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Endometriosis and Immunity with Leah Hechtman

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Endometriosis and Immunity with Leah Hechtman

It's becoming clear that endometriosis is more than just a reproductive disorder. The impact on a women's health is systemic and wide spread.

So what role does the immune system play?

Respected women's health expert, Leah Hechtman has dedicated much of her career to finding answers to endometriosis. Leah's research and clinical observations have led her to focus on the immunological signals, largely in peritoneal fluid which can give major clues as to the severity of the disease and aid in tracking response to treatment(s).

She'll be discussing this in greater detail at the forthcoming ATMS Endometriosis Symposium in Sydney, September 2017.

Today she shares with us some of her clinical pearls of wisdom on this topic. 

Covered in this episode:

[00:44] Introducing Leah Hechtman
[01:26] How Leah became a naturopath
[02:51] 2017 ATMS Endometriosis Symposium
[03:21] Understanding endometriosis
[06:21] Extra-peritoneal symptomatology? 
[07:03] Is there a correlation with immunity?
[10:20] The evolution of endometriosis
[12:30] The gut and histamine links
[15:55] Oestrogen displacement vs. oestrogen dominance
[19:18] The tests Leah finds most relevant clinically
[21:14] Aspects to look at underpinning pain
[23:19] The immunological relevance of peritoneal fluid
[25:09] The role microbiota have to play
[27:20] Some key therapeutic interventions
[29:57] Working with client's medical team
[32:16] Barriers to treatments not working as expected
[34:14] Further resources for learning
[37:14] Final thanks to Leah

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. With me today is Leah Hechtman

Leah is a very experienced and respected clinician. She specialises in fertility, pregnancy, and reproductive health for men and women. Her primary passion is her clinical practice where she is inspired and humbled by her patients. She's completed extensive advanced training and is a university lecturer, keynote speaker, author, and educator to her peers. She's currently completing her PhD through the School of Women's and Children's Health, Faculty of Medicine at the University of New South Wales

Welcome to FX Medicine, Leah.

Leah: Good morning, thank you. Thanks for having me.

Andrew: Now Leah, you have such a responsibility to your patients, and this shines through in your dedication to education. Can you please take us through where you began and where you're at now?

Leah: Absolutely. So, I was actually sick as a child, which I think has influenced my practice more than anything else because it helps me stay grounded. It helps me stay focused and stay sensitive to their needs. 

I wasn't able to finish school so I started naturopathy. I was always going study medicine, I couldn't quite do it that way, so I started naturopathy, then did health science, then did a masters of reproductive medicine and genetics, and then felt I had to keep studying, and also wanted to have kids, so doing the PhD rather than medicine was the logical path, wasn't it?

Andrew: The logical path to do a PhD and kids!

Leah: Well, there you go, there you go. So, yeah, that's where I'm at. Medicine is always still there, and we'll look at it again maybe when the kids are a bit bigger.

Andrew: It's a bit of a divergence, though, from medicine to natural health, and the two don't very often meet. Indeed they are very often at loggerheads. What was the draw card for naturopathy?

Leah: I knew that natural medicine was what helped me when I was sick. I knew that my brain needed more and was more inquisitive, but I knew that natural medicine had a lot of answers. So, I knew that I was always going bring it in together. I just thought I'd do it the other way around, which I didn't. And so far, so good.

Andrew: You'll be speaking at the ATMS Symposium on September the 17th in Sydney. And you'll be speaking on endometriosis and immunity, but there's a particular topic that you've chosen.

Leah: Yes, I'm wanting to talk about the immune involvement with endometriosis and its development, specifically looking at peritoneal fluid and all the immunochemistry within it, and some of the, you know, the mechanisms of change and how it may increase the proliferation of endometriosis.

Andrew: Endometriosis in general, though, is a very trivialised term, and it's like, oh, “it's a bit of Endo - a bit of tummy pain.” Not so. Can you please take us through what endometriosis means and the breadth of presentation?

Leah: Absolutely. I think probably the most important thing to remember when you look at some of the top guidelines for endometriosis, so the ASRM guidelines, The American Society of Reproductive Medicine; they talk about the guidelines and they make a very clear point which is that a woman can experience a certain level of pain, which may not necessarily be reflected in endometrial tissue or endometriosis essentially. 

