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Endometriosis: Neurocircuitry and the Emerging Role of Trauma with Emma Sutherland and Leah Hechtman

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Endometriosis: Neurocircuitry and the Emerging Role of Trauma with Emma Sutherland and Leah Hechtman

Leah Hechtman, well respected naturopathic practitioner, and reproductive health expert, explores the pain associated with endometriosis and the emerging understanding of adjusted neurological pathways through a woman’s life experiences that can shapes her perception of pain. She is joined by FX Medicine ambassador, Emma Sutherland, who delves into the concepts of the neurocircuitry that occurs in women with endometrial pain, and explores why some women may or may not feel pain depending on the physical severity of tissue proliferation. There’s a deep connection between lived experiences, emotions and trauma which impacts a woman’s feeling of safety, self-worth and empowerment which requires ongoing work to untangle in order to recover from experiencing ongoing pain - even when the clinical signs of endo have ceased.  

The importance of support and providing a safe space for women to discuss all the underlying factors to their pain is emphasised.  Importantly, knowing when to refer is explained, particularly if there are aspects of psychological, physical or sexual health that requires another experts skills to facilitate the road to recovery. Emma and Leah discuss various tests that prove to be valuable for measuring inflammatory and coagulation makers, both hallmarks of endometriosis, the use of medications and how they assist with management.

Covered in this episode

[01:04] Welcoming back Leah Hechtman
[02:23] Pain as an enduring symptom in endometriosis
[07:18] Inflammation influences pain processing 
[13:18] Retraining the brain’s neurocircuitry
[16:57] Vascularisation and coagulation challenges with endometriosis
[19:39] Biomarkers to assess and track inflammation 
[22:23] Trauma, the mind-body connection and endometriosis
[28:40] Addressing trauma in clinic
[30:30] The use of antidepressants in women with endometriosis
[33:24] Upskilling to support patients with trauma
[35:58] Cautions and tips around case-taking when trauma is present
[40:20] Sexual health as part of recovery
[42:53] Looking to the future of women’s health
[46:24] Thanking Leah and closing remarks

Key takeways

  • Endometrial pain is linked to dysregulated neural pathways, inflammation, and hormonal factors. 
  • The anticipation of pain itself can trigger painful episodes for people with highly altered pain neurocircuitry. 
  • Thermoregulation is common in women a typical symptom being cold hands and feet. This can indicate blood stagnation that can be inflammatory. 
  • Trauma can intensify endometriosis pain. Proper referral is crucial for managing emotional triggers in pain management.  
  • Building trust and providing a safe environment for women with endometriosis is essential. Pay attention to their cues and desires for exploration, without forcing conversations. Knowing when to refer is important.  
  • Antidepressants for endometriosis can be reframed as reducing the brain's perception of pain caused by amplified neural circuitry. 
  • Eye movement desensitization and reprocessing (EMDR) therapy may be considered to refer out to for women who have experience trauma. 

Resources discussed and further reading

Website: Leah Hectman
Research: Research progress of CA125 in endometriosis: Teaching an old dog new tricks (Gynecology and Obstetrics Clinical Medicine, 2022)
Gabor Maté: books, films and courses 
Book: Trauma, Tragedy, Therapy by Stephen K. Levine
Tara Brach: Meditation, emotional healing, spiritual awakening 

TESTING: Inflammatory markers in endometriosis 

Vascular Endothelial Frowth Factor (VEGF) 
Turmor Marker CA-125
C-Reactive protein (CRP)
Erythrocyte sedimentation rate (ESR)
Immunoglobulin G (IgG) subclass


Emma: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. 

FX Medicine acknowledges the traditional custodians of country throughout Australia where we live and work, and their connections to land, sea, and community. We pay our respect to the elders, past and present, and extend that respect to all Aboriginal and Torres Strait Islander peoples today. 

I'm Emma Sutherland, a Sydney-based naturopath. I'm extremely excited to be speaking with Leah Hechtman, a name who many of you will recognise as a powerhouse of knowledge within the natural health sector. Leah specialises in fertility, pregnancy, and reproductive health for men and women. She's also a university lecturer, keynote speaker, author, educator, and mentor to her peers. She's currently completing her PhD through the School of Women's and Children's Health at the University of New South Wales and is the author of Clinical Naturopathic Medicine and Advanced Clinical Natural Medicine. 

Welcome to FX Medicine, Leah. Thank you for being with us today.

Leah: Thank you so much for having me.

Emma: It's our pleasure. 

Now, endometriosis affects one in nine women, and unfortunately, it does take an average of six and a half years for a woman to be diagnosed. It's often under-recognised and misdiagnosed. And as we learnt in the episode with Natarsha, who was the patient in our series on endometriosis, pain is so impactful. In fact, pain is the most common symptom in endometriosis. And today I want to deep dive into pain, trauma, and their role in endometriosis.

Leah: Sounds good. Let's do it.

