Welcome back to the Healing Pain Podcast with Jessica Drummond, PT, DCN

We’re discussing how to treat chronic pelvic pain with a focus on endometriosis. Our guest is Dr. Jessica Drummond. She’s the CEO of the Integrative Women’s Health Institute and author of Outsmart Endometriosis. Jessica holds a license in physical therapy as well as clinical nutrition and is a board-certified health coach. She has spent many years working with women overcoming pelvic pain. She also runs educational programs for women health professionals in more than 60 countries and leads virtual wellness programs for the treatment of endometriosis. She will discuss how to treat endometriosis through the lens of nutrition, lifestyle and functional medicine. You can learn more by visiting OutsmartEndo.com. Let’s meet Dr. Jessica Drummond.

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Treating Endometriosis and Pelvic Pain with Nutrition, Lifestyle and Functional Medicine with Jessica Drummond, PT, DCN

Jessica, welcome to the show. It’s great to have you here.

Thanks so much for having me. It’s my honor.

I was at CSM, the Combined Sections Meeting of the American Physical Therapy Association, and you gave a great talk on endometriosis. I said, “I have to get you on the show to talk about this.” I know not a lot of practitioners are talking about endometriosis and they’re not talking about it from an integrated perspective, which is pretty much what you built your entire career around. A good place to start is to tell us a little bit about the career evolution you’ve had into physical therapy, women’s health, health coaching, nutrition and how you have this great integrative practice and institute.

It’s been a very organic evolution. I started in sports medicine and orthopedics physical therapy, then I specialized in women’s pelvic health, which is specialty orthopedics around pregnancy, pelvic pain, incontinence or pelvic organ prolapse. A little less than ten years into my practice, after my oldest daughter was born, I got sick. It was an issue of a viral reactivation of the Epstein-Barr virus looking in the lens that I have now. At the time, I was a mystery, invisible illness patient so I brought myself to the doctor that we send all the “difficult patients.” What was going on? They weren’t progressing as normal. I was sent for antidepressants, sleeping pills, and antibiotics. I was getting sick all the time.

What happened was the symptom of this underlying viral reactivation was a lot of hormonal imbalance, which gave me a lot of intense fatigue, anxiety and sometimes pelvic pain. I was having ovarian cysts that were rupturing. That continued until after my youngest was born. That was off and on for about ten years. Over that time, I wasn’t getting good tools from the traditional healthcare systems that I knew well and was working in. I had to explore what was then the early versions of functional medicine. It was a combination of integrative medicine and Chinese medicine. Because my doctor was pretty conservative and it was a very slow approach, most of what I did to improve my health was to make changes in my nutrition. My general relationship with work, stress and exercise even because as a physical therapist, if I couldn’t sleep, I just worked out harder and then try to make myself more tired.

I learned how to shift my life from a lifestyle medicine and nutrition standpoint. I then got certified as a health coach and taught the rules of health coaching and what health coaching is. It is a lifestyle behavior change. Going from running around like a crazy person to taking care of my own health. I did a Doctorate in Clinical Nutrition to get more specific for patients with pelvic pain and endometriosis to fine-tune the nutrition recommendations around things like gut microbiome, immunity, autoimmunity and digestive health. There are a lot of symptoms of endometriosis that aren’t just pelvic pain.

You did a case study. I believe it was one if not two. Tell us about that case study.

We published a couple of case studies. They were both on patients with vulvodynia, which is vulvar pain. It often goes hand-in-hand with endometriosis, sometimes individually and sometimes together. I was looking at it from a functional nutrition approach, assuming that it has some auto-immune factors. That was an unpopular opinion at the time. It’s not well-accepted even now. Even with endometriosis, we know that there are some genetic underpinnings. We know that there are inflammatory issues. I was at The Endometriosis Summit and some of the doctors are publishing about how when you excise some of the endometriosis lesions, you see changes in autoimmune markers.

Vulvodynia is a little bit different, but it often presents with endometriosis. A lot of times, anything that’s chronic pain has more of an autoimmune underpinning than most people give it credit for, except probably you and ten other people. That’s an emerging understanding and hopefully, we’ll have more research coming. What we did in both cases, one person was a vegetarian. That was a little bit more challenging for a food plan. It’s hard to be more autoimmune paleo-like when you’re not having any animal protein. She did eat some eggs. The other one was pregnant at the time. That was interesting because the immune shift of pregnancy helped us for a little while because there’s this calming of the immune response so that the fetus is not rejected. There’s a shift.

