Endometriosis with Dr. Lara Briden: Rational Wellness Podcast 165

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Dr. Lara Briden speaks about Endometriosis with Dr. Ben Weitz.

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Podcast Highlights

2:50 It has been thought that endometriosis occurs because of retrograde menstruation, which is when the menstrual fluid flows backwards out the fallopian tubes, thus letting the endometrial cells to get into the peritoneal cavity, where they can sometimes grow. A lot of experts in endometriosis now do not endorse this theory about why endometriosis occurs. There’s some evidence that some of this endometrial tissue was laid down from birth and some evidence for this is that endometrial lesions have been observed in fetuses and also occasionally in men. So there is a paradigm shift that is occurring in thinking about endometriosis. This disease can cause debilitating, life-destroying pain for some women that prevents them from working or having a normal life.

5:40 Endometrial lesions are hormone sensitive tissues, but Dr. Briden does not feel that these lesions are caused by hormones and common treatments that involve suppressing estrogen like Lupron and other hormone suppressing drugs or birth control pills are not a great solution. The common conventional medical approach is to give birth control pills, which shuts down your natural hormones, which is potentially harmful, since women need their hormones. Shutting down estrogen has a cost. Dr. Briden’s approach is to dial down the inflammation and the immune dysfunction that’s driving the disease.

7:45 Estrogen metabolism and the ability to excrete estrogen plays a role, but this should not be seen as the main focus of treatment. It is also interesting that endometrial lesions have progesterone resistance. Normally, progesterone has a downregulating effect on endometrial tissue, prescribing progesterone can play a role in treatment for endometriosis.

9:18 Endocrine disrupting substances like BPA, pesticides, teflon cookware, fire retardant chemicals, and dioxins can play a role in the cause of endometriosis. These estrogenic substances are epigenetic triggers and switches that determine whether your genes get turned on and expressed or turned off and not expressed. And even these epigenetic switches can get passed on for up to four generations. They can change the genetic expression of progesterone receptors and of immune system function.

12:43 There has recently been a paradigm shift in our thinking about endometriosis from focusing on the lesions, why they got there, and removing them or to suppress the estrogen that causes the lesions to grow. Even the diagnosis in the traditional paradigm is via surgery, since a typical ultrasound exam cannot rule out endometriosis, since these endometrial lesions are difficult to detect. The new thinking, the new paradigm is to focus on the immune dysregulation that has led to the inflammation that is facilitating the growth of these lesions. If you have the celiac genotype, the HLA-DQ2 genotype, that puts you at risk of celiac, but it also puts you at risk for endometriosis. The Functional Medicine approach is well suited to helping to find the root causes to modulate the immune dysregulation that underlies endometriosis.

19:12 Because of the new paradigm, there has been effort into finding a biomarker for endometriosis so that young women do not have to go on the operating table to diagnose their condition. To recap, first there is the genotype, such as the celiac genotype that puts you at risk, then compound that with epigenetic changes that creates an immune environment that is primed for this to happen. Then you have the lesions, whether laid down before birth or retrograde menstruation, and there has to be estrogen present, which is why children don’t typically have endometriosis. The presence of gram negative bacteria in the pelvic microbiome is also a factor, including that women with endometriosis have six times the level of LPS in the pelvic cavity and in the menstrual fluid. This is referred to as the Bacterial Contamination Theory. One study showed that antibiotics could reduce endometrial lesions, though this was an animal study.

23:12 Given the factors we just mentioned that promote the growth of endometrial lesions, the first tow steps of the treatment should include: 1. Strictly eliminate gluten, 2. Dial down those gram negative bacteria with anti-bacterial herbs, and repair gut integrity.

24:37 Nutritional deficiencies can trigger inflammation, including zinc and vitamin A, both of which are often low in vegans. Dr. Briden mentioned that vegans can lack the following nutrients: 1. zinc, 2. preformed vitamin A, 3. Omega-3s, 4. B12, 5. Iron, 6. Iodine, 7. choline, 8. selenium, 9. activated B6, 10. B2, and 11. taurine.

27:17 Food sensitivities can be triggers for the immune system for endometriosis. Besides gluten, cow’s dairy, particularly A1 casein is similar to gluten in that both create an opioid type molecule that upsets the immune system. Eggs can sometimes be an immune disruptor. Soy is another common sensitivity. And then there is the issue of histamine and mast cell activation.

30:02 While you can’t eliminate histamine containing foods, a low histamine diet might be beneficial if there are signs of excess mast cell activation, such as hives, urticaria, headaches, congestion, nasal congestion, swelling, and especially if they’re a cyclic pattern to that, because histamine will usually check up with estrogen. Improving the gut will improve histamine levels over time. You may not need to avoid avocado and high amine foods. You can take DAO enzyme and vitamin B6 to help clear histamine. And progesterone has an anti-histamine effect.

31:42 Dr. Briden may recommend oral natural bioidentical progesterone for women with endometriosis, though she does not like the synthetic progestins. Progesterone can help to down-regulate the endometrial lesions and reduce the pain, as well as help with mood, sleep, and hair.

34:02 Nickel sensitivity can make endometrial lesions worse. Nickel is present in the soil and can get into certain foods, like wheat, high coco chocolate, and foods that come in cans, like tomatoes. There is also nickel in some jewlery. Mercury is another heavy metal that can also be very damaging to the immune system. Zinc, N-Acetyl Cysteine, curcumin, and selenium are nutrients that can help with detoxification of heavy metals like nickel and supporting immune function. NAC has also been shown to help patients with endometrial lesions actually shrink. Dr. Briden recommends taking 1000 mg twice per day of NAC.



