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Understanding Adenomyosis with Leah Hechtman

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Understanding Adenomyosis with Leah Hechtman

It is estimated that 1 in 10 women have adenomyosis. So what actually is adenomyosis, and how does it differ from endometriosis? Who is most at risk and what are the best integrative treatment approaches?

In this episode, Naturopath Leah Hechtman returns to FX Medicine to discuss the specifics around adenomyosis: what we know (and what we don’t) about the pathophysiology, who is most likely to be susceptible to it, how it impacts fertility and how we can help manage it and support our patients through this painful and surprisingly common condition. 

Covered in this episode

[00:47] Welcoming back Leah Hechtman
[01:36] Defining adenomyosis
[05:10] Who is at risk?
[06:20] Does the immune system play a role?
[07:25] Common ways pain presents in adenomyosis
[09:58] Ureaplasma and other infections linked to adenomyosis
[11:49] Treatment  and diagnosis options
[16:24] Further discussion on ureaplasma and how it affects the uterus
[22:04] Ureaplasma symptoms in men
[22:27] Approaches to natural treatment
[29:13] Herbal remedies Leah uses for adenomyosis
[32:39] Neutraceuticals
[35:43] Supportive care for patients
[39:10] Do environmental pollutants contribute?
[40:51] Encouraging a team approach
[41:41] Considerations before giving curcumin
[44:12] Proteolytic enzymes
[46:12] Thanking Leah and closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line is Leah Hechtman. She's an experienced and respected clinician who specialises in fertility, pregnancy, and reproductive health for both men and women. 

She has completed extensive advanced training, and is a university lecturer, keynote speaker, author, and educator to her peers. She's currently completing her PhD through the School of Women's and Children's Health Faculty of Medicine at the University of New South Wales. 

And she is the author of Clinical Naturopathic Medicine and Advanced Clinical Natural Medicine. And I'd like to warmly welcome Leah back to FX Medicine today to talk about adenomyosis. How are you, Leah?

Leah: I'm good, Andrew. Thanks for having me. How are you?

Andrew: I'm great, thank you. Now, firstly, we're going to be talking about adenomyosis today. And I guess, first, we need a definition because it's a little bit ambiguous.

Leah: It is a little bit.

Andrew: Yeah. Can you take us through what do they think is the pathophysiology, if not, the aetiology?

Leah: Okay. So, there's a few questions. So, I'm going to start with the definition and then we'll work our way through. 

I think the most important thing for everyone to remember is, everyone kind of groups adenomyosis as, “Oh, you know, kind of like the sister to endometriosis.” 

Andrew: Yeah.

Leah: There are similarities, and then there are a lot of differences. And I just want to get the clarity out there for everyone if we can.

So, first thing’s first is, it's a benign uterine disorder and it's commonly described as the presence of endometrial glands and stroma, located deep within the myometrium. There's a lot of muscle hyperplasia and there's destruction of the normal myometrium as well. 

So, you've got the woman's uterus and there's enormous infiltration and enormous changes to the myometrium. So, she has, understandably, a significant amount of associated symptoms. So, if you're okay with it, I'll jump into symptoms and then we'll go around. Good.

With respect to the symptoms, the first thing that they often come in with is abnormal uterine bleeding. So, it could just be extremely heavy menstrual bleeding. You know, menorrhagia for women with adenomyosis is a high 90%. Some studies are suggesting even closer to 100% of women. 

And heavy menstrual bleeding, it's really important to go over those questions with people to establish what they consider normal and what you consider normal. And I always ask people questions like, "Are you flooding the bed at night? How often do you wake up in the middle of the night to change your sanitary items?" If you're using a menstrual cup, fantastic, because then we've got a ml and we can quantify that ml. And always reminding people that, you know, normal menstrual blood loss, statistically, is between 80 and 120 mls per period. But the average woman with adenomyosis could lose 120 mills in the first day.

Andrew: Yeah.

Leah: And that bleeding doesn't seem to stop just when she has her menstruation. She also has a fair amount of menorrhagia and just spotting after intercourse, spotting before she has her periods, spotting around ovulation, just constant bleeding. 

And I've had women with adenomyosis where, literally, out of a 30-day month, have 5 days where they don't bleed at all, which makes it difficult to live a full life. Very high, 85% of them will have blood clots. And in adenomyosis women, you know, the blood clots are not tiny, you know, size of a five-cent piece blood clots. 

These are the women where they basically feel like they're labouring when they go to the bathroom because they're the size of a hand, the size of a baby's forearm. We're talking huge menstrual clots, here. But they often are passing in the bathroom. And, really, understanding the look of those clots is really helpful, clinically, and the size.

Andrew: Right. So, there's already many confounders there, like infections, cancer, polyps.

Leah: Absolutely. And the biggest thing is that it's benign. So, that's...I guess, adenomyosis in some ways has been diagnosed post-exclusion of other aspects. But the infection piece is the contentious one because I do think that with adenomyosis women, they do have a huge infective component.

