Endometriosis, Period Pain, and the Limits of Hormonal Treatment (Episode 422)

Full Transcript: Episode 422

Lisa Hendrickson-Jack: Welcome to the Fertility Friday Podcast, your source for information about the Fertility Awareness Method and all things fertility. I’m your host, Lisa Hendrickson-Jack. I’m the author of The Fifth Vital Sign and the Fertility Awareness Mastery Charting Journal. I’m a certified fertility awareness educator and holistic reproductive health practitioner with nearly 20 years of experience teaching women to connect to their fifth vital sign through menstrual cycle charting, balancing hormonal health, and optimizing the menstrual cycle without hormones. I’m outspoken about hormonal birth control and its impact on fertility and overall health because you have the right to know how your body works and how artificial hormones disrupt that natural process. I teach women’s health professionals how to utilize the menstrual cycle as a vital sign in their practices. And I host live coaching programs to help you achieve optimal fertility and health because it’s important to have healthy menstrual cycles regardless of whether or not you want to have babies. I’m also a wife and mother of two beautiful boys. I know, I’m a busy girl, but I managed to fit it all in. This podcast is designed to empower you to take full control of your cycles, your fertility, and your overall health. And I’m so excited that you’re here with me today.

Today I’m sharing an important, powerful, and informative episode all about endometriosis. I’m sharing my episode with Jessica Drummond and in today’s episode she defines endometriosis, talks about how to get a firm diagnosis, some of the challenges doing that, some of the options for treatment, how surgery can come into play and when that might be a good option and what some of the limitations might be for that. So a really great episode to follow up last week’s episode about overcoming period pain as well as the week before, when Stasha shared her story about endometriosis. We also touch on autoimmunity and the role that it plays in endometriosis. So without further ado, let’s go ahead and jump into today’s episode with Jessica.

And I’m really excited to be here today with Jessica Drummond. She was a past guest on the show, I think it was like 200 episodes ago or something. But I’m thrilled to have her back, so I’ll just read her bio real quick in case you’re not familiar. So Dr. Jessica Drummond is the CEO of the Integrative Women’s Health Institute and author of Outsmart Endometriosis. She holds licenses in physical therapy and clinical nutrition and is a board-certified health coach. She has 20 years of experience working with women with chronic pelvic pain, facilitates educational programs for women’s health professionals in more than 60 countries globally, and leads virtual wellness programs for people with endometriosis. And so obviously Dr. Drummond has been really busy and is clearly passionate about women’s health. So without further ado, welcome to the show.

Jessica Drummond: Thanks so much for having me. It’s my pleasure to be here.

Lisa Hendrickson-Jack: Well, I’m thrilled to have you back. I think that I saw — was it a live or something that you did with Nicole Jardim recently — and I just felt compelled to reach out because it just so resonated with me what you were talking about with respect to the way our medical system fails to treat women’s pelvic pain issues. So this is what we’re here to kind of talk about. And so you probably know just a little bit about my experience, or if not maybe the listeners, but I had severe period pain since day one and then into my early 20s. And I’ve since been able to overcome that. But just it being in the public realm, and so many women reach out whenever I talk about period pain — and I’m sure you get this all the time — millions of women when you say things like period pain is an indication of a problem, and although it’s common it’s not normal, millions of women hear that and they’re like, what do you mean. Absolutely. So maybe let’s start there. Maybe share with us a little bit about what drew you to this work, and then let’s just get into it.

Jessica Drummond: Yeah, so my path to this was not the usual story in the sense that I didn’t personally struggle with period pain as a young teenager or anything like that. I started as a physical therapist in orthopedics. I was an athlete, so I didn’t even get my period until too late knowing what I know now. I essentially had primary amenorrhea from training 20 hours a week from ages 9 to 17, sometimes longer. And so then I went to graduate school as a physical therapist. I started in sports medicine and orthopedics and began to specialize in women’s health, which from a physical therapy standpoint, that essentially means orthopedics related to women’s health conditions like people who have shoulder pain related to a breast cancer surgery, or people with back pain related to pregnancy, or people with urinary incontinence or prolapse or pelvic pain. So you’re doing kind of a structural assessment — was the alignment off, are there tight muscles — and pelvic pain can be muscular because there’s a whole system of muscles of the pelvic floor which connect to the muscles and joints of the nervous system of the spine and the hips and the abdomen. So if you have a C-section, for example, there’s a large incision that is not without consequence, right? There’s a structural consequence to having an open abdominal surgery that is pretty undervalued in our medical system. You have a C-section, then they just send you home with a baby. There’s no rehab, right? Imagine if a pro football player had a knee surgery, an open knee surgery, and was just sent home — no rehab — that’d be crazy. So I’ve been told like, just don’t lift anything heavy. If there’s any instructions, like that’s it, maybe sometimes.

Lisa Hendrickson-Jack: Yeah, but by the way, take this baby and a 40-pound car seat to the doctor.