Emma: Let's do it. Exactly. So, let's cover some basics. Can you talk us through pain perception, pain interpretation, and pain wiring? Can you give us the rundown on that?

Leah: Absolutely. So, if it's okay with you, let's just... You don't mind if I lay the scene?

Emma: No, that's good.

Leah: Everything that you've talked about, that I've talked about that we know about endometriosis as drivers for it are still incredibly valid. I don't want anyone to think that we're all of a sudden saying there's a whole new justification or explanation for endometriosis. It's about the understanding of how it all develops and what actually happens for the body. And so, you and I both know yeah, you've got the patient, the example that you gave of Natarsha. They experience all these things. Something has occurred for them that has driven their body to develop endometriosis itself, but their experience of the pain can be one of the initial symptoms but is certainly the enduring symptom.

And the thing that I've found clinically is that you can sort out all of the things that drove the disease in the first place, but they're often left with the memory of the pain. So, their perception of the pain is distinguished by whether or not it's what they experienced at the early onset of diagnosis, or even pre-diagnosis versus during disease, during their endometriosis flares versus once actually everything's been addressed. And they can still have the pain that's enduring, possibly even lifelong. I don't know that definitively. I just know that in my experience, I'll have women and I'll support them, we’ll address everything and even post-menopausally, they're still experiencing the pain, but there's no evidence of endometriosis anymore.

Emma: Yeah. Right.

Leah: So, we're starting to talk about how it's actually affected their brain, essentially, the neurocircuitry, how their nervous system has accommodated the experience of the pain itself.

Emma: That's fascinating. And I think a new concept for us to explore because it's not one that as clinicians we are super familiar with. So, yeah, that pain interpretation and the pain wiring becomes altered in women with endometriosis.

Leah: Essentially. Yeah. I think one of the things that I found most fascinating when I really started to explore endometriosis as a clinician was how we would diagnose endometriosis and the progression of the disease was completely different to the experience of pain. So, you'd have the woman sit in front of you, she'd be diagnosed as Stage 4, severe, affecting multiple organs right through her whole peritoneal cavity, and she wouldn't feel a thing, versus the woman who would have extreme pain, couldn't be intimate with her partner, couldn't walk, couldn't exercise, couldn't sleep, couldn't leave the house when she had a period and barely a Grade 1.
And so then you have to start to look at it and go, "What is the difference between these women, and what is the difference around how their nervous system is actually organised and how the communication or the signalling of that pain, how they're interpreting that pain, and then how their brain is accommodating that pain as they progress through it?"

And it's quite fascinating when you start to look at the variables that influence it. Age of onset, severity of the disease, severity of the experience of the disease and support of their caregivers, support of their family, support of their partners. There's all of these mind-body connection pieces and emotional aspects that go with it. And certainly, which I know we'll get into later, the aspect of trauma and how that influences whether or not they actually feel in their body. And that's where I'm really fascinated, I guess, as a clinician and as a researcher at the moment with it.

Emma: Yeah, and I think that dichotomy of the woman who has Stage 1 diagnosed, but then extreme pain, I've always looked at that clinically and found it confusing. And this is so exciting that there's an insight here that can explain that anomaly because it's not only confusing for the patient, it's confusing for the clinician.

Leah: Absolutely. And I always cross my fingers if any of my patients go, "No, no, no, it's a decision. We need to do a laparoscopy, we need to do surgery." I'm sitting there crossing my fingers going, "Please find something substantial and make it worthwhile." Because there's nothing worse than a woman going through a surgery for endometriosis and then they go, "Oh, well, there really wasn't anything there." That's just totally demoralising and destructive for her and her experience of life and her confidence in her own mind-body connection.

Emma: Yeah. Yes. It's completely invalidating. That's right. When we're...

Leah: Yeah, perfect word.

Emma: When we're looking at brain structure and function with women that experience chronic pelvic pain, what changes tend to occur? What happens in the brain?

Leah: The language that I use with my patients is that your pain fibres and your pain processing is like a well-trodden track. So, if we take it down to inflammation before we go into the pain wiring. So, with inflammation, we know that collectively, as just a race of humankind, we're all having more and more inflammation for various reasons: environmental, emotional, stressors, you name it. There's a whole host of reasons that are driving inflammation. But inflammation we know is a sequelae driver for endometriosis. So, it sets up this whole neuromodulatory process within the brain that this inflammation pain cycle sets up. And until the woman actually addresses all of the inflammation, that circuitry doesn't settle itself down. 

But then once that pain cycle and that pain wiring has actually been laid down, it's a track that her body goes from 0 to 10 in a heartbeat, whereas at the beginning it went from 0 to 1, maybe 0 to 2. Your Endo women are the women that you sit clinically with, and you go, "So, can you tell me what was your period pain like last month?" And they go, "Well, 10." And you're like, "But wasn't it a little bit better?" And they're like, "Yeah, I could go out, I could do this, but the pain was still 10." 

Emma: Right.