The protocol was around digestive function healing, improving stomach acid, chewing and digestive enzymes, the lining of the small intestine and the composition of the gut microbiome. We then overlay that with a very anti-inflammatory and immune-supporting food plan and lifestyle. Things like mindfulness meditation and re-evaluating relationships with work, stress, and family responsibilities. One was a graduate student. One was a mom who was working. We can’t underestimate those lifestyle factors of sleep, work-life relationship, and even general movement. Physical therapy is one thing, but day-to-day physical exercises in a modest way. Using that perspective, we were able to get complete healing for both of their pain. Both of them had failed everything else. They weren’t doing anything else at the same time, which made it a little bit easier to report on.

Thanks for your work in doing some of the earlier case studies on vulvodynia, looking at it from a nutritional perspective. Not a lot has been done on it. Still to this day, it’s growing but you’re key to get that revolution going. As physiotherapists, we talked a lot about the nervous system. It’s a big thing in physiotherapy and even psychology. Both you and I have said that the nervous system is important, but there’s an immune system that’s supporting that nervous system. You’ve brought that into your work and the literature you’ve worked on. Now, you’re tackling endometriosis. It’s another topic that’s important for women struggling with pain. Let’s start with the basics. What is endometriosis if you can define it?

There’s an argument even about that. To simplify, it’s a disease that I like to think of as benign cancer. You’ve got lesions that are various tissue types. There is variability, but it’s all tissue that’s similar to the tissue that lines the inside of the uterus. It’s called the endometrial lining. It’s not the same but it’s similar. By definition, this tissue is growing outside of the uterus. One big myth is that if you do a hysterectomy, you get rid of this. It’s not true because the tissue is still growing outside of the ovaries, the fallopian tubes, the diaphragm, the lungs, the knee, around the bowel and bladders, the peritoneum. It can be very extensive like that. It can also be very mild. Sometimes it’s extremely painful and life-disrupting. Periods are messed up and heavy.

Even in between periods and at random times, there can be a lot of pain. Other times, it’s even silent. It’s not as deadly as cancer. It’s not directly going to kill you, but it does increase the risk for certain significant cancers, especially ovarian cancer by almost two-fold. It is a low risk anyway, but it’s still an important risk to be aware of. There’s an underlying genetic factor in that we see the same when there’s research done on female fetuses or fetuses with uteruses that have been studied. About 9% of those female fetuses present with endometriosis essentially before birth. These are done on the autopsy of fetuses. It’s about the same population in teenagers and adult women. It’s 1 in 10, about 10%. There’s that underlying genetic factor. We also see it running in families.

There’s a lot of increased inflammatory cytokines for people with endometriosis. There is this auto-immune factor that we’re now seeing even changes. We’re trying to change it, whether someone has excision surgery or not. There are two kinds of surgeries that are done for endometriosis to take out the lesions. Ablation is the more common. What the literature says is more effective is called excision, which is more like cancer surgery where you’re cutting the lesion out more completely. They’re seeing some changes which help improve fertility when the auto-immune picture is improved post-surgically. My goal nutritionally is to improve that auto-immune picture whether or not someone has surgery. That situation is up to them and their doctor or if they do have surgery, it prolongs that. How can we make that even better, not by just taking out the lesion but overall systemically optimizing immune function?

One of the things you said about the nervous system and pain science, I was working with a client who’s undergoing a lot of psychotherapy and psychiatry for her nervous system per se, and her brain neurotransmitters. No one is stepping back and looking at the nourishment of the brain. When we talk about pain science and physical therapy, we have to think about the immune system and inflammation, but that talks directly through the gut microbiome and sometimes directly through the vagus nerve. Also, in general, in many women that I see, their brains are starving because their digestive system is poorly functioning.

We want to optimize cognitive function in some way, whether you’re doing health coaching or whether you’re using some psychologically informed physical therapy. All of them are cognitive interventions, as far as I’m concerned. You and I know some psychologists have also been trained in nutrition. We have these discussions in professional circles. It’s like, “This makes sense,” because we’re optimizing the physiology of the entire body. When you optimize that, it’s going to spill over into the central nervous system, into your brain and your spinal cord and to the enteric nervous system. There are more neurons there than in your spinal canal which is interesting when you start to look at it.