Dr. Lara Briden is a Naturopathic Doctor with more than 20 years experience and her practice is in Christchurch, New Zealand. She is a period revolutionary–leading the change to better periods. Dr. Briden is the author of a best selling book, Period Repair Manual, which is a manifesto of natural treatment for better hormones and better periods and provides practical solutions using nutrition, supplements, and natural hormones. Her website is Larabriden.com.

Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.



Podcast Transcript

Dr. Weitz: Hey, this is Doctor Ben Weitz, host of The Rational Wellness Podcast. I talk to the leading health, and nutrition experts, and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to The Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast. Hello, Rational Wellness podcasters. Thank you so much for joining me again. For those of you who would like to see a video version to this podcast, please go to my YouTube page. If you go to my website, drweitz.com, you can see detailed show notes and a complete transcript. For those of you who enjoy listening to The Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcast and give us a ratings and review.

Today our topic is, endometriosis, and this is when endometrial tissue, the tissue that lines the uterus, grows outside of the uterus. Most commonly on the ovaries, the fallopian tubes, or the intestines, though it could occur anywhere in the body. It affects one in 10 women in the United States. The most common symptom is pain, especially in the pelvis or the lower back region. Endometriosis can also be associated with bladder problems, gut problems like diarrhea or constipation, and bloating, sounds very much like IBS or SIBO, headaches, menstrual irregularities, and infertility. There can also be pain during sex, or during urination. The conventional medical treatment typically consists of contraceptive pills, surgery to remove the endometrial tissue, and pain medications.

Doctor Lara Briden is a Naturopathic Doctor with more than 20 years of experience. She’s a period revolutionary, leading the change to better periods, in fact, the best periods ever. In fact, Lara will be having a huge rally in Oklahoma just so she can make women great again. Just kidding. Lara is a passionate communicator about women’s health, and alternatives to hormonal birth control. In her book, Period Repair Manual, is really a manifesto of natural treatments for improving hormones, and periods, and providing many natural solutions, including the use of diet supplements and natural hormones. Thank you so much for joining me today, Doctor Briden.

Dr. Briden: Hi, Ben. Thanks for having me.

Dr. Weitz: Absolutely. So when we think about endometriosis it’s hard to understand how endometrial tissue ends up in another part of the body other than the uterus, until I read that retrograde menstruation occurs in up to 90% of women. Perhaps you can explain how that occurs.

Dr. Briden: Well, the menstrual fluid flows backwards out the fallopian tubes, into the pelvic cavity, and as you said, that’s a pretty standard, common thing to happen.

Dr. Weitz: If that’s really the case, how come a lot more women don’t have endometriosis?

Dr. Briden: Well, that’s probably the fatal flow of the retrograde menstruation theory of endometriosis, which a lot of experts now do not endorse, so that was the theory that … it’s almost 100 years old now. The surgeons who first described endometriosis decided that’s how the disease came about, that it just happen to flow back out into the pelvis, and that was the origin of the disease, of course as we’ll talk about today there’s a lot more to the story. In terms of how the lesions actually get there with endometriosis sufferers, the consensus seems to be it’s probably a combination of reasons. Some think maybe it was from retrograde menstruation, and there’s some evidence that it can be laid down before birth, that tissue, that type of tissue is laid down as a fetus, but that doesn’t mean it’s necessarily going to turn into endometriosis. One of the bits of evidence of that, endometriosis lesions have been observed in fetuses, and actually men can have endometriosis as well. It’s very rare, but you can get, there’s been a few cases in the literature of men having active endometriosis lesions, but they have-

Dr. Weitz: Oh, interesting.

Dr. Briden: They have no retrograde menstruation.

Dr. Weitz: Fallopian tubes.

Dr. Briden: No. So there’s a lot more to the disease than the standard model. I think it’s fair to say that this disease is undergoing … well, not a bit, but a paradigm shift. You can’t have a bit of a paradigm shift, can you? It’s an all or nothing thing. A paradigm shift is coming for this disease. I think we’re just on the tipping point of that actually, and that will be looking beyond just the presence of the lesions, and really thinking more broadly about what’s going on that could allow such a terrible disease process to take … to begin. It can be terrible, I mean, terrible is not a hyperbole for this disease, it can be mild for some women, but for some women it can be life-destroying, as in just pain, debilitating pain that prevents them from working or having a normal life. It’s very sad when that’s the case.

Dr. Weitz: So what role do hormones, particularly estrogen and progesterone play in endometriosis?

Dr. Briden: Well, this is probably the paradigm shift. The lesions are definitely sensitive to hormones because they’re hormone-sensitive tissues, so by definition they’re affected by hormones of course. But the the position I take, my reading of the literature is that the disease, and the lesions are not caused by hormone imbalance. So they’re affected by hormones … once the lesions are there, and it’s active disease it’s affected by hormones, particularly by estrogen, which is kind of like petrol or gasoline on the fire. Once there’s a fire you put estrogen on that situation, and that can make it a lot worse. So that’s why the conventional treatment, in addition to surgeries, the conventional treatment of the lesions, the conventional treatment has been, and still is to suppress estrogen. The problem with that approach, as you can imagine, is that women actually need their estrogen, so estrogen … It’s not great for anyone to just shut that all down, whether that’s with Lupron, like the MediTropin suppressing drugs or even just hormonal contraception. Shutting down estrogen has cost, and I would argue it’s actually not really the right tool for the job for this disease anyway.

