The Endometriosis Series: The Specialist with Emma Sutherland and Dr. Andrew Orr

The Endometriosis Series: The Specialist with Emma Sutherland and Dr. Andrew Orr

Dr. Andrew Orr, reproductive and women’s health medicine specialist, Chinese Medicine doctor and Naturopath rounds up the final part of our endometriosis series as we look at endometriosis from the perspective of the clinical specialist.

With our ambassador, Emma Sutherland, Andrew describes the challenges in obtaining an endometriosis diagnosis for patients, and provides us with the clinical signs he attributes to endometriosis.

Andrew describes the challenges endometriosis patients may experience in finding appropriate pain relief, and of the many causes of pelvic pain often attributed to endometriosis. We hear Andrew’s preferred holistic strategies to support an endometriosis patient, and of the importance of a collaborative care model to support the complexity and individualistic nature of endometriosis.

Covered in this episode

[00:09] Welcoming Dr. Andrew Orr
[02:10] What is endometriosis and its key drivers
[03:35] Current methods of diagnosing endometriosis
[05:43] Can endometriosis be diagnosed via ultrasound?
[07:31] Key clinical symptoms of endometriosis
[10:01] Elevated CA125 can be a potential blood marker for endometriosis
[11:42] How the pelvic floor can contribute to pain
[13:50] Medical treatment options for endometriosis
[18:58] Referring to an advanced trained surgeon
[21:12] Addressing the microbiome and the gut-brain axis
[24:45] Diet basics to reduce endometriosis symptoms
[27:05] Using synergistic herbal medicines
[28:50] Modulating oestrogen levels by using cannabis
[34:05] Supporting the endometriosis patient with a well rounded team
[35:56] Summarising the clinical pearls from today’s episode
[37:00] The importance of hydration and electrolytes
[38:03] Thanking Andrew and final remarks

Key takeaways

Women with endometriosis have been identified as having high levels of inflammatory phenotypes, with endometriosis having the ability to spread endometrial-like tissue throughout the body.
Diagnosis of endometriosis is currently through laparoscopy or surgical intervention. Clinical diagnosis suggesting a high likelihood of endometriosis is based on the following symptoms:
- Menorrhagia
- Pain with intercourse
- Ovulation pain
- Irritable Bowel Syndrome-like symptoms
- Recurrent urinary tract infections
- Chronic fatigue
- Pain on bowel movement
- Darkened, clotted menstrual blood
- History of infertility
- A CA125 results above the reference range may be indicative
Deep endometriosis ultrasound cannot diagnose superficial endometriosis, with many people having superficial endometriosis. Not all sonographers can identify endometriosis via ultrasound, a gynaecological sonographer or radiologist is required.
Pelvic pain is suggestive of endometriosis, which can also be attributed to a hypertonic pelvic floor, back pain, rectal pressure, bladder and bowel issues and lower abdominal pain.
Treatment for endometriosis differs depending on whether the patient is trying to conceive or to manage the pain and should be individualised to the patient and their symptoms. Holistic treatment involves:
- Microbiome support - pre and probiotics
- Dietary assessment - FODMAP and glycaemic control
- Water and electrolytes (yes – we find out why these are important!)
- Exercise
- Herbs and nutritional supplementation
- Pain management
- Psychological support and stress reduction
Medical treatment includes progestins, oral contraceptive pill, GnRH analogues and opioids for pain management.
A collaborative care model is required to support the endometriosis patient with a multi-modality approach.

Research and resources discussed in this episode

Dr. Andrew Orr

Research: 'Deep immunophenotyping reveals endometriosis is marked by dysregulation of the mononuclear phagocytic system in endometrium and peripheral blood' BMC Med. 2022

Article: 'You no longer need surgery to be diagnosed with endometriosis. Here's what's changed' The Conversation, 2022

Pelvic Pain Foundation of Australia

Research: 'Chronic opioid use and complication risks in women with endometriosis: A cohort study in US administrative claims' Pharmacoepidemiol Drug Saf. 2021

Endometriosis Australia

Research: 'Cannabis Use for Endometriosis: Clinical and Legal Challenges in Australia and New Zealand' Cannabis Cannabinoid Res. 2022

Dr. Phillip Hall

Insight Timer

Listen to the other two episodes in this series

Transcript

Emma: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based integrative, functional, and complementary medicine. FX Medicine acknowledges the traditional owners of country throughout Australia. We pay our respects to elders, past and present.