You mentioned there are these growths and you mentioned a lot of different parts of female anatomy there. Are the growths happening in one spot or can they be in multiple places around the female anatomy? If they are in multiple places, it would make me think that surgery may be indicated for the larger growths, but maybe you can target it through lifestyle for the smaller growths that haven’t impacted someone or you can halt the progression.

We don’t know if you can do that. We don’t know if, with lifestyle medicine, you can halt progression, reverse or “shrink” the lesions. Some mouse studies show things like that. As far as I’m aware, not human studies. Usually, if someone’s doing a very complete excision surgery, which is something I’m supportive of in most cases, they’re going to be skilled at this. They’re going to do it all day every day. It’s laparoscopic surgery, but one of the problems is when most doctors do this and they aren’t well-skilled in this. They look around and see what they can see, take a few lesions out and may leave quite a bit behind or may not even see it because some of these lesions are very small.

In terms of everything we know, the better strategy is to excise as much as possible, if I had more funding and more time, that’s an interesting question. Many physical therapists have asked me about that like, “If we’re talking about these lesions are made worse by inflammation and autoimmunity, wouldn’t it make sense that we could potentially even impact lesions more directly?” I think that’s certainly plausible, but I don’t have any data to support that right now.

As far as your approach nutritionally to treating this, is it still more of a personalized approach or have you begun to create your own protocols for the women post-operative or even pre-operative if you’re preparing them?

In an ideal world, it would be both. We would see someone about 3 to 4 months pre-operatively if they’re not having surgery or they had surgery a long time ago. There is a systematic approach. It’s still always personalized a little bit, but I like to start with digestive function. How well are the stomach acid, digestive enzymes, lining of the small intestine and the composition of the gut microbiome absorbing? Very often, I like to look at things like GI-MAP tests and urinary organic acids. Those are the initial functional labs that can be useful. The backbone of the food plan, we do an elimination diet that’s based at least for the first 3 to 4 weeks similar to an autoimmune paleo food plan considering that many of these patients often have oxalate sensitivities and/or histamine sensitivities.

Most commonly, if they also have bladder pain when it comes to oxalate sensitivities and/or the person is breaking out in hives. I’m even stricter on the autoimmune paleo and not just paleo if someone has chronic joint pain. There are a lot of auto-immune comorbidities with endometriosis. Joint pain is a little red flag. Also, things like Hashimoto’s is super common. That’s the categories that we’re looking at. I have a lot of people who come to me who have been vegan because that’s what they’re seeing on the internet and it is more anti-inflammatory for sure than the standard American diet. The challenge with that is the lack in most cases of well-absorbed protein and the challenge we sometimes have with oxalates.

I find that most people can go back to eating at least some oxalates and I don’t take those out entirely. I always try to limit how much we have to take out because they can be starting to develop almost pre-clinical eating disorders. Some people come to me with that already given that it’s not clear and there’s always like, “Take out this and this.” I’m sure it’s similar to your approach. What can we add like herbs and spices, more fat, more cooked vegetables and more high-quality animal proteins? That’s sometimes a challenge for people who are more committed to being vegan.

Is it also affecting elimination or does it have an impact on elimination in women?

Absolutely, because the growth can be on the colon and also the small intestine. Sometimes the surgery requires removing parts of the colon. We see a lot of constipation, some IBS, diarrhea and chronic SIBO, which is a huge problem because there’s such a term as endo belly, which is bloating. In my experience, it’s mostly SIBO and/or SIFO. The challenge is because either the lesions or adhesions can be wrapped around the small intestine or the area where the ileocecal valve is. The ileocecal valve can be either not functioning very well or that part of the colon has been removed. You’re always going to be dealing with SIBO.

In other cases, you’ve got the adhesions around the small intestine. That creates little pockets of slower motility and beautiful places for bacteria to thrive. I like to work a lot in combination with pelvic visceral physical therapy and sometimes using motility supplements and things like that. Motility is a huge issue. The other thing that helps is certain yoga positions and exercises. It has to be very comprehensive because you’re dealing with the disease itself impacting the digestive tract. Sometimes we’re aware of that pre-operatively and then the surgeons can be looking for that and the same thing post-op. A lot of times, they can give us more information once they see what’s going on.

