The Connection Between Endometriosis And Immune Health

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Excellent. Well, thanks so much for having me, first of all. I’ve been working with people with Endometrium says for almost 25 years now, first as a pelvic health physical therapist, and then I transitioned and got a doctorate in clinical nutrition and work in clinical nutrition and health coaching and a lot of education and integrated all of that with the manual therapy and exercise therapy perspective of physical therapy. And that’s what I’ve been doing to support people with endometriosis in my practice. And then I’ve been teaching fellow colleague clinicians for about the past 15 years or so.

Terry Wahls, MD

Great. And I want to tell you. Thank you. I have severe endometriosis. In fact, when I was trying to have kids, I discovered those infertile in this part of that workup. We discovered that it profound, severe stage four endometriosis, which explained the years of infertility and pelvic pain and severe, painful periods. And I went through surgery and medication and fortunately ultimately had kids. And then I now know that that’s a problem for M.S. So it’s no surprise that I have of would develop multiple sclerosis. And it’s also why I’m so excited that to talk chat with you because there are so many people with M.S. that have endometriosis, infertility as part of their story. So can you talk a little bit more about the connection between endometriosis and immune health?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yes. So one of the most interesting pieces of data I saw was released at a conference in 2019 where if women with endometriosis had highly skilled excision surgery, which of course has to be done by a specialist, their autoimmune markers fairly quickly dropped and that lasted. There was this window of roughly 6 to 12 months, I don’t remember exactly, but what we found and I published a study looking at a case study of Vulvodynia, which is also very closely related to endometriosis, from a sort of autoimmune perspective, that if we take this functional medicine, functional nutrition and approach and optimize gut microbiome work on like small intestinal barrier function, those sorts of things to help optimize immune health from a gut brain barrier function perspective. Then that patient we studied out to 22 months and still were sort of able to maintain her being symptom free and her jumpstart was the pregnancy, the immune shift of pregnancy reduced the symptoms and then we built on that by taking that opportunity to optimize gut and immune health for her. And so with endometriosis, that’s the perspective that we take to optimize gut microbiome as a regulator of immune health and particularly around barrier health in the small intestine lining.

Terry Wahls, MD

Yeah. So big connection between your immune health, your risk of developing endometriosis. And then if we treat endometriosis with surgery, we have a window where we might do better, but and we can improve on what we do if we have a functional medicine approach.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah.

Terry Wahls, MD

If we do what I did, which is you have surgery that just the conventional stuff that’s a very narrow window in your back to having the severe endometriosis again.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Right. And I think that when we think about reproductive health, so people that struggle with infertility related to endometriosis, that’s really what they were looking for is kind of that that infertility was related to those increased autoimmune markers. And so there was always been kind of known that you have this post-op fertility window of 6 to 12 months ish. But again, my goal has always been in our practice to expand that window and even to reduce, you know, the many of our clients still benefit from surgery. I think people that are skilled with excision surgery, that’s an appropriate thing to consider and in fact can be considered relatively early on to preserve fertility because yeah, even if endometrium, cysts, lesions and stuff isn’t blocking structurally the path of reproduction, we do see a decline in egg quality for people who have endometriosis over time. So dealing with that younger, we’re kind of doing some things to preserve fertility. Younger is a good idea, but we also want to prepare the nervous system and the immune system prior to surgery. It’s not just like surgery is the solution. There are all of these other drivers of the symptoms, the pain symptoms, the fatigue symptoms, you know, the immune health symptoms that we want to both prepare for and recover from surgery in a very comprehensive way.

