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A Timeline of Endometriosis with Rebecca Reid

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A Timeline of Endometriosis with Rebecca Reid

Endometriosis was first microscopically identified in 1860 and the term itself coined in 1927, both in time periods when naturopathic medicine was very commonplace. So, what is the history of the naturopathic interventions in Endometriosis versus what we know now?

Today we are joined by Rebecca Reid, naturopath and researcher who has been delving through historical texts to uncover some of the key naturopathic interventions for endometriosis through the ages. What she has uncovered is an intriguing list of herbal, homeopathic and lifestyle therapies that she hopes will lay some essential groundwork to furthering future naturopathic research in this field in Australia. 

Covered in this episode

[00:40] Introducing Rebecca Reid
[01:47] Delving back into naturopathic history
[04:43] Defining endometriosis as we know it
[06:29] Hormonally driven theories
[07:08] Symptomology
[08:35] Barriers to diagnosis
[16:01] Better education may alleviate diagnostic delay
[20:34] The autoimmune theory?
[22:46] Key researchers and resources to be aware of?
[24:44] What's the role of complementary medicine in endometriosis?
[27:13] Rebecca's research: history of natural medicines in endometriosis
[34:19] Traditional approaches to menorrhagia and dysmenorrhoea?
[38:45] Historical management of endometriosis?
[41:38] The core aims of Rebecca's research

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Rebecca Reid, who's a naturopath from Endeavour College of Natural Health in Brisbane, where she graduated in 2014, and is a successful applicant to the Student Summer Research Program at Endeavour. She's the Research Project Coordinator and Student Liaison Officer for the Office of Research at Endeavour College of Natural Health in Brisbane. And she's only one of 11 competitively appointed fellows of the International Naturopathy Research Leadership Program at the Australian Research Center in Complementary and Integrative Medicine at the University of Technology in Sydney. That's UTS.  
In addition, Rebecca is currently undertaking her PhD at the Australian Research Centre in Complementary and Integrative Medicine, where she is investigating health service utilisation by women with endometriosis, and the naturopathic prescription characteristics and treatments utilised to manage endometriosis in Australian naturopathic clinical practice. 

Welcome to FX Medicine, Rebecca. How are you going?  
Rebecca: I'm great. Thank you. How are you, Andrew?  
Andrew: I'm good, thank you. Now you've done a lot of research and investigation into endometriosis and the tradition naturopathic management, which is something that I think we're sorely lacking. We sort of tend to go...we want to go science, and we want to go evidence and things like that, but there's a whole history of naturopathic... 
Rebecca: Yes.  
Andrew: ...treatment and management that's missing.  
Rebecca: That's very true. As far as I'm aware, no one's actually ever looked into this. Where I've done part of my project at the National University of Natural Medicine in Portland in Oregon in the U.S., I was the first researcher to ever go there and utilise their traditional and rare books to actually conduct a project in this form.  
Andrew: Wow!  
Rebecca: Yeah.  
Andrew: So what, were they all dusty and locked away in a triple vault... 
Rebecca: It was amazing. I can't even explain how wonderful...it was like, 2,000 really rare, old naturopathic texts, reading them for three weeks. It was wonderful. 
Andrew: I have to ask there, did you have to wear the cotton gloves and things when you were handling them?  
Rebecca: I wanted to. I wanted to. I did ask, but no, I had to use a foam casing and a foam bookmark to make sure that the texts weren’t like, damaged by me touching them or anything.  
Andrew: Oh, so even more protective.  
Rebecca: Yeah. Because a lot of them were falling apart. 

Andrew: Yeah. 

Rebecca: A lot of them had like, you know, mildew and spines were broken. So they're doing a rebinding process, particularly their Benedict Lust collection has just undergone a really large binding process. 

Andrew: Yeah. 

Rebecca: But some of their older texts, yeah, they are sadly, falling apart.  
Andrew: What era is this from? Is this from the eclectic physicians in America in the sort of late 18th century?  
Rebecca: Yeah.  
Andrew: Wow.  
Rebecca: So, the texts that I looked at were from 1800s to 1941.  
Andrew: The 1800s. Forgive me. Nineteenth century. Sorry
Rebecca: Yeah. And that was the year range that we chose because the American Naturopathic Movement as well as the Australian. So I really focused on the Western naturopathic front.  
Andrew: Can I just...I know this is a digress, but with the eclectic physicians, what was their influence? Was it the German immigrants coming across and wanting a natural health system, if you like? Where did they...?  
Rebecca: I'm not too sure. They did obviously come across and implement naturopathic practice into the American systems, but for this project in particular, the eclectics have strong roots in naturopathic foundation. 
Andrew: Right. Yeah. Yeah.  
Rebecca: You know, the same with nature cure, which came from Germany, and prior to nature cure was the water cure, as well... 
Andrew: Right.  
Rebecca: ...with Sebastian Kneipp.  
Andrew: But the eclectics also learned a lot from the American Native Indians as well, didn't they?  
Rebecca: Yes, and that's been in my data as well. Some of the herbs that I found are not very common. They're also not necessarily put into Australian practice or even American naturopathic practice. So I think there is going to be that traditional roots that come from each country.  
Andrew: Well I do hope that there's a resurgence of some of these herbs, because they...I've used them previously, and they just work like nothing else. You know, Squaw Vine and things like that. They're incredible.  
Rebecca: Yeah. Yeah, well Squaw Vine was one of the herbs that I did find. Yes.  
Andrew: So, here we go.  
Rebecca: Okay.  
Andrew: Endometriosis. Let's get an overview of what endometriosis is. I think therein lies the first confusion.  
Rebecca: So, endometriosis, it is a complex and it is a chronic reproductive disease. And it's characterised by the presence of tissue that is similar to the endometrium that grows outside of the uterus. That's sort of the basic definition. 