So, she may have, you know, a very low level endometriosis but have extreme pain or vice versa. So, I always counsel women, like I had a woman recently who had to have a laparoscopy last week and her pain was completely off the charts. You know, foetal position, vomiting, and you know, just on the floor screaming in pain, medication not helping.

And I said to her, “You do have to remember that no matter what they find, your pain is as extreme as it is, and the pain fibres and the communication of the pain fibres and the amount of endometriosis may not necessarily equal what we think it should.” So, you know, you've got women that will be staged and there are four stages one, two, three, and four. And, you know, the stage four woman will have endometriosis, you know, over reproductive organs but also her bladder, her bowel, you know, a whole lot of different areas. And so she'll experience cyclical symptoms that are debilitating, you know, and it's not just, "Oh, you've got IBS and a bit of period pain." You've got endometriosis all over your bowel, and that's why you can't have a normal bowel movement.

And there's, you know, there's a lot to be said that women with endometriosis, they're extremely brave, you know, like they go through this level of debility on a monthly basis, sometimes daily, and no one can quite comprehend how severe it is. And the fascinating thing as well, and not to be cruel but, you know what, these women will go through labor and they always say to me, "Labour was nothing, you should have seen my period before." And you go, "What do you experience on a daily basis to say that?" And it's dismissed and people just go, "Oh, take some Ponstan, you'll be fine."

Andrew: So, this is what I don't understand. Given that there are more and more women entering medicine, why is there not a plethora of research out there on endo?

Leah: I think the thing with endo is that, you know, I was speaking to one of my supervisors about it interestingly, and we were talking about a slight deviation. I'm sorry, but we were talking about, you know, study recruitment for my PhD and stuff, you know, and how do you eliminate women with endo, because almost everyone has little bits of endo now. And we're starting to realise is that, you know, these minor stage one bits of endo, is it because we're all having babies later? And is it just a normal phenomena? Or is it because of other factors, which I'll talk more about later? And so it becomes very difficult to know, actually, does everyone have little bits of, women you know, of reproductive age in their 20s and 30s? It's less common to find women that don't, and that's what I think is getting really scary.

Andrew: And what about extra-peritoneal symptomatology?

Leah: Yeah, well, they're finding it in all sorts of places, you know, and they're finding that it's just so prevalent. And I think that, you know, to bring it back to the research, that's where it gets tricky because they haven't been able to identify a specific marker, you know, the understanding around the immunochemistry. We call it the holy grail, you know, like the endo researchers are searching for the ‘holy grail’. 

When I was at Sydney Uni with my masters, you know, there was an entire faculty basically just trying to find this endo marker. And unfortunately, they didn't find it, and I think that that's where it gets difficult because it presents in so many different ways. And I think our understanding of it needs to broaden and we need to see it as a systemic condition, not just reproductive.

Andrew: So, talking about systemic presentations, is there a correlation with general immune signals and severity of endometriosis?

Leah: I think so, I think so. 

When you look at the research, let's say specifically at interleukins and identifying a specific interleukin and prevalence of endo, it's very much the holy grail still. You know, like you can find some studies saying, you know, interleukin 17 some say 9. It's not conclusive. They haven't gone, "Every woman with endo has this." But what I think clinically is, and I'm testing more and more women is, I will see interleukin abnormalities across the board. And when you say it across the board, you go it's an inflammatory condition, which we know, but you also see abnormalities in VEGF. And I think, you know, we're starting to be able to test some of these markers, so we're getting more understandings of that whole group of cytokines.

But they all have abnormalities, and I do see trends clinically. I'm seeing trends in the sense that pretty much all endo women will have elevated VEGF, which means that they were all increasing how many blood vessels they're putting down, which means the blood supply is distorted. So, could we potentially screen every potential endo woman for VEGF? Is that something we should consider? I'm not sure. But definitely if it's been diagnosed, you can use it as a therapeutic marker to track how your treatment is working. You can use the cytokines to track how your treatment is working as well. Are you actually making a difference or are you missing something?

And I think the really curious stuff that I'm finding clinically is where the cytokine panels, you can correlate it with specific bugs. You can correlate it with specific immune problems. And I've never met an endo woman that hasn't had a herpes virus, glandular fever, CMV, general herpes. She hasn't had something in her history before it. 

