Endometriosis affects an estimated 1 in every 10 women, many of whom suffer chronic pain. Despite the severity of this pain, sufferers often have to forgo strong pain medication, due to side effects resulting in them unable to function in their daily lives.
So what are the alternatives, and how can natural health practitioners help?
Dr Mike Armour returns to FX Medicine today to discuss his research into endometriosis pain relief, updating us on the various trials he is running, which include herbal medicine, cannabis and acupuncture.
Covered in this episode
[00:57] Welcoming Mike Armour
[01:14] What sparked Mike’s interest in natural medicine
[04:06] Mike’s current research on endometriosis
[07:36] Recruiting for the trials
[09:46] Cannabis for endometriosis pain relief
[12:11] THC vs CBD
[20:38] The benefits of acupuncture
[25:50] What works for helping with endometriosis pain
[32:33] Empowering patients
[37:55] Endometriosis Australia
[40:06] Thanking Mike and closing remarks
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining me on the line is Dr Mike Armour who joined NICM in 2016 as a postdoctoral research fellow, with areas of interest in women's health. Welcome, Mike. How are you?
Mike: I'm good. Thanks, Andrew. Thanks for having me on.
Andrew: I don't want to get into a long bio. But just recap for our viewers, a little bit of your history and where you've come from. Because you've got areas of expertise in natural health as well as bio science, correct?
Mike: Yes, yeah. So I started off with the honours degree in bio-medicine many years ago. And since then, I trained as a traditional Chinese medicine practitioner, so an acupuncturist and a herbalist. Then I did my PhD at Western Sydney in 20...well, I finished it in 2016. And that was in acupuncture for period pain. And then since then, most of my research has been on women's health with two main areas, endometriosis and primary dysmenorrhea.
Andrew: So did you have an interest for natural health before you did bio-medicine?
Mike: No, I don’t… I had always been curious. But I don't remember having an interest in natural health before then. It was always just, I think what happened was, when I was at the medical school there was a Chinese herbalist and acupuncture clinic down the road.
Mike: I’d often come up and have a look and I would go, "Well, this is pretty interesting." They had all the patent medicines and things like that. And so I said, "Well, this is really interesting." And then I got into it actually, because of a frozen shoulder that I got when I was working as a researcher. I got a frozen shoulder, it didn't respond to any treatment. So I went to that same place. I still remember the name. But the guy there was amazing, didn’t speak pretty much any English. I don't speak any Mandarin. But he just went to town on my shoulder. Acupuncture and cupping, heat packs, the works. And I left there a couple of hours later. I was like, "Wow, that is fantastic."
Andrew: And did it recur?
Mike: No, it got heaps better. Didn't quite fix it all in one treatment. But it was amazing difference.
Mike: Yeah, I don't know, they just kind of flipped a switch for me. And I was like, "Oh, I wonder if I could learn this." And I thought, "Well, I'm not sure if I really want to spend years in China at the moment," because I was about 22 at the time. And I went home, jumped on maybe it was Google, that was a long time ago. So I'm not sure if Google was around and found out I could study it. Not only did I not have to go to China, it was actually just around the corner from where I was living. So it was kind of the start of it.
Mike: Sure. So we've got a few current ones at the moment. The two major areas I think we're really looking into are right now or in the very near future is we're looking into the effect of herbal medicine on endometriosis.
So obviously quite commonly used in the community and clinics, but very, very little in the way research has been done, especially on Chinese herbal medicine. Some great work, Dr Andrew Flower on this, but really, in the terms of randomised controlled trials very, very little. So we're looking at a modification of a traditional Chinese medicine formula - and I apologise for butchering the pronunciation - Gui Zhi Fu Ling Wan. Just blame it on my Kiwi accent.And so we're looking at that probably the most.
The research suggests that the most common formula that's used in China, and Taiwan, and Hong Kong for endometriosis-like pathologies. And we're looking at a modified version of that and how that affects women with endometriosis. So that's a randomised, double blind placebo-controlled trial, and we're looking at using that for three months and then we're seeing how that affects women's pain and other endometriosis symptoms like fatigue and other pain symptoms, pain on intercourse, pain on bowel motions, reductions in medication.
