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Expanding Endometriosis Research with Dr Mike Armour

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Expanding Endometriosis Research with Dr Mike Armour

Everyday too many women are enduring chronic pelvic pain from menstruation and endometriosis.

What's more, sufferers often have to resist strong pain relief as it renders them unable to function in their occupation or to meet the needs of their family obligations.

It's clear that more options need to be explored and that begins largely, with more research and this is where Dr Mike Armour comes in. He joins us today to share an insight into his career and how his passion for gynaecology, pregnancy and fertility, and Traditional Chinese Medicine (TCM) research evolved.

Dr Armour takes us through some of the interesting findings from research so far, including the potential for cannabis, exercise, acupuncture and specific Chinese herbal medicines for managing this type of pain. 

Covered in this episode

[00:40] Introducing Dr Mike Armour
[01:38] Delving into Mike's career background
[07:21] How Mike became involved in Women's health research
[10:07] The challenges in delivering quality CM research?
[18:31] TCM/ Acupuncture: known mechanisms of action
[21:52] Quality and safety considerations in TCM
[25:41] Research giving insights into women with endometriosis and pelvic pain
[38:32] Accepted methods for screening for endometriosis
[40:06] Herbal medicines with promise


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

Joining us on the line today is Dr Mike Armour, who joined NICM in 2016 as a postdoctoral research fellow working in the area of women's health. Mike's background is a mixture of Western and Eastern medicine, having completed an honours degree in biomedicine before training as a traditional Chinese medicine practitioner. 

Mike's research areas include gynaecology, pregnancy and fertility, and traditional Chinese medicine. He's experienced in implementing research projects across international borders and has a specific interest in dysmenorrhoea and chronic pelvic pain. Welcome to FX Medicine, Mike, how are you?

Mike: I'm not too bad, Andrew, thanks. How are you?

Andrew: I'm good, thank you. I'm going to leave all of the Kiwi jokes out of our podcast.

Mike: Aw. That's very un-Australian of you. In fact, you're really letting the country down.

Andrew: So, with regards to the podcast topic, Research in Endometriosis, it's really making news at the moment, particularly I saw last night in the medical news. But first, I want to delve a little bit back into your history. You said that you did biomedical science, so biomed sci, and then TCM. Why search further than medicine?

Mike: Well, I really enjoy...So, I was a cardiovascular biophysicist, which sounds much smarter and more exciting than it actually was. And, look, it was great, I really enjoyed it. I really enjoyed being a physiologist and I was working for the medical school in Auckland and doing a lot of pre-clinical research in rats. And it was just...I guess it was...Well, it was actually a combination of things. I was quite...Yeah, I missed the human contact. Rats, very good research subjects, very compliant, not particularly great conversationalists.

What actually happened was I got a frozen shoulder. I'd been sitting in front of a computer a lot the way our very expensive and fancy microscope was set up. I was spending, obviously like a lot of researchers, you know, many hours a day in front of that and I got a frozen shoulder. And it was just driving me nuts, I couldn't sleep, it was hard to work. And so at that time, I was also living right next to the med school and walked down the road and into the city, and saw there was a Chinese medicine practitioner and acupuncturist there. And I thought, "Well, I'll give it a go. You know, I've got nothing to lose." I'd always been quite interested in, kind of, I guess, integrative medicine, alternative medicine, whatever you want to call it.

Anyway, I went in there and, you know, was an interesting experience because he spoke very little English and I speak still no Mandarin..

Andrew: Yep. 

Mike: And yeah, he basically just went to town on me. Acupuncture, cupping, heat packs, the works of, you know, kind of a traditional Chinese medicine practitioner, and after I came out and said, "Oh, that feels a lot better."

And I guess it got me at a time where I was just a bit...you know, I would like to say I was really missing that human contact, and so I decided to find out if I could study acupuncture and it turned out there was an acupuncture college very close to there. So I thought about it a lot and decided, yeah, you know, it was either that or, you know, like it had already been kind of decided that I'd start my PhD in physiology and then I thought, "Well, do I really want to spend years and years doing something when I already know that I'm not satisfied?" And so that's what happened. I told my supervisors, they were suitably...

Andrew: Unimpressed?

Mike: ...horrified. Yes. Unimpressed would probably be, you know, quite an understatement. Understandably, you know, physiologists, especially kind of biophysicists, it’s very quantitative, very data heavy, kind of, you know, science. And obviously, you know, the idea of someone leaving that to acupuncture was… just blew their mind. But you know, that was fine. So yeah, so then I left and decided to study Chinese medicine.

Andrew: And so when did you come across to Australia? What was the draw to Australia then?

Mike: Well, what happened was I obviously...While I was studying Chinese medicine, I still really enjoyed the research side of things. So I worked as a research assistant in a hospital while I was studying. And when I graduated, I went into clinical practice with a couple of my very, very good friends and really enjoyed that, but I was always really interested in research. I was still like, well, okay, this is good and we're getting these good results, but how do we know...you know, how do we know what's going on? How do we know what's working?