Andrew: So, you've covered the major symptoms. Populations at highest risk?

Leah: It used to be considered just for women over the age of 40 when she'd had multiple children. You know, it was just that women over the age of 40, they've had more than ideally two prior pregnancies. They were at greatest risk. 

But now, we're finding that in infertility population, some of the statistics are as high as 70%, some are around 25%. So, I don't think we know yet the numbers, but I certainly think in my practice at least 50% of the women with infertility or miscarriage risk are having adenomyosis as young as in their early 20s, and even nulliparous women. 

Andrew: Whoa. Right.

Leah: So, I don't think that prior pregnancy has to be a predictor.

But I think the biggest thing that we need to draw everyone's attention to is, diagnosis usually was only ever made post-hysterectomy for women, you know, post-menopausal hysterectomy women. But technology has evolved and we're diagnosing adenomyosis on ultrasound really easily now. 

So, I think it's important that we recognise that we can see very subtle changes in the uterus quite early on now, as well as that extreme adenomyosis woman.

Andrew: If you're talking about destruction or invasion of lesions into the myometrium, have any immune factors been elucidated here?

Leah: There's some suggestion around it. There's certainly a correlation with women in the infertility world that they have a correlation of adenomyosis and natural killer cell presence. There's definitely association with all the miscarriage statistics, and they're considering it to be both an immunological and an implantation error situation. 

But, look, a lot of women with adenomyosis have endometriosis. We know, endometriosis, it's proven that there's an infective driver. And we know that it's proven...all the other variables of adenomyosis are proven. 

So, we've got enough evidence around inflammatory predisposition or inflammatory driver. We've got enough information around cell changes and blood coagulation disorders. But the infective part is where research needs to catch up.

Andrew: Obviously, infertility is a major issue facing patients, and loss of work hours, loss of productivity because of ill health, feeling tired, all of that sort of thing. But what are the main ones that women report?

Leah: Pain is the first one. It's amazing how many women can literally be losing half a litre of blood with their menstrual period and not focus on that. But it's that classic burning uterus sensation that women talk about. 

Andrew: Right.

Leah: So, they have this thing where it's like their uterus is on fire. And they talk about that they can't do up their pants, they can't sit down properly, they can't have sex properly. It's the burning uterus sensation that all of my patients seem to walk in with, and as soon as I hear that, my alarm bells go off. And I'm like, "Okay. There could be adenomyosis here." 

Because endometriosis doesn't have the same sensation, necessarily. It can, but they'll often have all sorts of other things. And then as you go digging, they'll now start talking about the cramping around their period being completely a burning type of cramping.

Andrew: And is it the area where it's burning that's important?

Leah: Very much so.

Andrew: I guess, I'm going through my head here thinking about differential diagnosis. And I guess one of the things I'm thinking about is herpes.

Leah: Absolutely. It's very isolated into the uterus itself. And if the clinician palpates the areas and can identify where the uterus is, it's generally quite inflamed when they're bleeding. But it gives them a context to actually just identify the structure, and then identify where the ovaries are. And the palpation...and it's such a longitudinal burning sensation that they have, it's such a classic diagnostic. 

Herpes pain tends to burn through the whole peritoneal cavity, whereas adenomyosis, it's like a line. And you can just visually imagine the position of the uterus and just that line of pain through it.

Andrew: Is it on palpation, is it there are rebound tenderness or tenderness under pressure as well? Again, differentiating appendicitis, that sort of thing.

Leah: Yeah, absolutely. Under pressure, and forward flexion always seems to make it worse. But different to appendicitis because with the adenomyosis, it's just literally around that uterus. It can go around the sides of it and all that sort of stuff, whereas with appendicitis, it's not such a small area. 

And I think the thing to always remember, not that you would have forgotten it, the uterus is really small. Do you know what I mean? It's, like, you know, you just clench the patient's fist, put it down, and then imagine that you're doing a longitudinal line and there you've got just that clear band of the adenomyosis pain.

Andrew: Now, let's talk about the infection issue.

Leah: Well, it had to come out at some point.

Andrew: Yeah.

Leah: I find it challenging when you look at the research because it's not 100% conclusive. And again, as I said in my caveat earlier, we relied on it just being a post-menopausal disease. And we're realising more and more, it's just not that. We're catching up. 

But, literally, as research is going, they're catching up with all the endometriosis research. But the thing that I'm finding clinically the most fascinating is that pretty much every single adenomyosis patient I've ever worked with — and I've worked with a lot — they all have bugs, but they all seem to have ureaplasma more than anything else.

And ureaplasma is such a controversial one because there's so much contention around, is it commensal or is it infective? My rule of thumb is if you treat it and they feel better, I don't really care if you think it's commensal. Do you know what I mean? 

But it's very, very clear for me in patients. There's quite a few that seem to come up. And if you do microbial analyses and things like that as well, there's definitely a disruption in the microbiome, and there's a lot of interesting bugs that seem to be coming up.