My approach is to, as we’ll get to, to try to dial down the inflammation and the immune dysfunction that’s driving the disease, and so therefore a woman can have … can enjoy the benefits of her own cycling hormones. I think one thing it’s fair to say is, it’s in the literature, and what I’ve seen with my patients, most women with endometriosis do not … their hormones are okay, as in their hormone balance can be pretty normal, they could be having pretty regular cycles, going through the normal estrogen and then progesterone, it’s just that they’re being affected by those hormones.

Dr. Weitz: What about the estrogen metabolism, their ability to excrete estrogen, and what pathway, does that play a role?

Dr. Briden: I think it could play a small role, yes. I think definitely with an estrogen-sensitive disease you want to optimize how well your body clears estrogen, and don’t have any inflammatory … as few as possible inflammatory estrogen metabolites around. I think that can be part of the treatment strategy, but it’s not the only one, and it’s really not even the most targeted part of treatment, but it’s … Yes, I think there’s a role, certainly a place for trying to promote healthy estrogen metabolism. The other thing just to say on hormone balance, is there’s pretty strong evidence now that endometrial lesions, endometriosis has something called progesterone resistance. Normally, hormone progesterone should have a down regulating effect on endometrial tissue, that’s the normal response, but endometriosis lesions don’t experience that as well as they should. The situation could be a woman is who’s making progesterone, the beneficial hormone progesterone, but the progesterone is not managing to suppress the lesions. Then, of course there’s a whole strategy of coming in onboard with treatment with either a progestin drug, which is actually quite different than progesterone, or even using real progesterone as part of a whole treatment strategy to try to suppress the lesions, and there’s a place for that as well. I’m sure you get the feeling, people say it’s a complex disease and it is.

Dr. Weitz: What about the role of so-called environmental estrogen or endocrine-disrupting substances like BPA and pesticides, and non-stick cookware chemicals, and fire retardants, and all those lovely chemicals?

Dr. Briden: Well, there’s definitely a role. You know what, Ben? I think some of the role of those environmental toxins, particularly dioxins, that’s where a lot of the research has been around endometriosis, are epigenetic. What that means … There’s some research, I call it kind of troubling research, I mean, troubling in the sense that it just is sad to think it’s happened a couple of generations ago, but there’s some evidence that dioxin exposure creates epigenetic change. Do your listeners knows what epigenetic, what I mean by epigenetic?

Dr. Weitz: Yeah, yeah, it’s the sets of triggers and switches that determines whether your genes get expressed or not.

Dr. Briden: Right.

Dr. Weitz: Whether they get turned on or turned off.

Dr. Briden: Yeah, turning on and off genes that is inheritable. Right, inheritable, so you can-

Dr. Weitz: Right, the genes are inheritable, yeah.

Dr. Briden: Well, and the epigenetic changes-

Dr. Weitz: I guess-

Dr. Briden: The epigenetic changes as well.

Dr. Weitz: Right.

Dr. Briden: This is the radical thing about epigenetics. We used to think with every new generation, every baby they’re just kind of a clean slate, these genes are just waiting to be turned on or off, but now we know from studies of epigenetics, which is really less than 20 years old, that expo … not just exposure to environmental toxins, but any kind of environmental influence to one generation can switch on and off genes, alter gene expression that they can then pass on to subsequent generations, for generations. Potentially what some of the research … these are animal studies, but what some of the research are showing for some models of endometriosis is for example dioxin exposure to a woman, especially maybe with a daughter in utero alter some epigenetic expression of genes both in the immune system, and probably in hormonal receptors as well, particularly progesterone receptor. That is then passed on to the next generation, and then passed on to the next generation.

So potentially you have a situation of where one of the reasons that we’re seeing … starting to see quite a sharp uptick in cases of endometriosis, in severity of endometriosis, it wouldn’t surprise me at all through my lens, or I’m just looking at the literature that some of these is a lifetime delayed effect from, say toxin exposure two generations ago, in the 1950s or something. What this means for women who suffer the disease is … I think it’s important to say it also means it’s not something, it’s not a lifestyle disease. It’s not something they brought on themselves by eating wrongly, or having … or necessarily even poor estrogen clearance, or anything like that. There was something in the blueprint both genetically, potentially epigenetically that set them up for this disease. I think that’s important that you feel like it’s not your fault, it’s definitely not your fault.

Dr. Weitz: But even though some of these epigenetic changes are passed on, still there is an opportunity for us to modify our epigenetics by our diet and lifestyle.

Dr. Briden: But there’s still the opportunity to modify genetic expression through diet and lifestyle, and some other strategies as well, so yes. On the one hand, you can say that this is something that happened maybe out of your control, two generations ago, plus, but at the same time it doesn’t mean there’s nothing you can do about it. You can still, especially because we’re mainly going to be talking about the immune system, and immune dysfunction with endometriosis, then there are ways we can access that. In fact, in many ways natural medicine is better set up to … were better positioned to influence or modulate immune function arguably that some parts of medicine right now, because they don’t … we just have some tools in our tool box that are quite useful particularly for this disease.