And so it just happened that another friend of mine, who's now Dr Debra Betts, mentioned to me that she was starting her PhD with a professor in Australia and, you know, why don't I kind of join the fun? And so I contacted Ms Caroline Smith and said, "You know, I live in New Zealand but I'd like to study, you know…" And she was like, "Yeah, if you can get a scholarship, come and talk to me again."

So, what happened was I did my PhD while I was living in New Zealand, but through an Australian university. So thank you Australian government for your very generous scholarship. And then when I finished, you know, I decided I wanted to pursue this. And it just so happened that the day after my graduation, a role opened up in my area at NICM

Andrew: Ahh. 

Mike: And so I interviewed for that and I was fortunate enough to get a position and obviously that required, you know, a jump across the ditch.

Andrew: For our international listeners, the ditch is the gap of ocean, the Tasman Sea, which divides Australia and New Zealand.

Mike: Yeah, where the land bridge used to be, but not as anymore.

Andrew: Not as anymore.

Mike: For the American listeners, yeah, we used to have a land bridge and would commute. At least that's what...I've met a few people who believe that. 

Andrew: Yeah. 

Mike: Anyway, my wife and I made the move in August 2016. So I've been here just over a couple of years.

Andrew: Got you. And what got you interested in women's health research, when, you're a man?

Mike: Yeah, this is always, you know, a good party conversation. It was really...well, it was actually a couple of things. 

At the very beginning of when I started studying acupuncture, I met my then girlfriend, now wife. And she had very, very bad period pain. And I was very...and I still am very, you know, I guess pro...you know, I think biomedicine, orthodox medicine, Western medicine, whatever term you want to call it, is fantastic. And so I said, "Well, don't worry, we'll go to the doctor and they'll be able to sort you out."

And so I went there, we went there together and, you know, there wasn't a lot of options that she was given. It was kind of the contraception pill which she was already on, and kind of nonsteroidal anti-inflammatories, ibuprofen, or a combination of ibuprofen and Panadol. And that was kind of it. And I was actually like, "Wow, that's a bit crap, isn't it really?" Like, I thought there'd be something more. And obviously, she's tried that and still really severe pain.

And so that just, I guess, that kind of lodged in my mind, and then when I was studying acupuncture, when I was a student clinician, if you ever want a thorough examination, go to a student, whether a student doctor or a student osteopath, an acupuncturist, anyone, we have to ask all the questions, even if they're unrelated. 

So, we'd often ask all women who came into the clinic whether it was anything to do with...you know, whether they had a sprained ankle, a sore back, headaches, you know, about their menstrual cycle. And what I was really surprised with was, you know, we'd say, "How's your menstrual cycle?" and they'd say, "Normal," and then we delve a bit deeper because we had to, otherwise our tutors would be, you know, rather displeased with us. And I was seeing all of these things, pain, irregularity, mood swings, I was...I don't know whether I'd class that as normal. 

And then in the course of treatment I'd often...you know, we'd include some points, which an acupuncture might be, you know, considered to be, you know, pain relieving or reducing menstrual symptoms, and often at the end they'd report, "Oh yeah, my periods have been a bit better." So, that just kind of set a seed in my mind of, you know, firstly, it seems like acupuncture can be as effective…
Andrew: Yeah. 

Mike: In addressing this kind of thing. And also, why are we not treating more of it? Why are women not coming and requesting, you know, treatment for period pain? So that's really how I got started.

Andrew: You know, this is something that comes up time and time again, and this is, just because something is common, doesn't mean that it's normal. And it seems so...you know, this is so poignant in regard to women's health and women's health complaints. 

Can I ask you, Mike, what are the biggest challenges in researching complementary medicines, given that you're, you know, orthodox trained?

Mike: I think, well, there's probably a couple. The two main ones that come across in my mind a lot are funding. 

Andrew: Yeah. 

Mike: So obviously, you know, especially for things like acupuncture, really, you know, who's going to fund it? Because, you know, needle manufacturers obviously, that's huge money that we, you know, need to do proper research for them. And then there's nothing special about any particular needles really, so why would they, you know, sink hundreds of thousands of dollars into it when, you know, it could be any needle? So it's not going to translate necessarily into more sales for them.

So, funding for acupuncture especially, because, you know, you need to rely on really government grants and things like that because, you know, there's not a commercial interest really. So that makes it very difficult to be able to do good quality research. Because good quality research is not only about design but unfortunately it's also expensive. You know, because you need significant numbers a lot of the time, you need good follow-up, you know, you need really if possible, you know, good database systems to capture everything and make sure you're compliant. So that's one major issue.

The other major and probably even more difficult issue is most complementary, alternative, or whatever you'd like to call it, would be what we call a complex intervention. That makes it much more difficult. So, you know, when you’re wanting to test...say if we wanted to test a pill for period pain, that's, you know, relatively straightforward. You know, we take our active ingredient, we create a placebo which looks identical, you know, maybe both little blue or red, green, yellow, white pills. You know, we screen our participants first. They then go to see, you know, their doctor or whoever is, you know, dispensing the medication, they are, you know, randomised, they're given their treatment, and then we follow them up.

