Endometriosis with Dr. Felice Gersh: Rational Wellness Podcast 067

Dr. Felice Gersh talks about how to manage Endometriosis with diet and lifestyle changes with Dr. Ben Weitz.

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Podcast Highlights

3:15  Endometriosis, the growth of uterine tissue outside of the uterus, begins with retrograde menstruation, the movement of cells from the uterine lining up the fallopian tubes. Each month when women shed the endometrial lining of their uterus, some of the cells are still living and go through the fallopian tubes into the pelvis and then the body’s immune system gets activated. During this period, estrogen levels are lower, which is inflammatory, and this activates the immune system to do it’s job an remove these endometrial cells.  Because women today get pregnant later in life and have fewer pregnancies, women today have so many more menstrual cycles than women used to, which increases their risk for endometriosis and also breast cancer.

6:52  It turns out that estrogen is a potent modulator of inflammation and while low levels of estrogen are pro-inflammatory, high levels of estrogen are anti-inflammatory.  These inflammatory cells secrete enzymes called matrix metalloproteinases that dissolve these endometrial cells in the pelvis, along with the other immune cells. As women go through the monthly cycle to prepare the body for possible childbirth, estrogen levels slowly rise, peak and then drop in this beautiful ebb and flow cycle. But in women with endometriosis, this whole system is not working properly and it creates really a disaster for these women because this very elaborate, very well-programmed system is not working properly in them.

9:48  One of the things that disrupts this cycle of estrogen rising and falling and the immune system being primed at the right time are endocrine disrupting chemicals like pesticides, pthalates that are in scents and plastics and BPA and BPS in cash register receipts. We put them in children’s mouths in dental sealants and many other plastic products. These endocrine disrupting substances disrupt our normal hormonal flows and balance and they change our genetic expression (epigenetics) and actually have effects for generations. And so it’s really creating a tremendous challenge for reproductive functions when the hormones that are so intricately involved in all these functions are not going to work properly. And endometriosis is like the perfect storm of all of this coming together to create really a massive negative impact on these women’s lives.

16:29  Since estrogen receptor beta as being a key factor in endometriosis, should we avoid an estrogen receptor beta agonist like soy be avoided?  Dr. Gersh feels that because soy contains weak estrogenic substances, it serves as a blocker for estrogen receptors for stronger estrogens, so organic soy can be protective for women.  She also recommends consuming antioxidants, polyphenols, and quercetin, all of which can help with reprogramming hormone receptors. In endometriosis we have total body immune dysfunction, so it is really an autoimmune disease. Women with endometriosis have significantly higher rates of certain cancer. But we can use food as medicine. Foods like apples and onions that have a lot of quercetin can have an impact because quercetin is a mast cell stabilizer and mast cells are the first responders of the immune system and they are filled with inflammation, containing preformed tumor necrosis alpha. Mast cells also stimulate substance P, which stimulates nerve production, which results in more pain in the pelvis and bodies of patients with endometriosis. Quercetin, green tea extract, resveratrol, and vitamin C can all help to calm down the immune system. Studies also show that women with endometriosis have an altered gut microbiome, so improving the gut is also beneficial. And the interaction between estrogen, the immune system, the gut, and the brain is incredibly complex. And this new pill that has been approved to help with endometriosis that shuts down the brain stimulus to the pituitary to shut down estrogen production is not likely to be effective for modulating the condition, because it’s not just about having only high or low estrogen but the rhythm of the highs and low of the estrogen/progesterone cycle. 

28:52  Dr. Gersh likes to have her patients go through a 4 week liver/estrogen detoxification program to improve estrogen metabolism using DIM and broccoli sprouts to encourage estrogen to be metabolized in the healthiest way and produce the right estrogen metabolites. 

36:24 The body and our hormones need to be in balance and when you place women on hormone replacement and give them the same amount of estrogen daily for years, these women are not getting the fluctuations of estrogen from low to high that are so important for modulating the immune system and the other hormones. For example, when you get the spike of estrogen that is right before ovulation in a normal cycle, that spike upregulates progesterone receptors, and testosterone, and thyroid so that they actually work better. Women with endometriosis, their progesterone receptors are malfunctioning so they don’t receive the progesterone. It is clear that what we are doing with hormone replacement therapy is not physiological, though we need more research to tell us how to do it better.

 

                              



Dr. Felice Gersh is a board certified OBGYN and she is also fellowship-trained in Integrative Medicine. Dr. Gersh is the Director of the Integrative Medical Group of Irvine and she specializes in hormonal management. Her website is http://www.felicelgershmd.com/ and she is available to see patients at 949-753-7475, she lectures around the world, and she will be releasing her first book on PCOS in the Fall of 2018.

Dr. Ben Weitz is available for nutrition consultations 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.


 

Podcast Transcripts

Dr. Weitz:            This is Dr. Ben Weitz with the Rational Wellness Podcast. Bringing you the cutting edge information on health and nutrition. From the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube. And sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health.