We're all convinced of the research around EBV, you know, increasing tendencies towards MS, cancers, etc. I think we need to start thinking about it with endo. Is there something that switched on the immune system to stop behaving correctly? Or to start, you know, not recognising all the cells correctly and having such a strong immune reaction?

But I've never seen, as I said, the no herpes family. And I've never seen...you know, they always have some sort of immune history. You know, they were sick and then all of a sudden their periods got worse or there's something that's happened. But a lot of the research I'm doing clinically and, you know, that's influencing how I go, I'm looking at the specific interleukins and different bugs that may actually be correlating, and I'm seeing some interesting trends.

Andrew: One particular cytokine, is it a cytokine, chemical that you mentioned was VEGF, vascular endothelial growth factor. Is there any correlation between endometriosis and increased risk of cancers, for instance, breast or maybe ovarian cancer?

Leah: Definitely with uterine. But I do think that it's a tricky one. There was a lot of research out that’s supporting that yes, there is, which is why you want it to be addressed and supported, but it's very much dependent on a lot of contributing factors. You know, support for menopausal transition and whether or not that was a factor. But I guess the trickiest part is when you look at the data, they haven't always been able to screen if a person was or wasn't positive for endo. So, I think it needs to be expanded. I have never seen anything with breast cancer though.

Andrew: Right, and I guess, to go back to the future here, or we need to go back to the beginnings, the definition or the theory behind endometriosis, still not conclusive. Tell me what's happened. What's the evolution being and where are we sitting now?

Leah: We still have mainstream medicine using, you know, the Samson Theory from the early 1900s. You know, retrograde menstrual blood flow. Okay, yeah, but there's more… You know, it's not just a reproductive disorder. It is a systemic disorder. It is, you know, an endo woman has impact across the board, right through her entire body. You know, like a woman that has an aggravation of her endometriosis, she will also be presenting with thrush or UTIs or lowered immunity in getting a flu just before her period. She has all these systemic symptoms, and we're not expanding to consider that. And no disrespect to their gynaecological community, but I think endo might need to step outside the gynaecologist's room in a way.

I think they are the experts, don't misunderstand me, and I think that, you know, some of the most phenomenal gynaecological surgeons will bring in the gastroenterologist and, you know, the bladder specialist, etc., into the surgery. But the immunologist isn't there, and I don't know why that is in a way. And I think we need to start bringing the immune system into it. 

You know, like there's phenomenal research around the microflora changes in the endo woman, and how, if she has a disruption in her microflora, how that influences her proliferation of endo. You know the immune system, I don't know that we can class it as an autoimmune disease per se, but I do think that we can suggest that there is a derangement of her immune system.Why are cells going in funny places, you know? 

The first thing I always say to an endo patient is, "Yes, you have endo but I wanna know what's happening with your peritoneal fluid," which means that fluid is touching anything in your peritoneal cavity, which means anything in that area is up for grabs. So, what are we doing about that and, you know, what's the GALT tissue doing? What's the lymphatic tissue within the digestive system, how is that working? Do you have a gut parasite? And is that actually proliferating your endo? And 9 times out of 10 it is. And I think we have to ask these questions, you know, the immune system hasn't been able to protect itself, and why is that?

Andrew: These lymphoid-associated tissues, very interesting, very widespread, and obviously present in many different conditions. So, thinking about the immune derangement, how powerful do you see the gut as the...do I say the seat of treatment or a factor in treatment?

Leah: Only a factor, only a factor. I mean, yes, most women will walk into your rooms and they'll be misdiagnosed with IBS. And partly, it's just all of the oestrogen clearance so they have all these diarrhoea before they bleed or during their bleed, and they have constipation post-ovulation. So, they're misdiagnosed as IBS, but I think it's a factor. I don't think it's the cause. My thoughts at the moment, one of the bugs that are triggering all the processes. And I think some of the things we have to think about is high histamine levels feed oestrogen's, which feeds the endometriosis proliferation. Histamine levels are increased in the presence of a bug, and this is where we're starting to get into those weird and wonderful systemic bugs.

And I'm starting to think that there's a relevance there. You know, I'm looking at lymphocyte subsets, I'm looking at CD57s in these women and they're all having all sorts of unusual presentations, which is suggesting not that they're in the Lyme category or that whole group of bugs, but that there are bugs that might be influencing how this is actually transpiring.