Dr. Weitz: Right. Certainly we have the capability of being able to modulate immune dysfunction as opposed to just turning it off or turning it on the way some of the heavy-hitting pharmaceuticals do.

Dr. Briden: Yeah. I might just describe, because I’ve used the word paradigm shift, so I might just describe for your listeners what I mean by that in a nutshell. The old paradigm is that the problem is all about the lesions themselves, probably presumably from retrograde menstruation. You get these bits of endometrial tissue that lands in the pelvis, and then there’s kind of a to be expected sort of inflammatory response. Everyone knows it’s an inflammatory disease, but in the old paradigm the problem is these lesions shouldn’t be there, therefore this inflammation ramps up. Therefore, the treatment is to remove the lesion, or to suppress the estrogen that causes the lesion to grow, so that’s the old paradigm.

I think obviously the new paradigm is best described as the problem is the immune environment, that would permit these lesions, and not even permit, but promote the growth of these lesions, that probably got there by a variety of mechanisms, maybe by retrograde menstruation. But the interesting thing about endometriosis lesions compared to normal endometrial utero lining tissue is they’re not the same, they’re similar but they’re not the same. For example, endometriosis lesions have a nerve supply, which the endometrial tissue does not, so there’s some things going on, and there’s an active … with endometriosis lesions there’s an active, what’s called angiogenesis, its invasive characteristics to them, which is actually quite similar to a lot of autoimmune diseases, which is why there’s been a controversial part of this conversation is to discuss endometriosis as an autoimmune disease. Eight years ago I had gotten into a lot of trouble for saying that, quoting the literature that was saying that, at that time it was a lot more controversial. A few years on, I think it’s still controversial to say it’s autoimmune, at the end of the day I don’t think … We don’t necessarily need to designate it as autoimmune to state quite clearly that it has many aspects of immuno dysfunction, and it looks very similar to other autoimmune diseases, particularly inflammatory bowel disease, and celiac, and rheumatoid arthritis. In fact, the celiac genotype, or as you know the HLA-Q genotype, immune system genotype, basically if you have the genes that encode for that kind of immune system that puts you at risk of celiac disease, but also at risk of endometriosis. There’s a lot of overlap, in fact, there was a reproductive immunologist, Jeffrey Braverman, who did … he never published his research, which is a real shame, he only published it casually, but he tested the haplotype, HLA haplotype of all his endometriosis and subclinical endometriosis patients, and found that something like 95% of them had the celiac genotypes. So it’s hard to get a picture emerging of what kind of immune system you need to develop this disease.

Dr. Weitz: It’s interesting. I mean, it’s kind of been a big trend in, especially in medicine in the last 20 years, is so many diseases now have an autoimmune origin. We just had a discussion with Dr. Mark Pimentel, and there are just autoimmune story about the origin of IBS, which is the most common GI condition. We always distinguish between the autoimmune conditions like IBD and IBS, which wasn’t, now that has an autoimmune origin, and a lot of heart disease now seems to have autoimmune origin, so that seems to be an increasing story about health and disease.

Dr. Briden: Yeah.

Dr. Weitz: So if endometriosis is related to immune dysfunction, how do we analyze this? What kinds of things are affecting the immune system?

Dr. Briden: In terms of treatments or in terms … Yeah.

Dr. Weitz: Yeah, in terms of diagnosis, and essentially we want to look for the underlying triggers and causes. We have, for example, food sensitivities, right?

Dr. Briden: Sure. Let’s talk it through. So in terms of diagnosis, I’ll just touch on that first because this is … we’re 2020, but the diagnosis of endometriosis is trapped back in the Middle Ages somewhere, and the diagnosis is by surgery currently, which is …

Dr. Weitz: Right.

Dr. Briden: Bizarre, like kind of-

Dr. Weitz: You have these lesions, so let’s cut them out. They shouldn’t be there.

Dr. Briden: Well, and also the only way to definitively diagnose a lot of the time is with surgery, which is really … anyway, that is changing a little bit. There’s a new research about using a really specific type of ultrasound, or the old technicians have to be very trained to look, to try to see, and even then you can’t see all endometriosis, but to be able to try to see something on ultrasound. Just for your listeners, having had a normal ultrasound finding, like your run-of-the-mill ultrasound, pelvic ultrasound cannot rule out endometriosis. You could still totally have the disease, and [crosstalk 00:19:04].

Dr. Weitz: Is there any other imaging technique that can look at it? MRI?

Dr. Briden: No. Well, laparoscopy. So surgery, but the other … Because of the nature of the disease, that it is arguably a disease immune dysfunction, there should be a biomarker. There’s been a lot of, well, not a lot, but there’s been some research the last few years trying to find other blood tests, or a test of menstrual fluid or something, a marker that you could start to measure the presence of this disease. It would be really helpful for young women who don’t want to have to go on the operating table just to try to … so there is that in terms of diagnosis. Now, in terms of treatment, I guess, and what sets up for the difference, I want to talk about the cascade of things that need to happen.

Dr. Weitz: Sure, let’s do that.

Dr. Briden: To develop the disease. Because back to … We had read the role of estrogen, tons of women have high estrogen, and poor estrogen clearance who never get endometriosis, like you could have extremely high estrogen and endometriosis is just never going to happen for you because you don’t have that immune system. We’ve got top of the cascade, if you will, is having the genotype, probably the celiac genotype that puts you at risk, compound that with probably some epigenetic changes that happened either to your ancestors, recent ancestors, or to yourself, that creates an immune environment that is already kind of primed for this to happen, but still may not happen. Then you have the presence of the lesions, you had to get those somehow, whether laid down before birth or retrograde menstruation, somehow the lesions get there, but then that’s not even enough.

