A Functional Medicine Approach To The Root Causes Of Endometriosis with Dr. Cindy Geyer

Coming up on this episode of the Doctor's Pharmacy.

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. 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 tracts 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 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. The one I trust and take myself is Athletic Greens. They use high-quality, highly absorbable forms of vitamins and nutrients from real whole foods. Athletic Greens comes in a powder that tastes great and mixes easily with water or smoothies, and specifically supports my gut health, immunity, energy, and recovery. And it's not just vitamins and minerals. It has phytonutrient-rich superfoods and adaptogens and pre- and probiotics and even digestive enzymes. I love that they add the digestive support in their powder, since so much of our immune strength and overall wellness starts in the gut. It's really one supplement that covers so many bases, and you'd be hard-pressed to find something else in this comprehensive form in any single other product. I use Athletic Greens in the morning as part of my daily routine, and I love having it with me whenever I travel. I also love that it's diet-friendly, whether you're vegan, paleo, keto, dairy-free, or gluten-free. Right now, Athletic Greens is offering my audience a full-year supply of their Vitamin D3K2 liquid formula free with your first purchase. Now, these two nutrients are also so vital for a strong immune system and strong bones, and many of us are not getting enough of them. I use the Athletic Greens powder and their D3K2 formula to make sure I get extra nutrients that complement my diet. They're also going to give you five free travel packs as well. Just go to athleticgreens.com/hymen to get your free year's 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'll feel the difference Athletic Greens can make in your daily wellness routine. Again, that's athleticgreens.com/hymen. Now, so many of my patients ask me how I manage 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 Paleo Valley 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. It's no secret that I have high standards when it comes to what I put in my body and Paleo Valley 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. and also more of the fat soluble vitamins that are beneficial for a 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, Paleo Valley is offering my listeners 15% off your entire first order. Just go to paleovalley.com forward slash hymen to check out all their clean paleo products and take advantage of this deal. That's paleovalley.com forward slash hymen. 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 Pharmacy.

Welcome to Doctor's Pharmacy. I'm Dr. Mark Hyman. That's Pharmacy 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 gonna 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. 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, Integrated Medicine and Lifestyle Medicine. She served as a medical director at Canyon Ranch for decades and is just one of the most extraordinary doctors and people I know. And we're so thrilled and glad to have her here now. Joining us at the Ultra Wellness 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.

Thank you. I'm so excited to be here, Mark. It's really great. So let's talk about this topic, endometriosis. And you might be thinking, oh, this doesn't apply to me. I don't know. But I bet you or someone you know might have experienced some issue with this. And the challenge with traditional medicine is endometriosis. It's a 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, you know, what are the common symptoms of this? How common is it? And, and what, you know, what is a traditional approach to this? What is it? Yeah.

It, you know, it's interesting. We still don't know all of the factors that come together to lead to endometriosis, but what what it is as 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 10% of American women, but if you look at women who have- that's millions of people. 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.

Yeah. And 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 abdomen, all those places that shouldn't be. And so then when you're having your period, all of a sudden you're having a period in your kidney or your period in your bladder, a period in your intestines. And there's no place for it to go. And also blood in the abdomen is really irritating.

Very irritating. And painful. Yes, yes. And it turns out that those endometrial, 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.

Yeah. So that irritation just creates a lot of inflammation in the abdomen and it can scar things, right? Which leads to the whole infertility issue.

Absolutely.

A lot of women who struggle with getting pregnant have it. and we kind of, I learned in medical school that it was sort of a mechanical thing that, oh, you know, somehow the blood from the period blood got through the fallopian tubes and back out in the abdomen and squirted around and landed in places and started growing. But it turns out it's way more than that, right? Right. It's like, right.

So, 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, it 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.

So what kind of we silo things in medicine, right? It's hormonal, it's immune. Right? Turns out that endometriosis is both.

It's both.

And in fact, it's seen by some as an autoimmune disease.

Yeah.

Which changes how I think about it.

Absolutely.

And how I treat it.

