Endometriosis with Dr. Sasha Hakman | Longevity Optimization Podcast

Today I'm speaking with Dr. Sasha Hakman on the Longevity Optimization Podcast. In this conversation, we discuss endometriosis, a condition affecting approximately 10% of women, characterized by the presence of endometrial cells outside the uterus. Dr. Hakman explains the definition, symptoms, and prevalence of the condition, as well as the challenges involved in diagnosing it. She also explores potential causes, including genetic and environmental factors, and discusses various treatment options. The conversation emphasizes the importance of understanding endometriosis, its impact on fertility, and the need for increased awareness and proactive care.

Dr. Sasha Hakman is a respected expert in women’s health, specializing in reproductive medicine and chronic conditions like endometriosis. With a strong background in both clinical practice and research, she is dedicated to advancing knowledge and treatment options for women affected by complex gynecological issues. Dr. Hakman is passionate about educating patients and healthcare providers alike, aiming to improve diagnosis, management, and overall outcomes for women’s reproductive health.

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Timestamps

00:00 Introduction to Endometriosis

02:54 Understanding Endometriosis: Definition and Mechanism

06:04 Prevalence and Diagnosis Challenges

09:14 Symptoms and Impact on Fertility

11:59 Potential Causes and Theories

14:55 Genetic and Environmental Factors

18:05 Treatment Options and Management

21:03 Lifestyle and Dietary Considerations

23:56 Future Directions in Research and Treatment

32:39 Understanding Endometriosis Treatment Options

43:09 Common Misconceptions About Endometriosis

48:43 Navigating Healthcare for Endometriosis

51:45 Complementary Therapies and Lifestyle Adjustments

56:02 Future Directions in Endometriosis Research

01:01:16 The Importance of Gut Health

01:04:54 Cycle Syncing and Nutrition

01:06:40 Exploring Alternative Treatments for Endometriosis

01:10:01 The Role of Medications in Managing Endometriosis

01:12:06 Understanding Endometriosis and Autoimmune Conditions

01:15:00 Differentiating Between Endometriosis and Endometritis

01:20:23 Hormonal Treatments and Their Impact

01:21:15 Improving Fertility with Endometriosis

01:22:33 Understanding PCOS vs. Endometriosis

01:24:01 Managing Pain and Symptoms of Endometriosis

Transcript

KAYLA BARNES-LENTZ (00:00.302)

Today we have Dr. Sasha Hackman back on the podcast. Absolutely, I am so excited to have you back on. Dr. Sasha, will you just explain a little bit about your credentials? And today we're gonna be talking about a highly requested subject, something that I, be honest, don't really know much about, so I'm excited to learn. But yeah, just talk a little bit about your credentials, and then we're gonna be talking about endometriosis.

Yeah, thanks for having me back on.

DR. SASHA HAKMAN (00:24.172)

Yes. So I am a double board certified OBGYN and reproductive endocrinology and infertility specialist. So that means I did four years of residency training in obstetrics and gynecology and then another three years of REI training. So the focus now that I'm in private practice is primarily on infertility, but that encompasses a wide scope of diagnostic.

causes of infertility, including unexplained PCOS and demyotriosis. So that's sort of our bread and butter of what we manage on a daily basis.

and we'll thank you for that. And for anyone that hasn't listened to our other podcasts, you can go back and listen to My Fertility, kind of like Freezing and Embryo Creation. We also have a YouTube video out, so lots of different things with Dr. Hackman. So let's just dive into it. So I posted a question box on my Instagram. I also posted in my longevity membership, and we just got a ton of questions on endometriosis.

So let's start with the basics. So what is endometriosis?

Okay, so I'm going to try to explain it as simple as I possibly can because I know a lot of people find this very confusing. So endometriosis is the presence of endometrial cells located outside of the uterus. What are endometrial cells? So the lining of the uterus is where pregnancy takes place. those are endometrial cells. That's the endometrial lining. And it is designed to undergo

DR. SASHA HAKMAN (01:58.53)

thickening in the follicular phase of the menstrual cycle, and that's called the proliferative phase. And then after ovulation, when you have progesterone secretion, that lining becomes nice and sticky. If a pregnancy does not occur, then the follicle that released that egg that's creating the progesterone disappears, you get a progesterone withdrawal, and that causes you to shed your lining. Okay? And that is how it is normally designed.