Then there has to be some estrogen present, which is why children don’t typically have endometriosis, but it can kick in as soon as puberty hits, so then estrogen has to come on the scene to start, not just in creating the lesions, but altering immune functions into … pushing immune functions to more of a potentially autoimmune state. But that’s the final, fifth ingredient, that I think is pretty important, and is something we can access and treat, which is the presence of gram-negative bacteria in the pelvic microbiome. As you know, E. coli, gram-negative bacteria are present in the gut, and they produce something called LPS, micro polysaccharide toxin, which is highly … it’s a part of their cell wall, it’s a bacterial … bit of a bacteria, which the immune system can go a bit crazy when it sees that. It really doesn’t like to see bits of gram-negative bacteria floating in the body, somewhere in the bloodstream or in this case in the pelvic area. There’s pretty fascinating research called the Bacterial Contamination Theory, where they’ve … a few things they’ve done, they’ve measured that women with endometriosis have … it’s not small, it’s six times higher level of LPS in the pelvic cavity, and in the menstrual fluid, compared to women who don’t have endometriosis. Then there’s evidence that certain types of antibiotics can reduce the size of endometriosis lesions, although that was an animal study. The mechanism is proposed to be translocation from the gut to the pelvis. In other words, intestinal permeability but not to the bloodstream, and not just to the bloodstream, but actually into the pelvis, and then you get this combination of … There was an animal study that I’ve quoted a few times, where they had animals with epigenetic changes progesterone resistance, and with dioxin, combined with estrogen, combined with LPS toxin, and the lesion just went crazy basically. That is the perfect storm for how to create an active inflammatory disease in the pelvis. If you understand that, and think about it through that lens then, well, the first step would be … Well, the first two steps I’ll just say off the top are strictly-

Dr. Weitz: Fix the gut.

Dr. Briden: Strictly eliminate gluten, particularly if you have that gluten genotype, and dial down those gram-negative bacteria. Either do kill them off, I use anti-microbial herbs, not permanently, but knock them back, and yes, work on repairing gut integrity. This link with gut is why we see so much extreme overlap between irritable bowel, and inflammatory bowel disease, and endometriosis. It’s like 95% overlap or something like that, and in terms of endometriosis sufferers, 90% to 95% of them have pretty serious hardcore gut issues going on. It used to be thought, “Well, the endometriosis affects the gut,” which is true, but I think a lot of it is the gut is affecting, driving endo.

Dr. Weitz: From a functional medicine perspective, how many conditions are not related to the gut? It’s amazing.

Dr. Briden: True. It’s true. It should be no surprise, and ultimately it’s all right there in the same area. I mean, I think there’s something to be said for anatomical proximity, the gut is right there, and it can become quite an inflammatory environment.

Dr. Weitz: Right. So what are some of the other things that trigger that inflammation?

Dr. Briden: Well, nutrient deficiency, because the immune system is very nutrient hungry, like it has some requirements for, particularly I would argue zinc, and Vitamin A, these are simple nutrients, but are pretty darn important, and I mentioned them … I mentioned zinc, and preformed Vitamin A for any of your vegan listeners. I don’t know how many you have, but I would say pretty please, if you’re exclusively plant-based you need to think about some zinc, and Vitamin A because you can’t get it from plant-based diet. Your immune system requires that. Your gut integrity requires that. Yeah, gut integrity.

Dr. Weitz: People don’t often mention that for vegetarians. They usually talk about the need for Omega-3s, and B12, and iron, but they usually not talk about-

Dr. Briden: I would say iodine and … iodine and choline, and selenium, I mean, on one of my blogs I have a list of about 20 nutrients that I think-

Dr. Weitz: Right.

Dr. Briden: Anyway, but staying on the topic of … staying on the topic of-

Dr. Weitz: No, no, that’s good. Why don’t you mention those real quick? So besides B12, and iron, and Omega-3s, you just mentioned zinc-

Dr. Briden: Zinc.

Dr. Weitz: And then preformed Vitamin A, which is only found in animal foods, right?

Dr. Briden: Correct.

Dr. Weitz: Can they get a vegetarian form of Vitamin A?

Dr. Briden: That’s a really good question. I believe so. I mean, most Vitamin A supplements are derived from fish oil, so you would have to … a fish liver, so you’d have to kind of source that. I’m not a 100% sure.

Dr. Weitz: Right.

Dr. Briden: Then the other nutrients that would be missing on a vegan diet arguably, hopefully we’re not making too many people angry right now, but choline, iodine, activated B6, Vitamin B2 to some extent, taurine, which is a … this is a little bit off topic of endometriosis, but taurine is actually considered a non-essential amino acid, but it’s actually really essential for women’s health. Estrogen increases a requirement for taurine, it’s a neurotransmitter. It’s a common neurotransmitter for the brain. Again, I would argue if you don’t eat meat or don’t eat animal products you just take taurine, although I’m personally telling I think it’s often derived from animal products, so you kind of get into confusing territory around that, but yeah.

Dr. Weitz: Okay. So we got these nutrient deficiencies.