Andrew: So, what else is coming up?

Leah: I think what's also interesting is that there's a lot of research in Europe correlating all the herpes bugs with respect to natural killer cells. And then the herpes flares with adenomyosis, women are definitely coming up and correlating as well. 

That seems to be sort of burgeoning research in that infertility miscarriage population, but definitely needing to correlate the presence, particularly of oral cold sores and the flare-ups of oral cold sores correlating with flare-ups of uterine hostility and implantation rejection.

Andrew: Is this something where we've got to be just really cut and dry about it, that medical drug treatment has got to be first thing off the line? Or are there appropriate natural treatments that are effective and indeed safe, both in the short-term and for the long-term?

Leah: I think it depends on the severity of the situation and the variables that are needed. I'm absolutely not against using medical antibiotics or anything along those lines, if it's warranted. And I find that, yes, there'll be some interruption to the uterine microbial colonisation, but there's always going to be cross-contamination and different things anyway when you do the assessment. 

But also, you can repair it. Anything that you can repair and kind of look at then, well, I don't think it's such a bad thing. The relief in women and the ability to actually take them from an acute inflammatory state and then move them towards a healing state, so much more rapid sometimes with antibiotics, where the drug of choice is always azithromycin. It seems to be the most effective.

Andrew: Yes.

Leah: Herbally, again, we're extrapolating from LPS research using berberine and other substances like that. It does definitely work, but it takes a lot longer. And you often need to do it in conjunction with other herbs that can be supportive. 

But sometimes, a medication like azithromycin is just a quicker 10-day course because you have the anti-inflammatory property of it as well, just to actually arrest the aggressiveness of it and then work out where you can move forward to from there. 

Andrew: Right.

Leah: It really depends on the severity of what's going on. But I mean, I've had patients where, you know, the women that are flooding through the mattress, the menorrhagia is just so significant. And the reproductive community is saying hysterectomy only and they want kids. Ten days with antibiotics with some herbs, sort out the microbial colonies later, and they're back on track.

Andrew: Right.

Leah: So, sometimes shorter is better and you can actually get things in check.

Andrew: I was concerned from a long-term perspective. You mentioned inflammation there, and I'm thinking pelvic inflammatory disease. I'm thinking about the fallopian tubes. 

Leah: Absolutely. Same.

Andrew: So, this is why I wonder if it's just safer in the long-term to just use the antibiotics short-term, get it over and done with, and then use your herbs later to mop up any issues.

Leah: Yeah. Look. I think it's, again, really dependent on which type of adenomyosis woman we're talking about. I mean, if she's in her 20s and 30s, I think it's really like PID. If she's in her 40s, she's concluded her family, but after that last caesarian or that last vaginal delivery, she's just been in this constant burning pain, you might do the 10-day course and then sort it out later. 

And then if she's one of those women where it's concomitant with the fibroid, there's going to be a lot of other things that are going to be needed. She's perimenopausal, fibroid, constant bleeding. You'll need to do a lot of things all at once. And some of our beautiful astringent herbs work so much faster in some senses. 

Andrew: Got you.

Leah: I think it's really identifying what's your objective, what's your population that you're looking at, and then how do you want to approach it.

Andrew: So, historically, with the treatment options, if it hasn't been identified as adenomyosis, have you found in the past women having to rely on opioids and a lot of pain medication just again and again? Is it something like endometriosis which is poorly diagnosed and it takes a long time to reach diagnosis, or is it something that's diagnosed pretty well early on?

Leah: It's diagnosed a lot better because of ultrasound changes. Even if we go back five to six years, you'd only really diagnose adenomyosis when the woman was at what they call a “classic Venetian blind” appearance, which is literally where the myometrium has had so much destruction, you can see gaps in a sequential line.

Andrew: Gosh.

Leah: And at that point, I mean, the uterus is just stuffed. And I mean, the amount of scarring that's present and the amount of abnormal bleeding, you know, it's a completely different discussion. 

Now, you can do an ultrasound. And because they've got the 3D technology which they're using to diagnose endo, they're able to actually look at it and identify the adenomyosis' mild inflammatory changes, which you can then tackle and do a lot with. 

So, I think it's being diagnosed earlier and earlier, and I'm certainly having a lot of women come in where adeno is diagnosed, treated, and then lo and behold, some of their endometriosis goes away even though they couldn't detect it on ultrasound.

Andrew: So, forgive me to go back to ureaplasma. But it was traditionally defined as, like, an STD or a UTI. Where is this bug living, and why does it affect the uterus?

Leah: It's one of those ones, I think, we've got to just… Can I unpack just two little pieces, if that's okay? So, first and foremost, with ureaplasma, the study identification of it varies so much because, particularly, ureaplasma is a very, very hard bug to identify and to assess. So, the PCR technologies nowadays is certainly much more superior. So, we're able to see it and identify it more clearly.