Andrew: So, talking about histamine levels, I read a very strange story yesterday, which was talking about these dried grasshoppers as a source of protein. They contain a precursor to histamine, which is converted to histamine in the human body. And indeed, one lady had a toxic reaction from that. Do you find dietary derangement or, you know, high dietary histamine intake, playing a role in exacerbating symptoms?

Leah: Massive, massive. And I remember when I first started, you know, treating, I was always like, "Okay, so we've got to get rid of soy." Then a few years later it was to get rid of dairy. Then it was we gotta rid of dairy and gluten. But, you know, I cut out amines and pretty much all of the symptoms go. But it's about what form of dairy, yeah, you know, and controlling it. But I think the most interesting that we have to factor in is, so let's say we take a woman before she conceive and she's got her endo. Then when she actually conceives and she falls pregnant, and the placenta takes over say between week 10 and weeks 16, the DAO enzyme is started to be secreted and all of a sudden she can tolerate all these foods.

So, she's the woman with her endo, that gets a migraine or a headache when she has wine or citrus or aged cheese, or whatever it might be or vinegar, but she hasn't quite worked it out. But then when she's pregnant she can eat everything under the sun. And we have to remember that the immune system has down-regulated itself to accept the foreign material, enable the baby, her immune system has changed because of the baby. 

Then the DAO enzyme secretes, secretes, secretes. She gets to delivery, she has an oxytocin surge. She's fantastic. Two weeks after the baby is delivered, she has the most raging migraine and all these crazy systemic endo symptoms, what's happened? She's still eating the amine foods. Her histamine tolerance has gone through the roof. She doesn't have the protection anymore of the pregnancy. So I look at it and I go immune, DAO enzyme, histamine, dietary changes across-the-board makes a huge change.

Andrew: So, is this perhaps why the gonadotropin-releasing factor antagonists, have I got that correct? That they used as part of therapy?

Leah: They’re used to try to control the level of oestrogen in the body. Because we know that endometriosis increases in an oestrogen-dominant environment. But I do think that certainly in the natural medicine community, we focus on oestrogen changing treatments… you know, like we focus so much on the wording of oestrogen dominance, whereas I've always rephrased it as ‘oestrogen displacement’ because...

Andrew: Yeah, right, displacement?… Oh, explain that one.

Leah: For me, because that factors in different types of bodies and things like that as well. You know, let's say you have your endo woman, okay, and she gets crazy hot flushes and UTIs before her period. It's a displacement, because all the oestrogen is concentrating in the uterus at that time. So, systemically, she appears like a menopausal woman. But technically, her oestrogen levels haven't changed that much. And so it's a displacement because certain tissues will have higher levels than others. You know, it's the endo women that go, "I can't think straight. I've got no oestrogen in my brain." You know, they're acting like a post-menopausal woman, and it's just because it's displaced in certain areas where the endometriosis is richer. And in those situations…. do you know where I'm going with that?

Andrew: No, I've just got 20 questions going around in my brain. So, continue.

Leah: Trying to work it out..… For me, it's displacement because, yes, there's women where it's oestrogen-dominance but I think it's an overused term and I think it's dated. You know, I think just looking at a woman with endo and going, "Okay, let's cut out xenoestrogens and phytoestrogens and every oestrogen-like molecule." I don't think that's the answer. I think that that's just may reduce the proliferation but I don't think that it actually quenches or fixes the cause. So, yes, I agree in oestrogen modulation, to an extent but I think you’re bandaiding.

Andrew: So, where I'm thinking here is, if you're talking oestrogen displacement, are we talking a kind of like...I'm going to use the word syndrome, where the receptors on certain tissues are more sensitive to the existing hormones?

Leah: Yeah, definitely, definitely, but it's the cyclical nature of it. And so its that these receptors are active at particular times of the cycle and it's particularly concentrated in certain areas. I mean, I'd love to see a test that could somehow track and compare peritoneal fluid, follicular fluid, blood, you know, all the different serums and go, "Okay, so where in the body is it richer?" But we're not quite there yet.

Andrew: That's your second PhD.

Leah: Maybe, maybe.

Andrew: So, okay. I've got to ask then, do you find that women with endo tend to get certain types of symptoms or indeed don't have certain types of symptoms in contrast to or comparison to; PMS? Like, for instance, sore or fibrotic breasts?