Terry Wahls, MD

And again, everyone who’s listening here, many of you who have another immune condition, there’s considerable overlap with heavy periods. You may not know that you have endometriosis, but I am willing to hazard a guess that if they looked, they may find. And Dimitrios so how would how would they work? If you have M.S. or an autoimmune condition and you’re having heavy periods, a lot of pelvic cramping, how would you get your physicians to check to see if endometriosis is part of the problem?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah. So unfortunately, that’s one of the biggest barriers to good care for people with pelvic pain in general and endometriosis in particular is there’s no quick marker, there’s no blood marker or imaging that can be used to diagnose endometriosis. It has to be done via laparoscopic surgery. However, you can sometimes see endometriosis lesions on imaging and of course with a skilled pelvic exam by a gynecologist who specializes in this kind of surgery. If they find endometriosis, it’s there. It’s just that you can’t rule it out if it’s not seen on imaging. And so in that case, doing a laparoscopic surgery is how it would be diagnosed. And I think another misconception around endometriosis is that it’s a disease only of the pelvic and reproductive organs, but it’s actually a full body disease. Endometriosis has been found increasingly commonly on the lungs, the diaphragm inside the nose, even on the knee joint.

Terry Wahls, MD

Okay. So, yeah, let’s help our listeners understand how the endometrial cells we can understand how that gets to the fallopian tubes, the ovaries, the colon, how does it get outside of the pelvis?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Right. Right. So endometriosis is actually a genetic disease that 9% of female or utero fetuses with uteruses. So female or similar uterus, female fetuses are found to have endometrial lesions at birth when they do these studies of fetuses. So it’s a genetic disease that usually is already there. The issue is about how is it expressed and how severely is it expressed. So there was an old theory that endometriosis is actually the sort of retrograde menstruation of the actual lining inside the uterus, being sort of spread outside the uterus in a retrograde fashion. So it’s kind of in the wrong direction from the uterus that happens commonly, but it is not the cause of endometriosis, endometrial lesions are cells that are similar to the lining of the tissue that is inside the uterus, but not exactly the same. So this is something that people are essentially born with. The prevalence of endometriosis, again, in those fetal studies is 9%. And then people with uteruses in general living out in the world as teenagers or young adults is 10%. So the way I think of this as a functional practitioner is that while there’s this genetic underpinning and risk for endometriosis, the expression of these lesions, which are to some extent similar to cancer, they are benign, they’re not cancerous, but they do increase the risk of certain cancers. 

And, you know, when you have aberrant growths that trigger, you know, adhesions and lesions and can be growing on the bowel, on the bladder, all around the reproductive system, again, diaphragm, lung throughout the body. What we want to do is take a very holistic approach to settling inflammation for sure throughout the body and then optimize using that barrier function. So the immune system is not chronically over activated, but in a way that’s, you know, in that autoimmune way, in the context of inflammation so that it’s not very well targeted. So ideally the immune system would be cleaning up these sort of aberrant cells throughout the body. But when you have so much chronic underlying inflammation, that targeting gets lost in in the immune system. Sure. Yeah.

Terry Wahls, MD

Wow. This is really quite profound. If you have this pelvic pain, remember, endometriosis may be part of it and it may also be going on elsewhere in your body in this very holistic, integrative, functional medicine approach can reduce the severity of the endometriosis, whatever, make it completely resolved.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Well, we don’t have any we don’t have any data to support that in the sense that this functional approach sort of shrink the lesions. I don’t have any data to support that. However, I have certainly seen that symptoms can be completely resolved. The pelvic pain, the menstrual symptoms, fatigue goes along with this very often. Those kinds of symptoms can resolve. Not everyone requires surgery, but most people do will do better with surgery.

Terry Wahls, MD

And I’m thinking about I know people who have difficulty with painful sex, and I imagine endometriosis is part of that symptom complex.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Absolutely. You could certainly have painful sex. Certainly, if there are lesions growing on or around the vaginal canal or pressing into the vaginal canal or on or near the cervix. But you also could just have vaginal dryness and dryness related to hormonal manifestations of endometriosis, also what’s called the terrible triplets. It’s very common for people to have endometriosis and vulvodynia, which is a over pain syndrome and bladder pain syndrome, sometimes specifically interstitial cystitis, sometimes a more general bladder, bladder pain syndrome. So those three syndromes can.