Now the endometrial cells, the cells of the lining of the uterus, if they are located outside of the uterus, it can include the surface of the uterus, the fallopian tubes, the ovaries, the small and large bowel, the bladder, the lining of all of your organs called the peritoneum. And those organs are not designed to have that inflammation because when you shed your lining,

How does it repair so quickly? You have a period for maybe up to seven days, but then after seven days, your lining is completely healed. It's because it's designed to undergo this where tons of immune cells are secreted to help sort of rebuild it very quickly. Now, if you have this hormonal response, this hormonal stimulus during the menstrual cycle, where as you're getting ready to release an egg, your estrogen levels go up,

it causes those cells that are located outside of the uterus to also thicken, to also proliferate. And then after ovulation, and if you don't get pregnant, what ends up happening is that you get the hormonal withdrawal and then you get lots of immune reaction. Now in the lining of the uterus, when there is that repair from your immune cells,

There is no scarring that occurs because once again, it is designed to undergo this. But if that's happening outside of the uterus, it can create things like scar tissue. It can create large chocolate cysts known as endometriomas. So that's really one of the only ways we can diagnose it on ultrasound. But that's sort of the gist of what it is and what it entails.

KAYLA BARNES-LENTZ (04:13.966)

Okay, so just brief synopsis, it's a cell type, differentiated cell type that is supposed to be inside of the lining instead of the uterus that is now, for whatever reason, and we'll talk about the reasoning, potential reasoning, I suppose, is now outside of the lining, but it's still undergoing the same monthly inflammatory cascade. Yes. Yes. Should be going on inside of the uteral lining, but it's happening outside of the unilateral lining. Correct.

So as long as you are having a menstrual cycle that is not suppressed through various medications, then it will respond to that hormonal stimulus. Now, if you have endometrial cells located inside the muscle of the uterus, so it's sort of one layer deeper, then that's called adenomyosis. Also highly inflammatory, also can lead to infertility, can lead to painful periods, can lead to really heavy bleeding in that case.

And there are certain features that we can sort of tell with the uterus that you may have adenomyosis through ultrasound findings, even on physical exam when you feel that the uterus is really globular in shape, then that could be suggestive as well.

Interesting. Really quick, just as an aside, so you talked about this inflammatory cascade that occurs on a monthly basis when someone is menstruating. When is peak inflammation?

So it would be as you're having a period. Now there is some immune cells that are involved in the luteal phase. So if you're trying to get pregnant and a pregnancy does occur, what actually helps implantation is some of the immune cells. Now some women will have what we call uterine factor infertility because there is sort of not the right balance of immune cells because there's so many different

DR. SASHA HAKMAN (06:04.418)

Cells involve like your T helper cells, there's TH1, TH2, there's natural killer cells. And all of those cells are really important for the process of implantation and then during your period, the process of repairing your lining. But if things are sort of out of balance and increased, then that's where you have a pathology.

Got it. Okay, so we have the basis of what endometriosis is. How common is this?

So it's, depending on what studies you read, the prevalence of endometriosis can vary, but I would say the most common quoted prevalence is about 10%, 10 to 11%. So one in 10 women suffer from endometriosis.

Do you we see the rates increasing at all or are they fairly stable?

I would say that they're fairly stable. It hasn't changed much over the course of time. I would say that probably what will happen is if we do start to see an increase, it's likely because currently the average time to diagnose endometriosis is about 10 to 15 years. What? Really, really long. Why? A combination of things.

DR. SASHA HAKMAN (07:19.192)

First of all, I do think that women are generally either dismissed by their doctors and then also probably dismissing themselves. I think that culturally speaking, women are taught that you are supposed to deal with pain, whether it's for beauty or for health. A painful period, that's just a normal thing, but not necessarily. Actually, your periods are not supposed to be painful. If they're painful, that's usually a sign that there's something going on.

Yeah.

And that needs to be investigated. Now the other thing is, oftentimes I will actually see patients who I will diagnose their endometriosis and they tell me that their last doctor when they told them, my peers are really painful, it's really hard to even make it through the day at work, that they were told by their physician that this is just a normal part of being a woman, which kind of like, it just shocks me because in my world,

And even with my partners and my colleagues, none of us say that to our patients. And so I just can't even imagine a world where this is commonly being said to patients, but the reality is it is.

That is so tough. What about, let's talk about what are the symptoms? And I'm curious going back to this like 10 to 15 year diagnosis, why? So first let's just say they're being kind of gaslit, like medically gaslit maybe, but why? Is there no test for it?

DR. SASHA HAKMAN (08:45.454)

Correct. So the second piece of why it takes so long is that the gold standard of diagnosing endometriosis is a laparoscopic surgery. So this is where we make a little incision through the belly button and we place a camera in the abdominal cavity and may need to add additional ports in the abdomen. So you might have two to three incisions in order to get a tissue biopsy. Without the tissue biopsy, you technically

can't confirm that it's endometriosis. Now there are, there is a clinical trial underway where they're trying to test for a possible blood test that could help diagnose it, but it's definitely not out yet. And so we don't know that for sure. There are other things that can suggest it. So for instance, without doing a laparoscopy or a tissue biopsy of some sort, I tell my patients, I am pretty sure you have endometriosis, but I can't say.

100 % definitively without that tissue biopsy. But the reality is, do you want to undergo surgery just to have that answer? Many will say yes, but many will say no, I don't want the surgery.