So the tissue that develops forms lesions and can adhere to the reproductive organs as well as the neighbouring organs, like the bladder and the bowel. However, I've actually recently read some cases where it's even found in thumbs, in knees, the lungs, and the brain as well.
Andrew: Brain, eyes. Yep.  
Rebecca: Yeah. So it, you know, can really travel around the body. But those are considered quite rare. There is a lot of… a bit of data sorry, so from 2009, that looked at some of the prevalence of endo, and this was a worldwide study that stated it was 1 in 10 women of reproductive age that have endo. And in 2010, it was estimated that 176 million women worldwide have endometriosis. 

So we've got, you know, data that's a little bit outdated now, so we really need to be working on finding exactly how much women do have endometriosis. But it's also quite tricky because the condition itself is very complex.  
There has been some research where it's talking about the possibility of having inflammation aspects, autoimmune aspects, oestrogen, progesterone ratios being out of balance, as well. But we really don't know what the cause is. We are still trying to just even understand the basic pathophysiology. So there's a wide range of areas that kind of cover endometriosis at this stage, and we really just don't know the ins and outs of it to 110%.  
Andrew: What about the notion that it's hormonally driven, and therefore when the hormones drop in menopause that it therefore ceases to become a problem?  
Rebecca: That is definitely, I think, incorrect. I have spoke to very young women who have been forced into menopause, or have had a complete hysterectomy, and they still have endo. I've also met women that are 60 years old, have already been through menopause, and they still have it. So, we're really not sure. Like, there is that oestrogen component. I definitely think that that is something that is there, and that has been shown with evidence. But we really don't know what the single cause is. And I really think, with this condition in particular, that there just isn't one thing that's causing it. It can be genetic factors, it can have environmental influences as well. So, we're just, you know, not sure.  
Andrew: What about the symptomatology? You know, I would think that most males would think that endometriosis presents with some tummy pain, and that can be even severe, but they think it's going to be restricted to the sort of, lower abdominal area where the reproductive organs are. But what's the breadth of symptoms?  
Rebecca: So, because it is a complex condition and it can be quite progressive as well. The symptomology, a lot of them can be really debilitating. But it also depends on the severity and the stage of the endometriosis that the woman has. 

So, the main symptoms can be dysmenorrhea, painful intercourse, chronic pelvic pain, menorrhagia, infertility, and bowel irregularities. However, even though these are considered to be the main symptoms, women can have fatigue, headaches, bloating, limb pain. There's really a wide, wide range.  
But there's also, you know, if you think of the picture of irritable bowel syndrome, that is sometimes how it can present. That, they don't have any reproductive issues, their period or menstrual cycle is fine for them, and they don't have any period pain. So it really varies from woman to woman. But then women can also be asymptomatic and not even know that they have it. So there's no real big list of symptomology other than those top five or so.  
Andrew: Okay. So, diagnosis. I mean, this is...this one's the big one.  
Rebecca: Oh, definitely.  
Andrew: Misdiagnosis, nondiagnosis... 
Rebecca: It's a huge issue. Yeah. Just women wanting to get a diagnosis. 

Andrew: Yeah. 

Rebecca: So generally, it's diagnosed by laparoscopic surgery, and this is considered to be the gold standard for the diagnosis process for endometriosis. And it's because it allows visualisation of the organs, but also they're able to retrieve a biopsy of the tissue and get that tested as well. And once the diagnosis process has begun and the surgery has been done, endometriosis is classified into stages. 