Terry Wahls, MD

Define interstitial cystitis for our listeners.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah. So a painful bladder would be bladder pain, urgency of urinary urgency and frequency. Sometimes in a defined situation where inside of the bladder the lining has these little irritated what’s called cysts. Hunter says that is the definition of interstitial cystitis. But you can have other painful bladder syndromes. You could have painful and inflamed bladder simply from endometriosis growing on the bladder. So that’s very common. And then the other thing is, as you said, sometimes the treatment either pre or post surgery or in general is hormonal birth control or other hormonal suppression, which can be helpful for the symptoms in about 30% of the cases. But what that does is by suppressing estrogen and shrinking kind of the size, robustness and fluffiness of the tissues of the vulva, we end up having vulvar pain related to hormonal suppression. So and sometimes just vulvodynia related to the autoimmunity that tends to overlay all of these things. So, so there are a variety of causes, but symptom wise people do have pelvic pain, period pain, sometimes pelvic pain that’s not in alignment with the periods, especially the younger they are. So this tends to present at roughly age 8 to 12 and that pre puberty time. But first it often presents as IBS or digestive symptoms because as endometrium this is very commonly growing on or around the bowel, there can be adhesions and inflammation. And so it’s very common for people to have what’s known as endo belly, but is actually really SIBO or CFO or some combination of that, which is which basically means that in your small intestine, do you have bacteria growing or fungi growing that shouldn’t because those lesions slow down little areas of where that digestive peristalsis should happen.

Terry Wahls, MD

So sure.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

You know, so when we regularly treat SIBO, we don’t always think about the structure of the small and large intestines, but when someone also has endometriosis, we have to think a lot about that because even with good surgery, sometimes you’ll have these little sticky pockets. So we have to think of managing those things over time versus just sort of treating them, if that makes sense.

Terry Wahls, MD

So what is the approach that you’re taking with your individual patients?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

So step one really is to think about how can we settle the nervous system, because most people with unknown metrics have lived with and kind of powered through a lot of pain and a lot of fatigue over a long period of time, starting when they were preteens and young teenagers. You know, think about having to show up for practice or trying to struggle through a math test. I’m sure you had some of these experiences celebrating, you know, studying for exams and trying to progress your career when you’re in intense pain or your periods are really problematic. So nervous system upregulation is really the first step. So settling that on many different levels, we do that with mindfulness. We do it with our read, tracking breathwork breath work, changing our relationship with exercise, sleep quality. We do many, many different ways to kind of settle the nervous system. Second is, I usually use organic urinary organic acids. Testing is kind of a general look for chronic yeast or things like that.

Terry Wahls, MD

What would explain how people do that?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Right. So that’s a urine test that gives us a look through or the end range metabolites that can show up in the urine to see if there are things like overgrowth of yeast or other bacteria systemically.

Terry Wahls, MD

So do I have to keep my pee for 24 hours or can I just a cup once.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Just be a cup once you.

Terry Wahls, MD

Have your folks way. Yeah. The 24 hour test.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

It’s just once and overnight you will kind of like dehydrate yourself slightly. So the urine is a bit concentrated.

Terry Wahls, MD

In the morning.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

It’s a morning urine. Exactly. And that’s it. Just one pee. And then you send it off to the lab and we get this sort of general picture of your gut health. And so that’s sort of step two. So we start with the nervous system and then collaboratively with optimizing gut health, gut microbiome. And then to me, the gut and immune system are so interconnected by optimizing that barrier function. So we’ll look for things like increased intestinal permeability, also markers of general chronic inflammation or really endometriosis. We can just assume a lot of that because it is an inflammatory condition. So we’ll also look at reducing chronic inflammation. And the other thing that we see genetically very commonly with people with endometriosis are some subclinical hypermobility syndrome. So maybe not a full diagnosis of, you know, elbows down lows or something like that, but they tend to have like a little extra flexibility. And again, that relates to increased intestinal permeability, especially if it’s exacerbated by a histamine issue. So these lesions sometimes can be flared. I do see a lot of people that co-present with chronic hives or chronic redness or chronic allergies. And so there is this other three sort of co-morbid syndromes of subclinical hypermobility histamine intolerances or even mass l activation syndrome and disorder. No. Mia, because again, going back to the autonomic nervous system being so chronically stressed, we work with that as well.