Absolutely. You know, 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.

Yeah, so the treatment is 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? Like, let's just not putting out, it's like bailing the boat while there's a hole in it instead of fixing the hole. Right. Which is pretty much fish oil. And the 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, right?

Yeah, they can.

In some ways, it's like, it's not fun. I feel bad, you know, that we have all this stuff causing these hormonal issues. But, you know, I kind of have, I don't know what your religious or, you know, spiritual beliefs are, but, you know, I definitely think there was some higher intelligence that helped create us and that nature is designed to work. not malfunction, right? All natures and it can get screwed up and out of balance. And so functional medicine is really about like, where are we do we get out of balance? And how is it that 10% of women have this? How is it that 70% of women with pain have this? There's some causes. So what from a functional medicine perspective, you know, from traditional medicine, it's like, we don't know the cause. You just got this thing, take these drugs, let's cut it out. What from your perspective and the functional medicine perspective, what are the root causes of endometriosis?

Well, 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 like dioxins or PCBs or phthalates or bisphenol A. So, those intrauterine exposures may also play a role.

And, those names, you know, phthalates, dioxins, PCBs, bisphenol A, these sound like weird chemicals, who knows. They are everywhere in everything, in every plastic and, you know, and everybody has these things in them and more or less. And, and so they really do act like hormones. They call them xeno biotics or xeno estrogens, and they're, like, super nasty, and they, and they're often synergistic, and they're often not just additive, but they're multiple. In other words, you know, 101 is in two. It's, it could be 10 or 100. And so these, these compounds are everywhere, and they, and then some women are particularly susceptible to them, and someone can't detoxify. And we don't really think about that when you go to your, you know, gynecologist, they go, oh, let's look at your toxic load and let's figure out how to detoxify you and help your hormones work better. I'm like, they don't do that. That's what we do in functional medicine, and it's 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 affected by your environment and ways that affect their expression. It doesn't change the code, but it changes which ones are red or not red, and that can affect your function.

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 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.

Yeah. And in a way, it's like, it's kind of like, can be really mind-blowing I mean, if your mom loves KFC, eating KFC while she's pregnant, you're probably gonna like KFC. And if your mom's eating broccoli and grass-fed beef, you're probably gonna like that. And it really conditions your genes. And 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.

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.

Okay, this is mind blowing. Here's what you just said, just for those listening, because it was a lot to dig in. The products of bad bacteria, they're like bacterial toxins called LPS or lipopolysaccharides. These things get absorbed through a damaged gut and they somehow end up in the menstrual fluid.

Like, wow, right?

So your gut's talking to your uterus, right?

That is just mind blowing.

And so when you see a traditional doctor, they're not thinking about all these interconnections of the body as a system. They're like, oh, you have, you know, ectopic uterine tissue and it's, we better cut it out or give you drugs to turn off the hormones, not, gee, why is this happening? And is it inflammatory and what's, is it toxic and is it, where is it coming from? And, 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. Right. And it's a short list, right? 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, right? They'll look at your hormones and they'll look at maybe like an endoscopy or they'll look at a CAT scan or an MRI of your belly and they'll try to get a sense of what's going on, but they don't really don't look at these other pieces. So tell us like what is your approach when someone comes in and struggling with endometriosis? from that lens of everything's 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 to unwind this process?

So first we're gonna do an in-depth history. We wanna know somebody's family history. If we can figure out what they might have been exposed to, that's great. But we also wanna know where they could be potentially having ongoing exposures to these endocrine-disrupting chemicals that we mentioned before, their 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 and 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? 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 and a place to even bring in a food supplement that could potentially slow down the fibrosis. When you mention 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 sensitive or celiac disease, eating meal with gluten causes a disruption in the health of that gut lining. 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.

What do you know?

What do you know? Yet another condition, right?