So, it's relatively simple because what we're doing is we're looking at really the effect just of the medication. And it's quite easy to tease apart the non-specific effects from the placebo, and being part of a study, you know, from the active ingredients. 

Whereas if you compare that to something like an acupuncture trial, you've got so many different components. It's not just the needle. So, you know, you've got...So if a person comes in, they, you know, will meet their acupuncturist, they'll be discussing, usually, you know, they'll have a history taken, they'll get a diagnosis, they may get point-specific to that diagnosis, they may be standardised… But there's a lot of interaction that goes on, there's a lot of, you know, dialogue creating like that therapeutic alliance.

Andrew: Right. 

Mike: Then you've got the acupuncture itself, which is obviously, you know, quite an unusual treatment. And it's also very hard to create, you know, a good placebo for that. 

And then, so you've got so many different components. And you know, in clinical practice someone seeing an acupuncturist might get herbal medicine, they might get diet and lifestyle advice, they might get moxibustion, which is a, you know, like a warming stick therapy. There's so many different things that they'll get.

So, it's really hard for us to control for all of those factors, and to tease out, what are the active components when we're delivering a therapy? How do we control for those? What do we need to...you know, is it the needles? How much of a part do the needles play? Versus how much a part does the overall interaction with, you know, traditional Chinese medicine or acupuncturist or whoever play?

Andrew: Yeah, that's really...you know what? That's totally awakened me because I never ever thought about the therapeutic intervention of the consultation as being a variable to...a confounder of the research.

Mike: Absolutely. Yeah. There's a very...there's a guy that I...His name is Engel. And he wrote in a textbook in 1988, was a really...Sorry, I'm a big fan of this guy. He coined a term...well, we call it Engel's Double Need. And it talks about what patients need. 

So, they need to be known and understood, and to know and understand. So those are their two needs. So basically, they need to be heard by their practitioner, they need to be validated, they need to be able to talk about their symptoms, their medical history, and they need someone to go, "Oh, yeah okay, right. I'm hearing you, I'm listening to you." And then they need to know and understand. So they need to be...what they really want is an explanation of what's going on. Why have they got this problem, you know, period pain, for example? And they’d need to understand.

And I think, you know, acupuncture just as an example, consultations meet those needs for people. Because, you know, the complex Chinese medicine history-taking does provide that ability to be heard and understood. And the explanations that are often given, while they're not the same as the biomedical explanations, you know, are given to people. You know, we often...most practitioners will explain, "Well, this is what I think is going on in terms of Chinese medicine." 

You know, compare that to, you know, most women's experience with their general practitioners, when we talk to them about, you know, what causes their period pain, most of them, you know, have been told that they've got period pain, it's very normal, don't worry about it, you'll grow out of it. But very few have ever been told, well this is why. You know, we think it's probably, you know, too much prostaglandins or this or that.

So it’s, you know, I think that the difference in consultation is a huge...it is a really significant factor. And the interviews we did with our participants after the clinical trial, that came up again and again. The therapeutic alliance was so important. They felt listened to. Someone was finally taking them seriously. 

Andrew: Yeah. 

Mike: So we can't underestimate how important that is to people. And especially, I think to women who often have their...seem to have their pain minimised, belittled, not believed.

Andrew: Yeah, that's right. Can I ask though, wouldn't that also be a confounder for orthodox medicine, for pharmacological intervention? Because they're still going to have those… as an ethical consideration, you've still got to have a consult and regular follow-up. So, is that part of the confounders that they have to allow for?

Mike: Yes. It could be. But a lot of the time what happens in orthodox trials is the screening will be done prior to any interaction with the doctor, or whoever is dispensing the medication. 

So there's not always the same level of explanation and interaction that there would be. Time is another factor, you know? So when people are, you know, being involved in complementary medicine clinical trials, they're often spending a lot of time with the therapist. You know, 45, 60 minutes. So, I think we need to take that into account as well. 

But absolutely, there is always going to be that confounding factor, whether it's a complementary medicine trial, whether it's an orthodox medicine trial. I think it's just likely to be a great impact in complementary medicine because of the fact that the consultations are longer.

Andrew: Yeah. 

Mike: They do involve more components.

Andrew: And with regards to I guess part of the TCM repertoire or armamentarium. Acupuncture; I need to ask a question about...and this is something that various people will tell me different things. So, does it affect the opioid receptor, or not, or both?

Mike: So, as far as I know, the current research suggests is multiple pathways. 

Andrew: Got you. 

Mike: The last time I've read the research, which wasn't that long ago, it does seem like it increases the endogenous opioid mechanism, so it does dump endogenous opioids. And we've seen when… experiments where, you know, there's pain relief which is occurring and then so now...

Andrew: Can be reversed with Narcan? Is that the...?