Hello, Rational Wellness Podcasters. Thank you so much for joining me again today. I’m very excited that we’re gonna be talking about a very important topic related to women’s health. A condition known as endometriosis. Now, I’m sure a lot of you are not quite aware of what this is unless you suffer from it, but this is a condition that actually affects 10% of women in the United States. And this is when endometrial tissue … That’s the tissue that lines the uterus, ends up growing outside of the uterus. Most commonly on the ovaries, the fallopian tubes, or the intestines. Though it could occur anywhere in the body. The most common symptoms are pelvic or other pain, menstrual irregularities, and infertility. There can also be pain during sex or during urination. The conventional medical treatment typically consists of hormones, surgery to remove the tissue, and various types of pain medications. And then I just read an article that was sent to me by our guest, Dr. Gersh, about it. A new medication that is a hormone blocking agent that seems to have some effect as well.

And so I’m very excited that I’m going to get to interview and share some information with you from Dr. Felice Gersh. I just want to say I’m really excited about the fact that I get to interview these really super smart people on this podcast. And apart from being able to serve you, my audience, it’s also great for me to be able to interview these really smart people and do a little mini symposium every week about a new topic. Oh, by the way, those of you who enjoy the Rational Wellness Podcast, if you can go to iTunes and give us a ratings and review, that will help more people to find out about it.

So Dr. Gersh is a board certified obstetrician and gynecologist. And she’s also fellowship trained in integrative medicine. Dr. Gersh is a director of the Integrative Medical Group of Irvine where she sees patients. She also lectures around the world and writes on various topics relevant to women. And her first book on polycystic ovarian syndrome will be released this fall. Dr. Gersh, thank you so much for joining me today.

Dr. Gersh:           Oh, it’s my pleasure. And I definitely am thrilled to be able to discuss endometriosis with you and for all of your listeners to learn about it.

Dr. Weitz:            Yeah, it’s great because it’s really a very difficult condition for the women who deal with it, painful, and the treatments so far are not really that helpful. So I’m happy that we can bring a Functional Medicine approach to understanding it. So when we try to understand endometriosis, it’s hard to understand how tissue from the uterus ends up in another part of the body. And I was trying to put my head around it until I read that retrograde menstruation, which occurs in up to 90% of women, is believed to be the mechanism by which it occurs.  Can you explain what that is and how that happens?

Dr. Gersh:           Sure, that’s step number one. Because you have to have a root for the lining tissue from in the uterus to end up in the pelvic cavity. So every time a woman has a cycle … And that’s another issue is that women in this day and age have about 400 or more cycles per lifetime for their reproductive years. Whereas in more ancient times, women started having babies at a very young age and then they would nurse, which would delay the resumption of their menstrual cycles. So they spent a lot of their reproductive years either pregnant or nursing. They had fewer often than 100 cycles for their entire reproductive life. So that is another problem is that we’re cycling so often and having so few pregnancies and at a much later age. So what happens-

Dr. Weitz:            And by the way, that’s also a risk factor for breast cancer and a lot of other things too, right?

Dr. Gersh:           Well, there are apparently some amazing things that happen when women have their first pregnancy.  And actually the risk for breast cancer … A whole separate issue we can talk about another day, is actually dramatically reduced in women who have their first pregnancy before the age of 20.  But nowadays, that’s hardly something that we encourage women to do is to get pregnant, and have babies, and then nurse for three years before they’re 20 years of age. But there are all these interesting things that actually happen in the breast and with receptors, like the way the receptors work in the different parts of the body when the body does what it was originally programmed to do, which is to start reproducing.  And I say this over and over in all of my lectures is that whether we like it or not, we are what we are.  We’re animals of the animal kingdom.  And the prime directive of life is reproduction and survival to raise the young.  And that’s how the female body is designed.  And we have beautiful mechanisms, but nowadays with the world we’re living, we’ll touch on the role of endocrine disruptors. Which I know you’re aware of and how that relates to endometriosis and what that’s doing to women’s reproductive health. And of course, reproductive health is linked to all of health for a woman. They’re completely intertwined.

So what happens, if we go back to retrograde menstruation. So every time a woman has a period, the vast bulk of the lining which is shed goes out, of course, out through the vaginal canal and out of the body. And it’s like a renewal. And it allows the body to try again and to try to get a pregnancy going on the next cycle. And then a significant but certainly a small fraction of the uterine lining tissue actually goes backwards through the tube. So they call it retrograde menstruation. And some of these cells, they’re actually living. And a lot of the tissue is actually half alive, half dead. It’s filled with a lot of inflammatory cells.  And as it goes into the pelvis, the body’s immune system is activated.  So it turns out that estrogen in a normal woman and when things are working properly, low levels of estrogen are actually pro-inflammatory.  It actually calls the inflammatory cells to come and then do their jobs.