Leah: They can still get that, though. But the thing is, you can also have the woman with endo and PMS at the same time.

Andrew: So, at the same time, and they present the same time or do they tend to present in a different time temporarily?

Leah: There's a whole lot difference to it. But I find that the questioning around the endo woman, and it can be a clinical differentiator, is you sort of go, "Okay, so let's walk through your circle and let's walk through the types of symptoms. Let's talk about your dyspareunia and, you know, the timing of the month when the pain is worse." The classic is the hot flushes and the night sweats before their period. Any woman that says that, you know, that oestrogen's gone and crashed on them, it has to be an endo scenario. But they tend not to sort of sit there and go, "Oh, you know, I've just got all these breast pain and that's it, and everything else feels fine." That's not for me an endo diagnostic.

Andrew: So, the next question there with regards to oestrogen is, is it of any value to be monitoring the levels of hormones, you know, how you have like the four or the six tests throughout the cycle? Is there any point, if it's not an oestrogen-dominant condition, rather than being an oestrogen-driven?

Leah: I don't use it anymore clinically. I find that it, you know, it costs a lot of money for the patient and I don't get the clinical outcome from it. Versus if, they're comfortable and we look at the immune system, I get so much more clinical benefit. It's so much quicker, you know, like you think about let's say the top herb for me, for endometriosis will be turmeric. Above and beyond, no doubt, no questions. Why is it? You know? And I was reading a paper...

Andrew: Because it does everything!

Leah: It does everything.

Andrew: But it's not a “blocker”.

Leah: No.

Andrew: It's a dampener, a nourisher.

Leah: Absolutely.

Andrew: It's a balancer.

Leah: Absolutely. You know, and you look at the old Chinese medicine research around formulas for, what they would now call endo, you know, the “blood moving” formulas. They're not about oestrogen changes. They're about movement of blood, about reducing inflammation, about actually tonifying and strengthening the reproductive system, because something is driving it, that's not necessarily oestrogen. You know, and if it was such an oestrogen-dominant condition, I think we'd be seeing other changes with blood pressure. I think we'd be seeing other changes across the board that we don't see. I think that the immune system is where we have to be focusing.

Andrew: So, most common test that you use?

Leah: Always use a CA125 as an initial diagnostic. I mean it's concentrated in the peritoneal fluid obviously. It's a marker of reproductive inflammation. You know, if a woman walks in, her CA125 is 6, I'm like, "Okay, what's going on here?" But if it's 35 or 65, you know, it's your diagnostic, and you can watch the CA125 change as you treat them. Obviously, your gold standard is a laparoscopy but ideally you try and avoid it because of adhesion risk. But if they need it, they need it. 

But I'm using cytokine panels and VEGFs and things like that with all my endo women now and seeing phenomenal responses.

Andrew: One of my questions with regards to laparoscopic investigation, it's sort of the gold standard of proving that something is there because you're actually looking at it. But what I don't understand is that the women with the worst pain are the ones that can have the least lesions, and they tend to be of a different type, is that right?

Leah: Yeah, technically yes. One of my colleagues when I was at Sydney, she did her PhD on pain perception in endo women. And what she was finding was that it was more about the neurological impact and the communication of the neurons, and the perception of that pain that influenced their pain awareness. Rather than the endo. Which again suggests other involvements of endo that are not just oestrogen and hormones. It was a fascinating paper.

Andrew: You've now twigged another question in my mind, and that is you said the ‘perception of pain’. So, how valuable is, or are, treatments such as meditation, insight into what their disease, their disorder is? And so there's that greater acceptance or more relaxed attitude to it. How powerful or relevant do you find mindfulness, for instance, in helping a lady with endo?

Leah: Its a tricky one.. Something that's coming up in my memory, though, is I remember speaking with a very, very experienced therapist. Who said that of all the endo women that she'd seen, she did a paper on it as part of her research, she found 80% of them had some form of sexual trauma. And so this is where, yeah, this is not me saying that endo is in the mind of the patient, but that there is usually some emotional things that are going on. 