Yeah. So what are some of the other things that you are looking at that are indicative of having it without, you know, confirming a diagnosis through surgery?

Yeah, so when I get a patient's history first of all, so it's always important to start with a history Specifically of the menstrual cycle, so I want to know how regular their periods are it is possible Not common, but it is possible that endometriosis can lead to irregular periods Are the periods painful is there pain with sex? That's an important one. Sometimes you can have

DR. SASHA HAKMAN (10:29.058)

particularly with deeper penetration because the endometriosis can infiltrate the ligaments that are there and cause it to be really painful when you're having sex. Aside from the pain, there might be other signs. Like I've had patients tell me that while they're on their period, they always have rectal bleeding. That literally the blood only comes out of the rectum when they're on their period and they just have bloody stools.

interesting

So likely indication that there are any mutual implants within the bowel.

But they wouldn't always have because it sounds like there could be different types, right? So sometimes they might have to the little stall, but sometimes they might not.

That's not everyone's situation. Another common thing is, of course, you do tend to have more loose stools during your period. However, women with endometriosis will generally report that they may have really severe diarrhea while they're on their period. It's not just slightly loose stools, it's diarrhea. Another common complaint is having bladder issues, particularly during their periods.

KAYLA BARNES-LENTZ (11:26.744)

So.

DR. SASHA HAKMAN (11:37.064)

extremely rare case reports of women literally having endometriosis in their lungs where they end up getting a blood accumulation in their lungs. a hemothorax. That's not common. I think there was one case report I read of having endometrial implants in the brain. So it definitely can travel far.

Wow. Okay. So symptoms, what are, you mentioned a few things are so painful. Is there anything else that we should be thinking about?

So in terms of obvious symptoms, it's usually going to be painful periods or chronic pelvic pain, some combination of that painful sex like I just mentioned. More of a long-term thing is if you've come to a time where you're trying to conceive, about almost half of women with endometriosis are going to have infertility.

And what is the mechanism behind that? Why is it?

Various reasons. So endometriosis, because it's so inflammatory, it can impact ovarian reserve. So the number of eggs you have remaining is decreased. It could also affect egg quality. So we see sort of accelerated ovarian aging because of all the inflammation. It can cause anatomic changes and disruption of normal reproductive anatomy, causing scarring of the fallopian tubes.

DR. SASHA HAKMAN (13:03.37)

In some cases, it might actually cause scarring at the end of the tube where that tube then fills with water, that's called a hydrocelepinks, very, very toxic to the embryo. So even if the other tube is functional and you keep getting pregnant, it may cause recurrent pregnancy loss or just difficulty getting pregnant in the first place. We also know that ironically, even though it's the presence of endometrial cells outside of the uterus, it does actually affect implantation rates.

So it can affect the lining of the uterus itself as well. And so we see a massive decrease in implantation rates and ongoing pregnancy may cause increased chance of miscarriage as well.

Is there a link between endometriosis and obviously systemic inflammation, but also what about immune dysregulation in general?

It hasn't been shown to really be like a autoimmune disease. There are some speculations and theories behind it. really has been theorized about endometriosis is that, well, there's certainly an immune component to it. What the theory behind the cause of endometriosis is one of a few things. The first is something called

Salomic metaplasia. What does that even mean? So metaplasia is the transformation of one cell type to another. And there's something called the Salomic epithelium, which is the epithelial lining that lines the organs. And that can transform from epithelial cells to endometrial cells. So that's one theory. The second is that the endometrial cells will travel. So they can actually travel through the fallopian tubes and then go to other parts of the body.

KAYLA BARNES-LENTZ (14:53.774)

Why are they traveling?

I don't know why. Okay. We just know that that is a potential reason. Now, we do see a higher association with what we call malaria anomalies. So when the uterus is developing, when you're a fetus, the uterus is actually sort of two tubes that come together and fuse into one. Okay. Sometimes that process does not

work as it's supposed to, where you can have something called like a uterine septum. So when they come together, that septum should resorb and go away to create one cavity. If you have more advanced abnormalities, like what we call a uterine didelphys or a bicornuit uterus, where you basically essentially have two channels that are still not fused together, even as an adult, then if there's difficulty for that,

come out through the cervix, it can go out the other way. Those who have some form of obstruction of the cervix or the vagina where the period sort of builds up internally but never actually physically comes out because there is no opening to the cervix and the uterus, that certainly increases the risk of endometriosis.

Okay, so we're still investigating exactly why. Yes.

DR. SASHA HAKMAN (16:19.886)

I mean, it is just massively underfunded. We are lacking, just like almost everything else in women's health, we just need a lot more information. We're getting a little bit better, but there's still a lot more research to be had when it comes to sort of the way endometriosis behaves, the cause, what we can do to try to even prevent it and or treat it. But as of now, there isn't even a cure for it.

I'm just so shocked that with like medical imaging these days and like even AI interpretations that we can't use some sort of imaging with potential like an AI overlay to be better at diagnosing.

