The Endometriosis Series: The Researcher with Emma Sutherland and Professor Jon Wardle

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The Endometriosis Series: The Researcher with Emma Sutherland and Professor Jon Wardle

In part two of our series on endometriosis, Professor Jon Wardle provides us with an update on endometriosis research including his work on the Endo at Work project, designed to identify the challenges faced by endometriosis patients in the workplace. 

Jon shares his motiviations for transitioning into endometriosis research and how it aligns with his naturopathic approach to healthcare. Our ambassador Emma Sutherland and Jon discuss the opportunities complementary health practitioners have in supporting patients with endometriosis and the challenges faced by these patients in both the workplace and the healthcare system.

Covered in this episode

[00:39] Welcoming Professor Jon Wardle
[03:03] Discussing Jon’s research: the Endo at Work Project
[09:20] The Endometriosis National Action Plan and future research
[11:03] How COVID has changed work
[15:56] Drivers of endometriosis
[21:49] Why are there no biomarkers to detect endometriosis?
[24:15] The use of cannabis for pelvic pain
[25:59] Yoga and hydrotherapy as low cost treatment options
[29:06] Plant based diets and food as medicine
[31:54] Accessibility to health care and group medical interventions 
[35:06] Jon’s passion and research
[37:55] Thanking Jon and closing remarks


Key takeaways 

  • Many women face challenges with the healthcare system when trying to obtain a diagnosis for endometriosis 
  • Endometriosis has been described as the largest health crisis for women in our time 
  • Women with endometriosis do not feel supported in the workplace 
  • Women with endometriosis may need to take four unpaid days of sick leave off monthly due to their endometriosis 
  • The Endo at Work project is working to identify the impact endometriosis has on an endometriosis patient’s career and how a workplace can support these people. 
  • The Endo at Work project aims to identify ways workplaces can support employees with endometriosis. 
  • Data from the Endo at Work project identified one in six women had lost their jobs due to their endometriosis and one in three women were passed over for a promotion. 
  • Endometriosis flare ups are unpredictable and may result in women with endometriosis being excluded from social and networking opportunities. 
  • Many women do not feel comfortable discussing their endometriosis or the impact that it has on them. 
  • The shift to working from home during the pandemic has provided many women who work in offices with endometriosis the ability to improve their symptom management through greater access to health aids during the work day. 
  • Women with endometriosis make up 10 per cent of the Australian female workforce. 
  • The Endo at Work research project is government funded, a process that was supported by advocacy work. 
  • The National Action Plan for Endometriosis was launched in 2018 with $22 million of funding with the goal to improve the quality of life for people living with endometriosis. 
  • Research into intervention in lifestyle, workplace, and environmental interventions may work to empower people living with endometriosis in the future. 
  • Up to 80 per cent of women with endometriosis stated that the requirement to work from home during the pandemic helped manage their symptoms, almost 75 per cent were more productive and 90 per cent found that workplace flexibility had improved following the pandemic. 
  • Endometriosis costs women an average of $30,000 per year. 
  • First degree relatives of a person with endometriosis were 6.9 per cent more likely to have endometriosis compared to 1 per cent of relatives in controls. 
  • Holistic case taking for endometriosis is important and may support a diagnosis and is incredibly important. 
  • Diet and lifestyle support can improve the symptoms of a patient with endometriosis greatly and may help to address underlying factors. 
  • Endometriosis patients can benefit from support with hormonal balance, microbiome modification, stress management.  
  • It is important to treat every endometriosis patient as a unique individual. 
  • There is currently no single biomarker to support an endometriosis diagnosis, with laparoscopies and deep ultrasounds still being used for diagnostic purposes. 
  • Cannabis use for the relief of endometriosis symptoms has anecdotal reports of efficacy, with research underway on cannabis use for the support of pelvic pain conditions. 
  • Deakin Unversity is currently recruiting for a trial to assess the efficacy of yoga to reduce endometriosis pain. 
  • Jon Wardle shares anecdotal evidence to support hydrotherapy for the management of endometriosis pain. 
  • Collaborative care, or group visitis allow for patient-led care may offer support for endometriosis patients, allowing the group to learn from each other. 
  • The Centre for Intgerative Nutrition at the University of California are recruiting for three-month study on the effect of a plant based diet on endometriosis. 
  • Food as medicine can be beneficial for endometriosis patients. 