So you can think of estrogen as sort of a modulator of inflammation. High levels of estrogen are actually a very anti-inflammatory, while low levels are actually pro-inflammatory. And that’s why a woman has this beautiful cycle with highs and lows. It actually regulates how the immune system works. So during a menstruation cycle, the estrogen level is very low. And the inflammation is going to be higher. And so the lining is … The elimination of the uterine lining is actually an inflammatory process and the uterine lining is infiltrated with these inflammatory cells.  And the same thing happens in the pelvis. But these inflammatory cells at that time are there for a purpose. They do what they’re supposed to do in a healthy woman. They secrete these enzymes called matrix metalloproteinases. And these enzymes are specifically designed to dissolve these aberrant cells because they’re not supposed to be in that place for long. These cells that come up from the uterine lining, they’re supposed to be dissolved. And then the macrophages, those inflammatory cells that arrive, and the neutrophils, they are designed to gobble up these now dead pieces of tissue from the uterus. And they gobble it up and all’s well with the world.

And then the estrogen level starts to rise. And mid-cycle when you have that really high level of estrogen. And then for the next little while when the progesterone level starts to really rise, then at that time, the inflammation is the lowest. The actual level of time in a woman’s menstrual cycle when inflammation is lowest is when her estrogen peaks. That spike of estrogen because that’s when you wanna prepare for ovulation and then you prepare for implantation. And then at the very end, then of course the inflammation starts up again if there’s not a pregnancy.  So it’s this beautiful ebb and flow between the ups and downs of the immune system. But in women with endometriosis, this whole system is not working properly and it creates really a disaster for these women because this very elaborate, very well-programmed system is not working properly in them.

Dr. Weitz:            That’s great. Because that’s one of the thoughts I had. When I read that 90% of women have this retrograde menstruation, the next thought was why don’t all women have endometriosis?  So the explanation is that the immune system normally knocks out those cells. And so in some women that immune system doesn’t function quite as well as it should.  What are some of the most important factors that allow this endometrial tissue to survive and grow outside of the uterus?

Dr. Gersh:           Well, it’s complex. But more and more what we’re finding is it’s those ubiquitous endocrine disruptors. That’s what’s happening in women with endometriosis is that they’re malprogramed in terms of the way the receptors are working. And it involves at least estrogen and progesterone and probably others like melatonin. It gets very complex. So these hormones are very involved in multi-tasking. Like I mentioned, estrogen is very involved in immune system regulation, but so is progesterone. And they work with many signaling agents and growth factors. So it’s incredibly complex the way this whole thing works. But it all relies on the proper programing of the receptors so that when the hormones arrive in the receptor, the right thing happens. So hormones are signaling agents. They tell the cell what to do. Depending on how it reacts, it can make a protein, it can make a certain kind of enzyme. And so it all correlates and it’s very finely tuned.

So if you have endocrine disruptors that are in the mother and it gets into the fetus during the developmental time, when these receptors for estrogen and progesterone are actually developing, then you can have malprograming from the get go. And then it’s also been shown-

Dr. Weitz:            Can you mention a few of these endocrine disrupting substances?

Dr. Gersh:           They’re everywhere. So there’s been a lot of research on the organophosphates that are in pesticides and the phthalates that are in scents and plastics like vinyl and such. And then the bisphenol A’s and the bisphenol S’s that are in cash register receipts. And we would put them in children’s mouths for dental sealants and they’re in a lot of different plastics. That’s why you don’t want to heat things in the microwave in these hard plastics because it gets released. And water bottles-

Dr. Weitz:            By the way, even if it says BPA free, still don’t trust it. Because what they do is they take the BPA out and they put BPS in which just isn’t on the radar yet and probably soon will be as an endocrine disruptor.

Dr. Gersh:           Oh, it is. Right. And then there are these other things that are banned but they’re still out there. And in some countries they’re not banned and they’re like the aromatic hydrocarbons like dioxin. And these have enormously long half lives. They’ll live for at least a dozen years before the body can excrete them. And they are concentrated in fat tissue. And these things stay in the body for huge amounts of time. So we are inundated and it turns out that depending on the dose and the timing in pregnancy and also in the infant after birth and even around the time of puberty, all of these can combine to alter in every which way the way that these hormones work. So there’s been a lot of focus on the receptors, but it also … It’s more complex than that. It all involves the production, the dissemination, the excretion, so basically every facet that can be involved with these hormones is impacted by these endocrine disruptors.

So they are chemicals that work in the body to mimic hormones, but they’re not hormones.  But they interfere with the development in the embryo, in the fetus. And it changes what are called the genetic expression. What we call epigenetics. I’m sure you probably talked about that. And this thing that is so frightening is that it can last for generations. That it alters the way that genes work and then it gets passed down. So even if, say, a future mother then has a very careful lifestyle and somehow avoids as many of these endocrine disruptors as possible, she may be genetically programmed to actually have a baby who has malfunctioning of the receptors. And she didn’t … It wasn’t even from her. It was from her grandmother. So these things are now getting passed on and the human evolution maybe really being altered by these chemical endocrine disruptors.