So your Stage 1 refers to the minimal presence of endometriosis, and minimal involvement with neighboring organs. Stage 2 is mild, and Stage 3 is moderate, and Stage 4 is severe. So, even though those stages can clearly articulate how bad the endometriosis is, it doesn't actually match the symptomology.  
So, a woman with Stage 1, being minimal involvement, she might have, for example, four spots throughout her uterus, and she has no symptoms. But then she could have Stage 2, being mild, and be completely and utterly unable to work, unable to move. You know, she can have really bad symptoms, and same with Stage 4, being severe. You would think with so much involvement of neighboring organs and the reproductive organs that she could possibly be in so much pain and have really bad symptoms, but actually have none at all. So, it really varies. There's no real clear cut.  
Andrew: Yeah, that screams of an incorrect classification system. 
Rebecca: Yeah, but it's really based on the presence of endometriosis. It doesn't match the symptomology.  
Andrew: Yeah. But can you imagine that being applied to colon cancer, or irritable bowel syndrome?  
Rebecca: Yeah, it wouldn't work.  
Andrew: With the Rome criteria.  
Rebecca: Yeah, that's right. And that's what...you know, another thing that...pain is subjective. So everyone has very different pain thresholds. So, you know, you might prick your finger, and that's absolute agony for you, whereas for someone else they didn't even notice. So that's also another thing that would need to be taken into account. But the stages are based off the American reproductive system. So, yeah, they just don't match. Which just makes it confusing when women are told they've got Stage 4 and they think, "Oh my, this is really, really bad, but I have no symptoms. Like, what does that mean exactly?" You know, they're not feeling anything that's going on. So that can kind of create a lot of confusion and issues for women. 
Andrew: So, with regards to diagnosis, and if you've got...I mean, let's take a simple thing. You know, lower abdominal pain that's cyclical, and it's, you know, worse around either menstruation or halfway through your period, let's say. You know, I'm going really simplistic here.  
Rebecca: Yes.  
Andrew: What do women need to do if initial therapies from their GP or their natural health practitioner don't work? What should they be asking to be done? Who should they be seeking to see, or get referred to?  
Rebecca: Well, this is a really big issue for women. And even if she hasn't got any menstrual irregularities that are occurring, she's really not sure what's happening. She’s just got some abdominal pain. Like, of course, you go to, you know, your GP or your complementary medicine practitioner, but you really need to try and get to the gynecologist. 

So there's been some research that stated that once women get to a gynecologist, that can shorten their diagnostic delay period. So generally, it's seven to ten years for a woman to be diagnosed with endometriosis, which is beyond ridiculous.  
Andrew: Wow.  
Rebecca: If they are able to get to a gynecologist, then it's...they get closer to that diagnosis, which is really important. Because you don't want to be sitting with, you know, some mild endometriosis and leave it for a couple of years or decades, and then go and you're unable to have children, or you're told the only treatment available is a complete hysterectomy, which is not what you're after. 

So the best thing that women can do is really advocate for themselves. Really fight for themselves, and really push their practitioners to hear them. Because this is a really, really big issue. Women go in there and they're completely dismissed. They're told they're hypochondriacs. And that's just not okay. That's not proper care. You just don't do that. That's not right.  
Andrew: That's not medicine. No.  
Rebecca: No. And it's a really difficult issue. Because some women, you know, they may not feel comfortable advocating for themselves. They may not know exactly what's going on. But if they can go, "Look, no. This is not working. I want to see someone else." Get a second opinion as much as they can. 

Andrew: Yeah. 

Rebecca: But unfortunately, with doctor shopping, you know, you're always going to get that 50/50 chance of a doctor that will hear you and will follow up with everything, and a doctor that won't.  
Andrew: I guess this is...part of the problem is, people won't go back to the same doctor and say it's not working. They'll go to a different doctor.  
Rebecca: That's right. Which, you need to be able to go back.  
Andrew: Yeah.  
Rebecca: And say, "Look, is there something else that I can do? Get some more tests?" Like, even if women just educate themselves. You know, have a Google around, about different conditions and try and understand what's possibly going on. 

Like, I know of someone that just had bloating, and everything else was fine. And she was diagnosed with Stage 4 endometriosis, and she had a two week period between going to two different GPs, and one gynaecologist and two different surgeons, and like, in that two-week period she was able to get it sorted. But she really had to push. She was just like, "No, this is not right. I know my body. Something's wrong. You need to do something."  
Andrew: What if somebody's even seen a specialist, a gynae, and they're still not getting the answers that they want, is there anything further that they...anywhere further that they can go?  
Rebecca: I'm aware of, especially in Queensland, there's a number of clinics that are now specialising in endometriosis. So they are gynaecologists, but they're also laparoscopic surgeons. So trying to find to someone that specialises in that area and has the correct medical degrees for that would be the next step. Even asking for a referral or going back to a different GP or the same GP, if a woman's happy with her GP.  
Andrew: Yep.  
Rebecca: And saying that, you know, "I have found this specialist. I really want to get in and see them. Can I please have a referral?"  
Andrew: Yeah, so that's the Cree…
Rebecca: Yeah.  
Andrew: CREE specialty? Is that right?  
Rebecca: Yeah. And so, there is a specialty in this area. Yeah. But that's probably the next best thing that they can do. And it really comes back to advocating for themselves when doctors aren't listening. 

Andrew: Yeah. 

Rebecca: And doing that doctor shopping. Like, because there's not much else you can do. Even if your main practitioner was a complementary medicine practitioner, there's all those issues with complementary medicine practitioners referring anyway. So, really going through the medical system to try and get to…the laparoscopic surgeon is the only way to really get there.  
Andrew: Yeah. And I think there was some evidence that the first laparoscopic surgery is the real one that you want to get done right.  
Rebecca: Yes. That's correct. Yes. You do. You want to get the diagnosis, you want to clear out as much as humanly possible, and then you want to start having your team of practitioners to help support you and prevent the reccurence. Yeah.  
Andrew: And, just for our listeners, we will definitely be putting a lot of support material up on the FXMedicine.com.au site so that you can access it there, and so that you can help your patients from there. 

Obviously, listeners in different countries from Australia, you might get some guidance there, but you'll have to find those appropriate practitioners in your own country. 