Jessica Drummond: 100%. So that’s kind of how I got into this. And then after the birth of my first daughter, I had a hormonal crash, which knowing what I know now is likely related to a reactivation of Epstein-Barr virus postpartum. Postpartum is a vulnerable time for activation of autoimmune diseases and viral reactivations. I think that’s also underappreciated. So that’s how I started to study nutrition, functional nutrition, functional medicine, lifestyle medicine. I learned at that point that your first baby is a great teacher of how your relationship to stress and work and overwork is, because you suddenly have no extra bandwidth.

Lisa Hendrickson-Jack: Well, I would add your relationship to the modern world. Yeah, because it can be an existential crisis to realize that all of a sudden, now that you have this baby, you don’t really fit into this paradigm that you worked so hard to fit into.

Jessica Drummond: Yeah, yeah. And I even worked at that time at a maternity hospital — quite literally a women’s hospital. So that’s where I began to kind of integrate functional medicine perspectives, lifestyle medicine perspectives with physical therapy perspectives to treat complex pelvic pain conditions — endometriosis, vulvodynia, bladder pain, period pain — because our tools in physical therapy were valuable but not always helping us get complete either relief or root cause relief. And adding that biochemical approach and lifestyle approach and mindset approach helped me to have a wider lens and more tools for my patients who had plateaued with pelvic pain. So that’s sort of how I landed on really specializing in an integrative approach to pelvic pain, which — my oldest is 16 now — so that was a long time ago.

Lisa Hendrickson-Jack: Well, I think I was thinking about how to approach this topic and I think, like usual, it’s like a plane crash into it. So I released this post on Instagram a while ago and I think it’s still been one of the most contentious, and I believe I said something like the pill does not cure or fix anything. So it’s like, tell me what you really think, right?

Jessica Drummond: Yeah.

Lisa Hendrickson-Jack: But what was interesting about that post — it sparked a lot of outrage, a lot of conversation — but I think the women that came at me the hardest were the ones who had either endometriosis that’s been diagnosed, or women who’ve just experienced such severe period pain that in their lifetime the only thing that has ever brought them relief has been birth control pills or severe pain medication. But I do have to say the caveat that the pill doesn’t fix it for everybody in terms of reducing the pain. But anyway, so the question out of that is — I’d love to hear you talk about what exactly is endometriosis, and kind of get into the difference between paradigms. Because there’s obviously two paradigms at play here. There’s a functional paradigm that’s trying to figure out: what is this, why is this happening, and also acknowledging that this is not a normal state of the female body to be in severe pain. And then there’s the medical model that kind of says, well, you know, it’s fine to be in that kind of pain, we’re not going to ask why, but here’s how you get rid of the pain.

Jessica Drummond: So yeah, and I think to some extent that’s a little bit oversimplified, but it’s difficult because you’re right, this is a very hot topic because people have really difficult and highly variable personal experiences, which is what makes it very challenging. So, number one, it’s 100% not normal to have severe period pain. It’s not always caused by endometriosis, but it’s a really big index of suspicion, especially if that person has family members — other women, sisters, mothers, aunts, grandma — who had infertility challenges, period pain, because endometriosis does have a genetic component. Which actually makes it a little harder to find it early. Because now mothers who are in their 30s and 40s, who have 11 to 15 year olds, are more aware, but it used to be that within the family that 12-year-old intense period pain would be normalized because they’re like, “Oh, that’s how it is for women in our family. It’s just really bad. Take two days off of school. Take as much Advil as you need, lay in bed.” Or we can mask the pain with birth control, which sometimes works about 30% of the time, roughly, if we kind of look at the data. And so what happens is that no one’s really looking for an answer because the family kind of legacy is that this is what’s normal for our family. And in fact, the number one reason that girls in middle school and high school miss school is for period pain — number one. So even school nurses see this all the time. It’s normal. So one thing that I really like — there’s a wonderful non-profit organization called Endo What that produced a movie, and they have a school nurse initiative which aims to begin to educate nurses in elementary, middle school, and high schools, because this is where we should be picking this up. It’s not normal to have intense period pain, yet within families and even in the media — you see tampon commercials where people are laying in bed, writhing in pain — none of that is normal.

Lisa Hendrickson-Jack: So before you talk about the experience, can I just ask you to clarify? So for the women who are listening who do have pain — is there any pain that is normal? Where is the line between what you would consider to be normal and problematic?

Jessica Drummond: Right. So for the most part, you really shouldn’t feel your period other than maybe a day, maybe two days of like mild fatigue, a little bit of cramping, go to bed early, take it easy. You should never have to stay home from school or miss work. I would call it more of just a shift in your productivity. And I think that’s educational for us as humans — this is a time where we take a deep breath, a little extra nourishment, go to bed early, take a nice bath, a little extra self-care. But for the most part it should not be disruptive at all. One day of mild cramping would be the only thing I would even consider quote-unquote normal.