I'm Emma Sutherland. And joining us on the line today is Dr. Andrew Orr. Andrew is a reproductive medicine and women's health medicine specialist, and he has a master's degree in both these specialties. He's also a doctor of Traditional Chinese Medicine, a Naturopath, and he runs a busy practice in Brisbane. Andrew uses his clinical experience and research to bring the best possible treatments via an integrative medicine approach.

Today is part of our series on endometriosis and Andrew is joining with us to share insights from his perspective as an experienced clinician. Welcome to FX Medicine, Andrew. Thanks so much for being with us today.

Andrew: Thank you for having me. I'm looking forward to it.

Emma: Me too. Me too. Now, from our previous podcasts in this series, we've discovered that endometriosis affects one in nine women, and it takes an average of six-and-a-half years for a woman to be diagnosed. And endometriosis is often unrecognised and misdiagnosed. But to get us started, Andrew, what sparked your passion for treating endometriosis?

Andrew: I think my passion started with family members with the disease. And my two daughters also have endo. But I've had loved ones earlier on, and I suppose just seeing people come through the clinic, that they really aren't being heard or you, like you said, it often takes six or more years. Some people never get diagnosed. So, it was something I felt really passionate about to get out there and learn more about, but also then start advocating for women as well.

Emma: Yeah, well, I'm sure there's many women out there that are very grateful that you have chosen this path. So let's dive into it. A 2022 paper looking at immune cell phenotypes found that women with endometriosis had higher levels of inflammatory phenotypes, as well as decreased activity of endometrial macrophages. I would love to hear your insight into what is endometriosis and what are its key drivers?

Andrew: That's the million-dollar question, isn't it? What is endometriosis? And one of the things that I say to people is that the best way to describe endometriosis is it is like a cancer but it's not cancer. And there has been some recent research to show that there are similarities between some of the biomarkers of ovarian cancers and endometriosis, but the way it behaves, how it can spread through the body definitely behaves like a cancer, doesn't it? And then it is endometrial-like tissue, but it's not the endometrium. So, what is it? And it's like, well, what happens to it? How does it get there? And I mean, there's suggestions that every woman actually has the predisposition to have endo. It's just whether it expresses in the body through epigenetics or not. So that's the million-dollar question. What is it?

Emma: Yeah, I know it is, and it baffles all of us. And I'm hoping today that we can tease apart a lot of this and provide some great insights to our audience, myself included in that. And I was reading a recent article written by Dr. Mike Armour, who suggested that surgery shouldn't be used as a diagnostic test and that endometriosis should be more of a clinical diagnosis. I mean, currently, how is endometriosis diagnosed and how can this be improved?

Andrew: Well, currently, the definitive diagnosis is a laparoscopy or surgical intervention because some people, they are discovered accidentally through other surgical techniques or open surgery.

Emma: True.

Andrew: Yeah, and we know that it has been found in girls as young as five years old, so accidentally again. But where I think Mike was getting to, is that sometimes we place so much precedence on surgical interventions and forget about the clinical diagnosis. And let's face it, we can all diagnose endometriosis. There are clear-cut signs and symptoms that will suggest someone has like a 99% chance that they have endometriosis, and then, the surgical intervention is the definitive diagnosis. But what if someone can't afford that surgical intervention?

Emma: Oh, exactly.

Andrew: So you have to rely on your clinical skills, and this is what I say to practitioners is that if you have those diagnostics and differential diagnosis, and your pathological sieve, and you work backwards and down and go, "Okay, this person's got this symptom. She's got painful periods, pain with intercourse, ovulation pain, IBS-like symptoms, recurrent UTIs, chronic fatigue, pain on bowel movement, there's a high likelihood that that person probably has endometriosis." But we do need to do something more in the way of diagnosis that isn't so invasive but that's yet to come.

Emma: I mean, can you talk us through? Because there's a lot of talk around the deep endometriosis ultrasound, and I'd love to hear your thoughts on the pros and cons for our patients of this.