So, we've gone through diagnosis. What about diagnostic delay? This is the big one. This is the big issue. What does it cause?  
Rebecca: Yeah. Well, the biggest issue is the normalisation of period pain in society. That's just full stop. And that's because throughout all of human being life, really, menstruation's always been a ‘woman's business,’ and it's always been something that we have to hide, feel uncomfortable about. And this doesn't just come from women that possibly have endometriosis. It comes from men, friends, family of a woman who possibly has endometriosis. It comes from male and female doctors. So this is a huge social issue. Targeting that...and I know that there's been some work done in the UK recently where they've released a new ad for their sanitary items. And instead of using a blue liquid to pretend to be menstrual blood, they're actually now using a red liquid.  
Andrew: Yeah.  
Rebecca: So, even though that's something quite small, like they're actually showing, "No, this is what it kind of looks like." Which is really good, and it's educating the public on that. So, trying to reduce the normalisation of period pain is probably going to be the easiest thing forward. 

But even, you know, teaching not only females or, you know, young girls in high school or you know, in primary school, like really educating everyone. That is really important. Because women are going to need support from partners and friends and family, and so, really, you know, teaching everyone is what's going to really help reduce the diagnostic delay with this condition. 
Andrew: Absolutely. I think taking away these weird taboos...it's a human body, for goodness' sake.  
Rebecca: I know! I know.  
Andrew: I'm so glad... 
Rebecca: I don't understand.  
Andrew: Yeah, I'm so glad about our...like, sex ed, it was called. But I'm so glad about our sex ed that we had. Because it wasn't the deciding factor, but it was certainly one of those things where I went, "Wow, the human body's really cool."  
Rebecca: That's right.  
Andrew: And that's one of the things that led me, eventually, to do nursing.  
Rebecca: That's right. And there’s something that I've recently conducted, I did a systematic literature review, looking at women's experience of endometriosis, and in there, actually there was a theme that I identified, that women weren't even taught about reproductive diseases in their sex ed classes. So that's another area that we can try and teach women, "This is what endo looks like, these are what the symptoms are, this is what happens, and this is what you can do to seek help." 

So even just going back to the high school sex ed classes, and helping to really inform people then, and continue that on throughout high school's really important as well.  
Andrew: And I guess, I mean, one of the issues, one of the problems with endo, is that there's such a breadth of presentation, that's really hard to categorise.  
Rebecca: That's right.  
Andrew: So, you know... 
Rebecca: That's right.  
Andrew: ...as you say, Stage 1 to Stage 4, but the symptomatology has nothing really to do with the objective presentation of lesions.  
Rebecca: Mm-hmm. That's right. That's definitely right. It really comes down to really listening to them. 

So there is...a lot of women will explain that their pain, their menstrual pain, feels likes a stabbing, tearing, burning, stinging type of sensation. Whereas women who have primary dysmenorrhea, it's sometimes described as more of a cramping, pushing type pain. So you can see there's a little bit of a difference. And the other thing that's been identified in research is that if medical professionals asked women about their sexual health, that would help in reducing the delay in diagnosis as well. Because a lot of women with endo do have painful intercourse.  
Andrew: Right.  
Rebecca: But that's something that we don't actually talk about either. And so, if they just said, "Okay, you've got all these bowel symptoms, you've got menstrual problems. It sounds like IBS." But if they just said, "Okay, do you have any pain with intercourse?" And really talk to them about that, there is a possibility that they might go, "Okay, I think this is outside my scope, I will refer to a gynaecologist."  
Andrew: So, when you mentioned that stabbing pain, I seem to recall that, you know, one of the issues with endometriosis is that it's hard to look for either these, you know, sort of serum markers or anything.  
Rebecca: Yes. Yeah.  
Andrew: Is there any hints, any clues that at least there's inflammation going on? At least there's something to go, "Hang on, you know, we need to look further." You know, "We need to..."  
Rebecca: That's right. Well, from what literature I've looked into, women don't even get offered to do any blood tests, when they go to their doctor, presenting with menstrual irregularities anyways. 

But, as far as I know, that there isn't. But I have recently read, I think it was a news article, so I'm not really sure on how correct it is, but there are some researchers that are trying to look into possible serum markers. So that might be something that comes out in the future. But I think at this stage, there isn't.  
Andrew: Some people have even said that endometriosis might have an autoimmune component. Highly controversial, certainly not backed up by a lot of research. But there are researchers looking at it. What's your opinion of this?  
Rebecca: With my understanding of how endometriosis works, we're really not sure. I know that there's research that is showing there's possibly autoimmune factors, but then there's also research showing there's inflammatory factors, and there's oestrogen factors, and there's low progesterone factors, and there's environmental factors. So we really...there's no real clear picture.  
Andrew: No, and it certainly doesn't classify as a classical autoimmune condition, does it?  
Rebecca: No, it doesn't. And even when you just think about that, I just...it doesn't make...it's not very clear. It doesn't make a lot of sense. Whereas, you know, trying to understand exactly how it works, just based on one pathway, I don't think that's how it's going to work.  
Andrew: Yeah. I think the issue comes... 
Rebecca: Yeah.  
Andrew: ...me, not being an expert, forgive me, this is just me pondering. But I think that one of the issues comes from that autoimmune diseases have inflammatory components to it. That doesn't mean that every inflammatory component automatically makes it an autoimmune disease.  
Rebecca: Mm-hmm, that's correct. Yeah.  
Andrew: Yeah, you've got to autoantibodies, and they're not seen in endometriosis, as far as I'm aware.  
Rebecca: And really, we just need to do more research on...more research is really, really needed to really understand it. You know, research takes a very long time as well, and obviously is quite costly. But, that's the only way we're going to be able to find out the complete 100% pathophysiology. Like, we don't even know the pathogenesis. We don't know how it's caused. There's multiple theories... 
Andrew: Right.  
Rebecca: ...with autoimmune being one of them, same with inflammation. As well as, you know, as I mentioned earlier, the genetic components. And I know there's a bit of research going on, I think that UQ who’s looking into that as well. 