Leah: And it's not that it's in their head and it's not that they're making it up, none of those things, but it's that the body has this ability of it's gone from 0 to 10 and it's done that for so long that the brain's interpretation of that pain goes to 10 immediately.

And so much of what we need to be thinking about is the structure of the brain, the interpretation of pain, the interpretation of fear of that pain, the interpretation and resistance of impending pain becomes a cycle and it's a self-fulfilling cycle in their bodies. So, they interpret, "Oh, it's day 28, I'm about to get my period. I'm going to be in terrible pain,” and all the signalling in their brain goes, "Crisis coming." And that's both the trauma of the experience of pain and the fact that their brain has probably been rewired and set up for that pain from prior traumas that may or may not have been endometriosis-related.

Emma: Right. So…

Leah: Does that make sense?

Emma: It does make sense. My brain is rapidly thinking, and what I'm thinking, if I can talk out loud, is that it is that repetitive process that wires in that pain pathway to be the most easiest pathway to be activated and the most efficient pathway is in that pain pathway. That's the automatic default that gets pressed at that time, and that gets wired deeper and deeper the more often it happens until the point where it happens at a smaller trigger will get a 10 out of 10.

Leah: Yes. It's an irritation hypothesis. When you start looking at some of the research and the papers out there they talk about this irritation, sensitisation, pro-inflammatory driver. So this idea of any time there's inflammation in any environment — and these women are walking around with inflammation around those areas — any tiny sensitisation to that area triggers a whole cascade of events. And that's often why they have so much discomfort when they're intimate with partners and things like that as well because that area has so much hypersensitive, neuronal fibres that they're just reactivating all the time.

Emma: Okay. And there are so many questions that I've got.

Leah: We all do, we all do, and it's an unfolding area. And absolutely, as a caveat, you and I can talk in two years and we'll be like, "Right. Now we know this bit." But at the moment, this is what we know. But one thing, if it's okay, it's really about acknowledging that. We know that in periods of transition for all women, their brain restructures and we know that certain sections of their brain will get smaller, certain sections will enlarge, and it's dependent on hormonal drivers but it's also dependent on neurological output. And we know that in women with endometriosis, their brain shape changes and certain sections are certainly much more activated on MRI studies. And, in particular, their fear receptors and their frontal lobe activation and things along those lines are completely different because of that perpetual pain cycle.

Emma: Yeah. That's total survival response, right? Makes sense.

Leah: Absolutely.

Emma: Yeah. We fear the things that cause pain and that gets ingrained again and again. 

And what underlies that pain wiring in endometriosis? How does it happen initially? And then what can we do about it? And that's such a big question, but any insights would be great.

Leah: Yeah, no, for sure. With the pain wiring, it's a number of different aspects, but when you look through the research at the moment, and certainly when I correlate it clinically, it's inflammation, yeah? So, inflammation is the number one driver, and then that sets off the wiring, it derails the wiring and it sets up inappropriate neurocircuitry within the brain or within any of the pain fibres. 

But that inflammation can be driven by a whole host of things, which is what we have been focusing on clinically, be it progesterone resistance, be it increased secretion or increased uptake or unopposed oestrogen, be it infective driver, be it microbial imbalance or microbiome deficiency. All of those things are driving the inflammatory process, which is why we've spent so long at reducing inflammation systemically.

But the newer research is around looking at it and going, "Well, that inflammation, if it perpetuates, it perpetuates the pain but then it also drives all of the growth aspect of endometriosis, like the endometriomas and the unfortunate scenarios where it progresses to cancers and things and DNA damage. But it's still coming from that place where it's literally like their brain is inflamed and their whole nervous system is inflamed, which is moving it forward continuously.

Emma: Yeah. And so, as clinicians, we have been working on all what we thought were the drivers, which is the right thing to be doing. The question is, how do we start working on this bigger picture of the neurocircuitry?

Leah: I think we have to acknowledge a few things. So, one is that we're limited by where research is at at the moment but it's incredibly fast at how fast it's moving. And when you start looking at all of the AI interventions and AI developments in research around neuroplasticity we're going to get there quite quickly. So, what we understand at the moment though, is that the concept of neuroplasticity is the ability for the nervous system to reorganise itself, for parts of the brain to regrow, redevelop, rewire, redo everything essentially. And our entire nervous system has the capacity to be able to do that.

As clinicians, we need to look at it and we need to go, "Okay, so I've ticked all my boxes, I've ticked all of the initial drivers. I think I've got a pretty good grasp of the inflammation from a driven perspective but there is the residual inflammation and there is the residual old tissue." And one of the challenges I find with chronic inflammation is the damaged tissue perpetuates the inflammatory response. And it's about how do I clean up that old tissue? So, that's where we come in and we look at vascularisation and coagulation and all that. We'll get to that in a second.

But once we've sorted through the inflammation and we've sorted through the damaged inflammation, we can start looking at the repair process. And so, the repair process is looking at what are the strategies that I can do to support the brain and the nervous system to repair itself? And how can I retrain it? And so much of it is around the retraining. And the retraining might be using a herb, it might be using a nutrient.