Lisa Hendrickson-Jack: Well, thank you for clarifying that. I think it’s super important to make that connection. If for no other reason than I have to outright ask any woman who I work with to classify her pain, and I’ve had women who regularly experience pain that they describe as five or six out of ten and they’re like, yeah, it’s totally fine, it’s normal, it’s always been this way. And I know people who throw up, so this is totally fine for me.

Jessica Drummond: Well, we can get higher. You know, you deserve to not be in pain.

Lisa Hendrickson-Jack: Correct. And yeah, it could be worse, but why should it be a bar for life?

Jessica Drummond: Right. Although there’s some degree of that in everything, I guess. But yes, that’s how I classify normal. Now, with endometriosis, there’s also a broad range of experience. Two things: one, period pain is not always endometriosis — there are other things it could be — but it is certainly a big index of suspicion with period pain. And in teenagers, it’s actually more common to have acyclical pain — pain all the time, or pain not during the period, or pain randomly. So that’s also something to be aware of, because their cycle hasn’t quite regulated yet. So endometriosis pain could be at other times. And the degree of severity and extensiveness of the lesions themselves — these lesions of tissue that’s similar to the tissue that lines the inside of the uterus, but not exactly the same, growing outside of the uterus — so like outside of ovaries, on the fallopian tubes, on the rectum and the colon and the diaphragm and the knee, it’s been found in the nose, it can be anywhere: small intestine, outside of the uterus. These tissue lesions can be pretty extensive with no symptoms or very light symptoms. They can be less extensive, maybe just one lesion, and can cause severe pain. So there’s not a direct correlation between what the lesions are doing and the symptoms, which I think is really important, because there’s not an easy classification of what’s “bad” endometriosis.

Lisa Hendrickson-Jack: It does. I have a follow-up question because women talk about being diagnosed in different stages. So how does that relate to how it’s actually diagnosed?

Jessica Drummond: Right, so there is various staging, which off the top of my head I don’t remember the exact criteria for the various surgical stages. The only way to truly diagnose endometriosis is with a skilled laparoscopic surgery — and in my opinion, done by someone who does pretty much nothing but endometriosis surgery or similar surgeries all day, every day. It’s a specialty skill. There are different kinds of lesions — they can be very hidden. It can be complex around there being adhesions and the ovary stuck to the wall of the peritoneum. It’s a complicated surgery if done correctly. And essentially, the most skilled laparoscopic surgeons go in with the expectation — a pretty high expectation — that they’re likely to find it. Occasionally they don’t, but usually they do, and then they actually do the surgery right then and there. They actually excise the lesion. So there are two kinds of surgeries. Ablation surgery — which is sort of the old version, not gold standard — where someone with less experience will go in with a laparoscope and essentially burn off the lesions. That’s ablation versus excision, which is more like removing a cancerous tumor — you’re cutting it out from the root, which is more effective. And ideally you only have one of those surgeries ever. Sometimes you need two, or there can be secondary adhesions. But when I used to treat this starting 25 years ago, people would be like, “This is my 16th ablation,” because it would just come back. Fortunately, with the surgeons that I work with now, I don’t really see that. They do one, possibly two, good surgeries in a lifetime.

Lisa Hendrickson-Jack: Well, I have questions about surgery, because if you’re working with a patient, it’s not that they do the surgery and then just don’t do anything else.

Jessica Drummond: Oh, yeah. Of course. So maybe this would be a good time to touch on that. One of the challenges for women with endo — it’s still quite common to hear women say that they’ve had multiple surgeries and that it comes back. So maybe you could talk about the difference between that and also just touch on surgery in and of itself as a treatment.

So even with great excision surgery, there is a risk of challenges. You can have adhesions after the surgery, there can be secondary hernias, the endometriosis can quote-unquote grow back even in the same area or in other areas that they might not have seen the first time. The humans who do these surgeries are not perfect and these are complicated surgeries. But the people that do them well, just like cancer surgeons, do them pretty well. Now, to your point, you don’t just show up, have surgery, look around, find the lesions, cut them all out, and you’re good. Because the lesions are one part of the situation. But when you’ve been in constant or chronic pain for six to twelve years — which is the average time to diagnosis even now — your nervous system has changed. There are inflammatory cytokines locally and throughout your body. Your hormones can be out of balance. Your pelvic floor muscles are tight. Like imagine if you had an open wound on your shoulder for six to twelve years. You’d probably have headaches because you’d be walking around protecting your neck from having this open wound irritated all day, right? So there’s structural challenges. So ideally, just like with any other surgery, you have about three to six months prior to surgery where you’re calming the nervous system, you’re on an anti-inflammatory food plan, you’re working with the myofascia, nervous system, and circulatory system of the pelvic floor and other joints — sometimes people have hip pain and back pain and abdominal pain. You’re dealing with all of that to go into surgery as healthy and as resilient as possible from a hormonal, immune, and digestive standpoint. Because if you imagine the digestive system is challenged when there are lesions growing on your colon or in your small intestine — endo belly, a bloating situation, is often related to small intestine bacterial overgrowth — you want to maximize and improve the health of all these systems before going into surgery. Ideally especially the nervous system, because surgery in and of itself irritates the nervous system. But if you go in with a calmer nervous system, healthier and more resilient nervous system, digestive system, immune system, and myofascial system, and then do the same thing after — the recovery from surgery takes an average of about five to twelve weeks — but there are these secondary issues. People might have had chronic yeast infections for years, or chronic UTIs, or vulvar pain. The nervous system is involved, the immune system is involved, they might have been constipated for 12 years. We have to deal with all of those secondary sequelae that’s not exactly the endometriosis lesion itself — but it’s the inflammatory cytokines, it’s digestive function, it’s pelvic floor relaxation. So if we think of it as investing a few months pre-op and somewhere between 6 and 24 months post-op to really complete root-cause healing, it’s a much better long-term experience.