There's also the standard theory and the sort of historical theory is that it's retrograde menstruation, but research has shown that that doesn't answer the question. Because some women can have retrograde menstruation and not have endo. So really, we just...we don't know, yet. I think we're getting closer. I'm hoping we're getting closer. But we just...I don't think we're going to get a one, single answer. Especially with environmental factors as well.  
Andrew: Is there any, you know, dare I say the word, "hero" researchers that we should be looking at the work of?  
Rebecca: I don't know if he does too much research, but his name is Dr. Camran Nezhat, and he is a laparoscopic surgeon and gynaecologist in America. He does a lot of work with the World Endometriosis Congress as well, and he's phenomenal. He's written a lot of books on the history of endometriosis, he's done...so, I don't know how active he is in research. I know he's done a lot of publications, but if that's something that he continually works on? But he's got a lot of different research articles and textbooks that talk about the pathophysiology of endometriosis as well as how, throughout history, endometriosis has presented, what he uses for his patients, what works, what doesn't work. So he's got a lot of wonderful resources.  
Andrew: And of course, you've got wonderful people in Australia, like Professor Jason Abbott, and Natasha Andreadis, and others who... 
Rebecca: Yes.  
Andrew: They're Cree specialists.  
Rebecca: That's right. That's right.  
Andrew: They're these...I mean, Jason, I think, is on the board, isn't he, of Endometriosis Australia? Is that right?  
Rebecca: That's right. He is. Yep. So a lot of the board members on Endometriosis Australia do have a bit of research in that area, or at least doing clinical practice and maybe a point that women could go to as well. 

There are some researchers that are actually looking into the Australian healthcare burden in the economic class. I believe they're still doing data analysis. I'm not too sure when their publication might come out? I've also included a small section of this into one of my PhD projects, so I’ll have a little bit of information that I can contribute to the field as well. But, as I mentioned earlier, there was only really that 2012 paper by the World Endometriosis Research Center.  
Andrew: Wow. Five years ago, guys.  
Rebecca: Yeah.  
Andrew: Jeepers. 
Rebecca: Yeah, so we really need to get moving on this. But you're right. This is, if we can do some research in this area, there's a possibility that the government will start looking this way and really try to help.
Andrew: What about naturopathy? You know, one would think that, "Look, this is undiagnosed or delayed diagnosis. It goes around, causes a big healthcare burden, and so we need to treat it really effectively with strong medicines that we have." And yet, it doesn't seem to be that clear cut thing, that it's just, "Take a pill, or do a laparoscopic surgery, and it's gone."  
Rebecca: Yeah.  
Andrew: So, what's the role of naturopathic medicine here?  
Rebecca: I definitely think naturopathy and even complementary medicine practitioners, in general, can have a really strong role in supporting women with endometriosis. But there isn't much data to really show what naturopaths are doing. If it's effective, if it's safe, you know, if it's working for them, if women...if it's cost effective? We don't really know. 

But I think...one thing I really like about endometriosis and the way that the treatment plan should be working, is that women don't have one single practitioner, they have a team. And I think that can really help support women in multiple ways.  
So, for naturopaths in particular, they've got a large number of tools that they can draw on. They can use herbal medicines, they can use nutritional supplementation, diet and lifestyle...and there's a lot of research that's starting to come out about dietary impacts with endometriosis. So helping to educate women on what they should and shouldn't be eating to help reduce any possible risks that may be aggravating the condition is really important as well.  
So I think definitely having a naturopath on a team of practitioners in  support of women is something that we can move forward to. And there's, you know, a lot of research coming out about acupuncture being really helpful in managing pain as well. So, there's a wide range of researchers coming out in this area, but definitely naturopaths can be very supportive in this case. 

Even after a woman's had laparoscopic surgery, and just educating them, and helping to support their hormonal dysfunctions that are occurring. If there's inflammation going on...all the toolkits that naturopaths use to manage the condition can really help, especially after that surgery period.  
Andrew: Thank you for correcting me on the point of complementary medicine, because acupuncture is indeed very important in this.  
Rebecca: It is.  
Andrew: Yeah.  
Rebecca: Yeah. But there's a lot of research on acupuncture and complementary medicine research to manage the condition, as well as traditional Chinese medicine. There's a bit of research that's coming out. I think 2014 was one of the last systematic reviews that came out on the effects of traditional Chinese medicine in managing endometriosis? So there's research out there that can really help support people.  
Andrew: What about your stuff? What about your research?  
Rebecca: So as you mentioned earlier, I am a PhD, so I'm having...like, my project is primarily focusing on the naturopathy and endometriosis. And so, what I'm really trying to look at is understanding the historical and the contemporary naturopathic approach to managing endometriosis, as well as the associated symptoms of dysmenorrhea and menorrhagia.  
So I'm doing this in three large projects. I'm also looking at describing the prevalence of use of naturopathic consultations and treatments by women with endometriosis, as well as looking at what naturopaths are using in clinical practice. So I'm building on the foundational work that has yet to really be laid down in Australia.  
Andrew: Now can you tell us any data that you've gotten from that yet?  
Rebecca: I do. I have lots of data. So, particularly from the historical approach. So, I will go through the herbal remedies first, because it's actually quite extensive, which I was really quite surprised. 