And the language I use with patients is “I'm going to give you something so that your body learns the experience of not feeling this anymore so that we can start to work on the neuroplasticity at the same time and enable the repair.” But we always need a buffer. I always used to be incredibly anti-pain medication, for example, and then I was like, "Well, I'm just perpetuating a neurological response if I don't enable the pain medication in a healthy way," because I don't want to keep that pain there and the memory of that pain there.

So, it's remove the intensity of the experience, not necessarily through pharmaceuticals. We've got beautiful herbs that can do it as well. And then start looking at how can I repair the nervous system, and what are the ingredients to do that? And within that, we do need to dive into the whole endocannabinoid system and the research that we've got around that and the repair pathways that come from that too.

Emma: Yeah. So, to me, it sounds a little bit, in a simplistic term, like exposure therapy, that we need to reduce the pain so that the perception is that it's not as painful so we can come out of that well-trodden 0 to 10 pathway a little bit more.

Leah: Absolutely. But then we have to fix the damaged tissue because as soon as we take that anti-inflammatory agent out or that herb that reduces the pain out, that path is still there. So, we have to retrain the brain. And retraining the brain can be as simple as... This is where all the cognitive behavioural therapy comes in, where mindfulness comes in, where meditation comes in, where binaural beats come in and all the wave therapy and the brain changes, or any of the neurocircuitry work that we know that really does work beautifully. But doing it in conjunction with the agents that actually help the body to support itself and heal itself is when the magic starts happening.

Emma: Yes. So, there's a lot of work, isn't there, involved in as far as treating those things that we've been focusing on to date and then getting to this point where you need to start working on that brain-pain-neurocircuitry level. 

But you mentioned before about the impact of vascularisation and coagulation challenges with endometriosis. Can you just touch on that for us for a minute?

Leah: Absolutely. Women with endometriosis always have a coagulation imbalance, whether or not it's entirely detectable through various markers on pathology or whether or not it's just an experience and a diagnosis based on “You shouldn't be bleeding as much as you're bleeding.” and “There shouldn't be that many clots in your blood,” and that stuff.

But all women with endo have thermoregulatory disruption. They'll have cold hands and feet generally, they'll have stagnant blood through Chinese medicine language. They'll have disruption of where that goes through their body, and they'll all experience headaches and migraines for various degrees of severity, but their blood doesn't move through their body quite the same way. So, if you've got that inflammation, which then my visual brain goes inflammation, swelling to the area, blood can't move just from the swelling.

And then you've got all the inflammatory tissue, which is dead and damaged tissue, which literally from a vascular perspective is occluding the vascular structure to an extent and not permitting, blocking the ability of blood to pass through that area properly. And then you've got the particles and the fragments that are coming off from that vascular aspect, and then that makes that coagulation process more difficult.

Then you bring in the iron deficiency and the inability of the blood pressure to be rapid enough to move things through the body. But you've got all of these other aspects, on a very sensorial level, that are interfering with the process. When you dive into the research though, most women will have abnormalities with VEGF or abnormalities with other inflammatory markers and coagulation markers because that's how the disease works. And my brain further maps it and goes, well, because there's generally an infective driver, there are byproducts of all of those infective sequelae that are then occluding or obstructing the movement of blood. 

I think it's about looking at these women and going, "If we reduce all of those aspects, get blood moving through their body, then we can start to see what's underneath it." And that's where we can really see the damage and make the difference.

Emma: Yeah and that is a pattern that you do see in clinical practice. Women with clotty periods, cold hands and feet, the headaches, the iron deficiency, the low blood pressure. So, you can see that play out clinically. So, it's really great to get those little highlights there. 

Now, I've read the paper that you sent to me on inflammation in endometriosis and adenomyosis, and I actually found it fascinating. I have adenomyosis, so I've really hooked in on this. But inflammation is not just localised, but also systemic, which has far-reaching impacts, cardiovascular system, atherosclerosis. 

But what I'd really love to know is what biomarkers you use clinically to assess and track inflammation levels, because we've talked a bit about inflammation and it is something that is so pertinent, but how do we track and monitor it?

Leah: I think that there's a couple of different things to be mindful of here. So, when you've got patients, I've used this analogy many times, but I always say to my patients, "There are three versions of answers you're going to get from me. There's the researcher that wants to research everything, wants to test everything, wants numbers. There's the clinician that has the human connection with you and wants the clinical outcome. And then there's the human that also has mortgage and financial limitations. Let's find out what we need to test so that we can actually work out what's going to give you the best outcome." So, I'd love to test every interleukin for every patient and TGF-alpha and TGF-beta and all the chemokines and all the VEGFs, and all that stuff. It may be outside of budget for some patients.

Emma: For sure.