Andrew: Yeah, look, we've talked about imaging, and, I mean, imaging definitely cannot diagnose superficial endometriosis and most people with endometriosis these days have superficial endometriosis, not so much the deep infiltrating. But good radiology imaging can diagnose deep infiltrating endometriosis, but it all depends on the user. And this is the problem, because every radiology department or radiology place doesn't have a gynaecological radiologist or a gynaecological sonographer. And a good gynaecological sonographer or radio sonographer will be able to diagnose deep-infiltrating endometriosis. But general radiology, general sonographers just used to seeing broken limbs and bits and pieces, they'll will miss it. So in Australia, I understand we've probably only got 20 to 30 good gynaecological radiologists or sonographers. Yeah, so not many.

Emma: No, it isn't many. And I know in Sydney, there's Omnicare. They seem to do a good job. They're very specialised in this. But you're right, the value of the result on the test comes down to the skill of the sonographer, ultimately.

Andrew: It does. But I think the hard thing is when we start mentioning that imaging can diagnose endometriosis, then people cherry-pick and then think that all imaging can diagnose endo, and it just doesn't.

Emma: Yeah, okay. All right. That's a really good point. And you mentioned a couple of them before, but for you, what are the clinical white flags that make your brain immediately think, "Okay, it looks like we might have endometriosis here?"

Andrew: I think having part of the TCM background helps with a little bit of that diagnostics, and that sort of pathological, like the differential diagnosis. So when someone has period pain, darkened, clotted menstrual blood is another one, which a lot of people don't look for. That's that classic blood stagnation in TCM.

Emma: Yes, of course.

Andrew: And then going to all the bowel stuff, because if a woman comes in, or a person with female reproductive parts comes in, and says to me, "I've got IBS and I've been diagnosed with IBS," I'll automatically think endometriosis, because a lot of people will first go on about bowel complaints or digestive complaints. So that's another thing to look for.
But we know that a significant portion of women with endometriosis are asymptomatic too. So that makes it really hard for those ones. And that's when you would look at some person with long-term infertility that wasn't conceiving, everything you're doing is not working, then go on and have a look for and look for it. We know that, like I said, 50% of women on laparoscope will have endometriosis.

Emma: Yeah, that's a lot, isn't it?

Andrew: It's a lot. This is where this one in nine women having endometriosis, you have to question it a little bit because they are only the ones that are diagnosed. So is it wider spread than that?

Emma: Ultimately, I think absolutely, it's more widespread. And even after 20 years in clinic myself, I still can't pick it. I'll have a patient that will come back from the laparoscopy with zero symptoms whatsoever, and be told that she has stage 4 endo. I mean, it's such a confusing disease as a clinician.

Andrew: It is. It is. And that's where I think looking at, say, someone that did come into clinic, and say they didn't have time, but they had clotted menstrual blood and dark stagnation there, that's a key symptom.

Emma: Oh, and I love that. Let me press pause on that. For all the clinicians out there, that was a very, very good clinical pearl, the dark-clotted bleed. I think that's fantastic.

But, Andrew, are there blood markers that you do use that you think could provide clues about the possible presence of endometriosis? I mean, is there any that you value at all?

Andrew: Yeah, I still use... Whilst CA125 isn't a reliable marker — even for cancer, it's not a reliable marker — a low high can still be indicative that endometriosis might be present. So if all the signs and symptoms are there, and then all of a sudden a high CA125 comes up, you're like, "Aha," or say someone that was asymptomatic, and then that high CA125 comes up, you're like, "Hmm, okay, that's interesting. And then it might lead to questions."

Emma: Yeah, but what kind of numbers like when you say high, you're talking what kind of number?

Andrew: A low high, just in reference. So, sometimes you might see someone just outside the reference markers. And this is the hard thing too. Every pathology lab...

Emma: True. True.

Andrew: ...will have a different set of reference points. So, often when a practitioner says, "What's the reference I should...?" Okay, have a look at what your pathology lab is in, and if it's outside that or just outside that, it could be an indicator that they do have endometriosis.

Emma: Yeah. Okay. So if they have a slightly upper-end level of CA125, and they're also getting dark clotted bleeds, then for you, it's like, "Okay, bingo. There is something here that we need to look at."

Andrew: Definitely. And especially if they have the bowel. Like someone says to me, "IBS," I'm like, "Yeah, okay. Let's go and have a look at this.”