Dr. Briden: Yeah, and also, I guess carrying on with in terms of endometriosis and other things, yes, you mentioned food sensitivities in general, so there’s going to be some individual … I think gluten is across the board almost, and it has to be strictly. There’s no such thing as being partially gluten-free for an autoimmune disease, right?

Dr. Weitz: Right.

Dr. Briden: Unfortunately, you can’t just mostly do it, because unfortunately my experience is you might not get any benefit at all, which is really frustrating. In terms of other food sensitivities the big ones I see for endo would be cow’s dairy, particularly A1-casein normal cow’s dairy. It’s pretty similar to gluten, as you probably know they both create this opioid type molecule that could be very upsetting the immune system. Sometimes eggs, not always but eggs can be an immune disruptor in some people, and sometimes soy, and then of course there’s going to be sometimes, there’s going to be people who have another food sensitivity, but again, if you have a really long list of food sensitivities then you can’t just kind of accept that that’s going to be your life forever. I think a lot of that then goes back to fixing the gut, repairing gut integrity, so that you can then tolerate some of the other foods, some of the other offending foods. I mean, I guess the other thing to mention is the role of histamine, and mast cell activation in a lot of conditions, in a lot of women’s health conditions that definitely-

Dr. Weitz: Maybe you could briefly explain mast cell activation.

Dr. Briden: Yeah. So mast cells are part of our immune system, they’re the primitive part of our immune system, their strategy … They’re not making antibodies and targeting things, although that probably happens with endometriosis as well, but the mast cells are … if they get upset about something, and they just blow, they just send inflammatory cytokines everywhere, including histamine, and heparin. That kind of histamine response is quite inflammatory, and there are ways to try to stabilize that, including … I would argue avoiding casein, back to dairy, casein, A1-casein can be quite a strong mast cell activator in some people, not everyone. Also, for some women with endometriosis, avoiding foods that are really high in amines and histamine can help to reduce the pain. Foods like that would be fermented foods, smoked fish … Your listeners might be familiar with histamine intolerance or high histamine foods.

Dr. Weitz: Right.

Dr. Briden: But you don’t have to eliminate those completely, because you can’t for one thing, and they’re not like … they’re different category than gluten.

Dr. Weitz: Do you recommend a low histamine diet?

Dr. Briden: It depends. That would depend on the patient. So I would look for signs of histamine intolerance or mast cell activation, particularly hives, urticaria or hives, headaches, congestion, nasal congestion, swelling, and especially if they’re a cyclic pattern to that, because histamine will usually check up with estrogen. So if you get those kind of allergic symptoms during your high estrogen phases of your menstrual cycle, then that can be a clue, for example. Then I think that can be part of the strategy. Even then with improving the gut, even the histamine mast cells side of things should improve over time, so you won’t necessarily always need to avoid avocado and high amine foods.

Dr. Weitz: Are there certain natural substances you can take to manage or down-regulate histamine and mast cells?

Dr. Briden: Yeah. Well, yes, and I’m sure you had mast cells experts on your podcast before, I mean, I’m not fully situated as an expert in that whole field, but I’m happy to answer a little bit, but I can say for example the enzyme, DAO enzyme, it helps to clear histamine, that is dependent on B6. So B6 can be quite helpful for that. Having a healthy gut in general can be quite helpful for clearing histamine, reducing mast cells activation. Progesterone itself, the hormone progesterone generally has an anti-histamine effect. It’s another argument potentially for bringing some progesterone on board.

Dr. Weitz: So will you, maybe use progesterone even if women say, seems to have somewhat normal progesterone levels?

Dr. Briden: Yes. So in chapter nine of my book, Period Repair Manual, I would refer to this. There’s a patient, so there’s stories throughout my book, so chapter nine the patient story is Hannah, and she ended up with pretty severe endometriosis. She’d get gluten-free, and some of the things we’ve already spoken about. She also … she’s been on a progestin called, brand name called [inaudible 00:32:11], which have sort of down-regulating effect on the lesions. She switched to oral micronized progesterone on natural progesterone capsules, as that component of her treatment, and did quite well. The advantage of progesterone, real progesterone over, versus a progestin drug is usually progesterone is a lot more friendly to the mood, sleep, and hair, and also it’s a nicer thing to take than a progestin.

Dr. Weitz: Do you prefer oral progesterone over topical?

Dr. Briden: Yeah, generally yes. Mainly for a few reasons, but mainly because it actually … The first [inaudible 00:32:50] can be good because it generates a lot of, something called allopregnanolone, which can be quite good for mood. But just staying on the topic of histamine activation, mast cell activation, progesterone for many women, not all women should have a stabilizing effect on mast cell and histamine, so that can sometimes relieve those migraines, hives, kind of premenstrual histamine symptoms, and at the same time, help to manage or control endometriosis. The goal for endometriosis is not cure, because we all … most people agree that there is no cure for the disease, but the term I use is remission. I think a lot of patients can reach a point of if not no pain, no pain would be great, but if not no pain, then close to no pain, at least very much reduced pain, and that would be arguably a state of remission where the disease is not active. The disease is not invading, it’s not progressing, it’s not causing pain.

Dr. Weitz: I saw you write about certain heavy metals like nickel in particular. I saw that article where you wrote about nickel. That’s kind of interesting.

Dr. Briden: It is fascinating. The nickel-

Dr. Weitz: Now, is this somebody who is high nickel, like you’re on heavy metal panel, and they’re high in nickel?