Resources discussed

Professor Jon Wardle
 National Centre for Naturopathic Medicine at Southern Cross University
Endo at Work Study
Endometriosis Australia
Endometriosis National Action Plan
Safe at Work: Supporting workers with endometriosis in the workplace
Study: Endometriosis in the Workplace, Lessons from Australia's Response to COVID-19 (Armour, Ciccia, Stoikos & Wardle, 2021)
Study: Heritable aspects of endometriosis I. Genetic studies (Simpson, Elias, Malinak, & Buttram Jr., 1980)
Study: Is there a role for small molecule metabolite biomarkers in the development of a diagnostic test for endometriosis? (Tomkins, Girling, Boughton, & Holdsworth-Carson, 2022)
Study: Effects of cannabis ingestion on endometriosis-associated pelvic pain and related symptoms (Sinclair, et al, 2021)
RCT in progress: Yoga, cognitive-behavioural therapy versus education to improve quality of life and reduce healthcare costs in people with endometriosis: a randomised controlled trial (Mikocka-Walus, et al.)
Endometriosis RCT Recruitment: Center for Integrative Nutrition at University of San Diego
Podcast: The Power of Community Medicine with Dr. Michelle Woolhouse and James Maskell

To participate in the Endo at Work study 

The study is suitable for people who:

  • have a diagnosis of endometriosis
  • are aged 18 years or over
  • currently live in Australia
  • have been employed in the past 3-months

July Clinical Mastery information


Transcript

Emma: Hi, and welcome to FX Medicine where we bring you the latest in evidence-based, integrative, functional and complementary medicine. I'd like to begin by acknowledging the traditional owners of the land on which we are recording today. I would also like to pay my respects to elders, past and present. 

With us today is Professor Jon Wardle who is director of the National Centre for Naturopathic Medicine at Southern Cross University. In addition to clinical qualifications in nursing and naturopathic medicine, Jon has postgraduate qualifications in public health, law, and health economics. With more than 200 academic publications to his name, Jon is a highly accomplished researcher. Today we're going to discuss his research into endometriosis. 

Welcome to FX Medicine, Jon. Thank you so much for being with us today. I know that you have a passion for endometriosis and it was actually the focus of your clinical practice.

Jon: I do. Thanks for having me, Emma. Yeah, no, it was certainly pretty much what most of my practice was built around in Brisbane. And funnily enough, it came in many ways because of my experience as a nurse. So, I went into naturopathy thinking that I would work in one certain area and just all these stories of my colleagues in that...which, it is a female-dominated industry, nursing. I was one of the few male nurses. And every time they would hear that I was studying naturopathy, I'd be continually asked by friends and colleagues, "Do you know anything for endometriosis? I've been to this practitioner, this practitioner. No one can do anything. No one believes me.” It just really highlighted, I guess, how hidden this condition is for many women, how much it's significantly impacting their lives and just the immense need that was actually out there to work on it. 

And as I practiced more and more it was just...it is a very rewarding practice to be in because it is something that women do experience a lot, 10% of Australian women potentially. Probably more because it is quite a difficult thing to diagnose. And you can make such a difference in people's lives by treating this condition that still, to this day, women still go into a general practice clinic and be told they're just making it up. And it's not all general practitioners, I should say. Some are very, very good, but it's 2022 and it should be a lot better than it is now.

Emma: Yeah, I absolutely agree. Endometriosis has been described as the largest women's health crisis of our time and the need for significant research into endometriosis in the workplace has been highlighted with recent data showing that women with endometriosis, they don't feel fully supported in the workplace and they, on average, need to take four sick days per month to manage their symptoms. And these are often unpaid. And that puts an extra financial burden on women who are already living with an expensive disease. Now the Endo at Work project, it's a joint project between Endometriosis Australia and leading academics including yourself, Jon. And the purpose is to examine the impact of endometriosis on an individual's career and how workplace changes may influence the management of endometriosis.

So, can you give us an overview of how this research is actually being conducted, the timeframes involved, and the different stages? Can you walk us through, if you can?

Jon: Yeah, sure. So basically, what we're hoping to do is to make workplaces a little bit more endometriosis friendly, make employers a little bit more endometriosis friendly and actually find out how we can use the workplace itself as a tool for making life easier for women with endometriosis. And as you said, it's a very expensive disease. Some of this might be employer management. A lot of women reported not just being passed over for promotion or actually being fired for their endometriosis, taking what was viewed as excessive leave or whatnot for what is a very valid reason for leave.

Emma: Yeah.

Jon: One in six women, I think, actually reported they lost their jobs and about one in three reported being passed over for promotion.

Emma: That's huge.

Jon: This can happen for any number of reasons. Flareups are unpredictable. They happen when they happen. That might require having to leave a face-to-face meeting at any time. It means that a lot of women got excluded from social and networking opportunities that were actually intrinsic to establish themselves in the office. And just the stigma of endometriosis. As a privileged white male, if I say I've got a migraine and I have to excuse myself from the meeting, that's well accepted. Women who reported saying that they have a flareup or often they didn't even feel confident or comfortable to discuss. There's still stigma around women's health and its impact on the workplace.

So, this project...and it's actually a series of a number of projects. So, we're doing everything from surveys of women to identify exactly what is working, what isn't working, how we can make that better. We're talking to employers. We're working with the U.K. Endometriosis Association. Sorry, Endometriosis U.K. who have initiated an endometriosis employer-friendly scheme.