Emma: Yeah, interesting. So pelvic pain is the topic of a government-funded national program in schools and is being rolled out by the Pelvic Pain Foundation of Australia to raise awareness of this issue. In clinic, it's really common for a young girl or woman to say she's experiencing pelvic pain. I'd love to hear how do you view pelvic pain.

Andrew: Well, I probably don't know many women with endometriosis that don't have pelvic pain. It's interesting you brought this up because it's a topic that I've been discussing a lot lately. A lot of the time when they get the diagnosis for endometriosis, everything gets blamed on endo.

Emma: True.

Andrew: But the reality is that a lot of these people actually have chronic pelvic pain. It's not the endometriosis. It's the pelvic floor firing off and a lot of them have a hypertonic pelvic floor. And because the pelvic floor acts like a sling, so they get the back pain. They often get rectal pressure kind of feeling or they might get bladder issues. They have trouble moving their bowel or it could alternate. And then they have the lower abdominal pain, which can then radiate as well. So, it's good to focus on things like pelvic pain, but they also need to focus on what's the cause of that pelvic pain, too.

Emma: Yes, it's a really good point that it is not just one-dimensional. It can be many drivers resulting in that pelvic pain.

Andrew: Absolutely. And a lot of young women these days will have a hypertonic pelvic floor because they're usually a little bit more sedentary and then they’ll intermittent exercise, which is then tightening the pelvic floor, or the go-to for most women when you hear the word pelvic floor is like, "Oh, tighten, tighten, tighten." But that could be actually counterintuitive in making things worse.

Emma: Yes, yes, that's right. Good pelvic floor physio needs to come into play.

Andrew: Yeah, absolutely, a good pelvic floor physio, which every woman with endometriosis will need as well.

Emma: Now, endometriosis can be treated in several ways, depending on the severity of the case. It does tend to be driven by whether the primary goal is to become pregnant or to treat the pain. I want us to deep dive into treatment, both medical and holistic. The most recent data I could find states that there were around 34,200 endometriosis-related hospitalisations in 2017. First of all, can you talk us through the medical treatment options for endometriosis?

Andrew: Yeah, well, it's varied. And I think this is probably one of the biggest issues, and I think everyone needs to know, is that while endometriosis is a disease that is widespread, it still needs individualised care, because every woman with endometriosis will have individualised symptoms. Sure, they have endo, but some women don't have any symptoms at all. Some women get endo belly, some don't. So that's where your treatments will come into.

But the broad spectrum stuff on the medical perspective is progestins, because we know it's oestrogen-driven, and even small amounts of oestrogen drive it. But progestins are the mainstay to help with slowing the progression of the disease down. Obviously, they do use the oral contraceptive pill, but, personally I think the danger with a combined pill, even though some women do respond to it, is that it does have that oestrogenic response in it, which while you could be helping on one front, you could be seeding it and fuelling it on another.

Emma: Yeah, exactly. It's a little bit of a slippery slope. I agree.

Andrew: And then we've got our GnRH analogues, you know, like Zoladex and other things like that that can help, and then right down to pain management, which, often are opioids. And considering the opioid crisis that we do have in Australia, it's a catch-22. We've taken some opioids off the chemists shelves, but I think it's hurting on two fronts.

Emma: Yeah. Look, in researching for this episode, I actually came across a fascinating 2021 paper, I think it was, yeah, discussing chronic opioid use in women with endometriosis. And the conclusion stated that women with endometriosis had four times higher risk of chronic opioid use, compared to women without endometriosis. And I really want to just dive into this a little because I think it's something that isn't talked about, isn't highlighted, and we need to have it on our radar.

Andrew: We do. We do need to have it on our radar, because we will see some women that it's gone some way or the other way where women that need the pain medicines aren't being given them, but at the same time, some are overprescribed them, and then some will present to emergency department knowing that they will get a big hit of opioids.

Emma: I mean, you can imagine the level of pain and anguish, and I can't even put words to it that would drive a woman to do that.

Andrew: Yeah. Exactly. It's a real hard one, isn't it?

Emma: Yeah.

Andrew: When you're in chronic pain, you don't want someone to be in pain. But then, let's have a look at any drug. You've got a withdrawal symptom with that too, that could be actually making their pain worse. And it's not until you take those pain medications away that you can actually see how much pain they're in, because the opiates could be making them worse through that constant high and then low, and then high and low, withdrawing.