Mike: That's the one, yeah. And we know sensory nerves are involved because that will also...it stops any effects when… if sensory nerves are blocked or capped.

Andrew: Forgive me, I should have said...I should have been generic then for our overseas listeners. It's Narcan in Australia, but overseas if we go to the generic name, it's Naloxone.

Mike: Yeah. I think that's at least part of it. For menstrual pain, we think there's other impacts. 

Andrew: Ahh?

Mike: It seems like there's probably an increase in blood flow to the uterus through increasing perfusion to the uterine arterioles. And that's probably through the needling of a point called spleen 6. Spleen 6, on the inside of the calf. And it seems like it operates by sympathetic reflex inhibition. 

Andrew: Ahh. 

Mike: So, needling that point seems to increase blood flow to the uterus. And there's been some experiments, some research done by Elizabet Steiner-Victorin over the last 15 years or so looking at that. And reduced blood flow to the uterus is a very significant contributor to period pain.

Andrew: So this might answer at least in part why acupuncture might be worthwhile in mood disorders, for instance, with the sympathetic...with the vagus nerve? Is that right?

Mike: Yes.

Andrew: Is that where we're going?

Mike: Yeah. And also a lot of mood disorders, especially if they're related to menstruation, seem to be through increased inflammation. And so there is evidence that acupuncture reduces inflammatory markers 

Andrew: Yes. 

Mike: Such as in interleukin-6. And there's a lot of sixes in this, isn't there really? It's almost designed to cause an international incident, yes.

So we think that...There was a really interesting paper maybe 18 months ago in the "Journal of Women's Health," where they looked at women with PMS and found that there was...they did have...you know, the symptoms were correlated quite strongly with increases into interleukin-6 levels. 

So, you know, so we think that these increased inflammatory markers, you know, could be reduced by acupuncture. And that might also explain why acupuncture can be effective in treating premenstrual syndrome.

Andrew: And I guess one of the other things that I'm interested in is, when we're talking about research of TCM, but we're talking about it in the Australian landscape, and we are lucky enough to have the TGA as our ‘warden,’ if you like, of quality. 

Mike: Yep. 

Andrew: But it can be a real issue with overseas research because of adulteration and contamination with the heavy metals, etc. 

Mike: Yes. 

Andrew: Even drugs are in there. You know, there's a few drugs, a few major culprits that are found and they very often leak into Australia with internet purchases. So, I guess the warning to people is don't buy over the internet, particularly with TCM if you don't know where the herbal manufacturing is going on.

But what about these herbal quality issues when you're dealing with a multiplex, a multitude of herbs in a formula? How do you sort of control the confounders there? Do you talk to a...you know how they have like, you know, Bupleurum 6...or I'm sorry, Minor Bupleurum Complex is a standard formula. 

Mike: Yep, yep. 

Andrew: Is that how you control the confounding of the multiple herbs in there?

Mike: So, I mean, it sounds like you're talking about safety in some ways, and definitely like you said, you know, what's called patent medicines.

Andrew: Yeah. 

Mike: You know, it's definitely...I mean, the quality is dubious. And like you said, the adulterants, you know, can be present. And that's really concerning. You know, especially when you're looking at some formulas where the...you know, like for erectile dysfunction, you know, there's obviously traditional Chinese medicine formulas for erectile dysfunction. But you know, then when you popping things like Sildenafil in there without disclosing it. 

Andrew: Yep. 

Mike: And obviously, the patent formula is working because it has Sildenafil in there but, you know, you don't know that that's what you're taking. So huge safety issues with interactions and things like that. And obviously, just, you know, deception. Because, you know, you're taking a pharmaceutical medication without realising it.

Andrew: Yeah. 

Mike: So, you know, I personally think that, you know, I would always, from my own personal point of view, use formulas which were created, you know, in Australia. Or in countries where there's, you know, tight GCP...sorry, GMP, in this case, you know, oversight. 

So, there's, you know, certain formulas and products that I would feel very comfortable using, and then personally patented formulas, you know, from mainland China I do avoid. Because I don't know what's in there and that does concern me.

Andrew: Yeah, there are some extremely competent, ethical manufacturers in China, and we're certainly not denigrating all of the manufacturers. There are some incredible companies over there, but the problem is there are those that aren't and that leak through. 

Mike: Yeah. 

Andrew: So it's really hard to judge unless they've got the okay of the TGA in Australia.

Mike: Absolutely. And obviously, you know, looking for, you know, the GMP, you know, that they've been producing in GMP-certified factories. But I think it's just...like you say, it is a real issue because, you know, you don't want to tarnish, you know, everyone's herbs because of those people who break the guidelines. But it's also...you know, I think it's just something that people need to think about whether...you know, if they're concerned about risk, is there an alternative? You know, where they can, you know, get a similar or the same formula from another source where they, you know, perhaps, you know, they can be more sure of the oversight.

Andrew: Now, delving into our topic today, and that's pelvic pain and endometriosis, endometriosis is finally reaching the headlines. It's finally getting the news that it deserves to awaken people to the issues that women face with this treatment that doesn't just reside in the uterus, and it's trivialised so often. Let's talk about that, the role of integrative medicine in treating pelvic pain and endometriosis.