Emma: Okay.

Jon: To basically identify how this place where women spend nearly a third of their lives, a place where there is a lot of potential to actually make life easier. We saw with this natural experiment of COVID working from home actually improves symptom management in a lot of women. That's just simply because they had access to health aids during meetings.

Emma: Yeah.

Jon: They could actually take time out and come back to a task. They actually had more flexible hours. Not every woman. It should be said that obviously there are some types of jobs, office work for example, that are more conducive to this. And we do need to work with other employers. And the construction industry is actually one that's doing quite well with this.

Emma: Oh, good.

Jon: They're looking on the extension of their campaign around menstruation to include endometriosis management but there's a lot of things that we can actually do to make working life more flexible and particularly more flexible for women with endometriosis. Because if we don't, we lose 10% of the female workforce, which is an extraordinarily valuable and important resource that Australian society needs to actually be working to their full potential.

Emma: Yeah. And you can't underestimate what this research is going to bring to light and how this ripple effect can flow through workplaces and have this much-needed improvement for women, and it is such a taboo topic in many workplaces as well. That's what I hear from my patients suffering from endometriosis is that people feel almost afraid or nervous to bring it up. And there is that stigma that you mentioned and we've really just got to blow that out of the water and I'm hoping that this research really helps to do that.

Jon: Yeah, and it's really about making more employers actually knowledgeable about what they can actually achieve from this because our research initially showed that 60% of women found that even just the small amount of flexibility that COVID created actually made them more productive. So, increasing the option of women with endometriosis to be able to live up to their full potential, it benefits everyone. It benefits employers. It obviously benefits the women with endometriosis themselves, and it benefits society as a whole.

Emma: Yeah, it's a win-win-win all around. Absolutely. And this project, it's government funded. Was it difficult to secure that funding?

Jon: Yeah. It's always difficult to secure funding from anyone, not just government. But the thing that actually made this happen obviously...just the incredible work of people like Mike Armour at Western Sydney Uni, an army of people at Endometriosis Australia and Donna Ciccia and a whole host of just incredible people continually advocating for this.

Emma: Yeah.

Jon: But ultimately, the government funding came from the place that most government funding comes from, and that's the narrative and the stories and the power of human interest in stories that surround that. So, we were really fortunate that there were some wonderful women working in the back bench and the centre actually advocating for this, some who were Endo Warriors, some who are not. Obviously, the prime minister's wife was quite influential in some of these discussions as well. But it's slowly sinking into the community, just the powerful stories of everyday impacts of this condition for women and how most women are actually being ignored in their health needs. So, really, that's where the National Action Plan for Endometriosis came from because we've known this has been an underserved condition for a long time.

And I just really want to acknowledge the work that particularly Endometriosis Australia have done on really highlighting how important this work is to do and how important it is to pay more attention to this condition. Even some small changes from what we've seen can have actually quite a drastic effect.

Emma: Yeah, agreed. And that National Action Plan was launched in 2018 and it had $22 million worth of funding put towards that, which is incredible. And the overall goal was a tangible improvement in the quality of life for individuals living with endometriosis including a reduction in the impact and burden of disease at individual and population levels. And one of the pillars is research. Are there any particular areas of research that you would love to see explored under this action plan?

Jon: Well, this workplace project is a really good example. I think there's a really great potential in empowering women to actually manage their condition, to manage their endometriosis symptoms better. We were asking people to...we're asking square pegs to fit into round holes.

Emma: Yeah.

Jon: To make that hole that they need to fit in a little bit more square, a little bit similarly shaped because we...life doesn't go away.

Emma: Yeah.

Jon: But there's all sorts of things we can actually do to make life easier for women. Not just with endometriosis but with any condition. And we don't really do that as well as we could in Australia so...

Emma: Agreed. Okay.

Jon: Lifestyle interventions, workplace interventions, creating environments that are actually conducive to not just good health but actually empowering environments that actually enable you to manage whatever symptoms you have and building that flexibility. This is a non-pharmacological approach. It's almost naturopathic by definition.

Emma: Yes.

Jon: And I think sometimes naturopaths, we tend to focus on the power of what happens over the desk with a one-on-one intervention with a patient but actually that holistic notion of actually building health producing environments I think is something that I think not the research community or, to be honest, many of the naturopathic community have actually paid as much attention as they should on.

Emma: Yeah. It's a really interesting area. And anything we can do to make this an easier process is going to be a great thing. And you mentioned before about how COVID has changed things. And doing some research for this episode, I came across this 2019 information sheet from Safe Work Australia and it was detailing endometriosis and encouraging employers to consider flexible work arrangements and job modifications. And it might've been a recommendation but up until COVID happened, data is pretty clear that endometriosis sufferers didn't always have the flexibility that they needed. And one thing I've seen time and time again in clinical practice throughout COVID is how well it has suited these women. It's been just incredible. Can you expand on this a little bit more?