And the thing that is so disturbing is how little press this is getting. That’s why I’m so excited that you are allowing me to talk about it. I’m sure you talk about it all the time. I hate to use these words. It sounds so ominous. But I kinda say we live in poison world because we do. Because we’re just eating things and we have all these pesticides, and herbicides, and chemicals, and plastics, and we now know that things can off gas from the rooms that you have. The indoor air pollution and the outdoor air pollution. And all of these things impact. And so it’s really creating a tremendous challenge for reproductive functions when the hormones that are so intricately involved in all these functions are not going to work properly. And endometriosis is like the perfect storm of all of this coming together to create really a massive negative impact on these women’s lives. It just breaks my heart that there’s so many women now that are having to live with this condition.

Dr. Weitz:            Yeah, I think it’s so important we talk about the importance of these endocrine disrupting substances. For one thing, a lot of these substances, they’re not even listed on the ingredients. So if you’re using any personal care product and it has the word perfume or fragrance, it most likely has phthalates in it and they’re not required to list that because it’s an inert ingredient. So this is something as consumers I think we need to speak out and maybe not now, but maybe some time in the future, we can demand that these substances at least be listed on the ingredients so we can avoid them. But-

Dr. Gersh:           Something I was gonna say exciting is that in California, the state senator Dianne Feinstein, has introduced a bill that hopefully will get passed. And it’s like … Step number one is just labeling and acknowledging what you’re actually putting into your products.  And so hopefully that will get passed.  It actually has bipartisan support. So at least step one may actually come to pass in the near future.

Dr. Weitz:            Good, good, good, good. Nice to hear that. Yeah. Because we need to … As a consumer if you’re trying to avoid these things, you at least need to know if they’re even there. In the meantime, I encourage people to go to the Environmental Working Group, ewg.org,  which is a great resource for listing toxins in various personal care and cleaning products.

I read an article about estrogen receptor beta as being a key factor in fueling endometriosis. Should women avoid estrogen receptor beta agonist like soy and are there any natural estrogen receptor antagonists that we can include to help counter some of this?

Dr. Gersh:           Well, those are great questions. And it is true that as part of this whole endocrine dysfunction and the way that the body is now being sort of redesigned, is that it turns out that there … Well there’s … As a background, there are three types of estrogen receptors. Alpha, and beta, and what are sometimes called GPERs (G protein-coupled receptors) or membrane receptors. And it turns out that different areas of the body may have a propensity of one type or another type. There are estrogen receptors on every type of immune cell. So the T cells, the B cells, and the mast cells, and all the different … Every single immune cell has these receptors. And in the uterus and in the pelvis, there is a lot of the beta receptor. The gut, by the way, is predominantly beta receptor.  And so it turns out that you have this imbalance of having too many receptors. And so you have this inappropriate estrogen sort of stimulation that occurs. That’s right. And they’re actually looking at what can you do. And it turns out that it may actually turn out … That soy, if it’s organic … It has to be organic, may actually be somewhat of a benefit because it’s very weak. And it can actually create these phytoestrogens that can circulate. And actually also work in the gut which we can talk about how all the microbiomes are disrupted including the gut and women with PCO … And with endometriosis, not PCOS. They actually also have that too. And it seems like that’s involved in everything now, right? The gut microbiome.

Dr. Weitz:            Absolutely.

Dr. Gersh:           And everything.

Dr. Weitz:            There’s no conversation in Functional Medicine that shouldn’t involve the gut at some point.

Dr. Gersh:           It is. It gets into endometriosis as well. So it may be that if you can fill these enormous numbers of extra beta receptors with something that’s really weak … So it’s filled with a weak estrogen instead of a more powerful estrogen, it would actually work something as a blocker. So you’re filling it with something weaker. So we need to have more data. The problem is that Big Pharma of course … And you mentioned that there’s a new drug that’s in the pipeline that may come out and may have some benefit as far as pain. But they’re not looking at things like eating soy. They’re not looking at eating flaxseeds. They’re not looking at the phytoestrogen. There’s no money in that.

Dr. Weitz:            No there’s no billion dollar drug coming out of flaxseeds.

Dr. Gersh:           Right. And funding for these kinds of little studies. And they’re so complex too because it’s very hard to have controls. But when you look at it at least theoretically and what we do know from other studies is that if you fill … And even like breast cancer. If you fill a receptor with something that’s weak, you’re going to block the effect of something strong coming along. So I do think … And we have to be careful because there’s so many crappy soy products. I’m sure you talk about that. Soy pretending to be chicken is not what we’re talking about. It has to be organic because so much of the soy is GMO. So it has to be organic soy, it has to be unprocessed, it can’t be fermented.  But I think there will be some definite benefit with that.  And in fact, as a functional medicine doctor, and I’m sure all of your listeners are into that world as well, we use food as medicine.

So there’s definitely a role for giving antioxidant containing foods. The polyphenols that work … In fact, one of the things that I really push of foods that have a lot of quercetin because we can’t … We don’t have the power yet to know how to reprogram hormone receptors. I wish I had that power to … We can’t go back. We talk about this with the brain a lot. You get one chance to make a good brain for a child. You don’t get, oh, let’s do a redo. And the same thing with hormone receptors. When these things happen and they get altered, we don’t know how to undo it. So we have to create what I call workarounds. We find other ways. Because the body has many different back roads to try to stabilize things. So if we have an out of control immune system because their receptors, remember, also are not functioning either because it’s not just in the pelvis, it’s the pelvis in the female with endometriosis becomes the focus because their everything is so totally out of whack because of the menstruation cycle and all that inflammatory tissue with the endometrial cells coming into the pelvis that’s creating all this havoc. This chaos.