Emma: Yeah, but who's managing this, Andrew? I mean, this is where it gets really muddy. Who's managing this situation? So, when we did the episode with Natarsha, our patient, she really emphasised that the need for a care team around her was part of her really working with her endometriosis in a way that was good. But many women are not even aware. They don't know who to talk to. They don't understand how to gather a care team. I mean, for us, as practitioners, we really need to be supporting and facilitating women to do this.

Andrew: Oh, absolutely. And it's one of the biggest things, I'm really, really big on is, that no one person alone can do it, and no one can do it on their own either. And no practitioner has all the skills. A woman with endometriosis needs a team. They need a multi-modality approach, not just one medical approach, because we know that, despite the best medical interventions, women are still in pain, they still have symptoms. So we need to look at it on a holistic, individualised approach. And you need that care team there. You really do, and you can't do it on your own. You can't.

Emma: Talking about specialised people, I know you're very particular with this. And I think this is important, what is an advanced trained surgeon? And how do we actually find one to refer to, or how do we refer to one? Because I think if a woman's going down the medical route, and she is going to have surgery, this information is critical.

Andrew: It is critical and this is the biggest problem. Advanced trained surgeons cannot actually under the APRA, and under health regulations, they aren't allowed to advertise that they're an advanced trained surgeon due to anti-competitive laws. That's the biggest horrible thing. But you can ring the Royal College of Surgeons and find out who they are. So, there is a difference between an advanced trained surgeon and someone that's done advanced training, because advanced training could just mean a weekend course in advanced laparoscopic surgery, whereas an advanced trained surgeon has done their normal surgical training plus another five or so years on top of that, so they're the best of the best.

They also have to maintain a certain number of surgeries a year, usually around about 100 or more, to maintain their status. So that's another thing you need to know. And they're the top of the field. A good surgeon I know who is an advanced trained surgeon said, "Look, in 52 surgeons this year, how many do you think will go on to become an advanced trained surgeon?" I said, "I have no idea." He said two.

Emma: Wow.

Andrew: So, this is the problem when people are saying, "Oh, we need more We need more." We do. But getting them to that level, it takes a lot of time. Do your homework. And people like Endometriosis Australia will know who they are. Practitioners like myself, if they want to reach out, I can tell you who they are, and you get to know after a while. But it should be more readily available, but due to laws, it's not.

Emma: Yeah, it's a really good understanding of the difference there between it and how highly refined their skill sets are, which is what we want for our patients.

And because it's got so many drivers, endometriosis really lends itself to being treated holistically with diet and lifestyle, and effective therapies. I mean, I do feel like it is a perfect candidate for our kind of holistic treatment.

Andrew: Absolutely it is. And because it's not just about pain, it's not just about progestins. It's not just about surgery. We know that when they don't eat well, it makes it worse. When their microbiomes aren't great, it makes it worse, not only physical symptoms, but we know that gut-brain access and what that plays. And a lot of women with endometriosis either have some form of mood disorder, or anxiety, or something there as well.

Emma: Yeah. I want to look at holistic treatment for endometriosis. And what's your clinical approach to treating endometriosis? I mean, I've got to say, Andrew, I've got so many questions for you. We have so much to talk about. So I'm really hoping that I can pick your brains on all these things.

Andrew: You can pick my brains. And I'm glad you thought...because that's how we have to deal with things on that holistic front as well, because, like I said, we know that despite the best medical interventions, it's just not enough. So my go-to is, because I've got nutrition background and naturopathy, TCM background, I mix all of them together. But the first port of call for me is addressing the microbiome.

Emma: I did want to dive into this.

Andrew: Because if you address the microbiome, not only are you going to reduce the systemic inflammation in their body, you're going to help them, like I said, on a whole gut-brain front as well. So it's important. If someone said to me, "You can only use one medicine in your clinic for the rest of your life," I'd say pre- and probiotics.

Emma: Fantastic.

Andrew: Just give them pre- and probiotics.

Emma: Yes. I mean, that's the importance that you're placing on this whole driver of endometriosis. And what mechanisms do you think are at play with this?