Jon: You're right. This is something that's been recommended for a long, long time. COVID I guess snapped us all out of reality a bit and actually created a natural experiment. And COVID obviously was a challenging time for all of us but we really took this opportunity to actually highlight...this is the first time that people were being essentially forced to work from home. Employers didn't really have a choice on whether they could or not. Women were actually working from home, as were men in many jobs. And it's one of the few examples where basically the world provides you a natural experiment to test the hypothesis. The results themselves, we knew it was probably going to be helpful but the results were actually quite surprising to us.

We were gobsmacked, to be honest, at how much this has actually improved the lives of women with endometriosis. So nearly 80% of women said it made management of their symptoms easier. Nearly two-thirds said they were more productive. And I think it was 90% of women actually thought that flexibility in working arrangements was actually going to improve the management of endometriosis in the workplace if there was actually a more formal way of doing that. So, it's one of those things. Sometimes you can say, until you're blue in the face, that this is going to be helpful, this is going to be helpful, but actually having this experience and having that data and actually being able to show to people that actually it helped women, and it helped the bottom line has a lot of advantages here as well. So, through the end of our work project, that's the extension of what we're doing now is to actually develop those recommendations for employers.

Emma: Fantastic.

Jon: Because I think working from home was always seen as a cost for employers or it was going to result in lower productivity or people thought they were going to be watching Netflix and...

Emma: Yeah. Yeah.

Jon: ...eating tubs of ice cream and that was all they were going to be doing while they're at work. But this was actually one of the few silver linings of the last two years was we've had a radically different view of workplace flexibility and what workplaces were doing that was good and what workplaces were doing that was bad. And I think there's a lot we can actually learn from that.

Emma: Yeah, and I think it's incredible. So that paper is called Endometriosis in the Workplace, Lessons from Australia's Response to COVID-19. And we'll link to that in the show notes for people that want to go on and read that in detail. 

But in our previous podcast that I did in this series on endometriosis with our Endo Warrior, Natasha, she explained to us the extensive nature of endometriosis and its high financial costs. And statistics show that endometriosis costs women an average of $30,000 a year. So, the ability to work really matters to these women. And anything that can be done to make this an improved situation is so critical. 

And Natasha was saying...it was so fascinating. She was saying, "Look, I was always the one person in a meeting that was on Zoom before COVID. And so, I felt alone in that. And then in COVID, everybody joined me on Zoom and then we were all kind of doing it together." And she really helped them work out some working from home techniques and strategies that had been working for her because she was the expert on the matter. So, I think that there's a lot to be learned in this space.

Jon: Oh, completely. And look, some of the things that people found most useful, which is so simple for any workplace to develop, so just things like being able to build the capacity for 20-minute rest periods if people need to go away for 20 minutes. Something as simple as actually having heat packs available and the ability to…

Emma: Great.

Jon: ...heat them in the office which isn't always available. These are really low-cost and very easy things to implement that don't actually disrupt the workplace at all. And actually, potentially made people's lives a lot easier and a lot more meaningful.

Emma: Yeah.

Jon: So, and obviously there are additional interventions but there's a whole spectrum of things that are actually incredibly easy to implement and actually more advanced things that might take a little bit more infrastructure to do but actually can be very useful and have a real cost in clinical benefits.

Emma: So, there's a lot of low-hanging fruit that most workplaces could action and implement that could make some quick changes while these longer-term things are being rolled out. I mean, I love that positivity there. 

Now I want us to swing a little bit to the drivers of the pathogenesis of endometriosis and I was looking at one study that showed the occurrence was around 6.9% in first-degree relatives of women with the disease compared to a 1% rate in relatives of controls. And I found this really fascinating because as a naturopath, we know this is a multidimensional situation. There are many drivers. But that stat to me was such a highlighting one that showed me, okay, don't ever forget the importance of the case taking, of course. But what other drivers…like what are the drivers that you see and that you feel are involved? And I know there's many, but let's just delve into it a little.

Jon: Yeah, look, you're completely right. It's a multidimensional, multifaceted condition, for sure. And actually, I remember having this conversation with people who were dubious about many naturopathic treatments or many complementary medicine treatments because they'd say, "Oh, well, the trials say it doesn't work," or something like that. But when you're a naturopath, you do your case taking. You know that some people...your treatment might be related to microbiome. It might be related to the inflammatory component. It might be hormonal. It might be...there are many things that can actually come into play with that treatment and if you're picking out just one and giving that same treatment to everyone with endometriosis, by its very definition, you're going to be successful in the minority of cases.

Emma: Yeah.

Jon: So, this is one of the things that I find so interesting about endometriosis is it is so multidimensional. It is highly individualised.

Emma: Yeah.