But these same processes are occurring elsewhere in the body in the woman with PCO … I keep saying PCOS. In the women with endometriosis. So they have dysfunction in more sites. That’s where the focus is. And it’s really now a whole total body immune dysfunction. And it’s actually linked with autoimmunity as well because we know the immune system is one. So you can call it autoimmunity. But the new term that’s often used is autoinflammatory which actually makes more sense because it can manifest with allergies, with this type of crazy reaction in women with endometriosis and autoimmunity, they’re all linked. And of course, unfortunately, it also links with cancer. And women with endometriosis have significantly higher rates of certain types of cancers as well because you have to think of it as total body immune system dysfunction.

And we can do what we can do. But we can do a lot. We can use food as medicine like using organic types of whole soy and the polyphenols and the foods like apples and onions and such that have a lot of quercetin because quercetin is a mast cell stabilizer. And it turns out that the first responder of the immune system which is so heavily involved in this process in women with endometriosis are the mast cells. So they’re like the first responders. And if you can stabilize them so they are not so crazy and they’re doing … Because they put out all their inflammatory products. They’re the only cell in the body that has preformed tumor necrosis factor alpha. They’re just filled with all the inflammation to try to destroy an invading bacteria. But now they’re just exploding in the woman’s pelvis and they’re creating high levels of protein P, Substance P that is now producing more pain fibers.

So I’m sure that you’re aware because we were looking at the articles together that women with endometriosis have a different nerve innervation that they … And this all stimulates from the mast cells that explode and that creates more of the substance P which then stimulates more nerve production. It’s like the worst of all worlds. So you have all this inflammation and then you’re actually creating more nerve innervation to these endometrial implants so that you create more pain, so you’re getting this hyperesthesia. You’re getting more pain and more nerve fibers that are coming in that are all sensory. All about pain. So if we can just calm down those most cells, we can really have a big impact.

 So I use lots of antioxidants and these … All those different tools that we have to calm down the immune system. So I give quercetin and I’ll give green tea, and resveratrol and vitamin C.  All of these can really help to stabilize the immune system in women with endometriosis and as well when you help to get the gut healthier and you work on the gut health and the microbiome because they do have … We have studies now that show that women with endometriosis do have an altered gut microbiome. And also vaginal microbiome. It’s just sort of the uncharted territory that is going to be the next really area of explosive research is the role of the vaginal microbiome in women with all these different disorders including endometriosis which is altered.

Dr. Weitz:            The vaginome.

Dr. Gersh:           It’s everywhere. Yeah. And so we can do so much to improve the gut barrier health. So if we can reduce impairment of the gut barrier we call leaky gut, we can … Which also then creates more inflammation right because then you have these endotoxins or lipopolysaccharides that come out and then cause this immune system which is already in an up regulated state because of the way that the estrogen receptors are working on them. The mast cells are filled with estrogen receptor alpha. And it turns out when you have a lot of beta, it actually down regulates alpha. The whole thing is so complex, we’re just barely scratching the surface and understanding all that’s going on, but we do know that if you can improve gut health, if you can help restore the microbiome, if you can help to maintain gut barrier structure and reduce leaky gut, and reduce systemic inflammation, and calm down the response that’s so overwhelmingly inflammatory in the pelvis every time a woman has a menstrual cycle, then we can have so much benefit for these women.

And really, the whole mind body can make a lot of difference. We know that emotions and that our brain function can actually alter immune function. It’s so amazing. You can do … My personal favorite is guided imagery and you can envision in your mind how your brain can control and calm down these immune responses. And so the role for mind body and energy medicine in women with endometriosis is really huge. And happily, the mainstream medicine, which is usually entrenched in pharmaceuticals and surgical procedures … Which they still are by the way. But there is a group that have come out officially and said we need to rethink what we’re doing for women with endometriosis because it isn’t working. The conventional world of giving birth control pills is not stopping the progression. It usually has very minimal impact on the pain as well. Taking away women’s hormone is a horrible solution. Because hormones are not just about reproduction, hormones in women are about every function. It’s about cardiovascular health, and immune health, and brain health. So just taking away women’s hormones is a terrible solution and isn’t really solving the problem.

And this new pill that’s coming down the pipeline is sort of a variant of drugs that have been out for a while, which basically is to completely shut down the production of hormones so that you have no estrogen. And it starts at the level of the brain. So it just shuts down the brain stimulus to the pituitary. So it’s all shut down. So you don’t make any estrogen. And this drug, instead of being a shot, like the former drugs, like the depo lupron. Instead it’s a pill and it can apparently be more titrated so that instead of it being a total shut off of hormones, it’s gonna be a partial shut off. But as we mentioned, it’s not just about having estrogen, it’s about having this beautiful rhythm because you need to have the lows and you need to have the highs. You need to have that spike of estrogen in order to have that whole antiinflammatory effect. And if you simply have a low but static level, you’re gonna have chronic inflammation if you have chronic low levels of estrogen. Or even if you have chronic moderate levels, you’re not gonna have the right effect. You need to have the right cycle but it’s a problem if you have too many cycles.