Well, we have gotten better with imaging. So there are endometriosis protocols for MRI, for instance. But what I tell my patients is the absence of endometriosis on ultrasound and or MRI does not exclude the possibility of you still having endometriosis. And so oftentimes, if the clinical suspicion is still there, then it may lead us to need a tissue biopsy.

Got it, okay, so how early does this typically present? Is it usually around like menstruation? Is that when people start to?

So, yeah, so menarche is the first period and it generally does not present that early. It's usually years after you've started your period. For the most part, it tends to be a progressive chronic disease. So it progressively gets worse over time if untreated. There is a small subset of patients who will actually find that their symptoms improve as they get older. But technically speaking, for most,

DR. SASHA HAKMAN (18:05.966)

It really doesn't resolve until after a menopause.

Interesting. I have heard a couple of like, I don't know, just, you know, case reports or like, and one people saying that they got pregnant and then it went away. Is that a thing? So

So pregnancy technically does not cure endometriosis, but what it does very well is it suppresses the crap out of it because it's suppressing the ovaries. You're not having menstrual cycles for about nine months. And then if you're breastfeeding and you have sort of lactational amenorrhea, which many women do, meaning you stop having periods as you breastfeed, then you're still, you have very suppressed ovaries, which for the sake of endometriosis is a great thing.

So even though your estrogen levels do rise throughout pregnancy, it seems to still have a really good suppressive effect on it, and that's likely due to the higher progesterone. For those who their symptoms resolved after pregnancy, it may just be a coincidence that it is sort of on the mend.

But that's not everybody's story. For most women, it will return, sometimes with a vengeance, but sometimes not. Sometimes it'll be a lot milder because pregnancy did a really great job to suppress it.

KAYLA BARNES-LENTZ (19:24.182)

Is this a genetic, is this a genetic component to this? Yeah.

So it is a combination of genetics and environment. So if you have a genetic predisposition, it is common to see it run in families. So we always want to know family history. Did your mom have an emutriosis? Does your sister have an emutriosis? Those things are important to know. But then there's also, when you have that genetic predisposition, environmental insults that could lead to having it or worsen it.

Okay, so let's talk about those environmental insults.

So let's start with just overall lifestyle. Okay, I know people are gonna get mad about this, but this is just what the data shows. Animal fats tend to increase the chance of ending up with endometriosis.

Why?

DR. SASHA HAKMAN (20:16.33)

I don't know why, but we know that it is associated. So this is like one of the biggest studies, the Nurses Health Study 2, they looked at a little over 81,000 women long-term. And what they found is that high consumption of animal proteins, animal fats was highly associated with

developing endometriosis or worsening of endometriosis. Now, there is a caveat to that because we're talking animal fat and animal protein. However, if there are animal proteins that are rich in omega-3 fatty acids, then that appears to be protective.

Yeah, that's what I was going to ask. So like study design and like, did you feel like it was a well done study? And the other question I have is because just based on a lot of, let's say the red meat studies out there, it seems as if they are being conducted with people eating things like processed red meats versus something like, like there's not a lot of people out there eating grass fed grass finished beef, you know, prepared the right way.

So a few studies actually looked into this and what they found was even unprocessed red meat still increased the chance of developing an amyotriosis. And same with dairy. it just, every study that has done this has found the same results over and over again. So the things that help it nutritionally speaking or reduce the chance of even getting it in the first place with a genetic predisposition is

a high fiber diet. So if your carbohydrates are high in fiber, low fat diet. And what they found is that one study looked at the frequency of red meat consumption. those who consume, so let's just talk specifics here because not everyone who listens to this is going to be able to cut out red meat because they enjoy it and it's a big part of their diet.

KAYLA BARNES-LENTZ (22:19.15)

It's also nutritionally dense, so, you know what mean?

and really high in protein, so it's easy to get that much needed protein intake. It was the consumption of two servings of red meat a day, okay, versus, that's a lot, versus those who consumed it once a week. So if you consumed it once a week, you were less likely to deal with this because there is some inflammatory component to eating that much red meat, okay? So it is definitely

Yeah.

dependent on quantity. And this is where I always tie it back to a Mediterranean style diet where a lot of Mediterranean people, they do eat meat, but it is not the star of the show. It is not the main part of every meal every day. They just seldom have meat. They're very heavy on fish. They're heavy on plant proteins as well. And it is primarily whole foods, right?

The ultra processed stuff definitely is inflammatory. Probably the way that we're also processing and getting our, the way we're treating cows, for instance, to get our dairy is a lot more inflammatory. It doesn't mean you have to eliminate dairy by any means. There's a lot of people out there also saying, you should be eliminating gluten to avoid getting it or to avoid making it worse. That is not really, has it really been validated?

DR. SASHA HAKMAN (23:48.394)

So it's not that you have to eliminate dairy or gluten, but obviously it's all about moderation and balance.