And I would say one other thing — not every single person needs or wants to have surgery. It’s not always a requirement. Now, surgery done sooner rather than later and done at all does improve fertility. Endometriosis is a very common cause of infertility. People can have silent endometriosis where they have no pain at all, but they don’t realize it until they have trouble getting pregnant. So if someone is really concerned about their fertility, I recommend sooner rather than later that they have a consultation to decide whether or not and when they want to have surgery. But I’ve met clients who have had endometriosis forever, they’ve had three kids, now they’re in their 40s and have a lot of pain, and they just might decide not to have surgery. So we still kind of take that multi-system approach because the pain driver, the digestive issue driver, the anxiety driver, the fatigue driver is not always just the lesion — it’s all of the secondary factors that go along with having endometriosis.

Lisa Hendrickson-Jack: Well, I’m glad that you touched on that. One of the questions I was planning to ask is: is surgery required? And you know, I’ve had a number of different practitioners on the show with different pelvic therapy modalities — Arvigo Therapy, fertility massage therapy, Mercier Therapy. And many of these practitioners report significant improvements in fertility and significant reductions in pain. So I’d love just to hear you speak to that — is there another option for those who don’t want to necessarily go straight to surgery but are experiencing either fertility challenges or extreme pain?

Jessica Drummond: Yeah. So doing just kind of the functional medicine and pelvic floor physical therapy — which does include using visceral mobilization to the abdomen, some physical therapists are trained in Arvigo massage, all of us in pelvic PT do internal manual physical therapy of the pelvic floor, vaginally and rectally — so you absolutely can, especially combining physical and manual pelvic therapies with the functional medicine approach, relieve the symptoms completely. I mean, I’ve seen that. Fertility is a little bit of a different animal that I don’t think we have the data to say with any confidence. So, you know, if my daughter had endometriosis or suspected endometriosis, and it’s very difficult at 13, 15, 17 to know how much you’re going to care about your fertility, in that case the strongest data we have on fertility preservation is that earlier surgery is more fertility preserving. Now, if someone does not want to have surgery and they want to go essentially a combination of pelvic manual therapy and functional medicine, they can relieve the symptoms and potentially they could improve their fertility because obviously any structural improvements, fascial mobility, better circulation, lowered inflammatory cytokines, lowered autoimmune antibodies — which are one of the big reasons — when there was a recent study presented by Dr. Vidali, who’s out of New York City, and his clinic also does a lot of autoimmune infertility challenges. And I’ve referred a lot of patients to a physician up in the northern midwest in the US — her name is Dr. Kwok Kim. So there’s this perspective that sometimes infertility is related to a localized autoimmunity. And Dr. Vidali posted this data that he and Dr. Braverman found: that removing the endometriosis lesions with good excision surgery very quickly post-op and for at least 6 to 12 months post-op lowered those autoimmune antibodies and improved fertility. So we don’t have a ton of data — like there’s certainly no data comparing endo excision surgery post-op and autoimmune antibodies head-to-head with Arvigo massage therapy. It’s very difficult to do that kind of study, not to mention to get funding for something like Arvigo massage therapy. I don’t doubt that there are some cases that visceral mobilization, especially if it’s a structural problem with fallopian tubes or something like that, can directly improve fertility, because we know that visceral pelvic and abdominal physical therapy can improve fertility in general. But the best data we have is on excision surgery being the most fertility preserving, and the earlier you do it, the better. From a practical standpoint, 17 to 22 years old would be kind of when, if my own daughter was going through this, I would be considering having her assessed for a good excision surgery.

Lisa Hendrickson-Jack: It’s such an interesting and important perspective. I feel like I’m just at the stage of envisioning a world where there aren’t all of these barriers to good research — where if a treatment modality isn’t associated with surgery or medication, it would still be given equal weight in terms of funding. Because I feel like what I hear you saying is: we need those answers, and at this point we don’t really have them. So if we go with the best data, this would be the solution, but we don’t really have the answer.