And moving forward, one of the areas that we're really interested in, and I think that patients are really interested in, is looking at medicinal cannabis for endometriosis. And so that's being done in conjunction with my fabulous PhD student, Justin Sinclair. So not only for his PhD, but we also have...we're looking...we're trying to reach out for some funding into a larger project as well. So those are our main, I guess, herbal medicine and of all kinds of herbal medicine, I guess, is what we're currently focusing on.
Andrew: When you're talking about recruitment for particularly for the first one with a modified TCM formula. Where are patients recruited from? Orthodox medical clinics, or people interested? Was it an advertisement?
Mike: Yeah, mostly through social media. We have great support from our endometriosis organisations, and I am part of the clinical advisory group with Endometriosis Australia, and they have been absolutely fantastic in terms of supporting research recruitments. And most of our recruits have come via social media postings that they or some of the other groups have made. We found the one with endometriosis advertising, we did use some social media advertising, but it was very slow, didn't work as well as we hoped.
Andrew: Yeah. But that's an interesting point about Endometriosis Australia, because you'll get women from all walks of life, from all bents, if you like, or attractions towards natural medicine or not. I guess that's the interesting thing is if people aren't attracted towards natural medicine, would they be willing to try it? And then do you get a bias in your sample?
Mike: I think one of the things we do ask women when they join the trials are they taking other natural supplements? Or have they taken them in the past? So, obviously, I can't see that data at the moment. But I'm excited to see what it is. But I think one of the things we know from women with endometriosis is they are looking for solutions. And so, like me, perhaps, I wouldn't necessarily have thought about getting acupuncture, but a frozen shoulder is really painful. And so I think perhaps it's the same thing as that.
Maybe people who would not have necessarily gone to a naturopath or a TCM practitioner, or even to a health food store or tried a supplement, they are interested in being part of research either to help others, which is really common, or just because that they're in pain, and that they'd like to try something. And I think being part of a trial also, I think it gives, it's just a little bit more reassuring than just popping into one of the big chemist or chains, and kind of saying, "Oh, I've got pain, what do you recommend?"
Andrew: Yeah, and to me it smacks of a need. And it says a lot about current treatments, and the failure and such. We've seen the issue with the opioids. But what it says is that the pain is so great for these women that they seek other forms of medication, other forms of help.
Mike: Absolutely. And one of the things that we saw is… So we did a survey published at about...well, it's almost a year ago now. And we looked at what forms of self-care women in Australia used. And we were surprised to find that quite a few, around 1 in 10 of the women that responded to us were using cannabis to manage their pain.
Mike: This is especially interesting because at the time that we did the survey, cannabis was not available for medical or legal access, so they would use it illicitly. I think the fact that people are willing to try an illicit product, which has potential legal ramifications if they get caught driving or anything like that, suggests that the pain is bad. People are needing solutions. Because I think most people are not, if they have mild pain which is easily manageable, it's unlikely they will seek out a treatment, they won't delve in to that kind of...
Andrew: An illicit treatment. Yeah.
Andrew: So I guess the issue is, if they were using it for recreational purposes, then that's a separate issue. If they were just using it to get stoned, well, that's a separate issue. They're not, they're saying that they're using it as a medication for their pain. That's the absolute point for me.
Mike: Yeah, absolutely. And we've done some other research, which hasn't been published yet. Not only in women with endometriosis, but also in women with primary dysmenorrhea. I say it enough, you think I'd be able to pronounce it.
Andrew: It's New Zealand accent.
Mike: Yeah. That's what I just blame everything for that. And what was interesting is that women weren't really using it recreationally. They were saying, "Well, I never really enjoyed..;” a lot of women funny enough were saying, "I never really enjoyed it recreationally."
Andrew: That’s interesting.
Mike: And some say, "I don't even really like the high. But what I do like is the pain relief."
Mike: Yeah. So that's very interesting. So Justin and I have been working with a company in Canada actually. So they made an app that is used to log medical use of cannabis. And this data is from America and Canada, where it's legal for this use. And so they've been very kind, we've entered into a research partnership with them. And they've actually allowed us access to this data on women with endometriosis. And so I think we have around 13,000 individual sessions, where they've used cannabis. It's a lot of data.
Andrew: That's a lot of data.
Mike: And so we're working...it is. And thankfully, we're working with a biostatistician. And they are helping us. We have actually crunched the data. Well, they've crunched the data, I can't take any credit for that. And it's been very interesting.