Who knew? 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 what we call functional medicine. It's like, there's not a long list, right? Here's the things that are troublesome to humans, and let's get rid of them: toxins, allergens, microbes, stress, right? And one of the things the body needs to thrive and function, the right food, nutrients, light, air, water, sleep, love, movement, you know, community, all those things. So I, I feel, you know, what you just unpacked was so, was so critical for people to understand that if you are suffering from a hormonal disruption or some kind of hormonal condition, this is true for anything, and 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 like. Yes, we look at hormones, but 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 is it could be because of environmental toxins that disrupt those pathways. It could be because of folate or B12 or B6 deficiencies that cause those 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 hormones. And like I said, we look at the gut and the poop testing, which seems weird, but yes, we look at food allergies and sensitivity, we do gluten testing. we look at environmental toxins. We can do tests for a lot of things like dioxin, 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. And, and all 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 I've, you've done this and you've seen real changes in your patients and improvements. And I have too, I mean, I have patients who 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 bio lifestyle, but often elimination diet and exercise, stress reduction, sleep, all that, but then you start digging in, you start doing detoxification, and you do things to manipulate the hormones. 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 beautiful 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.

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 DHEA. 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 two hydroxy estrogens. There are four hydroxy estrogens and there are 16 hydroxy estrogens.

What do you mean? There's not such a thing as estrogen. There are all these different kinds of estrogens.

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 methylate them, adding a methyl group to it, we can glucuronidate them so we can sulfate them, so there's other detox pathways.

There's plenty of different chemicals on them.

That package them up so they're not going to cause a problem anymore. is not able to package them up, then you accumulate more of those reactive molecules and they cause a problem.

And then it causes breast cancer, uterine cancer, cervical cancer, you know, so it's.

Not just about endometriosis.

Right.

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 Catachol estrogens, we have catecholamines.

That's- Adrenaline.

Adrenaline, yes. They need the same enzyme to be able to methylate 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.

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 understanding it is you can actually fix them.

You can do something about it.

You can actually give the B vitamins, you can get rid of the toxins, you can improve some of the pathways. You can, you know, I mean, even, you know, 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 estrogen. Absolutely. 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.

And we talked a little bit about this in the podcast before that there is this phenomena of estrogen imbalance in our population. It's basically too much estrogen in relation to progesterone. So maybe an absolute or relative difference. But this, this, we live in an estrogen dominant universe. And I don't mean because there's more women than men, but I mean because, because the very things that 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.

And I think the big drivers we can measure insulin and inflammation.

Yeah.

So it's an upregulation of estrogen production. Yeah. Yeah.

Yeah. And, and, and, and obesity plays a huge role because your fat cells make estrogen, too.

Yeah.

And that's why men who, you know, are really overweight or you lost starch, your sugar have beer bellies. They'll get man boobs. They lose the hair on their chest, the hair on their legs. They get, you know, it's just, it's just a real estrogenation of, of men.

From the same phenomena.

So actually, this is more of a hopeful story than most people think around endometriosis, because if, you know, these are all diagnosable underlying causes and there are ways to address them all, then it's not just, oh, well, I'm stuck with this, and I've got to take these drugs and have the surgeries, and I won't have a baby. And, I mean, I. I'm, like, just amazed. I remember this one woman who had all these inflammatory issues, autoimmune issues, endometriosis. She was, like, 26, 27 years old, struggling. with chronic painful periods and, you know, infertile, trying to have a baby, and it was just a mess. And we just kind of went through this approach that we just talked about. And not only did all our autoimmune stuff go away and inflammation go away and her 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, the functional medicine approach is really effective in understanding the root causes of hormonal imbalance and then I'm treating them. Well, Cindy, it's been awesome having you on the podcast. You know, at the Ultra Wellness Center, we're 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 right. So if you've been listening to this podcast and you've struggled 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 love the podcast, you know anybody struggling with this issue, please share with them on social media. Subscribe wherever you get your podcast. And we'll see you next time on the doctor's Pharmacy.

Hey, everybody, it's Dr. Hyman. Thanks for tuning into the doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you 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 have to do is go to drhyman.com/pix to sign up. That's drhyman.com/pix, 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.

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