Jessica Drummond: Right. We don’t really have data, as far as I’m aware, on any kind of randomized controlled trial or head-to-head trial of Arvigo massage. And you know, there’s also the kind of third rail of endometriosis medications — whether they’re neuromodulators like gabapentin, or pain medication, or hormone suppression. The reason that many people don’t have an improvement using hormonal contraceptives or other estrogen suppression — back in 2018 in Belgium, a study was published where we now realize that we used to think that all endometriosis lesions were fed by estrogen. So kind of the alternative approach was: lower estrogen with more of a plant-based food plan and support the liver to better metabolize estrogen and support the gut to better metabolize exogenous estrogens — like exposure to plastics and tap water and things like that. Now, that’s all basically good, other than potentially the fully vegan diet, but liver support and gut microbiome optimization are great. But we also now know when the histology was done on the lesions, not all of them have upregulation of the estrogen receptor. Sometimes it’s progesterone receptors, sometimes it’s both estrogen and progesterone, and sometimes it’s neither. So it’s sort of like breast cancer — not all breast cancers are estrogen-fed. And so suppression of estrogen, which was a big strategy — Lupron, which essentially puts people into medical menopause with severe side effects — and other forms of estrogen suppression, we see that now with Orlessa — is not always helpful. And there’s no way to know unless you’re doing histology on the lesions. In the same woman, you could have lots of different kinds of lesions, and by then you’ve taken the lesion out so it doesn’t even matter, right? So you have people on these drugs that essentially put them into a medical menopause more or less, affecting their brain, their heart, cardiovascular system, metabolism, and bones long-term. And it’s okay — if that controls symptoms, which is why people get so fired up about this, because I need my birth control, otherwise I’m in intense pain. I get that. But that’s still not solving the problem. That’s still suppressing the symptoms, which is really valuable if you’re stuck in bed and can’t live your life. Really valuable. Over 72% of women with endometriosis say their life goes off track — they literally can’t finish school, they can’t get a good job, they can’t keep a job. So if it’s life-giving to be able to take hormonal birth control and not suffer every month, that’s hugely important and I understand why people fight tooth and nail for that. But even when we do that, it’s one thing to choose it deliberately, knowing all of the options and being like, okay, I’m going to do this for a period of time. It’s another thing — at 12 or 13, when you’ve got period pain — to be put on the pill and never talked to again, or put on Lupron or some other kind of hormonal suppression. You don’t stay on that until you’re 50. That just doesn’t make any sense. Or until you try to have a baby and then you can’t get pregnant because nobody dealt with the underlying issue.

Lisa Hendrickson-Jack: You just so eloquently put into words what I just keep saying. I’ve been doing this — this is the sixth year of the podcast — and it’s still the same thing from day one. And this is why I share about my own experience. Like, when I had my two babies at home, I pushed them out and everything, and I realized at that point that the first half of labor was not as bad as my period pain, to the point that I didn’t know I was in labor. So we live in a world where we’re told as women that that level of pain is just par for the course, and that’s not okay. And what you said — I just feel the need to highlight it — which is that no one is saying there’s anything wrong with controlling the pain. I’m anti-pain, it’s horrible, and no one should have to go through that. But as you said, there’s a difference between believing that hormonal treatment is the only possibility, and understanding all of the possibilities, some of which could actually address the underlying condition and resolve or reverse it. And although it strikes a chord when you say things like it’s giving you temporary relief but it’s not fixing anything — women are often really triggered by that, because it feels like you’re trying to take away the only thing that’s ever helped me. It’s like, no, I’m not trying to take it away, I’m trying to expand your awareness to the possibility that there’s actually a way out.

Jessica Drummond: Yeah, and I think another reason why that’s so triggering is it’s not really about you or I. It’s about the fact that there is a war on women’s reproductive autonomy. And so we aren’t trying to take it away, but any evidence we add to the discussion of it not being the be-all end-all gives people who are trying to take it away the ability to use that as fuel for their fire. And I think that’s an important thing to acknowledge. Because definitely in the US, to this day, there are literally people trying to stop the ability of hormonal birth control from being covered by any insurance, or limiting access to abortion. We need to be fighting for wide open access to hormonal birth control and even drugs that are hormonally suppressing for short-term pain relief. But we also need to be fighting concurrently for a conversation about the wider options — good surgeries, functional medicine approach, pelvic physical therapy and other similar pelvic manual therapies. Because when it’s like, “Don’t talk about that because they might take it away,” we can’t have a good conversation about efficacy — and to your point, really researching the risks and benefits of everything.