I’m glad you mentioned that manual therapy. It can be very important for people with visceral pain and helpful for motility for a lot of people. Supplement-wise, people are always concerned about it, “We’re going to work on a personalized diet that’s right for me and my biochemistry.” Is there a supplement or supplements that are supportive of this condition?

We start with digestive function supplementation. A lot of low stomach acid for sure. Some low digestive enzymes, gut-healing like small intestine lining healing, things like l-glutamine, zinc, demulcent herbs, chamomile and aloe, gut like probiotics and prebiotic foods. More therapeutic doses of anti-inflammatories and immune-supportive supplements like curcumin and a relatively high dose of resveratrol. Pycnogenol, which is French pine bark has some interesting studies in humans, which is pretty rare in endometriosis. That’s an exciting one for me, but the antioxidants in general, because many people with endometriosis are struggling with mitochondrial dysfunction that leads to intense fatigue and anxiety.

Although the anxiety is more related to lack of brain neurotransmitters, lack of absorption of amino acids and/or blood sugar instability. When you’re restricting your diet so much, you’re in pain a lot and your digestive system is always off, you’re not eating for blood sugar stability. Sometimes amino acid supplementation or even blood sugar support, but usually we do that more with food. Supplement-wise, we’re thinking mostly around supporting immune function and supporting digestive function.

You mentioned fatigue earlier in your personal story, which I was happy to hear because as physical therapists, we breeze over the fatigue part. We’re always laser-focused on pain and I feel like the fatigue is the red blinking light in the background that should point people toward, “Let’s look at optimizing nutrition and see if that has an impact on fatigue,” which oftentimes it does, along with other lifestyle interventions like sleep, relaxation and mindfulness but that part is unspoken of.

The fatigue is sometimes even worse than the pain because it’s very debilitating. Having experienced fatigue myself, I understand what that means. It’s like if you go to sleep for twelve hours and you wake up exhausted or you can’t sleep at all no matter what you do. It’s a glaring light around mitochondrial dysfunction, which as physical therapists, we’re in a unique position to support. We are always thinking about more activity, more movement, more function but if someone’s already that fatigued, which many people with endometriosis and other chronic pain conditions are, first we have to restore the system. I had to stop exercising and I’ve worked out my entire life. I was a competitive gymnast. I was a collegiate cheerleader.

I was a person who worked out. When I went to PT school, like everybody else, I started doing triathlons. It was peer pressure. I was so tired that I could not walk to the bathroom for some days. I didn’t have the energy. Even when I was on the way down because of my training, I was swimming every night. I was waking up with panic attacks because I was in terrible condition metabolically. What we have to remember is that people with chronic illnesses are foundationally depleted. Start rebuilding that first and rebuilding circadian rhythm because it’s hard to sleep when that’s off, then we’ll get to movement, then we’ll get to heavier loads. It’s so much faster to progress that if you’ve got that foundation of resilience.

The replenishment is so important. I’m glad you mentioned that. There’s a lot of information, a lot of talk around different types of fasting protocols. I’m not sure what your approach is with regard to pelvic pain in general or endometriosis. In my personal view is if you want to go for fasting between 6:00 in the evening and 6:00 or 7:00 in the morning, that’s fine. Having people fast for days on end or skipping multiple meals is not a good course of treatment or an approach for people with chronic pain because they’re so depleted.

Interestingly for the pain piece in my experience, that’s related to more the autoimmune piece of it. Especially hormonally because we haven’t talked about hormones yet. There is some overlap of hormones with endometriosis, less than I used to think. We now know that the lesions are not all estrogen-fed. That’s where some of that vegan diet came from was trying to deplete estrogen. It’s not that cut and dry. Also, that’s why all these estrogen depleting drugs don’t work that well. In my opinion, now we balance hormones, but that’s where we start balancing cortisol rhythm. You can’t do a fasting protocol other than, I agree, 6:00 PM to 6:00 AM. That’s probably generally good for people. I don’t do anything more intense than that until their energy is stable.