What we were looking at was exactly that, can we pick out areas that we should be exploring further? So one of the big ones obviously, is, what's the importance of THC versus CBD? Because CBD products, especially in places like America are available over the counter, from a lot of these stores. I was in Colorado last year for a conference, unrelated to cannabis. And you could buy CBD vape pens. So we're really interested in that because we think that THC is important in this pain relieving aspect.
Andrew: Right. Right.
Mike: But obviously, the downside of that is THC is also psychoactive. And some people listening, I'm sure will be like, "Why is that a downside?" And it's because really, when you think about using it for medical treatment, one of the issues that women have at the moment is, Endone oxycodone is quite effective for treating endometriosis pain. Women use it, it's prescribed a lot. It's not that it's not effective, but it is addictive. And it also impairs functioning.
So we know, and this is a paper we have coming out hopefully later this year. We talked to a lot of women about their experience of managing their life with endometriosis, and one of the things that came out was that a lot of them are stuck in this horrible kind of catch-22 situation where they need to go to work, or they need to look after their kids. So they don't want to take opioids while they're doing that. But then that means they're in horrible pain.
So it's a horrible catch-22, so one of the women, this was several years ago now, but I still remember she said, basically, "I'm in pain all day and the minute my husband walks in the door, I've got an Endone in my hand, waiting. And as soon as he walks in and can take responsibility for our daughter, that's it for me. Down the hatch. The pain goes away. But I'm wasted."
Andrew: That would be a funny joke if it wasn't so sad and angering. You know?
Mike: Exactly. And this is her life every day. And obviously, not just her but her family. So I think that, and she talks about terrible guilt she has over this because she can't play with her daughter in the evenings. She can't bath her because she's wasted, because she feels so out of it with the opioids. But without that she's in horrible pain.
So women are stuck in this terrible situation. So while I've got a lot of hope for medicinal cannabis, one of the things that we are worried about is, can we find a way for it to be effective without the high? So these women aren't put in this, again, terribly difficult situation where they have to choose between pain and functioning.
So it would be great - and this is something that Justin's PhD is working on - to see, how much THC is needed for an effect? Or can we find, is CBD good enough to take the edge off? Where you could say, "Okay, well, actually, I'm going to use CBD during the day.” It actually works quite well, maybe it's not as good as something with a high THC. And again, we don't know, I'm completely speculating, that's something we need to find out. But even if we could find that CBD works 70% as well as a high THC blend, it gives women choices.
Andrew: Wouldn't it also be great if we could find out all of the effective medicaments including herbal pharmacological, acupuncture, physical therapies as well. Wouldn't it be great if we could find out what works and how well so that we could stratify them?
Wouldn't it be amazing if we could use, let's say, a herbal medicine and acupuncture as a baseline? Knowing that it's safe and effective for X percent. And then you could add in your normal analgesics, and NSAIDs, or paracetamol, and then THC, and then, and then. Wouldn't that be great if we could have a guideline to help? What's the guesstimate of affected women in Australia?
Mike: So probably around 750,000 to 800,000.
Andrew: This is just… It's mind boggling.
Mike: It's mind boggling, absolutely.
Andrew: It's mind boggling that it's taken till, what was it? 2018, late 2018, when there was almost official recognition. If this was a male issue, it would be out there, mate. You know?
Mike: Absolutely. And unfortunately, even then, it's wonderful that we're getting funding, but $9 million sounds like so much, it really does to a lay person. You're, like “9 million? That’s..." But for researchers that's four or five research projects. And when we think of diabetes, and heart disease, dementia, these are all really important areas, obviously. But it's hard as a endometriosis researcher not to look at their funding and feel very jealous. When it's 10 times, 20 times or more, what we are working with.
I think things are changing, but it's very slow. And I think this is one of the major areas we have is, we do need like you say, obviously, everyone with endometriosis wants a cure. And that's hugely important to focus money on that. But equally important, I think, is to recognise that even if we found out tomorrow what causes endometriosis, say, there's one single cause, which doesn't seem likely, and it can be identified, it's a particular, something that can be switched off with a drug. We're still looking at 5 or 10 years between that discovery and a drug going on sale, generally.