Yeah, I mean personally just because of the potential impact on the gut like lining I feel like I don't know for me I'm like I just avoid gluten all the time and I know I don't know anyone that feels good on gluten like I eat gluten and I felt amazing. I don't know.

I've it really depend. So some people do and they feel great. And I think it also depends on where they outsource their gluten from.

Again, like are they in Europe eating them? So yeah, we possibly better.

Yeah, and it's so funny because, you know, there's that stereotype if you go to Italy, you just feel better after eating pasta compared to here. that seems to, mean, anecdotally, I feel that that is true. But yeah, so there's the nutritional component to it. While that's still being researched, it's kind of common sense to know that endocrine disrupting chemicals will certainly add to it and aggravate it.

DR. SASHA HAKMAN (24:57.974)

So if you have that genetic predisposition, we know that that is a really important thing to try to avoid. Obviously we can't avoid all endocrine disrupting chemicals because they're literally everywhere, but it's just a matter of reducing the exposure. So avoiding fragrances in your household products, using clean household products, laundry detergent, things that we spoke about before in our last episode together. So those are some things we know about.

there's probably other environmental things we just don't know about. And so whenever there is a disease that appears to be more genetic, but not everybody in the family is going to have it, it's hard to determine what the pattern of inheritance is, it's polygenic, then we say that it's multifactorial. So that's just our blanket statement for, we have an idea, but we don't fully know.

Yeah.

KAYLA BARNES-LENTZ (25:55.756)

Yeah. When you say it's, you know, potentially the genetic factor, are there any like DNA tests that we can be looking for something to see if there's like a genetic variation or a SNP that would predispose, that you would know that is predisposed?

Not that I'm aware of, maybe only in the research setting, but definitely not clinically.

Okay. Okay. So we talked a little bit about, have you seen maybe just even clinically like, well, it'll be interesting because I don't even know if anyone's ever done this test, but it would be interesting to see like a total tox burden in comparison to worsening symptoms with endometriosis. Level of environmental toxins are potentially contributing to worsening symptoms.

Yeah, that would be a really interesting stuff. Has to be done, but.

KAYLA BARNES-LENTZ (26:41.846)

Okay, we got this question a million times essentially like, well, let's talk about conventional, let's just talk about all treatment options. So what are the standard of care for endometriosis? And then of course, you know, because I'm me and I always, you know, doing like more longevity, you know, cutting edge stuff. Is there anything on, you know, a lifestyle or ability to potentially

it? Good question. Everyone wants to know if they can reverse it or cure it. Unfortunately endometriosis to date has no cure. It's a chronic disease, kind of like PCOS. You get the diagnosis and now we're trying to deal with symptom management. Kind of like if someone gets diagnosed with type 1 diabetes, that's it. Their pancreatic beta cells are no longer there and functioning and they will need insulin for the rest of their life. There is no cure as of yet.

I mean, there's experimental research things going on.

Let me ask something though with PCOS though, is it, feel like that is a little bit modifiable. No, like I've known people that feel like they kind of have reversed their PCOS.

Yeah, so PCOS obviously totally different disease than endometriosis. And this is where there's an issue between the communication of the brain and the ovary. so, you know, just for simplicity sake, hormones are sort of out of whack and the signaling is off. And that leads to irregular ovulation or lack of ovulation. Now, with PCOS, there's a lot of things that look like PCOS and

DR. SASHA HAKMAN (28:15.382)

women who are diagnosed with PCOS, but it may not actually be PCOS. So we know that if you are suffering from overweight obesity and you have PCOS, then lifestyle will significantly improve it. Some women just from weight gain alone, they will have an ovulatory cycles. And if they also develop insulin resistance, then they will have that hyperandrogenism piece that makes it look like PCOS. Okay, so when you do the lifestyle modification,

GONNIC

it tremendously improves, if not completely resolves it. And when it completely resolves like that, that's when I'm more inclined to think, was it really PCOS? Because you'll even see in lean women with PCOS, no matter what they do lifestyle-wise, it just does not go away. It can be a little bit better, but they will always need pharmacotherapy in order to sort of improve symptoms completely.

Bye.

KAYLA BARNES-LENTZ (29:09.538)

And is Metformin like the first line with PCOS?

So it is not, but it depends on what you're trying to achieve. So if you're not trying to get pregnant, then it's a combination of, of course, lifestyle modification, first and foremost. But then secondly, it would be basically protecting the endometrial lining. So the reason why we always encourage things like birth control pills or progesterone-containing IUD is because if you have what we call unopposed estrogen,

your lining thickens so much that it predisposes to uterine cancer and the women with PCOS have a six times higher rate of endometrial cancer. So we need to do the hormone therapy in order to shut that down. Now, if you are trying to get pregnant, it's a completely different set of treatments where we're giving you a medication to help you ovulate regularly. So that's sort of the strategy there for PCOS.

Mm. Got it.