And through the process of actually working through things for women, I do find that it is a major part. So, the mindfulness, the meditation part, the potentially needing counselling therapy, something to help them with past traumas, is huge. I mean I'm thinking of a woman that's a patient at the moment, and horrible traumatic sex traumas, just horrible, and one of the worst endo patients I've ever seen. And that happens time and time again. So, I do think that we can't ignore that component of treatment to really help them.

Andrew: Your talk at the ATMS Symposium in September is going to be on the peritoneal fluid, and the relevance, the immunological relevance of that. So, that would only be sampled in a medical environment, correct?

Leah: Yes, unfortunately we don't do samples on patients at this point. Obviously, if they have a laparoscopy they do have a look at it. But it's quite rare to have them actually test the fluid. They will usually more just be doing histopathology on biopsies.

Andrew: Can a naturopath in practice ask the gynaecologist to sample that and what do you think the willingness would be?

Leah: I don't think they'll get very far with that one, to be honest. It's not something that's tested that much outside of a research context.

Andrew: So, we're really looking at future hopeful therapies?

Leah: I think so, I think so.

Andrew: Sorry, assessment.

Leah: I hope so, I hope so.

Andrew: How much information have you gained by investigating the immunological relevance of peritoneal fluid?

Leah: It's a big driver for me. So, in clinical practice, it's just, for me, I have to find the answers, for patients, so I just keep digging. But this is what makes sense. This is the clinical outcomes that I see that are proving to me that this is where we need to be going. This is how we need to look at it. The response of patients and the improvement to their overall well being is quite profound. So, I'm very confident that this is the direction that needs to be taken.

Andrew: Okay. So, thinking about baseline and treatment testing or assessment, if nothing else, and of course the major thing is to gauge whether treatment has been successful. Do you find the correlation between those tests and the impact on the symptomatology of the patient i.e. improvement?

Leah: Absolutely, absolutely. And you can test them sort of every three months if you want to. And you can see improvements that are very significant.

Andrew: Even with CA125?

Leah: Always, always with CA125. It always improves. If you’re on the right treatment.

Andrew: Yeah. And what other markers do you look for?

Leah: Well, it depends on the full picture. So, let's say hypothetically, obviously someone where there’s... a gut parasite or something like that that we have to address. Then all of a sudden CRP, ESR, other, you know, basic white-cell parameters do improve. Lymphocyte subset is changed, so all the T-cell communication, the natural killer cell communication, all that starts to improve when you really actually tackle; Is there a bug in there? Have I addressed the bug? And then I start to normalize the immune function, but then all the inflammatory markers as well.

Andrew: Now, of course, you've said the bug. There's so many bugs. How do you...I'm going to make up a word, how do you “detectivise”.. How do you find the bug? There are so many bugs, and even pathogens can be pathobionts. You've got good guys that can be symbionts, you've got, you know, the normal commensal bacteria can overgrow in SIBO. How do you find ‘the’ bug?

Leah: Absolutely at the start, you've got to look at the symptoms and try and work out, where is this bug actually making its impact? 

If it's, let's say just isolated to gut bugs, then do some really good testing, microbiology as well as parasitology. But if it's systemic symptoms then I start with just systemic immunological considerations. So the things that I've talked about, CT57, lymphocyte subsets, that sort of thing. And then go digging depending on the symptoms and the presentation. But then we're starting to creep into, you know, the immune line community, which I'm not against creeping in to. But if you're starting to get really systemic symptoms like that, like you've have an endo patient and it just doesn't make sense. And yes, it does correlate with ‘I've never been well since’, and all that. That's another podcast probably.

Andrew: Fine by me.

Leah: Whenever you want. But that's really looking at it. And what I'm finding in that community though is, you can spend thousands of dollars and never really get to the bottom of it. I think clinical discernment gives you the best direction first. You can see a lot of information and basics. Like I said, the interleukins, you can pick between the interleukins and go, "Okay, there's a gut parasite, there's a virus, there's, you know, whatever." And that gives you the information and the direction from there.

Andrew: So, on to therapy, natural medicines and you've obviously mentioned the poster child of inflammation, which is curcumin or turmeric. Without getting into specifics, do you tend to include good old turmeric and make sure that they're cooking with it and making sure their tongue is always yellow, that they walk past the try in colds or willies and break it, snap a bit off and chuck it in their mouth. Because this is totally aromatic, totally different from when you get dried turmeric. Do you tend to encourage the use of good old turmeric in cooking and do you add these, you know, ‘super duper’ supplements?