Dr. Briden: No.

Dr. Weitz: No.

Dr. Briden: No.

Dr. Weitz: Okay.

Dr. Briden: It’s not heavy metal toxicity. It’s not heavy metal toxicity, it could be another … sure, I mean, that can affect the immune system, so that’s probably, that’s a separate issue, but this is … Now, this didn’t make it into my book because I only learned about it … there was a study that came out last, maybe six months ago. What they found is pretty mind-blowing. Some people have nickel sensitivity, immune system that reacts badly to nickel, and you know that, the test for that is jewelry allergy. If you try to wear earrings that aren’t pure gold, if there’s any nickel basically in your jewelry, and you get a rash from that, you have nickel allergy. The problem is that a lot of foods have nickel. So some foods contain it naturally, particularly high coco chocolate, some of the ones that make me … I don’t have a nickel allergy, but still I was feeling for my patients, it’s like, “Oh, that’s sad.” But also any canned foods are going to be high, particularly canned tomatoes because they pick up a lot of the nickel from the can.

Dr. Weitz: Is there a way to test for this? I’ve never seen nickel on a food sensitivity test?

Dr. Briden: Well, the test is the jewelry sensitivity. I think there’s some other skin tests they can do, where they actually just rub some nickel, and see if you get a rash, but I think the jewelry sensitivity is a pretty … When I posted that on my Instagram … So I’ll finish explaining what the situation is. So they’ve known for a while that nickel can play a role in IBS. So nickel foods can contribute to the inflammation, the dysfunction of the gut for some women, and that by removing nickel, you can’t remove them entirely, but dialing them down, reducing nickel intake can relieve IBS symptoms. Then there was a research paper about six months ago that found that endometriosis is the same, that women … I forget the details of the study, but basically it was that four people who have a nickel allergy, that allergy itself in the presence of nickel can worsen endometriosis, not cause it. Because as we said the cause is multifactorial, but can aggravate it. So when I shared that on my Instagram I got maybe a couple hundred women with endometriosis saying, “I have a nickel allergy. Oh, that makes sense. I have a nickel allergy.” I’m sure probably there are some endometriosis sufferers who don’t have a nickel allergy, but I haven’t encountered them yet, so it does seem to be … I think the underlying thing is the immune dysfunction. It’s not normal for the immune system to get upset about nickel.

Dr. Weitz: So is nickel … it’s in the soil, and it gets … is that how it gets to some of the food?

Dr. Briden: Yes. So it’s in the food, within cans. So it’s in the soil, so it’s just present in some foods that [crosstalk 00:37:07].

Dr. Weitz: Right. Okay. So foods that you buy in cans.

Dr. Briden: Yeah, so canned food is a big part of it, and the confusing thing about it is there’s actually been an overlap with other things, like FODMAPs and gluten. There’s quite high nickel in wheat. So then the question is … Okay, using wheat as the example, so wheat seems to be quite a problem for endometriosis for a lot of people, is it the nickel? Is it FODMAPs, because it’s aggravating SIBO or IBS? Is it gluten? I suppose it can be all three sometimes. I would argue probably it’s gluten, and truly gluten a lot of the times, but as you know not everyone who reacts badly to wheat has a gluten sensitivity. It can be those other things, it could be FODMAPs.

Dr. Weitz: Right. I think Alessio Fasano has taught us that virtually everybody is going to get some gut irritation or tendency towards loosening of the mucosal membranes, leaky gut from eating gluten, so we’re probably best avoiding it.

Dr. Briden: Yeah, all that he said that my two cents would be, I mean, yes, I’m very familiar with his observation that gluten does create some level of intestinal permeability for everyone, but I think for the majority, because for example I’m not gluten-free, so I don’t think every single person needs to be gluten-free. I think … I think it’s important to demarcate those people who do, and particularly if you have an active inflammatory disease, and then particularly if you have that haplotype HLA, celiac haplotype, then I think even if you’re not a confirmed celiac I think the writing’s on the wall that gluten is highly problematic.

Dr. Weitz: Right. What about other metals? Is nickel the only one?

Dr. Briden: Well, in terms of allergy type reaction, I believe so, but in terms of other metals that’s going to be more insidious. As you know mercury is an immune toxin, it’s nerve toxin as well, but I’d say immune toxin is one of its more stronger aspects. So we don’t want a lot of mercury as to how big a player that is for someone. I don’t know. That remains to be elucidated, discovered.

Dr. Weitz: Do you find any … Have you found use of detox protocols have some benefit for patients with endometriosis with active symptoms?

Dr. Briden: I don’t call it detox. I still don’t use that word. I don’t know why. I just … I start with the gut, and like I said I usually start with an anti-microbial, which is often kind of part one, phase one of detox things. I address SIBO if it’s there. Give the nutrients that are required for repairing intestinal permeability. A lot of it has a natural detox effect. For example, zinc helps with it, just getting your zinc back online helps promote … protect your body from heavy metals, and promote the active excretion of heavy metal. So anything you do to help the immune system also helps the detoxification system, and you know this, but they’re quite closely related actually, the detox and immune function. There’s some upstream signaling molecules like NR2, if your listeners are familiar with that, but it switches on and off genes, both involved with both immune function, and detox. As soon as you start supporting that system you’re going to be getting detox. You’re going to be getting … because we’re supposed to be detoxing everyday, like eliminating pesticides and heavy metals, and at the same time, yes, it always, in any scenario makes sense to try to minimize your exposure to any of those things.