Often, as well, in a lot of the studies, there's always been a strong association with bacterial vaginosis, for example. And so, then they would treat the BV and not necessarily pay any attention to the ureaplasma. 

Andrew: Right.

Leah: But the treatment of them are actually quite different. And then, finally, I think the thing to remember is that with ureaplasma, you're looking at seven species of these molecules which are basically all the ureaplasmas and the mycoplasmas. And they're kind of all grouped together, and they colonise and I don't think that we fully understand exactly what they do. 

I mean, they're intracellular organisms. They're very small, free-living pathogenic bacterium. And they basically live on the ciliated or the epithelial cells of the urinary and the genital tracts.

So, if you think about mycoplasma and respiratory pneumonia, for example, they're living on the cilia. Here, they're living on the cilia as well. And if she has a microbiome issue, sometimes the cilia can be flattened from other pathogens. Sometimes, they can hide. If she's got other infections, heavy discharges, they were never really picking it up very well. 

Andrew: Yeah, yeah.

Leah: So, I think when you look at the research, I think most of the research is just that they didn't have the technology. So, when you're looking at the newer stuff and you're actually able to look at it properly with a PCR assessment, you're actually able to pick it up. And it's so important to pick it up and so important to pick it up in the partner.

Andrew: Ah, the ping-pong.

Leah: Pardon? Sorry?

Andrew: A ping-pong infection?

Leah: Ping-pong, yeah. I mean, I call it, you know, sharing and caring bug. I mean, they love both male and female reproductive systems. And, you know, there was one paper that looked mycoplasma, not ureaplasma, but mycoplasma being prevalent in 86% of men that didn't even know they had it

So, you've got ureaplasma's presence because it's not as tested. It's probably really present as well in such sort of statistics. It's not something that's tested that commonly. You know, one of the main labs in Sydney, you have to call the microbiologist to confirm that you definitely want ureaplasma tested because there's still a bit of contention around the research. 

But again, I go back to clinical evidence, which is, you identify it, you treat it, all symptoms cleared. I don't think I need to wait for a paper to confirm it.

Andrew: I guess, however, when we're dealing with a milieu of bugs, not just bacteria, and certainly when you can see a precession of both pathology and also healing, you know, it becomes quandary. 

For instance, I mean, the classic one is, we were all happy to jump on the bandwagon about Blastocystis hominis being a pathogen rather than a facultative pathogen. And I wonder, I don't know, but I just wonder if maybe some of these bugs might be a pathogen in certain instances and not in others.

Leah: I think it really comes down to the patient presentation. And if you do anything about it, do they feel better and are they getting symptoms that are suggestive of its presence?

Andrew: Right.

Leah: So if you have someone with Blasto and they have absolutely no symptoms, there are two schools of thought. My approach has always been if I treat it and they feel better, then I know that it was doing something and I'm not limiting myself, that symptoms have to be specific to, let's say, with Blasto, that it has to be digestive or with ureaplasma, that it has to be something predictive in the sexual health area. 

But adenomyosis seems to be directly correlated to the burning pain symptoms. So, it directly clears as soon as you treat it. What does that mean? We could be clearing something else. I'm not entirely 100% certain. All I know is that the patient's better.

Andrew: Can I ask a different question then?

Leah: Yes.

Andrew: We know, for instance, with an infection like Candida that commonly it produces a cottage cheese-like discharge. So, there's a hallmark of its infectious nature. Are there any hallmarks of infection with ureaplasma?

Leah: No. Not always. I mean, in some women, it can just be an increased discharge overall. But again, you often get a lot of BV symptoms. So, you'll get all sorts of unusual discharge changes. And I think it's about identifying with the person… Like, I've got this one patient at the moment. She's never had normal discharge since she partnered with her now-husband 11 years ago. 

Andrew: Right.

Leah: And then we went digging and we did a full female ecology type of profile and had a look at it. The numbers of the ureaplasma were off the charts. It can't just be commensal when it's off the charts like that because, either way, it's disproportionate.

Andrew: Yeah. When it’s off the charts. Yeah.

Leah: And we treated it. Lo and behold, normal discharge again. I mean, it has to be some sort of, you know, a balance piece as well, but I think that it can produce such pathogenic changes. And then I think we have to elevate our perspective on all of these bugs and identifying microbiomes and all that sort of stuff. 

Andrew: Yeah.

Leah: We’re trying to simplify it. We're still trying really hard.

Andrew: Yeah. What about symptoms in the male? Anything, like, non-specific urethritis, any sort of discharge that's seen in the male?

Leah: Very often it's urethritis. 

Andrew: Right.

Leah: I mean, very often in the woman there's cervicitis. Very often, there's just inflammatory standard low-grade infective signs and symptoms. It's extremely common for both of them. And then sometimes, it's just silent.

Andrew: Okay. And what about other causes? I shouldn't say causes. Pathological changes not related to ureaplasma. What's the care that you give?