Lisa Hendrickson-Jack: Well, this is exactly it. It’s kind of touching back on what we were talking about with regards to period pain — like, the goal isn’t less bad. We have to really expand our imagination and our consciousness around what is possible. And I love what you said, because I feel that we should have all of these options on the table. But don’t put them on the table if you’re not going to talk about the risks associated. Because my question often is — and I just we’re recording this so when I publish it, it’ll be in the future, but at the time of recording this, last week I released another episode of my Pill Reality series and I interviewed a woman who had a stroke when she was in her early 20s. And one of the things that I often think to myself for women with severe endo symptoms who have been put on the pill because that’s their only option — it’s not to say that these women, because they’re taking it for medical reasons, are somehow exempt from the potential side effects. Some women are on this because they have to be and they may still be experiencing anxiety, depression, loss of libido. And some of them may have more of the severe side effects like pulmonary embolism and stroke. And so again, there are women in this world who can’t take estrogen-containing birth control. And so if we’re telling women with endo that this is the only way for them to address the pain, we are doing them a disservice. We should have all of the options on the table, all of the information, so that we can really make informed decisions. And then we can elevate our consciousness to realize that we can do so much better for women. We deserve to be healthy and not in pain and to have real answers and real solutions to our health concerns.

Jessica Drummond: Yeah, and in the world of pelvic pain even, sometimes you’re trading one problem for another. Because we know as a fact that hormonal birth control increases the risk of vulvodynia — and sometimes permanently — because it can elevate SHBG relatively permanently. And just quickly share what vulvodynia is — vulvodynia is vulvar pain, basically. So people will have pain on insertion of tampons or specula during gynecologic exams, or sex of course. And because sex hormone binding globulin is elevated by hormonal birth control, what it basically does is go around and bind up your own sex hormones and then give you a little bit back — enough to have some estrogen, but not enough to reproduce, which is helpful sort of for certain things. But that is where we end up essentially suppressing estrogen, which will cause an earlier vulvovaginal atrophy. So it’s your clitoris and your vulvar tissue that can kind of shrink and atrophy — a lot of dryness, risk for chronic infections like yeast and BV, potentially risk for UTIs because the pH can change — and increase risk of vulvodynia, which is basically any vulvar pain cause. And so you’re kind of trading one kind of pelvic pain for another. And for some women who are on hormonal birth control for as little as three months, the sex hormone binding globulin can be elevated permanently. Now, from a functional medicine standpoint, we do have some more tools that the medical establishment doesn’t really use on a regular basis for lowering sex hormone binding globulin, but it can be difficult to do that. Sometimes it’s not as quick as three months. Sometimes people come off the pill and their sex hormone binding globulin rebounds or reduces, but that is not always the case. And genetically, there are different kinds of receptors — some people need more estrogen for their receptors to be optimally stimulated and others need less. So we can’t and there isn’t like a good screening of like, this is a person who would be good on birth control. We just don’t have that level of granularity. So we’re always doing this trial-and-error situation.

Lisa Hendrickson-Jack: Yeah, I did an interview with Mike Gaskins who wrote In the Name of the Pill, and he talks about the most severe consequences of this little experiment that we’re doing. Because since we don’t have a way to screen who’s going to be sensitive to estrogen, what happens is everyone’s put on the pill and a certain percentage of women are just going to have a stroke.

Jessica Drummond: 100%. Like, this is the experiment. And then my biggest thing with that is — again, this isn’t even necessarily a conversation about not putting women on the pill — but as a health practitioner who is prescribing, why is there not across the board a mandated five-minute conversation to explain some of those symptoms that would be aligned with those risk factors? Headaches, migraine with aura, pain in certain areas that you might be prone to developing blood clots, etc. So that if you have those symptoms, you know immediately to go to your doctor. That’s all I ask.

Jessica Drummond: Yeah, and I think also just awareness. My daughter’s now 16, so a lot of her friends are getting put on the pill for various things — whether it’s acne or because their mothers are like, okay, if we just put them on the pill and close our eyes, we don’t have to worry about if they’re having sex. So the problem with that is, in teenagers especially, it’s not a huge number, but a percentage risk of suicide is significant, and nobody talks about that. And then there are warning signs — there’s anxiety, there are mental health changes. And I work with so many clients with this — teenagers, college students — and it’s constantly like they’re being gaslit. This happens three months after they go on birth control and are sent off to college, which is two major changes — one physiologic and one psychosocial. Put on the birth control pill right before you go, and then they come back with anxiety and it’s like, “Oh, it wasn’t the pill. Now let’s put you on an antidepressant or change your pill.” And this I see all the time in very highly educated populations, and it drives me crazy. Because that makes no sense. If anything else had happened and then three months later you had some kind of sequela from that, it would be like, well let’s look at what was happening right around then or right before then. If someone was put on high-dose vitamin D, they’d be like, “It was probably the vitamin D.” But hormonal birth control? “That was fine.”