Jon: Women are experiencing the same symptoms and the same manifestations in many cases but the journey of how that developed can be quite different, radically different for many women. So, I know the familial aspect as well. Certainly, there is a genetic aspect to endometriosis itself and it can be something that does form with that very high genetic component but all these risk factors themselves can actually...they've got quite a high relationship of sort of familial tendencies in things like how autoimmunity does, for example, or we're seeing a lot of really interesting stories about the microbiome of your grandparents is very similar to the microbiome of yourself. And there are certain things you have to do to actually negate the bad habits of your ancestors in some cases because that does actually get passed down generation to generation.

So, I do think it is something that we need to look at a lot more carefully. I think we need to look at it beyond just genetics because historically, in these sorts of papers, it's been about the genetic pathogenesis. It's actually more related to those risk factors and those behaviours, diet, lifestyle behaviours that might've been three or four generations ago but are actually still impacting children, grandchildren, great-grandchildren down the track.
So, when you are doing a case taking, you are right and actually no blood tests or anything can actually replace good case-taking technique. But I think it is actually increasingly important to actually look not just at the individual themselves but also the environment they've come from, the family they come from, the risks that might've actually filtered down through the generations there as well.

Emma: Yeah. That is such a good point. From that naturopathic perspective, we're always blaming oestrogen on things but I think in this case it's not the only thing at play. The inflammation process, the interferons playing with those inflammatory pathways.There's so many things at play here, and sometimes I think of a spider's web as a clinician and if we just start to tug on one of the strands of the spider web, move towards an anti-inflammatory diet or encourage the sleep hygiene to be better, we can start having an effect across the whole-body system. But yeah, I think addressing the underlying drivers are always going to be key here.

Jon: Oh, completely. We need to treat everyone with endometriosis with an open mind because you're right, historically, it's always been about the hormones and the hormones can be impacted by the HPO axis or the HPA axis. They can be influenced by the microbiome. They can be influenced by just stress and anxiety more generally. They can be influenced by diet. There are all sorts of factors that can come into that. 
So, every patient that comes through your door with endometriosis is a new patient and they might have endometriosis but you can't assume that anything that they actually have influencing their endometriosis diagnosis is the same as the last patient with endometriosis you saw. And for me, as a clinician, that was actually what I found even more rewarding about treatment was that these were people who would often go to a lot of other practitioners with essentially shotgun or protocol type treatments for endometriosis, weren't getting success And it wasn't just the detective work of trying to find out what was happening physiologically or sometimes not always physiologically but sometimes psychologically or all these things that are impacting. But it is often the first time that these women had actually had someone actually treating them and their condition as an individual....

Emma: Yeah.

Jon: ...rather than actually treating them as endometriosis. So, it lends itself to naturopathic treatment so well for that and it's something that naturopaths should be very...certainly make sure we don't let go down the route of evidence-based treatments and that we shouldn’t be doing the protocol type treatments. But I remember when I was first practising and just even the concept that gut health could actually impact women with endometriosis by modifying the microbiome, which wasn't even cool then. I remember being laughed at and sort of castigated and all sorts of things by other practitioners. And now the research around microbiome endometriosis is pretty standard now. It's a pretty standard thing to actually say that actually that is something you should look at when you are treating a woman with endometriosis. And that's something that you'll hear probably from a GP or a gynaecologist without much controversy.

Emma: Yeah, this aspect of whole-body medicine is really growing and it's so great to see that philosophy moving out to other forms of healthcare. 

But as a clinician, one of my dreams is to see an accurate blood marker for endometriosis to be discovered. And in clinic, we see this incredible suffering as women, as they walk the years long path to diagnosis. But laparoscopies, they can be invasive, they can be expensive. And a deep endometriosis ultrasound, it can be helpful but it's more predictive of severe endometriosis, not the mild or moderate. And in the research for this episode, I came across a paper from April this year that looked at 29 studies on potential biomarkers but unfortunately, they concluded that none had reached diagnostic utility and my feeling is that there's going to be a combination of biomarkers that might just one day become diagnostic. But I would love to know, I mean, do you have any insights on that front?

Jon: Yeah. Well, I'm sorry to disappoint you and say that they probably know a lot more than I do about this. You're completely right, Emma. Laparoscopies are very invasive and expensive and ultrasounds well, they are a lot better but they're still not great.

Emma: Yeah.

Jon: If, for no other reason, that you actually have to go to a specified facility and that kind of stuff. One of the things that often doesn't get discussed about diagnosing endometriosis this way, is it just also allows people to dismiss women when they say they've got endometriosis from being believed. So, a lot of women's complaints get dismissed because they might not be able to take the time out to have one of these things. They might, for pretty justifiable reasons, not want to go. Any operating theatre is not a pleasant environment that you’d sort of put your hand up and want to go to willingly.

Emma: Yeah.

Jon: So again, you've mentioned research is just so important. And it's 2022 and we're still reliant on an invasive surgical technique to actually fully diagnose women with endometriosis. And I think that speaks to the incorrect priorities in where we're placing our research dollars because there are biomarkers for anything that ever happens to the prostate.

Emma: Yes.