KAYLA BARNES-LENTZ (30:07.114)

And people that are prescribed metformin with PCOS, is that just because of the...

Yeah, so metformin is a nice add-on for various reasons. It could be to help treat the insulin resistance that may be present with PCOS, but also even if there isn't insulin resistance, especially for those who, no matter what they do lifestyle-wise, even when they're in a calorie deficit, they're eating really healthful foods, they just can't seem to lose weight. And we know because fat metabolism with PCOS is

definitely different than those who do not have PCOS. If you compare two women of the same weight, one with PCOS, one without it, the one with PCOS is going to have a higher body fat percentage. So metformin can actually help with that and it can help them lose weight when they have already implemented the lifestyle changes. So yeah, it could also improve ovulation. So we know that that makes it a really helpful medication to add on. But

Studies have shown that if you just give metformin alone, it does not significantly increase the chance of pregnancy and ovulation. Of course, you're going to have patients who are like, well, I was on metformin and I got pregnant right after that. But if you look at large, very well-designed randomized clinical trials, it has not been shown to really be superior to ovulation meds at all.

Got it.

KAYLA BARNES-LENTZ (32:03.206)

all of the important components of longevity such as labs, nutrition, exercise, sleep optimization, longevity optimization protocols that I'm doing along with real time updates to my personal protocols. There are so many benefits of being a member of the community. We'll also be doing in-person live events here in California and virtual events for anyone that can't attend. But if you're interested in joining the community, I would absolutely love to see you there and I will include a link in the show notes.

Okay, going back to endometriosis, so what is the standard of care currently?

So this is sort of the thing you learn in medical school and in residency. This is on your board exam. It sort of goes in a stepwise fashion starting from the least invasive to the most. So first is drugs. So you're having painful periods. Let's start you first line with NSAIDs, a nonsteroidal anti-inflammatory drug like ibuprofen.

If that helps to resolve your symptoms, that's great. That's all you really need to do while you're on your period to help resolve the pain. Now, if that does not work, which in most cases of endometriosis, it does not work, the next step would be hormonal birth control pills. So it could be a combination of estrogen and progesterone or a progesterone only pill.

And people sometimes say, why would I take a birth control pill containing estrogen if estrogen feeds endometriosis? As you're on the pill for a longer period of time, the progesterone piece of it actually starts to take over a little bit more. So it becomes a little more progesterone dominant, for lack of a better word.

KAYLA BARNES-LENTZ (33:47.95)

Can I ask a question? birth control, is this a synthetic form of hormones? Yes.

Yes, and I know that it gets a really bad rep. what people don't realize is that not only is it good for suppressing endometriosis, something that's really important to know about endo is that these women have anywhere, depending on the stage of it, a four to tenfold higher chance of ovarian cancer. So that's kind of scary. And birth control pills significantly reduces that risk. And the longer you're on it,

the lower your chance of developing ovarian cancer. And so some studies have shown that if you're on birth control pills for 10 years plus that you've reduced your risk by 90%.

What about, I'm just curious if there's any other option here, like a bioidentical for example, like could you prescribe that theoretically?

And yes, so theoretically you could. The only problem with most bioidentical forms of progesterone is that because they're not really regulated, you actually have no idea what the dose you're getting is in many cases. So the lack of regulation makes it that you're either getting too little and it's not doing anything, or you might be getting more than you need. Now progesterone is a fairly safe drug to take. if...

DR. SASHA HAKMAN (35:09.914)

you know, in bioidentical forms. Now, there are some more regulated, bigger pharmaceutical companies that make bioidentical forms of it. However, honestly, the safety profile of synthetic is also really great. And I think that it just gets a lot more of a bad rep than it deserves because it's a very, very effective medication.

That being said, I do have patients who are very anti, don't want to be on the pill, they want another option. And so this is where we sort of go down the list. But one of my favorite progesterone medications to actually prescribe for endometriosis symptoms is norethendrone acetate because a little tiny bit of it does convert to estrogen, so you get just enough to feel good, but it's highly effective at suppressing endometriosis and making you feel a lot better.

You know the only caveat to that is when you have a progesterone only containing pill if you are you have to take it every day if you're late to take it and you do not want to get pregnant You know be advised that is a possibility. You might break through ovulate and then have an unintended unintended pregnancy But for endometriosis itself, it tends to be really really effective So that's you know sort of part two now a lot of people say well

I complained that I have painful periods. My doctor said, let's put you on the pill first and if your symptoms improve, then we can just suspect that it's endometriosis without that confirmation. Now that is a really commonly done thing in hopes of avoiding surgery for a lot of women. So the suspicion is there. You start birth control pills, whether it's a combination pill or progesterone only. And for those who really do want to bioidentical, there are options there.

then if symptoms improve, you know that most likely that is the case, but you can't say definitively 100 % that it is endometriosis. Now, in many cases, it doesn't work. And then these patients either feel scared to go back to their doctor because it's almost like this weird feeling of like, failed my doctor, they tried to help me and it's not working. And so this is where I always say, the first or second line medication did not work,

KAYLA BARNES-LENTZ (37:12.686)

sorry.