Leah: I think the most important thing with adenomyosis is about changing the architecture of the uterus. And so, about making sure that there's significant anti-inflammatory agents to be introduced to start to reduce that so that you can get a sense as to what's going on. 

There needs to be scar prevention and scar treatment because the adhesion risk is obviously so significant. 

Andrew: Right, yes.

Leah: Because there's so much tissue injury and there's so much invasion, there needs to be proteolytic enzymes in addressing the blood coagulation aspects and stabilising all of the cellular turnover in the area. 

There's a lot of suggestion that it correlates with the oestrogen excess in the area which seems to drive everything. So identifying oestrogen processing and oestrogen metabolism, normalising the ratios between oestrogens, ensuring that glucuronidation is sufficient to eliminate it and excrete it. You know, all of those standard approaches.

Andrew: Yeah.

Leah: Look, there’s controversy around increased cancer risk and whether or not, you know, that metaplastic process can happen because there's such an over-expression of some of the genes and some of the cells and all those sorts of things. 

So, I think that you need to be mindful around that and really cognisant to not simplify it, always investigate it comprehensively, and treat it in a way that is supportive. 

Lots of interesting research coming out looking at the CB1 and CB2 receptors in the myometrium. And the cannabinoid receptor aspects, what we're talking about here. And certainly, there's that correlation of severity of dysmenorrhea with the increased CB1 receptors being involved.

So, looking at all the endocannabinoid system repair and, you know, doing all the investigation around that. And lots of really interesting research starting to come out, making interesting comments around PEA as a supplement. I'm cautious until I know a little bit more, I guess, because of adenomyosis correlation with increased miscarriage risk. 

And then the new research coming around with the CB1 receptors and correlation with miscarriage as well. And there's a couple papers that have come out looking at PEA. I think if you've got a patient with a history of miscarriage, don't touch it until we know a bit more. Yeah, there's lots of interesting things coming up.

Andrew: Yeah. Are natural agents strong enough to help in the preservation of the uterine tissue? Or do you really have to default to, you know, whether it be hormonal control, or balancing, or… I couldn't see D&Cs being curative or anything like that, but perhaps a resetting? Like, do D&Cs help in resetting the hormonal bed?

Leah: I think, again, it comes down to what type of person that you're looking at with adenomyosis and where are they at on their reproductive journey. So, a D&C, in some senses, is helpful for the infertile person wanting to move forward to “clean the slate.” 

But she does obviously have an increased risk of potential damage and potential disruption to implantation and increased scarring. But, again, if you're sort of in that late 40s, early 50s age bracket where her uterine bleeding is so profuse and she's extremely anaemic, some types of D&C can actually reset it and reduce that haemorrhaging scenario.

Andrew: Right.

Leah: So, in some instances, it is indicated. But then, if you look at some of the natural measures, I think with conditions like adenomyosis, the clinician really needs to be mindful that... I do think that the natural agents do work. It's very, very dependent on dose and duration. And I think that some clinicians think that they've failed if they've done two months of treatment at standard dose.

Adenomyosis, the depth of anti-inflammatory treatment is often six times what you'd be expecting, you know, like, something that you'd give for a severe arthritic patient. You sometimes even need more just because the micro architecture is so intricate within the uterus. 

And so, I think it's more that the clinicians don't have the confidence to really say, "No, you need six months of heavy-duty, high-dose prescriptions. And then we can have another ultrasound and see what we've done." And I think their expectations need to just be elevated a little bit. It does work, but you need to be quite emphatic about what you're going to do. Yeah, it's a full-on disease.

Andrew: Well, yeah. I couldn't think... When you've got, like, a gross tissue change happening, I couldn't think that a couple of capsules of fish oil is going to do much at all.

Leah: It doesn't do much at all. And that's where I think that clinicians kind of go, "Oh, adenomyosis. I can't really help you." You know, "Fibroid growths, I can't really help you." Absolutely, in some situations, you can't. You can only sort of collaborate and support with. 

But in a lot of situations, you can make enormous difference. And some of our herbs are profound at changing the uterus. There's a lot of old Chinese medicine formulas that I liken to being herbal D&Cs, or there are a lot of traditional Western herbs that are profound at rebuilding the uterine...the myometrium to rebuild the lining integrity and lining structure. There's lots of different agents that we can use to efficiently clean it out and get the blood flow to the area to be more stable.

And through a nutritional lens, we can certainly work on improving the quality of their blood so that as the blood moves into the uterus, it's rich, it's robust, it's fresher, it's optimal so that it can be efficient at actually cleaning it all out. So, I think our expectations just need to, really put the foot on the pedal, so to speak, and just really work out a little bit more.

And again, you know, in a condition like this, if a person wants to go natural, they need to be compliant both with prescriptions, but also any dietary or lifestyle recommendations. A woman with severe adenomyosis should never be in a public swimming pool, because she's got so much inflammation and infection in there. You put her in a public swimming pool. What are you doing? It's just going to get worse. She's a magnet, you know. 