Jon: And look, there might be physiological reasons for that, but a big part of that is actually because that's a male condition. If endometriosis affected men as much as it affected women, we'd definitely have biomarkers by now. I don’t doubt that.

Emma: Oh, my goodness. Don't get me started, Jon. Don't get me started because I cannot tell you how many times I've literally wrung my hands and said, "Why do we not have this clinical information yet?” It's so frustrating as a clinician to see and hear these stories.

But one of the keen areas of interest for me is the use of cannabis for endometriosis because, I mean, in clinic, many of my patients are using it for effective, really effective pain relief, but it would be just incredible to see some research in this space. And a 2021 paper by Justin Sinclair and Jerome Sarris showed pain was the most common reason to use cannabis. Now we know this clinically but it's great to see this backed up in the research. But do you have any research coming up that involves cannabis because I'd be very interested?

Jon: We have actually quite a lot of research in cannabis. Actually, we're running Australia's two largest clinical trials on cannabis...

Emma: Great.

Jon: ...through the centre right now. None of them in endometriosis, I should say.

Emma: Yeah.

Jon: They're on…pelvic pain is, I think, one of the real key areas of benefits of cannabis. And cannabis is something that can be a little bit overhyped sometimes. There's probably this large circle of stuff that it's claimed for benefit in and there's a smaller circle within that that it is actually useful. But one of the things that I find really fascinating about cannabis is it doesn't treat all pain equally.

Emma: Yeah.

Jon: There are some forms of pain that it just isn't effective in, and there are some forms of pain that it's really effective in. And the one that it seems to be really great for is pelvic pain.

Emma: Perfect.

Jon: And certainly, there seems to be a real appetite to actually explore this. So we are having some conversations around that at the moment. We don't have anything going in that at the moment but we've got a project up with cannabis in fibromyalgia, one of the other forms of pain it seems to be quite helpful for. We've been working with veterans on a few other things. Obviously, there's some work in cancer that Janet Schloss is working on. So, we do have quite a big cannabis program. I just can't wait to get these two programs working together…

Emma: Yeah. 

Jon: …because I think there's just enormous potential there.

Emma: Oh, we'll have to get you back on the show when the research comes out because that's going to be fantastic. 

And before when we were talking about that holistic nature of treatment, I know Deakin University is currently recruiting for a trial to assess the effect of either yoga, cognitive behavioural therapy, or educational quality of life with women with endometriosis. And previous studies have definitely shown the benefits of yoga. I mean, what do you envision for the woman of the future as an ideal treatment for her endometriosis? What do you see in 10 years' time to be available?

Jon: Yeah, well, this goes back to that research priority that I was talking to you before. Empowering women to actually be leads, actually not just reliant on practitioners but leads in their own journey to good health.

Emma: Yeah.

Jon: So, yoga is just a fantastic tool to use. One of the things that I actually use quite effectively in clinical practice, but have no research on it at all, is hydrotherapy.

Emma: Yeah.

Jon: And this is…everyone has the equipment already in their house. Water is free. Well, not free but very, very low cost.

Emma: Yeah.

Jon: And it's something that you can actually do by yourself without supervision. So we've reintroduced hydrotherapy into our naturopathic program because of that because that is such a wonderfully accessible and effective non-pharmacological approach.

Emma: Yeah.

Jon: Obviously education programs I think are really important. So, we've got some great students that are doing some fantastic work in the area of lifestyle medicine and group visits, which are primarily not just treatment programs but education programs. So, I would really like to see more patient, not just centred, but patient-led.

Emma: Yeah.

Jon: I really think there's a real great role for naturopaths not just as, sort of, practitioners that sit over on the other side of the desk but actually facilitate this to help people through this life.

Emma: Yeah.

Jon: Yoga. I found this just the other day. I've moved offices and I found my old yoga book from 1974 that I used to photocopy and give to every patient. But one of the things that I think would be really interesting, you mentioned yoga, is that there are individualised forms of yoga and we've just developed an MOU with SVYASA University, one of the largest yoga universities in India and a couple of naturopathic and yoga hospitals over there. They're doing wonderful  programs but they do individualised yoga for conditions...

Emma: Yeah, amazing.

Jon: ...condition-specific yoga programs and endometriosis is one of the ones that we're working with them on moving forward. 

So, we always talk about lifestyle medicine and that kind of stuff. It can be a bit of a, I guess, dumping ground, for just…there can be a bit of victim blaming as well or it can be...we would say, "Well, if only you were living the right lifestyle and doing the right behaviours, you'd be better." There's a real opportunity to have a much more sophisticated and nuanced approach to how we help people help themselves with the management of their conditions and symptoms.

Emma: Yeah, and that collaborative care model, as clinicians, that we need to always keep front of mind is who is the best person for me to refer to in the yoga space, in sleep space. Whatever it is, we need to wrap these patients in a fantastic support network so that they have what they need at their fingertips rather than trying to struggle on their own. That's super important. 

