis have some kind of digestive issue ask about it, it’s hard to be diagnosed because it’s such a vague condition and has a surgical diagnosis. Especially if there are any genetic clues, it’s something to start looking at.
Dr. Eric:
Wonderful. Dr. Jessica, where can people find out more about you?
Dr. Jessica:
Our website is IntegrativeWomensHealthInstitute.com. We also have the Integrative Women’s Health podcast. Our Instagram is @IntegrativeWomensHealth. We share a lot of information about endometriosis, perimenopause, menopause, and other women’s health conditions. You can find more about that there.
Dr. Eric:
Thank you so much. I’m sure everyone learned a lot. I definitely learned some new things related to endometriosis. Appreciate everything you shared.
Dr. Jessica:
Thanks so much for having me. I appreciate it.
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