Mike: Yeah, absolutely. Well, look, we're still in relatively early stages of investigating a lot of complementary or integrative medicines and treating endometriosis. But there's a couple of really interesting things that are happening at the moment. And a lot of it is...You know, I'm just going to toot my own...trumpet a little bit about some of the work we've been doing. 

So we're just in the process of publishing a survey that we did just over...wow, about a year ago actually. Where we asked women with endometriosis in Australia what kind of self-management strategies they used. And this was anything basically non-pharmacological, I suppose. Something that they could do or acquire themselves. 

So we asked them about yoga, exercise, rest, meditation. And based on some anecdotal evidence that we really heard from other projects like Citizen Endo, which is a great project that's running, collecting data by an app on a smartphone, they published their kind of interim results. And we looked at that. And we also found that women we're using alcohol and cannabis or CBD oil as well in terms of managing their symptoms. 

So, one thing we do know, women with endometriosis in general, they have a really tough time managing pain. Obviously, pain is probably the major symptom, you know, that women with endometriosis have. And that's everything from very severe period pain, to what we call non-cyclical pelvic pain, which is just a fancy way of saying it's like period pain but you don't have your period. And a lot of women have that at least several times a week. Some may have it every day. Pain on sexual intercourse, incredibly common, and same with pain on bowel motions or when with a full bladder. 

So, pain, you know, pain, pain, pain comes up again. And obviously, untreated pain has, you know, really catastrophic effects on, well, mental health, on, you know, work, social life, pretty much everything.

And it's a struggle for women to manage their pain. Because certain medications like Endone, so that’s Oxycontin, you know, can be really effective. But it's often, you know, these women are concerned with addiction, and what we hear from the women who've been in our focus groups is that it's often a Hobson's choice for them. 

So, they either sit with pain at work and are able to do things like pick up their children and do other things, driving and things like that. Or they take the medication, which relieves their pain, but then they're limited in some of the other things they can do. Such as, you know, looking after their children or picking up their children. So, it's a horrible decision that they have to make.

So, women are definitely looking for adjunct pain relief. So you know, something they can take on top of...so ibuprofen or Panadol or something to help improve their pain control. 

So what we found from our study was there's a very small number...well, a relatively small number of women who are using cannabis. It was about 13%, which, you know, while it's small, it's also high, no pun intended. Because, you know, cannabis is currently illegal in Australia for...you know, you can't easily access it, that we know of, for pelvic pain.

Andrew: Don't get me started.

Mike: Yeah. But these women were reporting very, very high levels of satisfaction at pain relief. Much higher than any other of the other interventions. 

They were also really importantly reporting a reduction in their medication that they needed. So I think it was about 52% of women taking or using cannabis reported a 50% or greater reduction in their endometriosis-related medication.

Andrew: Wow. 

Mike: So, the caveats to this are obviously, very small number, and we didn't ask them specifically what medication they were reducing. 

Andrew: Right. 

Mike: The implication is obviously it's pain-related medication, but we can't be certain of that. 

Andrew: Oh, I see. Right. 

Mike: So, we need to do some follow-up work on that. But they were able to reduce medication that they were taking specifically for endometriosis by 50% or more.

Andrew: It's a fair guess. Can I ask just for a bit of clarification?

Mike: Sure.

Andrew: Hobson's choice, that's the take it or leave it, is that right?

Mike: Hobson's choice is...sorry, it's a choice where it looks like you have a choice, but you don't. 

Andrew: You don’t, yeah. 

Mike: So, you know, it seems like you've got a free will but you don't. So, you know, for a lot of these women, they don't have the choice to take the pain relief because they might need to go and pick their children up from school. And they don't want to risk, you know, taking something which might impair their ability to drive. 

Andrew: Yeah, yeah. 

Mike: So, you know, to give you an example, one of the women in our focus group said you know, she puts up with pain all day, and then she goes and picks up her daughter, I think it was, from school, gets home, and basically as she's walking in the door, she's chugging down the...

Andrew: The codeine-based, yeah.

Mike: Yes. You know, so she can finally get relief.

Andrew: Which would rob her obviously of family time and things like that in certain situations.

Mike: Absolutely. And then she says, "Well, then I go to bed basically.”

Andrew: Yeah. 

Mike: “I'm exhausted from the pain, then the painkiller kicks in, and you know, there might be some sedative effects with that." 

Andrew: Yeah, yeah. 

Mike: So yeah, absolutely. She says, you know, "My husband is amazing. He has to basically...you know, we kind of like...I just tag out." So, you know, there's a huge impact on women's lives. So, that was one of the really interesting findings from our study.

The other one was just around exercise. Obviously, you know, there's a huge public health messaging at the moment about the benefits, the very real benefits of exercise. 

Andrew: Yep. 