Leah: Both, as much turmeric as I can get in, provided their VEGF can support it. Because obviously, I don't want to have any blood coagulation issues. But absolutely, I mean, and my patients always laugh at me because we talk about different recipes and how to cook turmeric and what to do with it, and all those sort of things. But as much as they can get it in and thankfully there's all that popular media around whitening of teeth from turmeric now, so they're less apprehensive.

Andrew: There's even a face mask with turmeric, which is weird, but anyway, off topic.

Leah: I'm not ready to do that one personally. Turmeric, absolutely, and then it's very much dependent on the person. So, if we go back to the histamine group, liquid herbs are never a good idea because of all the alcohol and the fermentation of the herbs. So, I never touch liquid herbs. So then in that community, I'll be using Chinese powdered herbs and then putting together formulas depending on the energetics of the patient. Certainly lots of berberine extracts are phenomenal in short terms. Different probiotics, depending on the flora requirements that they have. 

What are some other big things? Getting all the nutrition right, getting all the methylation right. See, if their methylation is all defunked then you never get rid of endo until it's actually working. 

Sometimes gene testing suggesting that I need to work on the liver. In those instances, it might be calcium-d-glucarate. It might be other liver support. A lot of glutathione tends to work wonders for endo patients. But it's very much based on how widely have I looked at the patient and how much information do I have to then determine what I need to do.

Andrew: Do you tend to use oral glutathione or oral N-acetyl-cysteine?

Leah: I use dermal glutathione. Sometimes I do suppositories of glutathione, depending on the severity, and if there's heavy metal chelation that's required. And NAC, I do use oral. I do have a couple of patients that I’ve used nasal glutathione and nasal NAC as well. Interesting case.

Andrew: Nasal NAC, hmm, yummy.

Leah: She still comes, she still likes me, it's okay. But yeah, they're the ones I focus on.

Andrew: So, obviously, there's this continuing dismissal of natural medicines by gynaecologists. And yet you are this famed personality in the natural fertility and women's health issues. You've written books, you were past president of the National Herbalist Association, you've presented, you've taught. Do you find the landscape changing at all?

Leah: Oh, absolutely. I've got a handful of gynaecologists that I work with, and they no longer use the drugs post-surgery. They go, "You see, Leah, she does her thing.” They go, “I don't 100% understand what she does”, but they go, "You see her, and then she'll do her thing," and then they do the second check and there's no scarring. They know it works. 

There are situations where you need the surgery. Like we can't be naive about it, and I'm okay with people having surgery if it's indicated. But look, I do think that, you know, the PhD has given me so many doors and I'm so grateful and respectful of those doors. Because I go into surgeries and they know me because I sit there and I look at the surgeries with them and we talk about the patient.

So, I think I have that advantage, but the landscape in itself is we have to remember that the mainstream medical community, they just don't know who is safe. It's not that they reject it, it's just that they don't know who's safe. They don't know who they can refer to, so they rely on, "Hmm, okay, she handled that patient well. All right. I'll give her a go." And I think the most important thing clinicians need to remember is it's not that they're against our medicines, it's just they don't understand them. Communicate with them, write letters to them, have coffee with them, you know. And they know that I am respectful of their way because I'm doing the research that I'm doing. It does help that my supervisor is head of reproductive medicine, I will say that.

Andrew: Yes, just slightly.

Leah: Just slightly, just slightly. But it's mutual respect because we're both doing the work.

Andrew: Yeah, I totally agree with you. And I guess one of the other things I'd tell you is don't overwhelm them with five billion studies which, of course, is my preponderance.

Leah: They don't want to read it.

Andrew: They don't want to read it, and they're not beholden to include in the patient notes. But if you write a very short succinct letter, maybe with one abstract, then they're actually beholden to keep it in the patient's notes.

Leah: I don't even include the abstracts. I say if you like them, I'll send them to you.

Andrew: So, I have to therefore ask the reverse. In your extensive experience, have you found using a plethora of nutrients, herbs, nutraceuticals throughout your career, that some you've just had to leave behind, they just don't work.

Leah: Look, I think, you know, when we were trained, you know, with some of the herbs and things, you know, like and you have this crazy amine sensitive person, and you'd be going, "But I'm giving you false unicorn root or I'm giving you all these beautiful herbs." And they'd be getting worse. 