It’s definitely complex, but I welcome even pharmaceuticals that can help with symptoms because these women have so much suffering that even if we can help reduce their pain and we’re not really solving underlying problem, for some women, short-term, that could still be helpful. We have to think about the suffering too, as well as the underlying cause sometimes.

Dr. Weitz:            Great. I only have about 100 questions after this discussion.

Dr. Gersh:           It’s so complex. Yeah.

Dr. Weitz:            I just want to mention quickly, I don’t know if you ever use detox programs. But since we’re talking about toxins-

Dr. Gersh:           Oh, yes.

Dr. Weitz:            Yeah. Is there a benefit to doing a liver detox, or an estrogen detox, or some sort of a detox program to decrease some of that burden in our body of some of these stored endocrine disrupting substances?

Dr. Gersh:           Well, we definitely … I always include that. Of course like so many things that we do, we don’t have hardcore published data on a lot of these things. But in practical use, what we really need to do is have proper metabolism of estrogen as well. It turns out that estrogen metabolites are so key to actually a lot of functions. So the estrogen metabolites production begins in the liver. So estrogen has to be detoxified, it starts off by going through the liver where it goes through the first phases, phase one, phase two, until you have glucuronidation and all these different processes. Sulfations, all these different things … Methylation that can then create the first step of metabolites. And then it goes into the gut and the gut has its own set of bacteria. The estrabolome that actually work to further detoxify and create other metabolites. And these metabolites actually have action. They even have some of their own receptors that are separate from estrogen receptors. And they’re actually very key to function.

 And you can’t have any of this work properly if you don’t have a healthy liver. So absolutely, I start every one of my patients for just about everything with a four week detox. And I would, for a patient like this, I would definitely use something like DIM or indole 3-carbinol absolutely and use sulforaphane. We definitely want to have broccoli sprouts and all of that because we definitely need to have the estrogen that’s in the woman’s body to get properly detoxified, and eliminated, and have the right metabolites produce. Not the wrong metabolites. 

Dr. Weitz:            For those of us who don’t know about the metabolites, if you’ve gone to your doctor or you’re a doctor and you’re just measuring hormones through serum, you won’t know anything about these metabolites so you have to look at your hormones in urine to see how the estrogen is getting metabolized, what pathway. Do you use urine testing for hormones?

Dr. Gersh:           I’m looking at it more and more now because like you said, the first step may not be that, but that is part of the process in Functional Medicine is to understand these pathways which are totally ignored. We know that what’s going on with the metabolites really does matter. There’s … One of the metabolites which is 2-methoxyestradiol has been shown to be very, very critical for liver health. So it’s one of those feedback things that you make … The liver is involved in detoxifying. And one of the detoxification products which is a metabolite, which is 2-methoxyestradiol is a back key to keeping the liver healthy. And it also works to … They found … We don’t even know too much about it. But we know it helps to maintain liver health, it also maintains myocardial health.

Dr. Weitz:            Wow.

Dr. Gersh:           So it helps to maintain the actual muscle fibers of the heart to be healthy. But you need to have the liver working properly to make that one metabolite. And that’s just one of other metabolites that … And then of course like you mentioned, you can also make the wrong metabolites that can then be carcinogenic even. So it’s very very complex, but you can’t have anything work properly in the body if you don’t have that incredible organ, the liver, doing its job right.

Dr. Weitz:            Isn’t it amazing how the body works when it’s in balance and can function properly?

Dr. Gersh:           It is. And it’s so … The thing that Big Pharma has done and it has been such a big disservice is what I call the dumbing down of medicine. Telling doctors, “Here, they have these … You have this patient with these symptoms. Just give this drug and don’t even worry about how it works because somebody at the big pharmaceutical company took care of that for you.” When in reality, of course, the drugs are going to have tremendous amounts of collateral damage because you can’t alter one area and think you’re not altering others because it’s this incredible interrelationship of enzymes, and pathways, and hormones, and neurotransmitters, and everything. And how they interrelate. And we are not smart enough to go in there and alter one pathway and think you’re not gonna then imbalance all kinds of other pathways.

So we have to go back to basics and start with having a healthy gut, and healthy food, and healthy liver, and healthy environment in utero. And as an OBGYN, I talk over and over that you have to be healthy before you get pregnant. Because you’re impacting your child’s life and future generations because of the epigenetic modification. So we have a system where women have a lot of infertility now. It’s just such a high problem. A big problem, high percentage. 

Dr. Weitz:            By the way, men also.