That’s a good indicator. They’re not fatigued and they’re not having blood sugar crashes. Their blood sugar isn’t all over the place. Sometimes, when all that gets nice and stable, the resilience gets built up nutritionally. To me, that means they’re absorbing plenty of excess nutrients. We then can do some intermittent fasting, which I suggest to be like 6:00 PM to 11:00 AM or something like that for a couple of days a month. That does help with resetting the immune system to lower the overall pain. I prefer to do it if someone’s cycling regularly around days like 10 to 15 of the menstrual cycle. That’s when estrogen levels are highest and the cells are more insulin-sensitive. That’s how I think of it. Even a one-day fast or 2 or 3 days a month of 6:00 PM to 11:00 AM. Beyond that, that’s not helpful in this population. It contributes to more eating disorder mentality.

That 6:00 PM to 11:00 AM fast, would you allow them to have a cup of green tea or half a cup of coffee to bridge to lunch?

Absolutely. If they’re hungry or crashing or anything like that, it’s probably not the right thing. If they want a cup of green tea in the morning, that’s probably good because sometimes they’re going to need that for bowel stimulation.

Knowing you take an integrated approach, people may need other services, other practitioners to come in. Who else do you find is key potentially in the team that you find yourself referring to or relying on to coordinate care?

Our team is clinical nutrition and health coaching. On the ground, we collaborate with physical therapy and we may or may not be doing more telehealth physical therapy in this climate. Excision surgery, at least consultation with doctors who are well-practiced in that. That’s a rare specialty so finding someone good is key, then psychotherapy and lots of pain therapy, even sex and relationship therapy. This is a disease that’s very impactful on people’s intimate relationships. That can be valuable as well.

You’ve been working with women for over a decade-plus. What would you like women with endometriosis to know about this condition and finding treatment for it?

I want them to know that there’s a lot of hope and a lot more coordination. That’s one of the benefits of global social media. People who are working on this, there’s not a lot of perfect solutions yet, but there’s a lot more integrative collaboration that has been increasing very rapidly. There’s more and more good information available, generally. There’s more and more available globally through telehealth models than has ever existed. There are communities available too of healthy, positive support, even among various local areas. It’s a time to be hopeful. While it’s a very difficult disease, there’s more and more good attention to it. Even some research funding, we got through the work of Endo What? which is a nonprofit organization. They brought together Elizabeth Warren and Orrin Hatch crossing the aisle, which is super rare in the US right now to add a lot of good research funding for endometriosis. It’s happening around the world as well, in the UK and Australia and other places. It’s a time for hope.

You’ve also written a book, which is a great resource for people. Tell us about the book.

The book is called Outsmart Endometriosis. It maps out that integrative approach in a step by step way. We have recipes, resources, and help you build that team. I feel like it’s finally where my head is all in one place.

If people want to access that book or if they want to download that book, where can they find that?

They can download an eBook version for free at OutsmartEndo.com. It’s also available on Amazon and it’ll be available in print.

For practitioners, pelvic health specialists or women’s health practitioners who are interested in learning more about the services and courses that you provide for practitioners, where can they find you?

Our institute is at IntegrativeWomensHealthInstitute.com. We offer lots of training for all kinds of practitioners who work with patients with endometriosis across disciplines. The book would be very valuable for them as well because it maps out that integrative approach and they can start to see who they can collaborate with.

I want to thank Dr. Jessica Drummond for being on the show, talking about endometriosis and other pelvic pain conditions. You can find out everything about her, whether you’re a practitioner or someone who’s looking for solutions by going to the IntegrativeWomensHealthInstitute.com. Make sure to download her free book at OutsmartEndo.com. Make sure you share this information out with your friends and family on Facebook, Twitter, LinkedIn or Facebook group where you know there are people searching for help with endometriosis and other pelvic pain conditions. It’s a pleasure being with you and we’ll see you next episode.

 Important Links:

• Integrative Women’s Health Institute
• Outsmart Endometriosis
• Jessica Drummond – LinkedIn
• OutsmartEndo.com
• Combined Sections Meeting of the American Physical Therapy Association
• The Endometriosis Summit
• Amazon – Outsmart Endometriosis
• https://www.Facebook.com/IntegrativePelvicHealth/
• https://Twitter.com/jessrdrummond

About Jessica Drummond

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.

Dr. Drummond lives and works with her husband and daughters between Houston, Texas, and Fairfield, Connecticut.