And a woman with severe adenomyosis can't have sex with a partner that refuses to get tested. I think we just need to be quite strong about certain aspects with it.

Andrew: Can we go through a few of the herbs that you like and a few of the Chinese formulas that you've found effective?

Leah: Yeah, absolutely. The Chinese formulas, there's actually really interesting research looking at dong quai or dang gui, depending on which language you want to use. So, the research around it is actually quite interesting, and you'd expect China would be probably leading the way with all of this.

So, the thing to be mindful if you're a Western herbalist is, obviously, the increased risk of increased bleeding if you're going to give them too much of it. So, the Chinese formulas always balanced it so much more efficiently than if we just put dong quai in a formula with some lady's mantle or something like that. 

Andrew: Right.

Leah: So, there's always blood-building herbs that are combined with the dong quai to enable it to actually tonify the uterus and clean it out. So, any of those traditional formulas that had dong quai as the main herb were always very efficient and still are.

Cinnamon and hoelen is always going to be really useful if it's your initial step of, "I don't know how to clean this uterus out, but I need to get it all moving." So, fairly reasonable doses of it get things moving very, very well. 

And then all of your herbs that support gluconeogenesis, that support liver detoxification of all the oestrogens that stabilise the hormone cascades a lot more are really, really useful as well. Certainly, you know, some of the nutrients might be a little bit more powerful for some of those, like Calcium D-Glucarate or anything along those lines. But definitely, they're very efficient.

And then from an anti-inflammatory lens, both Chinese and Western medicine will all think that turmeric would probably be your number one herb. Obviously, making sure that you're aware of coagulation genetics, just in case.

Andrew: Yes.

Leah: But it has such a particular affinity. Some of the Western anodyne herbs, though, they've had such a traditional use. I'm thinking things like Pulsatilla or even some of the Shatavari or older research that was always used around it. Those types of herbs were always used as drop doses on a daily basis. I think they were more a management strategy, rather than a treatment to eradicate it. But you can certainly always use that to support things as you're moving through treatment.

Andrew: Because Pulsatilla is something that you don't have to use a lot of.

Leah: No.

Andrew: Yeah.

Leah: No. And it works really well.

Andrew: What about things like Bethroot?

Leah: Oh, the traditional uterine astringents and things. Yeah. Some of them are fantastic. I find that... Yeah, you just need to have the confidence with it and really give it a long period of time to let it do its thing at a lower dose. Because if you give heroic doses of it, you can cause lots of complication.

Andrew: Got you. Okay.

Leah: But pretty much all of those female astringents do work well. I tend to lean more towards squawvine, personally. 

Andrew: Right, yeah. Got you.

Leah: But Squawvine works beautifully in a situation like this, provided the patient can tolerate the alcohol component.

Andrew: Got you. And Shepherd's purse, the most horrible smelling herb on Earth.

Leah: Oh, smelling. But, boy, it works.

Andrew: I hate it.

Leah: It works, though.

Andrew: I know.

Leah: It works.

Andrew: I know. It's a beautiful herb, but just give me a tablet. Well, not me, but give my patients a tablet. 

What about these nutraceuticals, you know, DIM or I3C if you're that way inclined? I'm not a fan of I3C, but that's my opinion. 

Leah: No, no.

Andrew: Do you ever employ that? Are you cautious? Any usefulness that you've seen?

Leah: I've definitely seen usefulness more from a hormonal management component, but not from necessarily a driver. So, it's basically finding a nutraceutical alternative to a hormonal IUD or the contraceptive pill or something like that, in a sense that we're blocking a hormonal pathway. 

Yes, it works. My preference, I try and work out the genetics of the person and their oestrogens...you know, multiple levels both blood, saliva, that sort of stuff, and urine. 

Andrew: Sure.

Leah: And then make a call as to, you know, "Is it Calcium D-Glucarate? Is it DIM? What is it?" But they definitely work. I just don't find that they fix the problem.

Andrew: Well, I think with any of those sort of things, seeing as we know how it works, we should be testing how it works. 

Leah: Exactly.

Andrew: We should be doing a baseline and a treatment level to see that we've got things that are aberrant in the oestrogen metabolism pathways. And then we should show that we can correct them.

Leah: There are some people out there that seem to give all three to all women in these “high-oestrogen conditions” and just go and do it all. Not all women with fibroids or adenomyosis or anything like that have an oestrogen issue, necessarily, that needs all of them, let alone one. I think it's really important to know what's going on.

Andrew: What about other treatments? We mentioned fish oil before. How high do you go if you employ it at all?

Leah: I don't employ it.

Andrew: There you go.

Leah: I don't employ it, but I've got quite big concerns around fish, which I know people have had to talk about before. And I know that we're not testing fish oils. We don't have the technology, really, yet to test for all the radiation exposure in some of the pollutants in the ocean and stuff. So, I'm not prescribing it and I'm relying on other anti-inflammatory strategies or oil substances as indicated.