Leah: And what I always look at is, is it going to change how I clinically manage you? I do think CA-125, not in the follicular phase, it has to be luteal, CA-125 is a really good diagnostic and it's not that expensive and can be through Medicare if medical professionals are referring. But I think that some of the interleukins and all those ones, I just don't know if they change my treatment enough to warrant the expense. I find them fascinating. If a patient goes to me like, "It's just everything," then absolutely I want to see it. But different things like stool calprotectin can give us a really good insight from an inflammatory perspective, or even zonulin, an inflammatory perspective within the digestive system, and then that can correlate with it.

Good old CRP and ESR and immunoglobulins and the IgG subsets, all of those other things will give us an insight on the immune influence to the inflammatory process. But I think from a diagnostic perspective and how that translates clinically, it's really about identifying what are the symptoms, are they presenting with cardiovascular diseases or cardiovascular abnormalities? Well, I do need a check and a high sensitive CRP, for example. Trying to delineate it based on the system of the body I think is really important.

Emma: Yeah. And inflammation can be like trying to find a needle in a haystack sometimes when you are testing. So, I know symptoms are, of course, the most important thing. And looking at some well-researched markers, CA-125 I think is such a great one in this space. But yeah, looking at the body systems affected and then diving down that side of things from a biomarker perspective.

Now we’re going to dive into the role of trauma. Leah specialises in trauma in endometriosis and her clinical experience may not be relative to us all. Please be mindful to refer cases that are outside your scope of practice, and be aware that this part of the episode contains sensitive content.

Now let's move on to trauma. I would love you to, first of all, define trauma and what is its role in that mind-body connection in women's health because obviously it's big and it's something that we haven't really dived into before. So, I'm super excited to have this conversation.

Leah: Oh, look, I don't think we have enough time to do it. It's so big. Look, with trauma, okay, so let's get a few of the base parameters out there. We all experience trauma. Yeah. So, we're not just talking about people that have an incredibly traumatic sexual abuse scenario or something like that. Obviously, there is definitely a correlation with women with endo and sexual abuse histories. The data is somewhere between 80% and 95% of cases of women with endo have a history of some sexual trauma.

Emma: Wow.

Leah: But it does mean that any trauma... And the thing that I always find most fascinating when you dive into the research around trauma and you look at how to process it for people, you may have a memory when you were three or four years of age where you didn't have narrative language, but mom didn't pick you up on time and you were on your own and that created a traumatic experience for you as a three or a four-year-old. And that memory in your brain created a schema, so a way of learning and a way of interpreting the world, and then added memory after memory after memory to create a construct of how you see the world through that trauma lens.

So, it's about the simplicity of it, but also the extent that it can go to. Absolutely. We're going to have women that have had horrendous violent experiences that we can see how it correlates with endometriosis. And then we can have really simple scenarios. And Gabor Maté, who's beautiful with trauma work, he talks about Big T trauma and Little T trauma. Stephen Levine talks about trauma through the narrative lens. Tara Brach talks about. There are so many beautiful people that have wonderful language around it, but fundamentally what we're talking about is the inability to be present in the moment and to be able to regulate your experience of your reality, which everyone can relate to. We can all relate to it. We're all works in progress. We're all trying to be better humans. We're all trying to do the best that we can in this experience.

But with women with endometriosis, and certainly, with women with women's health, you'll often see that there's a correlation with a silencing of them as a female. A process where their feminine self hasn't felt safe. A process where they felt betrayed, either by themselves or somebody else. An inability to express the extent of their femininity. And that's usually where it tends to develop in their reproductive system.

But we can go deep as you want into all of this, but I have a belief that various parts, certainly various parts of the body, but various parts of the female anatomy will correlate with different ways and different levels with which each of those women can connect to greater senses of themselves. So, women that, for example, will have endometriosis that will occlude their cervix will often correlate with cervical trauma, which will correlate with an inability to extend and encompass all of themselves and really be as big as they can be for one of a better example.

Emma: Yeah. It's really fascinating, isn't it? And I think this work is something that we definitely need to have a good black book clinically, we need to know when to refer and who to refer to. 

But what are you seeing in clinical practice that led you to this angle of trauma and endometriosis? Because it is a bit of a novel angle and you know this space so well, but what were the patterns you were seeing clinically that made you think there's something else?

Leah: I've never had a patient with endometriosis that hasn't had a negative experience. And I find that there is this...and this is my patients and that doesn't mean every woman with endo. So, that's my caveat. But I find that they've all had some experience, the people that I see that tends to be some form of...either that they had some form of abuse, or that they were intimate with someone and they stepped outside their body and weren't entirely empowered. But it's set up this safety challenge in them. And so there's this feeling of feeling unsafe, this anxiety that they can't manage, and this sense of foreboding or fear of what will come. And so because of that, they have that foreboding of their pain, and so it's in due process, but safety is such a big piece for them.