So out of 37 traditional texts that I reviewed and 61 journal articles that I conducted at the National University of Natural Medicine, I've identified 139 herbs that were traditionally used to manage dysmenorrhea.  
What's quite interesting is while I was studying to be a naturopath, I can't even remember... I've been studying 139 herbs. I swear there was probably, like, 10 that were recommended for dysmenorrhea. So, that shows, you know...because change in evidence and change in maybe how things are working and how we understand how herbs and whether or not they're effective. 

But the top 10 that were traditionally used for dysmenorrhea was black cohosh, blue cohosh, pulsatilla, cramp bark. This one's quite interesting. It's called ‘Liferoot’. I'm really quite interested in looking into this one more, because it was dubbed the "female regulator" by a lot of the eclectics. But I've spoken with Australian and American naturopaths... 
Andrew: The Liferoot?  
Rebecca: Yeah, life root. And they haven't heard of it. They're not really sure where it came from. But it's very strong in American naturopathic texts.  
Andrew: So what was the botanical name of this?  
Rebecca: Senecio aureus.  
Andrew: I've never heard of it.  
Rebecca: Yeah. So I've spoken with quite a number of American naturopaths, and they haven't heard of it, either. So I'm not sure if possibly it's from Native American or possibly even Canadian. So, there's a lot of research I'll probably be doing to look into that one. 

The very famous False Unicorn Root which we still currently use for dysmenorrhea. Gelsemium was also quite prominent, as black haw, wild yam, and partridgeberry, which was more likely used in American naturopathic practice compared to Australian. So that's the top 10 for dysmenorrhea out of the 139 herbs.  
But I did also identify homeopathics. And there's a small number that are recommended, particularly nux vomica, which was used for women who had dysmenorrhea but also had a sensation of a very weighty, heavy uterus, or had bearing down pain that occurred at the same time as their menstrual cycle. There was Sepia as well, which was more recommended when a woman had dragging or bearing down pain down her legs, like her inner thighs. That was more likely recommended in those type of situations. 

There was ignatia, pulsatilla, apis, belladonna, chamomilla, coffea, and graphites as well, which were more likely recommended from a homeopathic point of view.  
Andrew: What’s the evidence… this is just looking at use, not evidence behind that use. 
Rebecca: This is looking at the traditional naturopathic prescriptions used for dysmenorrhea. So when I went through all of the texts, they would have, whether it be a chapter on dysmenorrhea, and they would list out what homeopathics or herbal medicines or dietary interventions that they would recommend. So, for example, […inaudible…] stated that nux vomica was beneficial in a woman that experienced dysmenorrhea with a weighty uterus, or had an irritable uterus.  
Andrew: Yeah.  
Rebecca: So this is traditional evidence that we still use in clinical practice.  
Andrew: Okay, but one of those herbs I noted was gelsemium. Now that's a... 
Rebecca: That's right.  
Andrew: ...an S4, prescription-only herb in Australia.  
Rebecca: That's gelsemium?  
Andrew: Gelsemium.  
Rebecca: Yeah. So we know it's poisonous as well. But, now we don't use it. But traditionally, they did. 