Andrew: So, oil substances?

Leah: Well, if a person needs DHA for example and they're happy to eat it, I'm encouraging meat fat. If they're needing it, like choosing different omega sources.

Andrew: And you mentioned PEA before. How strong is the evidence? Where is it heading? 

Leah: Pro? Or against? 

Andrew: Is it just a poor sister to cannabis?

Leah: Cannabis? Oh, yeah. You can't really compare them. I mean, cannabis, you're dealing with something that's a whole plant. And there are so many functions of it that I think we still are discovering. And I will say I've got plenty of patients that are self-prescribing CBD, or CBD and THC for adenomyosis to much effect, positive effect.

Andrew: Yeah.

Leah: But PEA, I'm just not comfortable with it. I just don't think we've researched it enough. And some of the papers that are coming out... Particularly, obviously, because I work so much in the fertility space, I just think it's very risky. And I don't think we fully understand it yet. So, I'm not touching it.

Andrew: Now, what about other supportive care? You know, we mentioned the physical aspects. There's got to be huge psychological aspects here. Family planning frustration, I mean, the list goes on and on. How do you care for these patients?

Leah: Absolutely. I think it's... Look, it’s similar to the patient with endometriosis. And I do want to add here that often most women, I think, have endometriosis if they have adenomyosis. But I think, you know...and I'm making a word up here. So, this is a major caveat. They have what's more likely an endometriosis syndrome rather than endometriotic nodule, per se. 

So, they have all the peritoneal fluid changes. They have their endometrial-like cells going everywhere. And then they have adenomyosis in the uterus. So, they have the cluster of everything, but their biggest challenge in family planning is implantation challenges and high chances of miscarriage and lower chances of live birth. 

The woman with adenomyosis both has a very high propensity towards early miscarriage, lack of implantation, you're like the 5 to 6-week miscarriages. But equally, lots of research showing second trimester and even third-trimester loss because of intrauterine growth restriction from the adenomyosis. So, it's actually very difficult for them to carry a baby to term.

So, they've got lots of challenges along the way. So they need a lot of support around it. They may or may not need assisted technologies to get them to actually holding a baby in their arms, but I do think that women with adenomyosis often need obstetric care through their pregnancy to track and manage all of the potential challenges. 

I think one of the most fascinating things that I’ve seen clinically is that every woman seems to know the implantation site that her child took. And I don't think that subsequent pregnancies ever take that original implantation site. It's very left-of-centre, but just work with me for a second.

Andrew: Whoa. Yeah.

Leah: Every single woman that I've ever worked with, myself included, I can tell you, for example, I've got two kids. I only have had two pregnancies. I can tell you where my uterus both my kids implanted. 

Andrew: Right.

Leah: And the patients that I work with, either we've identified where they implanted on ultrasound or the woman has already subjectively felt it or we've palpated and identified it. And she never seems to have an implantation in the exact same spot. So, it's almost like each pregnancy owns a section of the uterus.

Andrew: Yeah.

Leah: If you fast-forward that, positives and negatives. But if you fast-forward it down the negative route and she's had 11 or 12 miscarriages with a heavily adenomyotic type of uterus, it becomes very complicated to implant beyond that.

Andrew: Right. Yeah.

Leah: So, then you're running into challenges and surrogacy discussions and all those sorts of things. So, I think the biggest thing in the family planning space is to identify, is it a conception challenge, a fertilisation challenge, and/or is it implantation? 

And if it's implantation, if she's had extreme amounts of miscarriage in the past, really get a good analysis and a good ultrasound of the uterus, and see what is left. And those 3D type of endo scans where they palpate and move the uterus around to identify adhesion risk and scarring, you can really get a sense of how immobile and hostile and inverted comma is this uterus. And then what am I actually able to expect here? And then make decisions accordingly because, you know, another D&C is just going to increase the scarring.

Andrew: Yeah. Just going back to the future a bit. You were talking earlier about pollutants and I wonder about... I know that the aetiology isn't known. What's your opinion on persistent organic chlorine pollutants or xenoestrogenic pollutants in the aetiology or a driver of this condition?

Leah: Look, I think the research is emphatically conclusive around correlation with infertility statistics both for men and women with exposure to any of the POPs as well as all the other things. I do think that the uterus is an environment that can absorb some of these toxins very intently. And it's very affected by it. 

And because the cellular changes and the cellular turnover is cyclical, related to the cycle, etc. and it's an organ that changes more rapidly than any other organ in the body when you factor in a pregnancy. I think that we need to be mindful that it is a very sensitive organ and will be very responsive. So, these pollutants, I think, are wreaking havoc.

I do have to bring my caveat in which was at the very start of the talk, of the podcast, which was, is it because the technology has advanced that we're identifying it more efficiently now? 

Andrew: Right.

Leah: Have women been walking around with this for a long time? I don't know that we know yet.