And I guess the most beautiful thing though is that as they do the work that they need to do, they become so much bigger than they ever imagined that they could as they work through their endometriosis and they work through all the aspects of it. And so much of endometriosis is that denial of self-care and that distance of really listening to themselves and taking care of themselves the way that they need to and speaking up for what their needs are. And as they navigate that process and as they address their symptoms and then they rewire their brain, the rewiring is around that they are safe and that they can take care of themselves.

So, I've got a whole group of women that are all trying to come off a group of pharmaceuticals that have been prescribed to them for pain, for example. And every single one of them is managing their own sense of lack of safety. Every single one of them has had some form of sexual trauma. It might be the people that I attract, I don't know, but this is what I'm seeing.

Emma: And this is really interesting. So, what if a woman is not aware of the trauma but you suspect there may be something underneath? Because obviously trauma gets buried deep a lot of the time.

Leah: Absolutely.

Emma: And if they're not consciously aware that there may be trauma there, what would you do?

Leah: Well, number one is don't rip the bandaid off. 

Emma: Yeah.

Leah: Don’t rip the bandaid off and don't try and be the clinician that tells them that everything's wrong with them. No one is helped from that process. 
It's about first looking at yourself, honestly, and going, "What skills do I need to acquire?" Or, "What referral network do I need to develop?" Firstly, are you comfortable looking at trauma? Have you looked at what's in the dark closet for yourself so that you know this territory and this terrain? And if you haven't, do some work on yourself. And also make sure that you have a good referral network that you can work with, like people that do EMDR or people that do various types of therapy.

There are so many different modalities, but for so long I've always found that there's the importance of the visceral aspects of endometriosis, the reconnection of our patients to their bodies. The ability for them to feel again. But so much of the initial groundwork that needs to be done is the relationship that we develop with them, that they have someone that they trust, that they have someone that they know that is there for them, that is supportive of them, that is not giving up on them, not telling them it's in their head, not telling them, "Go drug yourself with some really strong analgesic and you can sort yourself out later," but listening to them and then helping them. And just that relationship of safety enables them to feel like they can start to open that cupboard and see what's inside.

Emma: And really interesting about the...because what I've been seeing clinically in the last 12 months, I'd say, is an increased prescription of antidepressants for women in this space. And I don't know if that's being driven by other factors, but I have noticed this trend and I'm just not comfortable with it because women are coming in saying that it's in their head, they've been told it's in their head. And I just think that there is opportunity here to have really good conversations with patients in a safe environment around, “Well, have you thought about it in a different way? You have endometriosis, there is this thing with your brain and pain and we may need to look at it a bit differently.”

Leah: There's two pieces to that. So, I think that one is that some of these antidepressants and anxiolytics do have neuronal benefit, so they'll have a retraining capacity to them. So, some clinicians are referring these prescriptions because it's to help them manage their pain. Some of them, they're like, "It's in your head," and some of them it's like, "You are really not functioning well. Let's help you function with life."

But the thing that I always look at, antidepressants, anxiolytics, antidepressant herbs, any of these things, what I often find with women with endo and certainly women with a history of trauma and endo, they need containment. And they have this sense of over expansiveness and oversensitivity, not that they are oversensitive and that I'm not believing them, but more that they feel everything so deeply, and it's not in their head, but their brain and their nervous system is wired to feel everything and to see everything that's going, and to have — as I was referring to earlier — that idea of that initial reactivity towards something to protect themselves. That doesn't make it in their head, it's just their nervous system is wired that way.

But the beauty of these drugs, the positives is that it offers them a containment. So, it puts them, and it narrows the bandwidth of their experience neurologically and emotionally. So, there's a coping capacity to them. There's an ability to help them cope with life better, but when they put them in that, and then they go, "See you later, we'll see you after menopause," or, "We'll turn off your hormones so you don't menstruate and you don't feel anything," that something, it's entirely disempowering. And so then I think as clinicians, we have to look at it and go, "How do I help them come off this medication and normalise their self sense and their experience?

Emma: Exactly. And I know it is dose-dependent, lower doses is often used to the pain and higher doses for the neurological impact. But explaining about this hyper-vigilance response has been developed to keep them safe, I think is a really nice way of framing this information. 

But how have you upskilled yourself to support patients with trauma? Obviously, you're going to have a good book of referrals to lean on, which we should all develop. And any particular modalities that you see working better in this space from a referral perspective?

Leah: I think the number one is something where their physical body feels safe, so some form of visceral work. That may or may not be pelvic floor physio. Sometimes I have women where they need to work towards pelvic floor physio because the idea of someone physically contacting them in those areas is too much, but something where there is touch so that they can start to get oxytocin going through their neurological pathways so that they can start to naturally produce their endorphins and start to get the right chemicals coming through. That might just be a hug from someone. I think it might even be a hug from me.

Emma: I was going to say I hug my patients.

Leah: Yeah, I do too. We can argue about it, but you know what, we're all human and we all need hugs. But it's this idea of something where there's some touch. I think that's always number one. Because some people are so traumatised and so dissociated that the idea of talk therapy is like, "Oh, my God, they can't even process walking in the room. They're so overwhelmed by what's going on."