We still need to think about how we're going to control women's pain for that 5 to 10 years. So I think it's still really important to make sure we are improving quality of life while we're searching for this very important cure.
Mike: So we're going to publish our paper on acupuncture very soon, I hope. And that showed really promising results. It was just a feasibility study. So we need to be cautious about talking about things in solid terms, but there is other research out there to support acupuncture for endometriosis, seems to be really effective. And we're talking in terms of reductions of 40-ish percent in pain scores.
Andrew: Wow. Okay.
Mike: So, it is effective. I think that the downside, for many women is just the cost. And this is something that...and this is the same issue with medicinal cannabis, unfortunately.
Mike: It’s hard to afford these things, especially when we know that women with endometriosis are financially impacted anyway. They're often having to work part-time, they use up all their sick leave, they might be denied promotions, they might have to stop work altogether. So I think acupuncture looks very promising, if there's a way that we could figure out to deliver it in a cost effective manner.
And I think that's something that, as acupuncturists, we need to think about. In the past, I've offered a community style clinic where there's heavily discounted rates come in, there's 5 or 10 beds, or 5 or 10 chairs and you can get treatment for a much lower rate. Because the frequency of treatment seems really important for endometriosis.
Often we don't talk about it, but acupuncture, there's definitely evidence that has a dose effect. It doesn't work by magic, it works physiologically. So it does mean that the number of times you treat, or the frequency of treatment is really important. And especially for something like endometriosis it seems that twice a week is quite important, especially in the beginning to kind of get that effect. So that's something to think about.
But I think definitely acupuncture, we had very, very low rates of adverse events, they tended to be mild, the usual kind of small bruise, a bit of pain when the needle went in, but relatively, obviously very mild and transient. And so I think that, that shows a lot of promise.
I do think that self-report measures that we've had from women using cannabis so far…obviously, with the caveat, it's all self-reported. So it might be only people that are big fans of the “devil's lettuce” are continuing to use it and kind of coming back to us. But definitely, we cannot ignore the data. And we have another data set, which is under review at the moment, and another journal from New Zealand, showing that almost identical results to our Australian data.
Andrew: Ah, now that's where we... That's what's needed when you get the multi-centre trials showing similar or same results. That's where the beauty lies.
Mike: So, these are all, again, it's all self-reported survey data, but there's a trend there. And then when we look overseas, I know it hasn't been published yet, but we've seen poster presentations and things like that. And the theme, it's the same song. You're getting these big reductions in pain, improvements in sleep, reductions in nausea and digestive symptoms, which are very common in endometriosis.
It also means when we think about treating pain, it doesn't have to be an either/or situation. We can say, "Okay, cannabis might reduce people's need for opioids, maybe by 50%." And that data suggests exactly that, that people can stop the opioids, but if they can't, they do reduce them a lot. Or it can be used to manage the side effects of other medications that they needed.
So, depression and anxiety are very common in women with endometriosis. They're often put on SSRIs or similar medications to help manage that. One of the side effects of that is nausea. So women report using cannabis to reduce the nausea from their other medications.
Andrew: Ah, right.
Mike: So I think we can use these as part of the toolkit. Because there is no one size fits all. But it's really important that women have access to these effective treatments.
Mike: Yeah, so that's a nice, simple question. I think that it's an excellent question. And the answer is, it's hard to say, because I think certain things… there's a bit of research out there, for example, suggests yoga can be beneficial for women with endometriosis.
But the thing is, for many women with endometriosis, depending on the location of their lesions, and the severity of their pain, exercise especially can be very problematic for them. And again, they're caught in a catch-22, because it's so, so beneficial for many things, including mental health. And we now know, well actually if you could make the ultimate pill, it would be exercise, it pretty much helps so many different areas. So I think what can be done is try yoga, try it yourself, and especially during COVID-19. There's some fantastic resources on YouTube, there's these other apps that you can get. We used a couple, my wife and I, during the time, we have a great friend who's a yoga teacher, she did her classes online. I think it's worth trying that.
And if you find that, actually, "This is making me worse, it's aggravating my pain." You've got two choices, you can go and speak to a yoga therapist or a professional, and get them to customise a program for you. And I've done that myself, because I have a back problem. And that was fantastic. I find it hard to use “over the counter” yoga.
Andrew: Over the counter yoga?