So there's a lot of traditional treatments that they used that I'm aware of that we don't use anymore. And it's possibly because as time has gone on, and evidence has gone on, it’s come about that it’s actually, that's detrimental. That's not being effective. That's a poison.  
Andrew: Right.  
Rebecca: But, you know, that knowledge is coming through now, which of course you don't want to be giving someone gelsemium, seeing that it's poisonous. But, you know, you can use it homeopathically, but I'm not sure if there's any research that has backed up to say that it's effective and safe.  
Andrew: I was blessed to come from an era where the S4 herbs were made by a certain company in Australia... 
Rebecca: Oh, okay. 
Andrew: ...who had medical herbs. And a doctor used to use gelsemium.  
Rebecca: Wow. 
Andrew: And this doctor was very safe in the utilisation of the prescriptions. Never an issue, that I saw? And seemed to be very effective. I think the only issue with overdose was that it could depress breathing. So I get that there's a...there could be an issue with over prescription and over/ improper use... 
Rebecca: That's right.  
Andrew: ...and unregulated. But, you know, it's just...to me, it's just sad that these S4 herbs aren't made any more, aren't utilised any more.  
Rebecca: Yeah, yeah. And that's, you know, quite a big issue as well. We need to have more research to really work out what the appropriate dosage is as well. Particularly if they are...you know, you need to have more caution.  
Andrew: Yeah. So we need...we've got the list of historical use, but we don't have the data to show safety and efficacy yet.  
Rebecca: Correct. That's right. And that's just because...well, particularly in Australia, like, I know that there is a little bit of research on endometriosis and naturopathy. There's not a lot. And so I'm really hoping that the work that I'm doing will help lay down some of the foundational work so we can build research projects off that, and in fact, you know, look at the efficacy and making sure that what we're prescribing is being a benefit to women and is helping them manage their symptoms or address the cause of the problem. 
Andrew: Right. I also noted one of the...you know, it is the poster child of hormonal herbs, and that is the false unicorn. And it is diabolically expensive.  
Rebecca: Oh, yes.  
Andrew: So, you know, you bring this to a cost benefit factor, and it's going to fail... 
Rebecca: Yeah, That’s right. 
Andrew: ...over time.  
Rebecca: That’s right.
Andrew: Why is it so expensive?  
Rebecca: I believe that it was used, and particularly based on what data I've looked at, because it's number 4 out of 139, but it was pretty much wildcrafted and utilised so much that it was getting to the point of extinction. That's what I've read about it.  
Andrew: Yeah.  
Rebecca: I know you can still use it in clinical practice now, but that would be up to the discretion of the naturopath, whether or not they were comfortable spending that much money and making sure that it was actually, you know, suitable for the woman.  
Andrew: What about the symptoms of dysmenorrhea and menorrhagia, common symptoms in endometriosis, what's the traditional approach?  
Rebecca: Yeah. So for menorrhagia, it was very similar to dysmenorrhea, in that herbal medicine was more prominent for the treatments. And so, I've identified 101 different herbs that they recommended to use in case of menorrhagia. 

So the first one was one that I've never come across before in my studies, studying my naturopath degree. But was ergot, and it was a fungi.  
Andrew: Yeah.  
Rebecca: That particularly grows on rye. But what's quite interesting about ergot is that they've actually now made, a lot of pharmaceuticals, that they now use in afterbirth bleeding and hemorrhage. 
Andrew: And migraine.  
Rebecca: Yes, Cafergot. Yeah, for migraines. Yeah, so there's Ergometrine, which is used for heavy bleeding that occurs after birth. And that works by stiffening the uterus to control the bleeding. So you can kind of understand how that might be of benefit for women who have menorrhagia, if the constituent is the actual one that's having that activity.  
But other herbs for it out of the top 10 was beth root, and yarrow, life root, again, came back. And ipecac, which we know is a very strong emetic, so dosage of that did actually vary. Cinnamon, Canadian fleabane, wild geranium, goldenseal, and black haw. So, some of these herbs I'm aware of that we do still use, such as cinnamon and goldenseal and yarrow. But some of them, I think have more...and Black Haw, that have more of a prominence in American naturopathic practice, as well.  
Andrew: Yeah, I've never used fleabane. Have you ever used it or heard of it?  
Rebecca: No, I've never studied it. I'd never heard of it at all. But it was Canadian fleabane that was more likely recommended, so that might have just been that there was a large volume of the American and Canadian texts that actually stated that that herb was of benefit.  
And there was also some homeopathics as well. Apis was number for menorrhagia, as well as carbo veg. But it was more likely used when a woman had oxygenation issues. So if she had a pale complexion, or you know, poor circulation, blue lips, and menorrhagia, they're more likely to use that homeopathic remedy. Ipecac was another one, as well as belladonna, chamomilla, and nux vomica as well. So it's quite an extensive list.  
There was also hydrotherapy. A lot of the applications were cold water applications and vaginal douches and enemas and cold baths as well were more likely recommended, which we don't practice in Australia, unfortunately.  
Andrew: No, I know. We just go to the, you know, the hot water bottle rather than something like a slippery elm or castor oil poultice.  
Rebecca: Well, I'm hoping hydrotherapy comes back.  
Andrew: Yeah. I think I need to make the salient point to our listeners about safety, and that is, when you mentioned those homeopathic remedies, some of those remedies are toxic if you don't take them in a homeopathic form.  
Rebecca: Yes, that's right. But yeah, so definitely hydrotherapy was recommended. But diet and lifestyle for menorrhagia was really quite interesting, because they actually stated what they believed the cause of menorrhagia was. Which I was quite shocked. 

So they believe that women have menorrhagia because there's been ‘excessive stimulation of the body’. So this meant that a woman has done excessive physical activity, she's overworked, she's exhausted, due to diseases, she's had an extreme cold or she has excessive sexual indulgences. And that's what they used to think caused menorrhagia.

Andrew: God.  
Rebecca: So a lot of the diet and lifestyle treatments were about locking a woman away in a dark, cold room, being left alone. 

Andrew: What!?

Rebecca: Which sounds really horrible. And consuming a really bland diet. Like, no tea, no coffee, no salt, no pepper, no herbs. You know, very, very bland. You know, mashed potato-type diet.  
Andrew: Anything to cause more problems.  
Rebecca: Yes, that's right. Yep! Yep.  
Andrew: What?  
Rebecca: But it was really interesting to actually see that and know that that's not what we do anymore. So, you know, research is coming out there, and we've got, you know, really good, wonderful practitioners that are working in these areas and doing the best that they can. Instead of locking them in a cold, dark room. 