Terry Wahls, MD

Know what disorder normal looks like.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

So what it looks like is the sensation that you’re not super stable. Like you’re always sort of like you can’t quite sit comfortably in a chair. So if you’ve ever been required to sit in a lecture at school and you find yourself sort of always, you know, shifting position and stabilizing yourself or every time you cross your legs, you sort of stick a hand in between your legs to stabilize yourself. And that sensation to the nervous system is that there’s this little bit of wobbly ness. And then you amplify that with people who actually have hypermobility and then the autonomic nervous system essentially is like your automatic car, right? So every time you stand up, your blood vessels will shift to make sure your blood is pumping up and your blood pressure doesn’t drop is one example. So one example of a disorder known me syndrome is postural orthostatic hypotension. You stand up and you suddenly have a blood pressure drop and you feel dizzy or you feel dizzy if you’re standing for a long time. So you combine this hypermobility and this disorder. Naomi And there’s the sense that you’re always like a little bit wobbly and inner vertigo. Like, like you’re a manual machine. You have to make sure you’re drinking enough water, you’re drinking enough salt to keep your blood volume optimized. And there’s this sense that you’re not stable no matter what position you’re in, you’re always looking for a more comfortable, more stable position. And it’s very difficult to just stand static or sit static for a long period of time.

Terry Wahls, MD

And I’m thinking that people have a sense of things to be not quite right. They may go to their primary care team and try to describe this and their primary care. Most primary care practitioners will not know what to do with those with what you just described.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Right. And it’s also very fatiguing, as you can imagine. Right. Because all day long, you’re not only just.

Terry Wahls, MD

Sort of work.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah, you’re kind of shifting and your eyes and your brain are having this stabilize all the time. Your blood pressure is stabilizing all the time. There can be a sense of numbness, tingling, other sort of paresthesia as so there’s all this work to just sort of be at rest. Does that make sense?

Terry Wahls, MD

Sounds exhausting.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yes. So this is why when you add up the layers of things that people with endometriosis and autoimmune conditions are dealing with, all this energy output is happening just to participate in a Zoom meeting like this.

Terry Wahls, MD

And it’s no wonder that there’s so much fatigue working with these individual patients. And this goes on for years, probably decades before anyone cancer diagnosis. I’m thinking that women often come to a diagnosis when they’re trying to have kids.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yes, that’s common. Or if they have severe pelvic pain, you know, it’s increasingly considered even among more conventional systems. But the average time to diagnosis when I started this work just over 23 years ago, as I mentioned, was 15 years, and now it’s 12 years. So we’ve made a little progress so far, but still a long time.

Terry Wahls, MD

No. And I’m sort of guessing that painful sex is another reason that people can sometimes come to diagnosis as well.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah.

Terry Wahls, MD

It’s pain, infertility and difficulty with your internal relationships.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

And also digestive issues is a common reason that people seek treatment, but not always some. And gastroenterologists are becoming more, you know, alerted to the fact that especially in certain age populations and also looking at family history. Because remember, this is a genetic disease. So if a girl is nine, ten years old, just starting having new onset digestive issues and she has a family history of her mother or sisters or and her grandmothers having endometriosis, and they may not know that they had endometriosis, but they might have had painful periods or infertility or something like that that can add to the diagnostic suspicion.