Lisa Hendrickson-Jack: Such an important conversation. I’ll kind of bring it back to endo because I could be there all day, as you know. But these are really important points. And the challenge too, I think, with the world that we live in is that we kind of live on sound bites and your average person is so busy with their lives that they’re not spending two months researching, looking at the scientific information, even having a nuanced conversation like we’re having today. Someone could take a sound bite out of our conversation that makes me sound like a pill-hating crazy. But taken out of context. If you actually listen to the full hour-long conversation that we’re having, we’re hitting some really important points — which is that, yes, it can control pain management; yes, we actually should be advocating for access; but yes, we need to have conversations about the side effects. And yes, this is the whole point. This is nuanced stuff. But I wanted to ask — we’ve been talking for almost an hour but we’ve been talking about endo — and I wanted to ask you to tell us what endo is. I’ve heard a number of different pieces of information. You brought up that many practitioners believe that it’s estrogen sensitive. I’ve heard people say there’s an autoimmune component. And people have even talked about infections, inflammation, and dietary factors. So what is endo from your understanding? You also spoke about the genetic component. What makes us susceptible, what is driving this?

Jessica Drummond: Yeah, so it’s a complex disease that we don’t know everything about, but there are three main components. One, it is these physical lesions that are created from tissue — if you look at the tissue histology, it’s very similar to, but not exactly the same as, the tissue inside of the lining of the uterus. Now, how does it kind of get there? We actually think that’s embryologic — that’s true. When they look at female fetuses that did not survive for whatever reason, I think it’s 9% have endometriosis lesions. And 10% of the people with uteruses, the population of cycling females, have endometriosis — 1 in 10, right? Also transgender men, so we don’t want to miss that. So it’s established pre-birth, but there are inflammatory and autoimmune factors that can make it worse, essentially, or activate it, and hormonal factors. So there’s this underlying genetic factor. Then the symptoms begin to present in pre-puberty — eight, nine, ten, eleven years old — where it’s often a lot easier to see this in retrospect or in the context of knowing that this is a heritable disease, because it’s very common at age 9 or 10 to have IBS for whatever reason — stress, eating a lot of junk food at birthday parties, who knows, right? And so usually the first battle is some kind of GI issue. And then when the cycles begin, more of the period kind of pain begins, anxiety, fatigue, depression. And some of that is compounded by just the medical trauma of it all when someone’s like, “This is normal, you’re fine.” So there’s a lot of that. And the anxiety is related to some challenges with the digestion which makes it hard to absorb the nutrients that feed the brain essentially to support optimal mental health. But it’s also related to the fact that anyone’s going to be frustrated, depressed, anxious, fatigued if they’re battling a pretty significant pain and exhaustion battle day in and day out and no one’s really believing them, or if they are, they’re kind of slapping them with medications that have a lot of side effects. So essentially the disease itself has an underlying genetic factor. It’s worsened by inflammation, so an anti-inflammatory food plan is very helpful. Lowering exposures to xenoestrogens and other environmental hormones is very helpful. And then from a nutrition approach and a lifestyle approach, autoimmune factors are definitely at play. There’s a lot of overlap with Hashimoto’s and other kind of subclinical autoimmune markers — we see that all the time. And so from a functional medicine standpoint, I’m not really looking to whack-a-mole out the symptoms. We take a system-by-system approach. “Don’t chase symptoms, optimize systems” is what I always say. And it’s easiest to start with digestion and musculoskeletal — which is why I like to work collaboratively with physical therapists or other pelvic myofascial therapists — because calming that physical tension, people carry a lot of stress in their pelvic floor like they do in their neck. Then optimizing digestion first, because the digestive and immune system are very intricately connected. So if we’re dealing with inflammation and autoimmune factors, that’s key. And then you can get the nutrients you need for the body to heal its own nervous system and endocrine system. We have to also recognize that a large percentage of women with any pelvic pain condition have a history of sexual trauma, birth trauma, or other kinds of trauma in their early lives. And when that happens in childhood, the teenage years, or around birth, in the nervous system it’s amplified, can be pronounced longer, and can lower our resilience to stress. And I think of endometriosis as a biochemical stressor among other stressors.

Lisa Hendrickson-Jack: I think that everyone listening should just rewind this back and listen to what you said again. And I mean that — especially the women who are listening who tuned in because they have severe pain and they’re looking for information and have never been believed and have been pushed aside. I honestly just want you to rewind it back about five minutes and listen again to what Jessica just said. I can’t even underscore the importance of that and how you brought in the underlying factors and the past trauma. It feels, when I was listening to just your explanation, it really resonated on a deeper level. And I think one of the reasons why it resonated so deeply is because you’re coming from essentially a place of love. It’s like, I see you, I hear you, I understand you, and I want to care for you. It’s like the direct opposite of what we experience collectively as women when we go to the doctor. I’m not trying to undermine any individual doctors, but this is a system that they work within — a system that wasn’t designed to care for us in the ways that you’ve described. So the question that comes out of that is: one of the biggest challenges in the work that I do is supporting women to find the care and the support that they need. And sometimes a big challenge there is that we’ve all been indoctrinated to believe that the doctor has all the answers. And so often the biggest challenge is to get a woman to think — you know, we all need doctors, of course we all need to have a really good family doctor — but I think one of the biggest challenges is often having that conversation around: if you really want to get to the root cause, your MD isn’t trained to do that. I don’t know if you want to speak to that. And for the women who are listening who are like, okay, I’m on board, what do I do first?