DR. SASHA HAKMAN (37:32.686)

please go back and insist that it didn't work, you need something else. So after that, there are various options. So the next option would be to do surgery, okay? With the surgery, not only is it diagnostic, it could also be a treatment for the pain. So there are two different techniques that we do with laparoscopy.

I don't do it anymore, but there are a lot of specialists pretty much everywhere that do them. And they're typically minimally invasive gynecologic surgeons who do an excision surgery. So you go in laparoscopically, once again, it's about three incisions, one in your belly button, two in the right and left side of the lower abdominal area. And you just sort of look for endometrial implants everywhere and wherever you see them.

you excise them. Now you can do ablation, which is burning of the tissue. And ablation is a faster, easier surgery. It doesn't require as much skill. However, if some of the endometriosis lesions are deep, they go deep into the tissue, simply burning the surface is not going to get rid of it. So in a small percentage of patients, this surgery can actually be curative in the sense that

and the mutual implants do not return. And so it can provide significant relief. Now for many other women, it will return, but at least it gives you hopefully years without the treatment. When you do ablation, that time without pain and being symptom free is a lot shorter, which is why I say if you're gonna go through the surgery, you might as well get the excision done.

Now there was one really small clinical trial, I think it only included about 39 or 40 women. So very, very small study, but they randomized them so that, and the women were blinded to whether they were getting ablation or just a diagnostic laparoscopy, sorry, excision versus diagnostic. So there was no ablation involved here. It was either they went in, they confirmed that there's endometriosis just with a small tissue biopsy.

DR. SASHA HAKMAN (39:53.838)

versus half of them, they actually had the excision surgery. And what they found is that with the excision, they were pain-free for longer and that it was slower to come back. However, in many cases, it did come back. But overall, it seems to have done a better job than, you know, not surprisingly, to diagnostic laparoscopy alone. However, what's really interesting with the diagnostic laparoscopy, they said in 22 %

of women, they reported that their symptoms improved just from going in and looking. So that's probably the placebo effect of having surgery, which, you know, we know placebo effect is extremely powerful. It's really amazing.

Doesn't it get the percentage get higher too with the more invasive that the like from either like a fake pill to fake surgery the results are higher.

Probably, yeah. I mean, the mind is really, really powerful. And so if I knew that me taking a placebo pill is gonna make me feel better, I would definitely take the placebo pill. Why not? But it was only 22%. So it was only a small percentage of women. And I think 46%, if I remember correctly, reported that their symptoms got worse. And that's because they didn't treat it. So when you're not treating the endometriosis, typically it is progressive.

So it will get worse over time. let's say you're younger and you're dealing with this in your 20s and you're not even thinking about kids yet, just know that it's important to treat it because you do want to protect your fertility. Now, at least half of women with endometriosis are not going to have any problem conceiving, but it's kind of the flip of a coin. You don't want to end up in that category where things are so far gone, that egg quality is so severely compromised that...

DR. SASHA HAKMAN (41:42.648)

There's nothing much you can do.

And why is it impacting the egg quality? Because the eggs are becoming in the-

The implants can be on the ovaries. Okay. And so you're dealing with tons of inflammation. And then, like I mentioned before, you can develop something called endometriomas, which are these big cysts. They can range from small to big on the ovaries. And they are filled with old blood because it's like menstruating, right? So we call them chocolate cysts because if you go to drain it, which is really hard to do, it's going to be this thick.

brown stuff coming out of it. As of now, there was always this controversy going back and forth. Do you remove them? Do you leave them alone? And the thought was remove them because they're inflammatory. Let's help protect the ovaries, so just get rid of it. But what had been found when that was sort of becoming more commonly done is that ovarian reserve plummets because you are removing inadvertently parts of the ovary that contains eggs.

And so you're getting rid of a lot of eggs by removing the endometriomas. And the more surgeries you have, the more you are really losing eggs. And so what is now pretty well established is you don't remove endometriomas unless they're big and unless they're causing severe pain.

KAYLA BARNES-LENTZ (43:06.264)

comments.

Okay, what do you think the biggest misconceptions are about endometriosis?

I think a few common misconceptions is that

Number one, if you don't have menstrual pain, then you don't have endometriosis. Okay, unfortunately, endometriosis can still be silent. You might be walking around, you have no clue you have it, and the time you find out is usually when you're dealing with infertility. Okay, so we know 40 % of unexplained infertility when all the evaluation looks perfectly normal, 40 % of the case is caused by endometriosis. Yeah.

Cheers.

DR. SASHA HAKMAN (43:53.358)

Another common misconception surrounding endometriosis, would say, is that...