Well, these are the founders of Naturopathy, this is what they used to do.  
Andrew: Oh, my goodness. So naturopathy's got a bit of stuff to answer for as well.  
Rebecca: Yes. Just a little.  
Andrew: It's not just the medical field that, you know, put people in sanitariums and things like that. Asylums, forgive me. Asylums.  
Rebecca: Yeah, that's true. That's true.  
Andrew: How about the traditional approach to managing endometriosis as opposed to dysmenorrhea or menorrhagia? 
Rebecca: Well this is actually really interesting, and it's something I was really shocked to find when I was doing my data collection and data analysis. So from all of the texts that I actually looked at and reviewed, the term "endometriosis" didn't come up once.  
Andrew: Wow.  
Rebecca: So I looked at hundreds and hundreds of books, and there was no mention. But to provide, I guess, a little bit of background and history of endometriosis, to understand why this possibly didn't happen, was in 1927 Dr. John Sampson coined the term "endometriosis." So he dedicated a lot of his life work to endometriosis. And he was also the one that stated that endometriosis was caused by retrograde menstruation. However, in 1860, that was when endometriosis was microscopically discovered. So, my time period of my project fits within the history of endometriosis, but I found nothing.  
Andrew: Wow! 
Rebecca: So, yeah. I was totally blown away by this. I really thought I would find like, even just one sentence from someone, but there was just no mention at all. So I've done some extra personal research to really identify why this has possibly happened, and what I've been able to find is that how we understand endometriosis, is that it was called different things throughout history. So for 4,000 years, it was called "uterine fury," "suffocation of the womb," my favorite is the "wandering womb" because it...you can understand how endometriosis is and that it wanders the body. As well as "irritable uterus," and a really big one was that it was once called "hysteria."  

Andrew: Ahh. 
Rebecca: And, yeah, so there's a lot of data that has been conducted by Dr. Camran Nezhat that I mentioned earlier, in the U.S., where he conducted a project that looked over 4,000 users' medical data that identified a history of endometriosis. And his conclusion was that the presentation of hysteria and endometriosis were extremely similar, and it's possible that hysteria in a lot of these cases was actually endometriosis.  
So I think that's kind of where my data has lacked, is that there's a possibility of the eclectics and the naturopathic practitioners of the time were just not aware of the change in medical terms or, it wasn't something they came across. Like I said earlier, women can be asymptomatic, or they might just have a few symptoms such as dysmenorrhea or menorrhagia and they're just treating those conditions. Rather than realising that there’s a larger condition going on underneath. 

So unfortunately, I don't actually have any data, but I think this really shows, you know, the lacking evidence in endometriosis in naturopathy, from a traditional point of view.  
Andrew: So how are aspects of your project going to advance the field of research? What's happening?  
Rebecca: Well, as I mentioned earlier, there isn't really much data in the Australian naturopathic setting that's showing how, you know, the role or the value of naturopathy is for women in endometriosis. So, I'm really hoping that my work will lay down some of the foundational work so we can build up some further research on this area, particularly looking at the effectiveness of naturopathic care, and seeing what the outcomes are? Like, if a woman does have endo, and she's decided not go through and have surgery, like is there a way that we can possibly see if what we're doing is improving her quality of life, as well as whether or not, you know, the integration of naturopathic cure is appropriate for women with endometriosis, too. So I'm really hoping mine will be laying the foundational work.  
Andrew: Absolutely brilliant. And I got to say, like I know you outside of FX Medicine, and you are thorough.  
Rebecca: Thank you. I do try.  
Andrew: So like, I just can't applaud you more. You don't try, you succeed. You do really well.  
Rebecca: Thank you.  
Andrew: And I've got to say, wow. Like, I want your autograph for going to research those texts.  
Rebecca: Oh, gosh.  
Andrew: That would have been an honour, just to go and see those old texts.  
Rebecca: Oh, I cannot even describe the joy that I felt being in that room.  
Andrew: Oh, wow.  
Rebecca: It was best experience of my life. I can't wait to hopefully go back.  
Andrew: Bec, I hope to see the next phase of your research. I really do.  
Rebecca: You will.  
Andrew: Because I know that it's going to be pointed, it's going to have a direct...you know, an endpoint that you can use to them jump, or that you can use in practice. So, very well done for you.  
Rebecca: That's right. Thank you. Thank you very much.  
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Additional Resources

Rebecca Reid
Endeavour College
Endeavour Office of Research 
The ARCCIM International Naturopathy Research Leadership and Capacity Building Program 
UTS: University of Technology Sydney
Australian Research Centre in Complementary and Integrative Medicine
National University of Natural Medicine
Dr Camran Nezhat
Prof. Jason Abbott
Endometriosis Australia

Research explored in this episode

Lacy B, Patel N. Rome Criteria and a Diagnostic Approach to Irritable Bowel Syndrome. J Clin Med. 2017 Nov; 6(11): 99.

Simeons S, Dunselman G, Dirksen C, et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Human Repro. 2012 May 1;27(5):1292-1299. 

Steel A, Reid R. A need for a better understanding of the role, value and effectiveness of complementary and integrative medicine for women with endometriosis. Adv. Int. Med. 2017 Apr;4(1):3-4


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