Dr. Gersh:           Men. Oh yeah. Sperm counts are plummeting. It’s a huge problem. A lot of it is coming from things like phthalates. So you end up going to these fertility centers where they put everyone on fertility drugs and then they do in vitro fertilization. And they don’t even think is this really a problem because nature is saying, “This is an unhealthy couple.” This woman or this man, they shouldn’t really be making a baby because they’re not healthy. It’s like a clue. Fertility is a vital sign of health. If you’re infertile, it means something is wrong with you. Unless you just had your tubes tied, but other than that, there’s something really wrong and you need to go figure out what that is before you then trick a body into getting pregnant and then of course have lots of pregnancy complications and then have children who then have significant problems because we now know the children are very much the product of the environment that they are growing in, in every which way.

So we have to change the whole paradigm of how we consider fertility. We have to look at the health issues before we try to get people pregnant and not just trick the body into getting pregnant and then having all these repercussions down the line. So we just have to change the way we think about everything. And endometriosis is the perfect example of a medical condition that is so prevalent that is really the result of all these things that we have done wrong.

Dr. Weitz:            Yeah. You talk about the gut and one of the important things about the gut is that estrogen, after it’s metabolized, needs to get excreted. And if you’re constipated and you have gut problems, gut dysbiosis, that estrogen may not get excreted so it’ll just keep recirculating and causing more havoc.

Dr. Gersh:           That’s right. You want the perfect balance when people talk about the different enzymes that detoxify estrogen. They’re not good, they’re not bad. You just need the right amount like everything. They’re not evil enzymes. Beta-glucuronidase is not evil. You need it. Because it actually can help recycle estrogen and get more, especially in women in the menopause. But you don’t want it at the wrong amount. Everything is supposed to be in the right balance. And we live in a world that has become very imbalanced. So we’re struggling. All of us health care providers, we’re just struggling to try to help our patients get back in balance. And it is a challenge, but we can do so much good with all these different things that you’ve mentioned.

Dr. Weitz:            When you talk about the hormones and the importance for estrogen and progesterone, and all this and how all that serves a purpose, I think sometimes about hormone replacement therapy and the way sometimes it’s done is to give women an exact same level of estrogen every day for the rest of their life. And if all these fluctuations are so important, I wonder how beneficial that way of approaching it is.

Dr. Gersh:           You are so brilliant and you hit it right on the head. That is exactly what we’re doing and it is absolutely wrong. The reality is that there’s never a time in a woman’s existence when she has a static amount of estrogen. And of course, this also goes back to birth control pills which we can talk about another day which are … Actually, they are what they are. They’re endocrine disruptors and they create a static situation and that’s why they’re involved with a lot of metabolic problems including higher rates of breast cancer. And women in the menopause are not getting treated in a physiologic way. Estrogen, as I mentioned … Low levels have one effect. High levels have a different effect. And the body made this beautiful balance. And in fact, there’s now some data that the way that the estrogen ebbs and flows impacts dramatically the hormone receptors of other hormones and itself as well. So when you get the spike of estrogen that is right before ovulation in a normal cycle, that spike upregulates progesterone receptors, and testosterone, and thyroid so that they actually work better.

So if you live in a world where you have a static amount of estrogen and you’re never gonna have that upregulation of those hormone receptors, so those hormones may not work properly. And in fact, in women in menopause, for example, they may have physiologic or so called normal levels of thyroid circulating. But they have all the symptoms of being hypothyroid. And of course the doctor says, “Oh, another crazy woman. She says she has low thyroid and all the symptoms and I measured her thyroid and it’s perfect.” Well it doesn’t matter what you have if it doesn’t get in the receptor and work. And if you have static low levels of estrogen … Either if you’re taking a little bit or you’re not having any, then those thyroid receptors are not gonna be working properly. And neither will the testosterone, neither will the progesterone receptors. And none of them are gonna be working properly.

And as … And unfortunately like in women with endometriosis, their progesterone receptors are completely malfunctioning. They don’t receive … They have them, but they don’t receive the progesterone, so you don’t get the desired effect. The same thing can happen if you don’t have progesterone or you have little bits or if the receptors don’t work. So it’s not just about how much is in your body. It’s how the receptors are actually working with it. And you need to have that beautiful up and down of the estrogen with the menstrual cycle in order for all these hormone receptors to do their job properly.

And it gets even more complex because there are tumor suppressor genes that are actually activated when you get that estrogen spike. And then that actually sets the tone for what happens as far as program cell suicide. To kill off … Our body’s ability to kill off the incipient or growing cancer cells. And there’s actually some data that when the menstrual cycle happens, which is sort of a purging of these cells from the uterine lining, that a similar thing happens in a normal menstrual cycle in the breast. And that crappy pre-cancerous cells of the breast are actually creating programed cell suicide or apoptosis and they’re killing themselves off. So nature actually has it’s own tools to actually eliminate breast cancer cells in a normal cycling woman.

But of course, none of that is going to come into play if you have a static situation. So I really think we need … And I’m actually supporting a new nonprofit that’s actually trying to create … To raise funds to do research on doing hormone research on women in menopause where you actually try to do a more physiologic replacement to mimic the ups and downs because we need data. We absolutely need data. Because all I can say is what we’re doing is not physiologic and it can’t be the best. It cannot be the best. Is it better than nothing? I think it’s definitely better than nothing. But I know it’s not best.