Jessica Drummond: Yeah, so obviously our organization — we have a health coach program, and we work with health coaching and lifestyle medicine, functional nutrition to support this from the root cause. That’s what our clinic does for women with endometriosis and pelvic pain in general. And we have a really strong network of doctors all over the place — pelvic health physical therapists and manual therapists — who do all take that approach, and even pain management physicians, because as we talked about before, all of these things are just tools. Some are more politically charged than others, but there’s a time and a place for every single one of these tools. But at the end of the day, ultimately you will be responsible for building your own team. The hard part about doing that when you’re in intense constant pain and you don’t really know where to start — I feel like that’s what our clinic offers. We have health coaches that I’ve trained for years, clinicians in a functional medicine approach, and we essentially have a process of helping you start to take ownership of the things you can do day to day. What time you go to bed, what you eat for breakfast, lunch, and dinner, getting outside in the sunlight, your daily movement practice, your mindfulness practice. We help you navigate all the things that you can do. You have a lot of power in this that you actually may not know about yet. And then the second piece of what we do is help you build that team. And I have 25 years of experience in complex pelvic pain. So if you have endometriosis, vulvodynia, bladder pain syndrome, period pain — I’ve been speaking at professional conferences on this for more than a decade. So I know a lot of people who really do have that approach. Some of them work in fairly traditional medical settings, others have more out-of-the-box practices, but most people who go into this, who are good, who stay for the long term, really do have our best interests at heart. It’s just that we have to find them.

Lisa Hendrickson-Jack: I really appreciate you saying that, because if I’ve learned anything from all these years of interviewing, it’s that there are so many amazing practitioners everywhere. But you wouldn’t necessarily know unless you look. And often they’re in your backyard or in the next town. They’re not on TV.

Jessica Drummond: Right, they’re busy. They’re actually working.

Lisa Hendrickson-Jack: But what’s interesting is that there are so many. And one of the things I’ve been saying for years is that when you find somebody like yourself who has devoted their practice to a specific type of care, when you need support in that area — that is the person to go to. Yeah, because they also know all the other good people.

Jessica Drummond: That’s right.

Lisa Hendrickson-Jack: And so for the listener, if you can take anything from this, it’s that there is support. And even in this crazy time, depending on when this episode is coming out in 2020, many of us are finding that we’re really limited into who we can access. There’s still many practitioners who do work virtually. Help is available. It may be difficult to find it because it may not be the doctor right down the road, but they’re out there. So there’s hope. Absolutely. So as we bring our interview to a close — is there one kind of thought that you want to leave the listeners with today?

Jessica Drummond: Yeah. I think the most important thing you can start with — because people often come to me on very restrictive plans, very worried about exactly what to eat and things like that — what to do is one of the most nourishing things you can do for yourself starting right now. When you get up in the morning, expose yourself outside — if at all possible, or at least through an open window — to 15 minutes of light, and drink something comforting. Do that every morning as a way to start your day, and the rest of it we can support you with.

Lisa Hendrickson-Jack: Ah, I love that. Doesn’t that feel good? One of the topics that came up — and it just keeps coming up in all these interviews — is really to trust your intuition, to tune into what feels good. Unfortunately we’re in a system where we’re being gaslit. You feel a certain way and you go to someone who says, “Oh, no, it’s in your head.” And I think if anything, these challenges bring us back to: that feels good, this resonates with me. We really have to tune into that. Jessica Drummond, thank you so much for coming on the show. I just loved our conversation. I could honestly stay in this conversation all day. I’m so thankful for the work that you do. And I just love knowing that you’re out there not only doing this work, but training professionals all the time. You’re making the world a much better place.

Jessica Drummond: Thank you. And can I give everyone who’s listening a free copy of the new book?

Lisa Hendrickson-Jack: Of course.

Jessica Drummond: Yeah, so if you go to outsmartendo.com, you can download a free copy of the book, and that kind of lays out step by step — if you want to just start taking ownership of this yourself — it’s essentially our process step by step in the most clear way I think I could put it on paper. So outsmartendo.com, you can go grab your free book.

Lisa Hendrickson-Jack: That is amazing. And would you like to share any additional information for how the listeners can reach you and also reach out specifically for support?

Jessica Drummond: Yeah, so our main website is integrativewomenshealthinstitute.com, and I’m also on Instagram at @integrativewomenshealth. And so if you have any questions, you can DM me over there. Find us, explore our website at the main site.

Lisa Hendrickson-Jack: Well, thank you again for being on the show and sharing your expertise. This has been amazing.

Jessica Drummond: Thank you.