But let's talk about one of my passions, which is food as medicine in clinical practice. And I know the Centre for Integrative Nutrition at the Uni of California are currently recruiting for a three-month study on the effect of plant-based diet on endometriosis. Do you know of any current research in this space?

Jon: Yeah, well, that's pretty much it at the moment.

Emma: Okay.

Jon: If you know Gordon Saxe and his group at UC San Diego on that, which is a plant-based diet but also, it's actually a Chinese medicine-oriented plant-based diet as well.

Emma: Okay.

Jon: So, there are a lot of TCM principals in that. I think there's enormous scope to doing that. We're certainly developing what's called a culinary medicine component to our degree.

Emma: Oh, fantastic.

Jon: But we've got the infrastructure that is going to be very much taught to do that sort of seminal work. And the thing that always sticks with me about this whole food as medicine concept is I remember going to a research conference and seeing the colleagues from the U.K. talking about how disappointed they were in their Chinese medicine trial because they had this Chinese medicine trial, they designed it perfectly and it worked really, really well but so did placebo.

We asked them about placebo, we asked them what the placebo was and they said, "We designed it really well. We wanted to make sure the placebo was equally as disgusting to take, equally as smelly, equally as..." And when I asked them what it was, they said, "Oh, we just put lots of garlic and cabbage and brussels sprouts." And I said, "No wonder it worked so well. It sounds remarkably like a naturopathic food as medicine treatment for someone with endometriosis." So, I think there's just so much that we can be doing in the food as medicine space because it is the medicine you take every day. And it might not be as powerful as pharmaceuticals but it makes up in just being able to completely reorientate the body's physiology. It makes up for it just in its constant presence.

Emma: Yeah.

Jon: I used to always relay to my students that if your patient walks away and you've made no other change than for the rest of their life but to see one more vegetable or just a few more legumes or something like that, then you've actually made an extraordinary difference in their life.

Emma: Yeah.

Jon: And we know from nutritional studies that these things can make a lot of difference to symptoms and symptom management of endometriosis. I'd love to bring this back to food because a lot of them are lentils and microbiome or the cruciferous foods rather than supplements.

Emma: Yeah.

Jon: Even simple things like just restoring those fatty acid balances, can actually make a big difference in that inflammatory response as well. So, I think there's just enormous potential. And we do have one student that's, sort of, starting on this but that's just part of a bigger group program.

Emma: Okay.

Jon: But it is one of the things that seems to be just working really, really well.

Emma: Yeah, fantastic. And look, I think for all the clinicians listening, don't ever forget that food as medicine is your baseline. Don't go getting fancy and throwing supplements and all sorts of other things if you have not covered that food as medicine baseline. I'm so passionate about that. 

Now one of your PhD students is doing some - well, quite a lot of them are doing some good work - but the one that really, really fascinates me is the one with Sophia Geroktakos who's doing a clinical trial to investigate how accessibility to naturopathic care can be improved, and her studies focused on examining the effectiveness of group delivered naturopathic care. And I really feel this is ground-breaking research and can't wait for these outcomes to be published. And Dr. Michelle Woolhouse did an episode with James Maskell on community-based care and the early data from his work is really so incredibly positive. I can see this model working so well with endometriosis. So, when will these results be released? I'm very keen to hear them.

Jon: Yeah, well, you'd be very happy to hear that Sophia is very close to finishing data collection now.

Emma: Great.

Jon: So hopefully, hopefully very soon. But just the initial feedback has been fantastic. And it's everything you'd expect from a group intervention. So, one of the key tenets of naturopathic medicine is the whole doctor as teacher phenomenon. And then group interventions are basically...they just take that principle and just run with it. So, women are learning about themselves and about their conditions. They're not relying on the practitioner themselves to actually learn something.

Emma: Yeah, great.

Jon: They're actually learning from each other. There's a lot of opportunities affording reflection on their own experiences. For many people, it's one of the first times they've had a luxury, I guess, of sitting in that sort of supportive and facilitative environment to walk through their own experiences. So group interventions, basically how they work is generally a sort of a program of care of 6-week, 12-week, 24, depending on the condition and whether you have regular meetings. Education sessions on things like food as medicine...

Emma: Great.

Jon: ...light mindfulness, light self-care, those sorts of things. And then also the opportunity to have individualised brief consultations if there is something more specific that the women want to talk to.

Emma: Yeah.

Jon: So, group medical interventions, what they previously have been called are shared medical appointments. I like to call them group visits because I think naturopaths have a very unique and are very well poised to work in this kind of space. And I think it's something that does make naturopathy more accessible to many people. Some people aren't ready for that one-on-one consult.

Emma: Yeah. And it's too expensive, Jon, for a lot of people.

Jon: Yeah.

Emma: It's cost prohibitive. And I love that this is just so much more inclusive on so many levels. So, I'm really looking forward to getting all the details from that one. Now, my last question for you...