Mike: Not just for getting ‘beach body ready.’ But, you know, mental health. I think this, you know, has been...My colleague, Dr Joe Firth has, I don't know, published like a million meta-analyses now on the... well it's probably pretty close to that. On exercise and depression and schizophrenia, all kinds of mental illness. And I think, you know, there's some pretty solid evidence that exercise is beneficial.

And what we found was women with endometriosis often reported exercise made them feel worse. And again, we didn't collect exactly the type of exercise, so it's just a broad category. But there was a high rate of adverse events and they reported that they felt exhausted because obviously fatigue is another very, very common symptom of endometriosis, which is just gaining more recognition now. So they're exhausted. And they had what they called flare-ups. So, very common term in the endometriosis community. Basically means their symptoms, especially their pelvic symptoms, just got worse, much, much worse for a short period of time.

Andrew: Right. 

Mike: And so, you know, there's difficulty there because, you know, women are wanting to, you know, get the benefits of exercise, you know, stress and depression and anxiety, which are very, very common in women with endometriosis. But when they're trying to they're kind of getting thwarted a little bit because it's often causing the increased pain. So there's a lot of frustration there. 

So, we think that, you know, probably the best idea would be, you know, that there's more resources for women with endometriosis, in terms of exercise. Getting some oversight or supervision by someone who's trained…

Andrew: Yep. 

Mike: To be able to kind of slowly grade-up that exercise, rather than jumping on straight into something like...

Andrew: Yeah, that happens in a multitude of conditions, you know, the Weekend Warrior type thing.

Mike: Absolutely. And I think it's just...you know, this is psychologically quite...you know, could be very tough. You know, like, I'm trying to do something for my health but my endometriosis is thwarting me again. 

So, I think, you know, exercise could be great, but it probably needs to be done under the supervision of someone. You know, who can kind of prescribe exercise rather than being like, I'm going to go and do an eight-week boot camp or I'm going to, you know, start CrossFit or...you know? And then you're getting this kind of flare-up.

Andrew: Yeah. And what about certain types of exercise? Like, we're learning from the exercise physiologists at...god, I hope I get this right, Curtin University in Perth? That certain types of exercise or varying types of exercise benefit varying types of cancer therapy. So, protective against, say, prostate cancer was jumping…

Mike: Ahh, yep. 

Andrew: Yeah, to maintain bone density. You know, I'm a big fan of dad dancing. But were there certain types of exercises that didn't have the flare-ups at all?

Mike: We don't know. Unfortunately, you know, that was a shortcoming. It was a very large questionnaire, so we tried to make it as broad as we could. 

Andrew: Yep. 

Mike: So we really just had exercise as exercise. We did get some indication that yoga...we asked that as a separate question. We did get some… and we asked a lot of free texts, so where we gave women the opportunity to talk about it, different things. And we found that yoga, there was definitely a positive trend towards yoga being beneficial, and it could again just be that slower, more graded movement. 

You know, so when you've got, you know, adhesions and things like that, it's possible, but that kind of slow stretching is beneficial where, you know, perhaps jumping or high impact exercise may not be. Because of, you know, the structural component.

Andrew: And what about any biochemical measurement with the exercises that...you know, obviously, this is early days, but has anybody looked at this? Like you were talking about inhibition of interleukin-6 with acupuncture. 

Mike: Yes. 

Andrew: Has anybody looked at inhibition of inflammatory markers with varying types of exercise?

Mike: That's a good question. I actually don't know. I did read something recently, but not recently, or well enough that I would comment on it. But there was definitely...there was some...I think there's some conflicting research. What I remember, this particular paper was contesting the idea that exercise has an anti-inflammatory effect. 

Andrew: Right, got you. 

Mike: So, I don't know. And there's certainly no one as far as I know who's really looked at exercise in women with endometriosis in a prospective kind of way. 

So there's been some retrospective of studies where they've looked at, I guess, you know, trying to tease out what might cause endometriosis, and I think they looked at, you know, was exercise, either a lack of or too much...

Andrew: A trigger for it?

Mike: ...you know, a trigger for. But it doesn't seem...

Andrew: Yeah, or a driver?

Mike: Yeah, it doesn't seem that way. And also, I think it's really just so many different factors that, you know, I'm quite cautious about using, you know, that kind of epidemiological data.

Andrew: Right. 

Mike: Unless you've really captured all the other possible components. But as far as I know, there was no link between endometriosis and exercise. 

Andrew: Yep. 

Mike: What would be really interesting is to look at, you know, the effect of exercise, of different types of exercise on endometriosis in, you know, kind of like a randomised control...

Andrew: Yeah, structured way here.

Mike: Yeah, structured way, absolutely.

Andrew: And measuring inflammatory markers. That would be interesting.

Mike: Absolutely.

Andrew: But I think there was also some...I think you used the word contested. There was also some argument as to what inflammatory markers were more appropriate to measure, weren't there?

Mike: There's absolutely no consensus at the moment on inflammatory markers to endometriosis. Obviously, the Holy Grail is an inflammatory marker or some kind of marker which allows accurate detection of endometriosis without a laparoscopy. 