Andrew: It's an interesting... I mean, all of us, we hear it around every so often, oh endometriosis, the suggestion it's an autoimmune disease, but it's autoimmune-like but it isn't an autoimmune disease, because it doesn't fit the classification of an autoimmune disease because it doesn't act upon itself. Whereas say, the thyroid, it produces autoantibodies, does act upon itself. And endometriosis, at this present time, doesn't have autoantibodies. That's not to say that we might not discover them in a year's time. But at this present time, it doesn't.

But it's an inflammatory state. It affects their bowel. I mean, you look at a woman with endometriosis as having an endo flare. They look like they're six to nine months pregnant. That's dysbiotic the bacteria play at its best. And then it's further inflammation, pelvic floor, the whole lot. And their stomachs, they will present to the ER. So you've got to clear that dysbiotic bacteria, lay down that foundation of prebiotics, fix the gut using things like glutamine, and things like that. And then use your strain-specific bacteria like the 299v's, like the plantarum, and then feed them with prebiotics, because you need those prebiotics. So that's your first port of call.

Emma: Yeah, the first one. Tell us more though. I want to hear more.

Andrew: Obviously, diet. Number one rule with anyone is diet. And reducing those high refined foods, so, it's not just a low GI diet, but some of them might need a modified FODMAP-y, primal-based diet, like a Mediterranean-style diet, if you really wanted the best sort of diet. But anything that's reducing sugar and refined carbohydrates is going to help them. I'm a little bit bigger on watch some legumes, because I know that some people, they'll eat lentils, chickpeas, and things like that thinking that they're good for them, and they'll just inflame them. But look at the individual and see.

But the wellness sort of pyramid should be there. The higher amounts of protein, the good fats, less refined carbohydrates, plenty of fresh veggies, water, electrolytes, electrolytes, electrolytes, electrolytes. And try and get them moving, some form of exercise, as well when they can, definitely. And then I use herbal medicines too, herbs as food.

Emma: Yeah. Any particulars that you like?

Andrew: M favourite herbs are definitely parsley.

Emma: Beautiful.

Andrew: It's a superfood. And then turmeric, if you grow your own turmeric and things, and gingers, you can't go past those. And even things like basil.

Emma: Yeah, and I think this whole food as medicine, we have to continually remind people to come back to that, and really think about the fact that it could be one small thing. You just start growing some parsley and adding it to your food once a day, because these things make a difference in the long-term.

Andrew: They do. And they're things that everyone, no matter where you live, you can grow those things on your balcony or in your yard. Yeah, I remember there was an ABC reporter a few years ago, she grew 70-something kilograms of vegetables on her little balcony somewhere in Sydney.

Emma: Incredible. Yeah, there you go. Everyone can do it.

And so when you're looking... If we zoom out, and we look at your holistic approach, your first focus is on working on the gut, clearing the gut out, calming things down with things like glutamine and strain-specific probiotics...

Andrew: Probiotics, yes.

Emma: Feeding them with some really good prebiotics, both sort of food and supplement-based ones, and moving their nutrition to more of a Mediterranean-style diet, and reducing sugar and adding in herbs as that food-as-medicine approach as well.

Andrew: Absolutely. And then using herbal medicines and formulas. I'm big on synergistics.

Emma: Okay, tell us more about that.

Andrew: Yeah, because I think a lot of practitioners don't understand is that when you start using single herb, it might have a certain property, but when you put it with another one or two herbs, it changes the whole properties altogether, and that can work in a synergy. And that synergistic approach is more what probably someone with endometriosis needs, because, one, they will need gut herbs. Oot that the whole focus should be on the gut by the way, because it's not just the gut, but then they'll need herbs that will help with the micro-circulation into the uterine lining, into the lower reproductive area. And then antispasmodics that help with pain and things like that.

So that's where I tend to use more the Chinese herbal medicines for gynaecology, because I find they work, dare I say, better than the naturopathic herbs. But then the naturopathic herbs will work better on another front. So it's marrying the two together.

Emma: Yeah, and you mentioned before oestrogen is one of the drivers. What do you do clinically to help modulate or alter those oestrogen levels?