Jon: And one other thing, Emma, too that's really exciting about it is I was just talking to someone. I won't name names but a very large veterans' clinic which is actually using a similar approach for veteran care and pain. And what they've been able to do through it being a program rather than a naturopathic visit is they've actually managed to get the major private health insurer actually to pay for naturopathic treatment.

Emma: Incredible.

Jon: Even in the light of the ban for this. So, there's...obviously, our centre are very actively trying to, sort of, repeal that prohibition, which is...

Emma: Yeah, great.

Jon: It's a very unfair prohibition. But this model is going to be a way that we can actually get that accessibility barrier overcome as well.

Emma: Yeah. And I love all the advocacy work that you're doing at the centre. It's much needed in our industry. So, a big thank you. 

My last question in the last minute or two is, as a researcher, I know you're eternally curious and I would love to know if you could design a study without any barriers to resources, what would you want to research in this space? What question do you want answered?

Jon: Well, hopefully, I'm working towards them.

Emma: Okay, great.

Jon: Slowly, a little bit delayed. So, as I told you, I started working in clinical practice in this setting and sort of went off into the research community and kind of had to let endometriosis not go, but didn't get to focus on it as much as I wanted and now I get to make a few more decisions. So I'm really trying to reorient…

Emma: Yeah, great.

Jon: ...back to my passion, which is this. But my passion always has been the same. It's that accessibility, that affordability, getting the power of naturopathic treatments to those who need them the most. And sometimes that's the really low intervention stuff that no one has an interest in funding.

Emma: Yeah.

Jon: I mean, hydrotherapy is one example we've chosen. Even food as medicine. No one makes money out of food as medicine projects at all. But one of my lecturers when I was studying made a comment that the more years that they practice, the less and less products that they prescribed.

Emma: Yeah. I love it.

Jon: And the ones they did prescribe were really targeted and very necessary. But when they first started, they were just giving people everything. People were running out of there, out of their clinics.

Emma: I know. It is a big no-no but I think as you learn more, you realise how to practice in a way that's much more efficient for the patient as well.

Jon: But really learning from those naturopathic principles, and we've got other PhD students like Rebeca Redmond as well who's doing great work going back through not just the naturopathic archive as it were but hundreds of years of historical documents. Some of these things we shouldn't learn from, some of these - and they were always men - but there are some really interesting traditional approaches that were really useful. I know that one of my...one of the treatments that I used a lot in my practice is Poria cocos which is a Chinese medicine herb which is used for damp heat, usually, and I found that quite effective for many women.

But there's not been a lot of that kind of what can we learn from traditions and can we take the best of bits of Chinese medicine and incorporate them in naturopathic ways or bits of other naturopathic medicine and incorporate them in Ayurvedic treatments? I think as you said, that lifestyle building, empowering women to actually have more control in producing good health themselves rather than having to go back to a pharmacy or a practitioner every second week to get their fix.

Emma: Amazing.

Jon: So much potential.

Emma: Yeah, there is so much potential, which is so exciting. And I just can't wait to see this research path unfold for you. 

But thank you so much for joining us today, Jon. The key points, there's so many key points, but the future looks bright ranging from better access to naturopathic care, to blood-based biomarkers for a quicker diagnosis and more inclusive workplaces. There is so much for us to look forward to in this space.

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


About Professor Jon Wardle

Jon Wardle is an Associate Professor of Public Health at the UTS Faculty of Health and holds visiting positions at the School of Medicine, University of Washington and the School of Medicine, Boston University. He has clinical backgrounds in naturopathy and nursing and postgraduate training in public health and law.

Jon is the head of the Regulatory, Policy and Legislative Stream of the Australian Research Centre in Complementary and Integrative Medicine. He is also a core committee member of the Public Health Association of Australia's Research Advisory Group, which promotes and advocates for public health research and development. Jon has worked Jon has worked on complementary medicine and primary healthcare policy in Australia, the UK, Germany, the US, Latin America and India, and holds editorial positions on a number of journals, including editor-in-chief at the International Journal of Naturopathic Medicine and Advances in Integrative Medicine.


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Emma Sutherland
Emma Sutherland is a successful mum, author and clinical naturopath. Her mission in life is to inspire women to get their Mojo back and to help families raise vibrantly healthy children. Emma is a fully qualified Naturopath, having completed four years of training in Herbal Medicine, Nutrition and Homoeopathy as well as a Bachelor of Health Science. She has over 17 years of experience in treating women and children at every life stage. Her busy clinic provides her with many clinical insights as well as keeping her finger on the pulse of patient led trends. Her friendly personality results in a unique ability for people to feel comfortable and listened to. Emma’s daughter, Sophia, is her greatest teacher and constantly pushes her to do better and be better. Emma is passionate about always learning and discovering new concepts and strategies that she can apply to her clinical practice. And let’s not forget her number one value in life is fun!