Mike: Yeah, which it kind of is now. You can jump on any of these apps and be like, "Okay, I've got 20 minutes,” and they’ll be like, “Right, here is Barry. He's going to take you through 20 minutes of..." And for many people, that's great. But I think we need to also think of it as yoga therapists, experts in this area, and they can obviously customise it to you. What responds well, which can't be done so easily at the moment for now.
Same with diet. We know many women with endometriosis try different diets. Andrew, we have another paper coming out on this, I'll give you the spoiler: it doesn't seem to matter what diet people use, they seem to feel better on the various diets.
Andrew: Oh, okay.
Mike: And again, this is self-reported data. But I think when we think about it, it does make a bit of sense, is that most of these diets, it's about paying attention to what you eat. Whether you are eating vegan, whether you're eating keto, you're unlikely to be able to pop to McDonald's or KFC and eat there. You generally have to think more about what food you're putting in.
So, I think that that's one of the things is that by paying attention, most people's diet probably improves. They're probably eating more unprocessed food, they're eating more vegetables. That's not to say, certain diets don't have more evidence for them. And certainly, one of the areas which seems promising is the FODMAP diet.
Mike: And actually, some researchers got some money as part of the recent $9 million to actually investigate how well the FODMAP diet works. Looks very, very promising, with the caveat that the FODMAP diet is not designed as a lifelong diet.
Mike: It's designed as a symptom, to treat symptoms. And we know, when we analysed the data from our participants, what they said when we gave them free text to talk about, it was that FODMAP was great for their symptoms, but bad for their social life.
Andrew: Yeah, that’s right.
Mike: So it was a balancing, very hard, like if you have to eliminate all these. And so we need to think about our case, "How do we transition people to a diet that works?" And at the moment, the honest answer is, we don't know what that diet might look like. And some women report fantastic results with going vegan, others report fantastic results with going keto, others report great results with going dairy free or gluten free. So we just don't know. But we do know that diet, obviously, like many other conditions seems to play a role in symptom management.
Andrew: Do you think...
Andrew: Sorry, you go. You go.
Mike: No, I was just going to say, and again, this is we're going to speak to a dietitian or a nutritionist could be really valuable. Diets are probably one of the major areas where if you're on Instagram, and you look good in a bikini, you can give advice.
Andrew: And I do. No.
Mike: Yeah, Pete Evans, I don't know if he wears a bikini. But one of the things is, it's very tempting to take advice from people. But I think, again, we need to value the expertise of people that have studied these things and speak to someone about a plan that they can customise for you. Again, same with yoga.
I think often with natural therapies, just in general, we tend to sometimes downplay expertise, and we think, "Well, we can read a blog, or we can watch a new clip." And it's not a replacement, especially in women with endometriosis, because they have very complex pathologies, often have a lot of comorbidities, migraines, IBS-like symptoms. They're all very, very common. And so I think it's worth investing some time and money in going to see a professional.
Andrew: Yeah, I think it's really interesting that Sue Shepard devised that diet. She is celiac. And she devised that diet to be the low-FODMAP diet, not the no-FODMAP diet. And this is where people's switch mentality comes in, rather than managing something and saying, "Okay, I have to restrict or lower something” versus “No, it's bad all bad."
Andrew: Wrong. This is where you need to speak to somebody who's appropriately trained and educated in that area.
Well, what about the concept about empowerment? That you're talking about, you say that women choose their own diet. And one of the issues that's overarching endometriosis is that women aren't listened to. Diagnosis is late along the path where disease has progressed, pain has progressed. It's just a sad situation. It's a sad medical situation. And so we need appropriately trained medical practitioners who listen to women's issues. And don't box them.
So is part of this issue, empowerment of women, that they feel listened to?
Mike: Absolutely. I think we need to be careful, because we don't want to...we want to empower women, we don't want to put all the responsibility on them.
Andrew: A good point.
Mike: So I think, and the reason I say that is because someone said that to me, and I wish I could remember who it was, they're smarter than I am. Because I was talking about all these resources that we're making for women. And there's these fantastic programs which are being done, educational programs, and just amazing.
But I think we also need to say, "All right, we can't say if we just educate women that that'll fix the problem." Absolutely, we need to empower women with good knowledge about their health. But when they go and see their doctor, they can be very empowered, and they can still not be listened to. So we need to attack the problem on multiple fronts.