Andrew: Well, this is where we can bring in herbs as well that can do that. And certain herbs will actually help with that. And then, we're just talking about food, like broccoli extract, and that will help. So there's all that. And then you can look at some of the bio-identical hormones and stuff that we see now that can be compounded are better because they are more like the body's own progesterone or oestrogen, so they work a lot better than the synthetics, in my opinion. And then now, I dare say it, cannabis.

Emma: Oh, good. Yes. I wanted to cover this. Yes. When I spoke to Professor John Wardle in that episode on the researched-based one, we did discuss it. And I came across a 2021 paper showing that 72% of Australian women with endometriosis have self-prescribed cannabis. So, the demand is there. But can you tell us about your clinical experience in this space? Because cannabis is not just cannabis, you know? It's not that simple.

Andrew: No, it's not. And look, one of the biggest things that we don't want women doing is smoking on any front, and that includes smoking cannabis. And a lot of people will mix tobacco and cannabis together to smoke it as well. So that's that other side of it.

But then, what people don't understand, it's not the THC that's acting on them. It's the actual cannabinoids. And the cannabinoids and the endocannabinoid system, it's amazing. And PEA has endocannabinoid pathway receptors. So, those two together are amazing to use, like PEA and CBD. But you have to reach an optimal dosing with it and that's what people don't understand.

So, women with endo will grab anywhere from anywhere, the CBD oil. And it could be made from a backyard Joe and it doesn't have that proper extraction process. They're not getting the cannabinoids that they need to in the right dosages, so this is the problem. So it needs to be in a prescription of about 120 milligrams per mL in that concentration. And I've found that about 0.25 of a mL twice a day is where they need to start off on. And then they can work up to 0.3 of a mL and then up to 0.35 of a mL. Because the smaller the doses, the better it works. And it can't just be taken one off, so you've got to reach that optimal dosage. And it might take a month. It might take two months for it to fully kick in and work, just like PEA does. So that's what practitioners need to know as well. It's not like taking an aspirin and 30 minutes later, it works.

Emma: Wouldn't it be nice? But that's a fantastic clinical insight around the cannabis, and the dosing, and the strength. I mean, that's really important. And obviously, we are referring to GPs for this because this is way beyond our scope of practice. How do you go with that process?

Andrew: Well, it's easy now. What one of my colleagues, Dr. Philip Hall, is actually doing, he's actually part of prescribing cannabis through his practice, but he actually works for one of the cannabis companies. And what people can do now is go directly through the companies. So they go onto a website, they fill out all their details. So just like you would if going into a GP's practice. They take down those details, and then they give it to a specific practitioner who will be a medical specialist. The medical specialist then calls them back, asks them a few questions, and then prescribes them the CBD. So there's a lot of those now.

Emma: Okay.

Andrew: Yeah, so it's a lot easier for natural medicine practitioners to get their patients to do this. And then to reorder it, they just download an app, because they filled out all their information already, and then they just reorder it via the app. And that’s it.

Emma: Yeah, that sounds quite amazing. Because it does worry me when patients come in and say that they're taking it and they've bought it online, and they really don't know much about it. And I spend hours researching what they're taking, in case there's interactions with what I'm giving. It's just a bit of a nightmare. So it's great to have a service like that that we can utilise. So thank you for sharing that with us.

Andrew: No problem. And they will screen for medicine interactions, before you even get it. But then the process to order it once you've done the initial paperwork, it's very easy.

Emma: Yeah, fantastic. Okay, that is beautiful.

We heard in our previous podcast on endometriosis from Natarsha, and she really emphasised the need for rest on all levels, including mental and sensory, which I thought was a great point. How do we as clinicians best support a woman emotionally and psychologically? I mean, we've talked about the importance of a care team, but when they're sitting in front of you what are some tips that you can share with us that you find work well?

Andrew: Well, obviously a good psychologist. Because I think when people think of a psychologist, they think just working with cognitive behavioural therapies and things like that. But there are some clinical psychologists that does just deal with pain and actually help work through mindfulness techniques, coping strategies, working through triggers, things like that, which will then reduce their pain.
Then there's apps like Insight Timer, you can download on your iPhone. Great app. You can set it to ping you a couple of times a day, ask you how you are. If you say you're stressed, you can chart and say, "Yes, I'm stressed," and it runs you through a few programs, things like that.