Terry Wahls, MD

And so, so I finally made my diagnosis. I finally got someone. So, yes, I have endometriosis now. We’re talking about do I have surgery or not? And hopefully someone is talking to me about the functional medicine, integrative medicine approach to calming everything down. How long should I think it will take to either a improve to reduce the pain, improve my energy? What do you think?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Realistically, 3 to 6 months and I like to have that amount of a time frame prior to surgery, if at all possible. So that the nervous system can be more settled going into surgery in particular. And then post-op, you know, the acute healing is anywhere from 3 to 6 weeks, maybe 12 weeks, depending on the complexity of the surgery. If the bowel was involved or, you know, you’re dealing with long or diaphragm. But I always tell my clients, you know, it takes 6 to 24 months to really fully recover because as we just talked about, there’s autoimmune impacts, there are immune, there are inflammatory impacts, their nervous system and hypermobility impacts on pelvic floor myofascial impact. So the pain drivers are not just the endometriosis lesions and adhesions, but there are lots of different other things that can be pain drivers from, you know, the myofascial pain to the nervous system adaptation to all the gut microbiome changes that are going to take some time to unravel. And we can only heal at the pace of the body being able to tolerate that healing. You know, sometimes I see patients who have worked with other functional practitioners and there’s been a really aggressive approach to things like yeast detox or something like that, which is an important part of the puzzle. But this person’s system has often been through a lot for like a decade before they have had appropriate treatment. So we really have to be patient with that and do that in the context of a really safe, supported, nervous system. Otherwise, the symptoms will actually often get worse.

Terry Wahls, MD

No, listen to your thinking on behalf a really very important part of this healing journey and that lots of bone broth, lots of attention to healing a leaky gut, maybe some cod liver oil if they tolerate fermented foods. But if not, I’m using some probiotics in reassuring them that, you know, this will take time and this is not a diet. This is a new way of living. And that, you know, in my practice, I certainly have had people come in that were treating for their arms, for their immune problem. And they tell me that they had gone through IVF, trying to get kids unsuccessfully and had had, you know, bad enemy choices, bad pelvic pain. And a year after working with me, they come in and said, you know what, I’m pregnant.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah, absolutely.

Terry Wahls, MD

And so their pelvic pain is resolved and their fertility is improved. So sometimes we get to have really great, great outcomes.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah. And that year, you know, as you said a year later, I think that’s so important because 6 to 12 months can make a dramatic difference when it’s so gentle like that. And that’s when we definitely see fertility healing and improved end quality because you finally have strong levels of antioxidants that the body can take in.

Terry Wahls, MD

Are there any particular nutrients that you see as key?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Dr. Drummond A couple are strongly evidence based. One is pretty notional. It’s mass cell stabilizer, but it also helps stabilize. That’s one study that we do have around the utilizing of the lesions.

Terry Wahls, MD

Know the food that’s in pine bark.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

French maritime pine bark.

Terry Wahls, MD

Yes. Okay.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Yeah. So that’s one, as you said, glutamine in bone broth and acetyl cysteine and co Q10 for supporting of egg quality. I also really like just kind of a general approach to adding nourishment. So again, people with endometriosis have also often had a lot of digestive issues. So there they have limited and limited and limited also with the bladder pain limited and limited in limited what they’ve been eating like by the time they see me, they’re eating for foods. That’s problematic, too, because you’re not getting enough nutrients. And so we start with a lot of soups, a lot of slow cooked vegetables, a lot of proteins that are most easily absorbed to support the digestive healing and the immune healing collaboratively.

Terry Wahls, MD

That is excellent. And patients, this will take some time. Yeah, this has been just so fabulous. Dr. Drummond, where are you located? Where is your practice?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

So my practice is virtual. We work all over the world with patients.

Terry Wahls, MD

Excellent. And so how do people come find you and how. How can they come work with you?

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

So our website is outsmartendo.com and they can find us there. Our training practice for practitioners is integrativeWomensHealthInstitute.com and for people with endometriosis who are seeking healing it’s outsmartendo.com.

Terry Wahls, MD

Outsmart and overcome. This has been fabulous. Dr. Drummond, thank you so much. And like, oh, my God, I wish I would have gotten to know about you. You know, 40 years ago when I was struggling with my pelvic pain and my endometriosis. Yeah. Thank you. You have such a powerful and such an important message.

Jessica Drummond, DCN, CNS, PT,  NBC-HWC

Thanks so much for having me. I really appreciate it.