And I'm happy to say that that is definitely happening in Australia. As part of the recent National Action Plan for Endometriosis, there's a huge amount of money, time and effort being put into improving the quality of education around women's health, for doctors, training, ongoing training.
I'm hoping it also will just be, unfortunately, some time for people's attitudes to change. Because like you say the research clearly shows, and we have some more papers coming out on this. Women are not listened to. They present to the emergency department in severe pain. They are told… one that I remember is one of them was told she had an ingrown hair from shaving her bikini line, which was causing her pain. Others were told they had a UTI.
Andrew: It makes you want to scream. I'm sorry.
Mike: And a part of it is just, there's a lack of awareness of what is endometriosis, I suppose. But again, I think it also reflects a systemic problem. So women's pain is marginalised. It's not listened to. There's some fantastic research done by Professor Jane Asher, and my friend, Dr. Alex Hawkey around this, women are present positioned as hysterical. And this has been going on for a long time.
Andrew: Such a monolithic term. Isn't it?
Mike: It is. Well, it's...
Andrew: Even hysterical, the word.
Mike: It's, and women… We might not use the word hysterical in medical notes or anything like that, but the principle, I would say, is still there. It's the pain is all in women's heads. And I don't mean that in the actually scientific accurate term, that pain really is in everybody's heads. But the idea is that it's being overblown. It's not that bad. And I would challenge anyone to spend a day with a woman with endometriosis and think that the pain is being exaggerated.
Andrew: Well, you know what, if a health professional dictated to the patient what their pain was and was not, isn't that tantamount to assault? Because in my memory, it is the right of every patient to adequate pain relief, and if that is denied them, that is assault?
Mike: Well, I am not touching that with a ten foot pole.
Andrew: I actually wonder if we should empower women on that one. I did want to make a call out, Mike, to you we're talking about education before and we really do have to make a call out to Donna, the fantastic work of Donna Ciccia, and Professor Jason Abbott, and others, that have Endometriosis Australia. That is an organisation that has browbeaten the Australian Government into waking up.
Mike: Yeah, look and obviously, I can't speak highly enough of Endometriosis Australia, and especially Donna who you know, in the interest of full disclosure, is a great friend of mine. She is tirelessly working.
Mike: And really, I don't know, even looking at other academics, and we have problems with a work/life balance and working too much. But I know very few people who work like Donna does.
Andrew: She's a driven woman.
Mike: We were at an endometriosis event. And she's multitasking, she's on her phone answering questions that people are posting, about what they should do, counselling, all the while one hand on the phone doing that. And she just gives and gives. So, yeah, absolutely.
Without these advocacy groups, and the effort that they put in who knows where we would be. But I think that I would feel very confident in saying we wouldn't have a national action plan, we wouldn't have $9 million. And for all of my complaints of that of not being enough, I think without them we wouldn't have $9.
Andrew: So we need them cloned so that you can get multiples of $9 million.
Mike: Absolutely. I think yeah, if we could clone Donna, that would be pretty...that would be quite useful for sure.
Andrew: Heaven help Canberra.
Mike: Yeah, I'm sure, but I think the government would put a stop to...
Andrew: They would be running to hide.
Andrew: But look, Mike, you're doing fantastic work on so many different fronts from the sociological aspects to the physical medicine. And how you and indeed, every natural and medical practitioner can help women who are affected by endometriosis.
I thank you so much for taking us through at least a snippet of what your research is entailing today. And we need to give also a call out to those other researchers who were involved. Of course, Justin, my great friend, but there are many others behind the scenes working tirelessly to help women with endometriosis.
Mike: Look, absolutely. Australia is hitting it out of the park. And as tough as it is for me as a New Zealander to just say nice things about Australia or Australians, there are so many fantastic researchers here. And we are all passionate and driven. And I consider these people, friends and colleagues, they're working so hard on different areas.
We've all got different expertise. But everybody's working towards the same goal, which is improving quality of life of women with endometriosis looking for a cure, looking for better management, looking for earlier diagnosis. And yeah, so there's some amazing work going on.
Andrew: Thank you so much for joining us on FX Medicine.
Mike: Thanks for having me back. All right.
Andrew: This FX Medicine. I'm Andrew Whitfield-Cook.