Dr. Weitz:            Right. One more quick question because I know you have to get to your practice. Is … You touched on some natural substances that can be helpful for women with endometriosis and you talked about antioxidants, and phytonutrients. And a couple that I saw in some articles, one was pycnogenol which is for pine bark extract at 30 milligrams twice a day. I saw melatonin and any inflammatory substances like quercumin, boswellia, fish oil, and there was also discussion about NAC which seems to be one of the most amazing nutritional supplements for almost anything.

Dr. Gersh:           Yeah, actually pretty much all those are wonderful antioxidants and antiinflammatory agents. Quercumin is actually very important. I’m glad you mentioned that. Specifically quercumin for women with endometriosis. Because it seems to act as a blocker of the enzyme aromatase. So you actually can have some blockage of this really excessive amount of estrogen that’s produced locally. And because of all this … What’s going on in the pelvis of women with endometriosis, they actually can produce high amounts of estrogen. So remember, high amounts of estrogen in a normal woman, what did I tell you? They’re antiinflammatory, right? So high levels of estrogen actually is antiinflammatory. So what happens in the pelvis, there’s so much inflammation in the woman with endometriosis, that her body locally produces more estrogen. There’s a lot of areas of the body that have the enzyme aromatase and can produce their own local estrogen. We call that a paracrine effect as opposed to an endocrine where you make the hormone where it circulates through the body. In these cases, it’s made and used locally. So the pelvis is one of those places that it can make its own estrogen.

So the body is making humongous amounts of estrogen trying to put out this fire. All this … To reduce the inflammation. But it doesn’t work. Because the hormone receptors aren’t working properly and you’re actually creating more havoc because the alpha, the beta, none of this is working properly. So you have this explosion of inflammation and estrogen production. Quercumin can actually help block the enzyme aromatase. So you’ll make less of this estrogen that you don’t want in this case. You want to drop the estrogen. And that’s the same thing with breast cancer. Where the breast can also make it’s own estrogen, it has … And that’s why dense breasts are a warning sign because it means the breast is inflamed and it’s making a lot of estrogen. And estrogen is all about healing. It’s about proliferation, it’s about growth. But when you have an abnormal environment whether it’s cancer or endometriosis, you’re taking what is a good thing and you’re sort of turning it on it’s head and it’s actually creating havoc instead of healing which is what its original plan and goal is. So quercumin is an absolute must in women with endometriosis. Or boswellia, wonderful- I’m sorry.

Dr. Weitz:            Do you have a recommended dosage for quercumin for the average woman?

Dr. Gersh:           Well, why don’t you … I would say start with 500 milligrams three times a day. And you definitely want one that’s absorbed. So quercumin or turmeric. If you take it in one format, it’s very good for the gut. Which is I’m totally in favor of. But if you wanna make it a systemic treatment, you have to make sure that it’s on the absorbable form. So that you get it in systemically. So that is a very important thing. And NAC, like you mentioned, it’s a precursor to glutathione, the master antioxidant, detoxifier of the body. But it has amazing functions in its own right. So NAC is part of many detoxification protocols. So I use it all the time.

And melatonin is essentially an estrogen related hormone. And people don’t realize that estrogen is actually in control of the production of serotonin. There are actually serotonin neurons and they’re actually controlled by estrogen. So when you don’t have enough estrogen or it’s not properly received, you will not make serotonin properly. Which is one of the reasons why women in menopause have more depression and sleep problems. And serotonin goes on to make melatonin. So you’ll have this problem as I mentioned in the beginning. Melatonin has many functions in the body and it’s one of the most potent nonrecyclable antioxidants. So melatonin is another very wonderful tool for women with endometriosis to use.

Dr. Weitz:            Awesome. Awesome. Thank you so much, Dr. Gersh. You’ve given us so much important information and some great tools to help with women with endometriosis, both for patients and also for practitioners to use. For patients and practitioners who’d like to get a hold of you, what’s the best way for them to contact you?

Dr. Gersh:           Well, we see patients in the office. So you can certainly give us a call. I have an office website-

Dr. Weitz:            What’s your phone number by the way?

Dr. Gersh:           Oh. Our phone number is 949-753-7475.

Dr. Weitz:            Great. And that’s in Irvine, California?

Dr. Gersh:           And we’re in Irvine. Right, right. Central Orange County. In Irvine. And our website is www.integrativemgi.com. That’s for … The name of the group is the Integrative Medical Group of Irvine. So it’s integrativemgi.com.

Dr. Weitz:            Great. Excellent. Thank you so much for spending this time with us, Dr. Gersh. It was very [crosstalk 00:46:38]

Dr. Gersh:           Oh, it’s my pleasure. And if people … If you live far away, you can’t come, if you go to the website, you can also sign up and we’ll send you our regular newsletters as well.

Dr. Weitz:            Okay. That’s great. Excellent. Talk to you soon.

Dr. Gersh:           Oh, bye. Have a wonderful day.

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