Or, you know, you'd have women and you'd be giving vitamin C, which is the worst amine-reactive nutrient we've got. It's learning, yeah, it's learning. And I think I've learnt on my own body more than anything else, because I've had endo. So, I've learnt on my own body, I've learnt how that works, and you've got to understand it. And it doesn't mean that I don't think men can understand it, it just means you've really got to step into the female's body and go, "How and why is this working?" And then you can eliminate things.

Andrew: One of the things that I think you've just helped us realise though, is that we might think a type of treatment is failing, i.e. herbal treatment, but it maybe actually the delivery of those herbs?

Leah: Absolutely. In my spare time, I would love to make some tablets of some formulas that I know would work if they didn't have the alcohol. And it's the alcohol that the patient's reacting to. So, like I use homeopathy in my practice, but I don't use ethanol or alcohol for anyone. It's all a salt water-based. As soon as I made that change a number of years ago, they started working again. And so it's maybe you actually go to a tea, you go to the capsule, you go to the food source. Not just, you know, like, years ago when we would be like turmeric and tincture form works and then we all went, "Uh, hang on a tick, it doesn't have the fat to actually carry it. What are we doing?"

And then all of a sudden it works again. So, I think we need to start thinking about delivery systems and we need to get a bit more sophisticated. You know, this disease is sophisticated. And I think we need to individualise our treatment and really meet it and go, "You know, you're a really cool disease. You're pretty clever. I'm going to try and match it."

Andrew: Okay. So, further learning for naturopaths. Because obviously this is, you know, forgive my arrogance, but I'm going to say that it's not taught correctly, that there are still people saying the wrong message and repeating the wrong message. So, where can they get further research? Can we talk about your book?

Leah: We can absolutely talk about my book. So, "Clinical Naturopathic Medicine," we are in the final stages of second addition. And if the publisher lets me, we have a second volume coming out as well, and they will be out early next year so that's really cool. But the endo symposium that I'm a part of, there's some phenomenal speakers there. I'm excited to just sit there and listen to them, I have to be honest. So, I think that will give a lot of information for people, too.

Andrew: You said something that really heartened me, Leah, and that is when an expert such as yourself with, I'm gonna say decades of experience with helping women, in a plethora of conditions. That when you say you don't know it all and you're going to be learning from other people, that to me is the sign of a true expert. 
But I need to ask you, where can naturopaths and natural health practitioners get further reputable information regarding endometriosis, and especially I guess with natural treatments?

Leah: So, there's a few things that they can do. There's the symposium that I'm really honoured to be a part of in September in Sydney. The panel consists of Jason Abbott, Lara Briden, Andrew Orr, the Endometriosis Association. I mean phenomenal people, phenomenal brains. You know, I'm really, really looking forward and really grateful that I can be a part of it. And I think it's gonna challenge a lot of the collective models that people have, and unfortunately, incorrect understandings of what the disease actually is. So, there's that. There's, you know, I think that...

Andrew: There’s your book as well.,,,

Leah: There is the book, there is the book we’re in the final editing stage for the second edition which will be out next year. And hopefully the publisher doesn't kill me but there is a second volume that goes with it, which is all advanced conditions and it's pretty exciting. So, that will be out next year. 

I've written in a number of textbooks on endometriosis as well, mainstream, and in the complimentary medicine world, so there's all of that, too. But I do think that, for me, there's always the two parts to my research. There's my clinical practice, and I think if you ever feel stale in your practice and don't feel like you're learning, get some supervision from someone, get some mentoring, continually upskill in that regard, continually challenge yourself.

And also make sure that you do all the research. You don't have to be in a formalised research structure. I just choose it because I find it helpful and easier for doors. But stay abreast of research, you know, have memberships with the main reproductive associations around the world so that you're aware of things that are happening. And don't just narrow your focus in the complimentary medicine world, because there isn't enough there to really show you where the growth is.

Andrew: Your expertise truly shines through, and I'm so honoured to have interviewed you on FX Medicine today, Leah Hechtman. Thanks so much for joining us.

Leah: Thank you, Andrew. I really appreciate it.

Andrew: This is FX Medicine and I'm Andrew Whitfield-Cook.

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