And then I think it's about building them towards what they can tolerate, something like EMDR, which is essentially the eye movement process of hypnosis to reconfigure and rewire the brain. It's getting the eye movement to move in the direction of where something is stored in the body and then helping the brain to literally declutter itself and reorganise memory. Things like that are phenomenally powerful but they may not be able to jump there yet, so it might be some form of therapy, whichever modality and which way they want it to be. And I actually have... My referral list is massive because I always try and connect the person to the person that I'm referring them to and try and match their energies almost.

Emma: Yeah. Nice.

Leah: And then it's like what are they actually able to do right now? It might just be someone that's a counsellor that does meditation and breath work, and then it might be someone that actually does go all the way down deep into even psychedelics. There's all sorts of things that I've referred people for.

Emma: Yeah. I love that. And I love that the baseline is to start building oxytocin. That's a beautiful place to start and it builds that safety sensation as well, which is just amazing. 

How much caution needs to be taken when you are doing case-taking with trauma? Sometimes I feel like you might be opening a can of worms. I think it's a fine line.

Leah: Definitely.

Emma: I think if you are very energetic, focused or gut instinct focused, you can pick up a lot from patients when they're not talking. But yeah, where's the boundaries? How do you tease it out? Any pointers in this area?

Leah: I think it's really important that clinicians are really aware of where they're at in themselves so that they can use themselves as a barometer, so that when they have the interaction with someone that has experienced trauma that's fairly overt and triggering for their health, that they're aware of the sensations in their body and how they feel about it. If they're not comfortable going there with someone, don't.

I have this one question on my questionnaire, I'm sure I've said it somewhere in the past. Have you experienced any major stress or trauma or anything like that that you think is affecting your health? And I keep it at that level because if someone has a lot there and they're obviously wanting to discuss it, I'll go there with them, but if someone leaves it blank, we don't go there necessarily at the beginning.

I think the relationship that we build with our patients is the number one thing that... It's not that it protects the patient, but it supports them and it creates a framework and a foundation of how to navigate it. But if we're uncomfortable with anything that's being discussed or said, we can't hold them. So, really use your own barometer to gauge whether or not it is or is inappropriate. And don't be inquisitive for inquisitive's sake because as much as you're like, "Oh, my God, I read this paper and I can see that there's a correlation, I've got the answer." No. Assume that people when they've got severe endometriosis and they do have a history of trauma, it's a very delicate, sensitive process that you really need to support.

Emma: Yeah. Yeah. I think sensitivity is huge there. And I love that reminder that we need to become aware of our own triggers if we're not already and really be okay to be asking those more sensitive questions, and if not, don't go there. Possibly refer at that point to somebody else that can hold space in a way that is supportive and builds that safety sensation with the patient. Yeah. 

Any white flags clinically that would make you think that trauma is involved in the case? There's probably going to be quite a lot, but any things that pop to mind?

Leah: I think anything with the female reproductive system there is bound to be conversations around sex, around pleasure, around sensation, around experience, even if it's just experience around the menstrual cycle. And I find that women invite us. I always joke with my patients where I say, "There's pretty much nothing I haven't heard yet and that I haven't been asked, and nothing phases me."

Emma: Yes. So, true.

Leah: And I always give that statement to them, which is feel free to ask anything that you've really been wanting to ask someone. Go for it. Just do whatever it is that you need. And I make jokes and stuff like that so then they will, but they'll give you a little subtle cue of, "Oh, look, I haven't had a libido for I don't even know how many years." And you just gently see how far do they want to go with that? But a woman will offer you these little points to say, "Can you go there with me? Can you handle it?" And we have the luxury of longer consultations, so we have the luxury of really building that relationship and that trust. But they will always give it to us. We just have to hear it.

Emma: Yeah. And I'm often surprised clinically how many women are very happy to talk about their libido with me quite openly. And I'm saying that 95% of those women feel their libido is too low, but they're very open about talking about it. And I can sense sometimes that they're often almost relieved when I start asking them questions like, "Well, is there a problem with lubrication? Is sex painful?" They're like, "Oh, I haven't thought about it like that before." Well, maybe that's why. It really does evolve the conversations to a deep level. And I can see that that's a good springboard for those deeper conversations to come up where trauma could be discussed. 

But curiously, how does sexual health and orgasm form part of the recovery from endometriosis?