Andrew: Got you. And I also wonder whether... Humans are very good at identifying one thing, and we really like to point the finger at one thing. But when you've got a procession of things that needs to happen before a perfect storm hits you, we're not very good at identifying the perfect storm, the multi-factorial aspects.

Leah: Absolutely.

Andrew: Is there anything that we've just got to be very wary of, to not do or to watch out for, when dealing with a woman with adenomyosis?

Leah: Any abnormal uterine bleeding needs to be investigated. 

Andrew: Got you.

Leah: So, I think it's super important that all clinicians regardless of their expertise make sure that the woman has a comprehensive specialist women’s sonography ultrasound and an assessment from a gynaecologist to both confirm diagnosis and assess extent of it. And it needs to be a collaborative treatment. 

I think everyone needs to be heavily involved because, obviously, the sequelae of events, potential predisposition to cancers, definitely, but certainly anaemias and loss of function in life and all those sorts of things. You need to have a team approach to it.

Andrew: Yeah. We were talking about curcumin earlier. We mentioned fish oils which you're not a fan of, I get that. But when you're dealing with these anti-inflammatory therapies which also have an effect on coagulation, but there's the inflammation which can cause the sloughing, the clots and everything like that. Where's the balance between dampening the inflammation and causing an issue with potential bleed?

Leah: Look, I think we need to look at it holistically and we can't just throw buckets of curcumin at a person and then hope for the best. So, I think we need to be mindful of, first and foremost, how anaemic is this person? Try and lean into a Chinese medicine language around stagnation of blood, consistency of blood, health of blood. Really try and get a sense of just basics around anaemia signs and symptoms to see how stagnant is this blood and is it moving? And then be mindful that we need to do, you know, concomitant supportive strategies that go with it.

How far out do we want to go? Do we want to start talking about the microbiome of the blood? And regulation of the microbiome systemically through the body to normalise blood coagulation. 

Do we want to be looking at proteolytic enzymes and blood nutritive substances? Do we want to be looking at the foods that the person is eating, both from a temperature perspective but a nutritional perspective to assist in the whole framework of it? 

Is the person stagnant? Are they exercising? Are they moving? So many different variables. Are they getting blood flow to their reproductive organs at all or are we just giving them curcumin and they have a cold abdomen? Do you know what I mean?

So, I think that we've got to look at it holistically, and we've got to look at it safely. But I think it's simplistic to just give curcumin which I know you would never just suggest. But it's simplistic to give it in isolation without thinking of the other variables and what else we need to do for it.

Andrew: No. There's too many beautiful herbs.

Leah: So many beautiful herbs. But I think accessibility of curcumin is probably one of the quickest ways with it. You know, so much around my practice is looking at the regulation of electrolytes to support if I do give an anti-inflammatory. So, do I have the right balance of sodium, potassium, phosphorus, magnesium, calcium, etc., to be able to have the blood move in a healthful manner? I think we've got to be looking at the totality of blood, its components and what regulates it.

Andrew: And now you mentioned it, so I'm picking up on it. Proteolytic enzymes. I can't believe I left this out.

Leah: That's okay.

Andrew: What do you tend to favour?

Leah: Look. I think that in any of these situations, I definitely use proteolytic enzymes. And I think that there are a number of different companies and a number of different options that are available to us. 

And I think it's important to try and work out which person it is and what you're using. I think there are some heroics, serratiopeptidases and things like that that may or may not be indicated. And I think that they're helpful for some people.

Andrew: Yeah.

Leah: But, you know, even some of your basics around some of the substances, like bromelains and proteases and ginger, some of those sorts of things can be really, really efficient and helpful and not necessary to sometimes go for some of the heroic substances.

Andrew: So, just adding a tiny bit of ginger into, say, a herbal mix. Would you do that?

Leah: Always.

Andrew: Yeah.

Leah: Is there a herb mix that doesn't have ginger in it? Let’s be honest. No, of course…

Andrew: I smell ginger, I'm in. I've never ever used the dose that's stated on the bottle. Not ever.

Leah: Oh, god, no, me neither. And I remember this student in student clinic was like, "No. Everyone should have started up with ginger."

Andrew: Oh, my goodness.

Leah: And the supervisor was like, "Please swallow that thought." I was like, "Yeah. You're probably right."

Andrew: Yeah. So much to learn. And I think one of the things that I'm picking up from you is that the traditional Chinese medicine paradigm of medical treatment, or of disease and management, it is so intricate. And it smacks of balance. 

It might seem wishy washy to somebody who's just like, "Give me this diagnosis, this treatment." But in actual fact, if we can think about it a little bit more, it has so much more to offer than just a simple, "Here's a symptom. Here's a treatment."

Leah: Absolutely.

Andrew: Leah Hechtman, I love and admire your humanity and your individualised care, but also your expertise in dealing with so many conditions, not just fertility, but especially that. 

Thank you so much for taking us through the complexities of adenomyosis today on FX Medicine.

Leah: Thank you, Andrew.

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

Other podcasts with Leah include


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