Andrew: Yeah. 

Mike: I think there was a Cochrane review on this just a few months ago, and unfortunately, at the moment still nothing. Because obviously, that would be amazing. 

Because one of the major issues is, you know, there's no diagnosis really for most women of endometriosis without a laparoscopy. They can have suspected endometriosis. But most doctors won't say they definitely have it without a laparoscopy. And it's certainly a current research standard, that that's the gold standard, that you must have a laparoscopy diagnosis. 

Andrew: Yep. 

Mike: And that's obviously invasive and not to be taken lightly. And most, you know, doctors can be quite reluctant to go down that route.

Andrew: And should be done by somebody suitably trained like a CRI expert.

Mike: Absolutely. And so, you know, having a non-invasive, you know, like a form of blood test would just be fantastic. It would allow much easier screening of women who've got symptoms suggestive of endometriosis.

Andrew: Yeah. Just going back to herbs a little bit, when we're talking about TCM, what about some Western herbs? Forgive me, you were also including the THC and CBD use. 

Mike: Yes. 

Andrew: Firstly, THC and CBD versus opioids, has anybody looked at that with regards to benefit less adverse effects or side effects, more compliance, greater acceptance? Anybody looked at that?

Mike: I'd say that's more Justin Sinclair’s area than mine. I do believe that there has been...you know, there is research to suggest how minimisation, substitution effect, you know, so that people are actively substituting cannabis or CBD oil for their opioid-based medications. 

But again there’s, you know, the research is quite contentious. Because there's been a lot of trials, not all of them well designed. You know, so you've got issues with, you know, the strains, with dosage, with outcome measures. You know, so that always makes it a lot more difficult to determine.

Andrew: Yeah. What about some Western herbs? Anybody look at...you know, curcumin is very commonly used, for instance. 

Mike: Yes. 

Andrew: Then you've got other ones like Jamaican dogwood, Californian poppy. There was a herb that I used to employ, not for endometriosis, but for other chronic pain years ago, but it was always an S4, that is, a prescribed herb, and that was gelsemium. I had a very understanding doctor that I used to consult with. And that was the herb gelsemium, not the homeopathic remedy, gelsemium. I was blessed with being able to use some of these herbs. But overseas, like in Germany, these are often employed. What's our knowledge of the use of these herbs at this stage?

Mike: I think there's very little on Western herbs that I know of for treatment of endometriosis. You know, there’s some research on Vitex, but that's mostly around premenstrual syndromes rather than endometriosis-related pain. 

Andrew: Yeah, yeah. 

Mike: I'd say that most research is actually on traditional Chinese medicine formulas and one formula, in particular, which is, excuse my terrible pronunciation, Gui Zhi Fu Ling Wan. So, that is G-U-I space Z-H-I space F-U space L-I-N-G space W-A-N. And Wan just means pill. So, could be Gui Zhi Fu Ling San, Gui Zhi Fu Ling Tan, depending on how it's taken. 

Andrew: Yep. 

Mike: And it's cinnamon and poria twig concoction. 

Andrew: Right. 

Mike: And that's the most commonly used traditional Chinese medicine for endometriosis. There's some survey data out there from Taiwan, I believe it is, where that was overwhelmingly the most common formula used. And that seems to be quite promising.

Now, most of the research, unfortunately, is not particularly high quality and hasn't been published in English language journals. But it certainly seems like, from the research that's out there, it could be very promising. And we are about to undertake a clinical trial looking at a slightly modified Gui Zhi Fu Ling Wan formulation for the treatment of endometriosis.

Andrew: Got you. 

Mike: And we'll be starting that in 2019.

Andrew: Great. Excellent. Say no more, you can't say any more.

Mike: Yup. So, we'll...yes. But I think that that's probably the most promising traditional Chinese medicine formula we have at the moment.

Andrew: Yep. 

Mike: And I think that, you know, herbal medicine has such a possible role that could be played, but like you mentioned earlier, endometriosis is just...it's just coming out of the shadows, if you like. So, unfortunately, there hasn't been a lot of research funding for endometriosis. 

So, you know, in Australia, for example, you know, there is now...through the National Action Plan, there's going to be specific funds for endometriosis. But we go back a couple years to 2016, the amount that endometriosis got was 2.8% of the amount that diabetes got.

Andrew: Yeah. 

Mike: Despite the fact that in terms of cost of illness burden and impact on life, incredibly similar.

Andrew: Wow!

Mike: So, I'm really hoping that, you know, some researchers in Australia or anywhere in the world, you know, do look at properly designed clinical trials for herbal medicine for endometriosis. Because women do want alternatives. They do want adjuncts. They do want something to help control their pain where, you know, hopefully, there is less risk of addiction-less side effects.

Andrew: Yeah, being able to function, yeah.

Mike: Being able to function, absolutely. You know, it shouldn't be a choice between being in pain and being kind of, you know, compos mentis. 