Leah: We could probably talk about that for a day. Sexual health, I think where we're at collectively in society is that we have better language and better discussion around it and much more transparency around it. But for women to recover, particularly from endometriosis, it's about the humility, the gratitude, the self-support to be comfortable with the concept of pleasure, and pleasure in all forms not just sexual. But sexual pleasure is about "I deserve to be here, I deserve to be alive, I deserve to experience good things.” And that can be an incredibly big hurdle for some women to overcome, particularly when they've had a history of trauma and certainly pain and perpetual pain. 
But the rewiring of that circuitry, we talked about the idea of oxytocin before. But oxytocin that comes from an intimate connection or from orgasm for that matter helps in that rewiring because it reeducates and tells the body, "This is how you're actually meant to experience it." And it's often a very blurry, confusing state for some women, like if they, let's say, had sexual trauma historically and confusion of part of it had pleasure and part of it had pain, and then they bundle it together and then they get the blundering, for want of a better word, of the information as it comes through. But it's about them being comfortable with their body again and trusting their body again, and trusting that they can feel good things from their body, not just bad things, and not just fear of the bad things. So, it actually becomes a really important part.

So, it's pretty empowering for women when they get over that hurdle. And I think the normalisation of the language and the support and the encouragement of “You deserve to feel good," really helps them enormously.

Emma: Yeah, and oxytocin, that hormone is so incredibly powerful and it is released in huge amounts with an orgasm. And I was just thinking as well when we orgasm we have this huge change in blood flow, and that in itself will be such a benefit with pelvic floor health. So, interesting. Really interesting. And I love that shift of how oxytocin can help reeducate the brain and change that perspective a little bit on “My body isn't just pain, it's also pleasure.” That really makes sense.

Oh, we've had such a great conversation. I wanted to just ask you one last question. What are you seeing on the horizon? Any future trends that we should start thinking about or the future of women's health in naturopathic medicine? Where do you think we're heading?

Leah: Well, we're entering all the AI area. So, I think we all need to be comfortable with the idea of where that will influence things. I do think that it's going to be influencing tracking and influencing personal data and personal health data and the ability of analysis of that data. I think we're getting more and more into the research around peptides, bioidentical hormones, the in inverted commas, the “manipulation” of the female hormonal management in that context.

I think we're certainly moving all the sexual health aspects. And I think it's changing a lot with all of the gender sexual health world and how all of that's changing with comfort of just experiences of pleasure regardless of historical constructs. But I think that we're also getting into really exciting times around what we're able to research in the sense of assays and markers, but also in how we can analyse herbs, how we can analyse nutrients, and how we can analyse the development and the understanding of where that biochemistry is going.

So, really exciting because I think as you bring AI into assays, for example, we're going to be uncovering things that we haven't had the technology to be able to even see. So, you think about we've got this idea of these are all the hormones and this is how they work. Well, now we're going to be able to use that technology to be able to go, "There are other hormones that we didn't have names for, one, but also what we thought was the limitation of that hormone, we now have an understanding of where else it's playing in the body."

And I actually think we're going to get there really quickly. I think about the research that I've done with all of my thesis and things like that. The assays for all of those things are going to mind-blow us. We're going to be able to assay progesterone secretion from the brain, from the thyroid, from the thymus. We're going to differentiate between what gland has secreted that hormone at what time because we can start to get into the really, really small doses that haven't been detectable.

Emma: Yeah. So, the nuances of that are huge.

Leah: The nuances are huge. And so our understanding of how it all works is huge. We've got science around neuroplasticity. But we're going to have science around plasticity of every system because we're going to understand the functional units, the hormones, the chemistry of how all of these things work because we can go deeper. Beautiful, hey?

Emma: Yeah, it's really so fascinating. And I was just sitting here thinking, "Gee, I love my industry." We just never stop learning, which is such a joy. But we definitely need to be keeping an open mind, don't we? Because paradigms might start really shifting on how we thought about things and what we thought we knew and what the future's looking like. We are going to have to keep an open mind, keep our curious hats on as we always do, but keep an open mind. It's just changing the way we think about things.

Leah: Exactly. Beautiful. Neuroplasticity of our own brains.

Emma: Yes. Well, you got to practice on yourself first, right?

Leah: Pretty much. Pretty much.

Emma: Leah, thank you so much for joining us today. We really appreciate all those insights that you have given us.

Leah: Thank you for having me. It's been a pleasure.

Emma: Now, it's been such a great conversation. The key points I have taken today are this new way of thinking about endometriosis. The impact of pain wiring, inflammation, and the subsequent changes in brain circuitry mean that pain perception is heightened, and that once you have addressed the usual suspects in endometriosis, it's time to think deeper about brain neuroplasticity and neuronal repair. And lastly, the importance of being aware of our own trauma when working with women's health.

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

About Leah Hechtman

Leah Hechtman is a naturopathic clinician, researcher, author and educator who specialises in fertility, pregnancy and reproductive health for men and women. Her primary passion is her clinical practice where she is inspired and humbled by her patients.

She has completed extensive advanced training and is a university lecturer, keynote speaker, author and educator to her peers. She is currently completing her PhD through the School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales and is the author of Clinical Naturopathic Medicine and Advanced Clinical Natural Medicine. She is also a regular media spokesperson for her profession.

Leah leads by example, remembering to live life to the fullest and believes that ill-health is merely a stepping stone to help you reclaim your true state of being.


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