Herbs, obviously. There's wonderful herbs. Acupuncture is amazing for reducing, not only pain, which I use in my clinic for pelvic pain, for any forms of pain, but relaxing the patient. Getting them to play some nice music, sitting outside in the beautiful sunshine. You know, you can't beat that.

Emma: Yeah, that's true. Nature's antidepressant, isn't it?

Andrew: It is. And I don't know the exact stats, but we know that 97% of Australians are vitamin-D deficient, and I would generally say that most people with endometriosis would be vitamin D-deficient because they're not getting outside enough.

Emma: Yeah, really good point. And really good point. Oh, I've just loved these chat. I know we're going to have to wind it up. But are there any final clinical pearls you would like to share with us? You've given us a lot already, but I'm always going to push for a few more.

Andrew: The clinical pearls are that, again, that no one medicine can do it all. So you are going to have to work with a good team and that requires you meeting a good advanced trained surgeon, find a good pelvic floor specialist, find a good psychologist, find a good naturopath, nutritionist, acupuncturist, the whole lot. Work together. It's a must, and that's part of what I do in my practice.
Differential diagnosis, you've got to use differential diagnosis. Forget the pathology in this one. You're not going to see anything in blood work at all. You have to rely on your differential diagnosis. So, be confident in that.

Pre- and probiotics as I said. And water, plenty of water.

Emma: Yeah. You mentioned electrolytes, I'm just going to take you back there just for a minute. So, the role of electrolytes, what are they doing? Apart from the obvious, but what do you think that they're doing that makes the difference?

Andrew: I think most of us are probably dehydrated in a day. And if we're dehydrated, that leads to muscle cramps, spasms, all kinds of things, and we aren't drinking enough water, and we don't have enough of those essential minerals and elements in our system now. So, a good electrolyte daily to hydrate is going to make a world of a difference. And some of them even, you know, might even have some high-dose magnesium and stuff in them as well, which will help. But electrolytes, yeah, definitely, because water alone does not hydrate. It doesn't. Coconut water has electrolyte properties, but it's not a proper electrolyte. So get a proper electrolyte into it.

Emma: Yeah, fantastic. And easily done, and you will get good patient compliance with that. So I love that tip.

Andrew, thank you so much for joining us today. The key points I've taken are so many. I mean, the importance of holistic treatment, the urgency of early diagnosis and treatment, and the power of food as medicine. I mean, incredible. Thank you so much.

Andrew: It's my pleasure. We could talk for hours.

Emma: That we could. Thank you everyone for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the FX Medicine website, fxmedicine.com.au. I'm Emma Sutherland, thank you so much for joining us. We'll see you next time.

About Dr. Andrew Orr

Andrew Orr (DTCM, MRMed, MWHMed, Ba.Sc, Ba.HSc, AdvDipNut) is one of Australia’s leading healthcare practitioners, with over 20 years of experience in assisting Reproductive conditions,Women’s Health conditions, Pregnancy conditions and many other health complaints. Andrew has qualifications and degrees in medical science (MRMed & MWHM) and complementary medicines (Ba.Hsc, Adv Dip Nut, ND), & and uses a multi-modality approach to assist his patients. Dr Andrew Orr is Doctor of Traditional Chinese Medicine (DTCM/Registered TCM practitioner), Nutritionist and Complementary Medicine Practitioner.

Andrew and is also the owner/Director of his own practitioner only Herbal Medicine and Nutritional Supplement Company-ConceptShen Nutritional Medicine PTY LTD. He also runs a successful clinic practice in Brisbane and helps women and couples locally, interstate and from overseas. Andrew’s special interest is difficult fertility cases, Women’s Health conditions and Gynaecological/Reproductive conditions such as Endometriosis, Adenomyosis and PCOS. There isn’t much that he has not seen during his 20 plus years of practice, and he has seen the worst of the worst for many of the conditions he assists. Andrew draws upon his experience and qualifications in complementary medicine, medical science, reproductive medicine and women’s health medicine to assist with these conditions.

He cares about women having a voice for their health and wants to make sure we end the silence on disease states such as endometriosis. He actively gives his time to help in the education and awareness of Endometriosis, Adenomyosis and PCOS and many other women’s health and reproductive issues.

Andrew also travels to country lecturing to healthcare practitioners and the general public about fertility, women’s health and gynaecological issues and the importance of early intervention and treatment for all women and couples.

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