Dr. Weitz: Yeah, I guess when I think of detox I’m thinking about particular the nutrients that support the liver, pathways that facilitate detoxification.

Dr. Briden: For example, one of the best studied nutrients, a couple of the phytonutrients that are … well, one is a phytonutrient, one is just an accessory nutrient that are studied for endometriosis. One is n-acetyl cysteine, which has a reputation as being a detox nutrient, it’s also an immune modulator.

Dr. Weitz: That’s an all-star nutrient [inaudible 00:41:28], and so many purposes.

Dr. Briden: Yeah, so it … there had been a … Well, there was one pretty famous clinical trial using NAC or n-acetyl cysteine for endometriosis. It was years ago now. It was in 2014 or something, and I was so … and of course they were recommending that this be followed up, there’d be more trials, I’m not aware if there have been many more trials, which is kind of sad, probably it’s because NAC is … Who cares? No one’s going to make money on NAC, but in that trial, it was an Italian study, and it was about a 100 women or something like that, and their results were astounding. Not to hyperbole, not to overstate it, but there were women who had surgery, women who became pregnant, women who had surgeries plan to remove endometriomas, which is quite a large mass of endometriosis, whose endometriomas shrunk to some degree, who canceled their surgeries just from that one intervention.

Dr. Weitz: What was the dosage of NAC?

Dr. Briden: It’s a really good question. I tend to give 1000 milligrams twice a day. In the study, off at the top of my head I don’t know what they use. It’s in that range? So that’s one. Another one that is, probably borderline superstar for endometriosis is curcumin or turmeric, which you can imagine that works by modifying, modulating so many aspects of the immune function.

Dr. Weitz: You have your favorite form of curcumin?

Dr. Briden: I don’t. I’m always asking my supplement reps, “What’s the … I know there’s all different forms. It is true that some are better than others, the question is, how much-

Dr. Weitz: The supplement companies are always coming up with a new, greatest form of curcumin.

Dr. Briden: The interesting thing about it … Some of the questions they will have you need to be able to absorb it, which is probably true, but also we know now that curcumin exerts a lot of its actions in the gut itself, healing probably, probably having an effect in the microbiome, healing the intestinal permeability. So even if you’re not absorbing, and I think it’s exerting benefits.

Dr. Weitz: Right.

Dr. Briden: Curcumin is also a natural aromatase inhibitor, so it can help to dial down estrogen a bit more. So those are a couple of the big ones. Arguably, lots of different modalities or nutrients could be brought on board to try to heal endometriosis. The other one I’ll just mention is selenium just because it’s such an important immune-modulator. For people who live in a selenium-deficient region, and this is interesting because … I don’t know. I think it depends where you are on the state, it depends where your food supply is coming from, but down under, down here Australia, New Zealand, the food supply is very low in selenium, so I feel very confident that everyone needs it, eating food grown down here. But I think it’s going to vary a little bit [crosstalk 00:44:09].

Dr. Weitz: Our commercial farming techniques in the United States, and the overuse of commercial nitrogen-based fertilizers, and the overuse of pesticides, and glyphosate, and the way our food is so processed, our foods here are pretty much deficient in many things.

Dr. Briden: Arguably, yes.

Dr. Weitz: Yeah, yeah, yeah. So it’s interesting, some of the same nutrients that could be potentially beneficial in this arena can also be part of your anti-COVID program to support immune function. You mentioned NAC, that’s all-star for COVID, and zinc, and Vitamin D, Vitamin A, selenium, curcumin, those would all be great in that arena too.

Dr. Briden: Probably true. I won’t weigh into that conversation, but yes, yes, probably.

Dr. Weitz: Well, not a problem for you.

Dr. Briden: No, New Zealand, we always-

Dr. Weitz: New Zealanders.

Dr. Briden: Yeah.

Dr. Weitz: Great. So thank you for this discussion.

Dr. Briden: Yeah.

Dr. Weitz: Any final thoughts you have for our listeners, viewers? Tell us about how they can get a hold of you, and get your book.

Dr. Briden: Sure. Well, I guess my final thought in endometriosis is just to take heart, there is a lot more … there are more options than you might realize. There’s stuff out there you can do, and I’ve seen in patients, and colleagues, lives, just be transformed. You can … even if you think all hope is lost, and you’re different, and your situation is way worse, you can always be better than you are. So I would look at it … like I said, I have a couple blog posts about endometriosis, one is called Treat The Immune System, something like that, Immune Treatment for Endometriosis. I have chapter nine in my book, Period Repair Manual, it’s about that. So my blog is larabriden.com, all my social media is at Lara Briden, I’m the easiest person in the world to find, and my book is Period Repair Manual. I have a second book coming out next year about menopause.

Dr. Weitz: Oh, wow.

Dr. Briden: Pausing menopause, so it’s a slightly different topic that we could-

Dr. Weitz: Oh, that’s great. Okay, and then it will be out when?

Dr. Briden: Not ’til early next year.

Dr. Weitz: Right.

Dr. Briden: It’s just being edited right now, fact-checked and all that.

Dr. Weitz: There you go. Awesome. So you’re keeping yourself busy. Thank you, Lara.

Dr. Briden: Yes, thanks for having me.

199 episodes