So, I think that will be a great place for researchers to look in. There might be some trials going on at the moment. Obviously, that's one of the problems we have in research is that, you know, it's years between conception, execution, and publication.

Andrew: Yeah. I've got to say, I'm so glad in Australia we've got these great research institutions, integrative medicine research institutions. You know, like where you're working, you've got The Jacka Foundation, you've got NIIM in Melbourne, you've got Endeavour College and UTS, and with this great research areas in Australia that are really looking seriously, scientifically, at integrative medicine, adjuncts, alternatives, options in a responsible way. Like, you know, for instance with existing medications and with, you know, reasonable populations that we're going to work with rather than "well people."

Mike: Yes.

Andrew: You know, that sort of thing. I've got to say, Australia really is at the forefront of so many areas of research. Thankfully, in women's health issues as well. Like polycystic ovarian syndrome, and endometriosis is coming up now, thankfully. It's just so great to see this finally, as you say, come out of the shadows.

Mike: Yeah, absolutely. And as much as it pains me to say it, you are right, Australia is...you know, they are… Australia is doing fantastically well, you know, and all of those institutes, you know, we collaborate with a lot of them. And, you know, it's really high-quality research, which is what needs to be done. You know, we need to have research institutes who are doing, you know, whether it's government-funded or commercially-funded research, independently. And looking at, you know, sensible outcome measures, you know, sensible research designs, you know, so we can really have a good look at what place integrative medicine...you know, what role it plays? Without, you know, overstating the case, but also, you know, without dismissing things without looking at them first.

Andrew: That's right. So, you know, this is something that always plays on my mind, and that is, you know, just because there's no evidence against it doesn't mean there's automatically evidence for it. I get it. I get that responsible thing, we can't over-claim. 

But for goodness sake, where there's real need, where people are in pain, where people aren't well treated by orthodox options, we should responsibly, ethically, be seriously looking at scientific options in the integrative sphere. And that includes exercise and lifestyle and diet, I get that. But we really, really need to have some serious investigation into these, you know, ‘alternative therapies,’ which include TCM and herbal options as well.

Mike: Yeah, absolutely. Like you say, you know, we have a population...with women with endometriosis, they’re a population which do not have good pain control. It impacts every single aspect of their life. From their work, their social lives, their friendships, their romantic and sexual relationships. You know, if there's a cure that comes out and, you know, like herbal medicine and acupuncture is no longer needed, that would be great. 

Andrew: Great, great. 

Mike: That would be absolutely...I would be the first person to celebrate that. But we don't have that at the moment, I hope we have that in the future. But in the meantime, we need to think about the women who are living with it.

Andrew: Yeah.

Mike: And that's the ethical thing to do. 

Andrew: Yeah. 

Mike: You know, I agree. Like, you know, we need to say, okay, so we want a cure, absolutely. We need to fund research into that, we need to fund that without a question. 

But we also need to fund research into...you know, if we find a cure tomorrow, let's be realistic, it's going to be 10 years before, you know, it gets through trials and approvals and things. So we need to say, okay, so for those next 10 years, how are women going to, you know, live on a day-to-day basis? So, you know, that's kind of my thinking.

Andrew: Here, here, Dr Mike Armour, thank you so much for your wise words and opening up this sphere of research in...you know, including TCM and acupuncture and things like that into women with gynaecological issues. I really admire your research. As a man, I might say, it doesn't preclude us caring. You know? Well done to you.

Mike: Yeah, absolutely not. And I think that, you know, men should care. You know, we, all of us, just as humans, you know, we should care about, you know, other people. And when you think about it from a practical point of view, everyone's got a mum, most of us have sisters, cousins, aunties. The chance of them being affected, someone you love being affected by, you know, a woman's health condition like endometriosis or even just period pain, is so high. And so it's not a woman's problem, it's a, you know...

Andrew: It's a community.. it’s a societal problem, that's right.

Mike: Absolutely. You know? And we need to think about it like that, rather than just secret women's business, you know.

Andrew: Yeah. 

Mike: That they need to fix. And I think probably, I haven't heard Lara's podcast with you, but I'm sure she probably said the same thing. It's a taboo topic. You know, that's why it's one of the huge problems. You know, I often say that I can't talk about my research at the dinner table because, you know, it's kind of considered to be shameful, dirty, sexual, taboo, something. And I think that's a huge part of the problem, that we...you know, 50% of the population, you know, menstruates and it can't be talked about?

Andrew: Well done. Mike, thank you so much for taking us through these issues today on FX Medicine.

Mike: No worries. Thanks very much for having me, Andrew.

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

Additional Resources

Dr Mike Armour
Dr Debra Betts
NICM Health Research Institute
Caroline Smith
Elisabet Stener-Victorin
Dr Joseph Firth
The Jacka Foundation of Natural Therapies
NIIM: National Institute of Integrative Medicine
Endeavour College Office of Research
UTS: Australian Research Centre in Complementary and Integrative Medicine (ARCCIM)

Research explored in this podcast

**coming soon


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