DR. SASHA HAKMAN (44:06.336)

You know, I'm like, I'm trying to think of what other common ones are. And I just had it in my head and I just blanked. So hopefully we can remove that one out. But yeah, we can. Yeah, I would say another common misconception is that if the first few forms of treatment were not successful, that you just are sort of out of luck and now you just have to deal with the pain. That is not true. There are still

other treatment options. Some are temporary, some are more long term, but it's important to keep going back to your doctor, even in some cases possibly getting a second and or a third opinion until you reach that place where you are no longer in pain. Another common misconception is that if you get a hysterectomy, so let's say you're done having kids, removing the uterus will improve symptoms and make you pain free. But the reality is that you can still

have the pain because the ovaries are left in place. And we're very reluctant to prematurely remove the ovaries if there is no cancer, for instance, in the ovaries, because we know that once you get rid of estrogen in your system and you remove the ovaries early on, the risk of all-cause mortality goes up. And so that's always something that doctors are reluctant to do for that particular reason, but everything is a matter of like, you

assessing risk versus benefits, so it's still definitely an option. But if you just remove the uterus alone, that's not necessarily going to improve your symptoms because if you have endometrial implants throughout the pelvic cavity, you didn't really do anything. Now, something else that's really important to know that I didn't mention before is that what's really kind of nuts about endometrial implants in the abdomen or elsewhere is that

they can actually, these implants can convert cholesterol to estrogen within these little pockets of endometriosis. And so you might suppress, this is why not all women will get relief with hormonal suppression. You can suppress the hormones, but in some cases it could still feed itself estrogen by taking cholesterol in your body and converting it.

KAYLA BARNES-LENTZ (46:26.99)

Wow. Yeah, it's pretty.

which makes it really challenging to treat sometimes.

What do these endometrial implants look like? Is it like scar tissue or like what is it?

They can look pretty different. So they could be white, they could be black or gray, they could be red, and they could be scar tissue. The scarring can look anything from this filmy scarring that's really easy to remove to very dense scar tissue. And in those cases, when you have really dense scar tissue, sometimes it totally obliterates pelvic anatomy.

and we'll call that a frozen pelvis. And I've had a few cases. I think the hardest one I ever had was, I think, two years ago when I did a laparoscopy and I could barely even get my first port in. And I couldn't figure out why it was so hard. I had to use so much force, which is always scary because there's a lot of risk with using force. And once I got my camera in there, I...

DR. SASHA HAKMAN (47:29.93)

all I could see is scar tissue. I couldn't even make out where the tubes were, where the uterus was because it was literally like a whole layer of just thick, dense scar tissue. And it took me hours to get to remove her fallopian tubes, which is what we were in there for because she had a hydrosalp banks on both sides. And we knew that her embryo transfers would not be successful unless we remove the tubes. So in that case, when you have that much scarring, sometimes you can't even remove the tubes. And so you just...

ligate the tubes on each side and separate it from the uterus. yeah, anatomy in some cases can be just totally, totally distorted. And what's really interesting is that the severity of the stage of endometriosis and how it looks does not correlate to pain.

Wow, that is so sad and tough. So someone that is like, know, obviously not everyone has access to doctors like you, it's, you know, for a variety of reasons. What questions can women like ask their doctors or statements that they can say? How can they, you know, if you're like in a small town and there's like only a few doctors covered by insurance, how can you start like getting better care? Any recommendations?

him.

DR. SASHA HAKMAN (48:43.07)

So yeah, that's always a really tough one. If you're really only looking to see someone with a network for insurance purposes, then sometimes you're a little bit stuck there. I would say that you want to look for an OBGYN who says that they're an endometriosis specialist. While we are all trained and specialized when it comes to the treatment of endometriosis in various forms.

Like in my case, I'm a reproductive endocrinology and infertility specialist. And while I do treat endometriosis, my focus is still infertility. So I'm doing the endometrial biopsies to see if they're going to test positive for a marker known as BCL6, which can affect implantation rates. So that's like really specific to what I do in addition to the laparoscopy if and when it's needed. However, for most cases,

of laparoscopic surgeries for endometriosis. If they need a surgery to do excision of their endo, I actually send them out to a minimally invasive gynecologic surgeon who specializes in endo. So these are OBGYNs who are very, very passionate about endometriosis. This is what they do day in and day out. And that is what you want to look for. So if you're trying to look for someone with a network, reach out to the insurance company and say,

hey, I need an endometriosis specialist. And usually those OB-GYNs will put out there that that is their specialty, primarily because they've done extra work to build this niche, as well as attending different types of conferences, staying the most up to date on the research. And so those are the doctors who will allow you to, number one, will educate you to allow you to advocate for yourself and for your needs.

Okay, that's super helpful. There's no, at this point, biomarkers of any kind that we can take a look at, right?

DR. SASHA HAKMAN (50:44.288)

Not at this point in time. know that I'm blanking on the name of it. I actually don't even know if I'm allowed to say it anyways, but there's a company that has worked on a blood test to diagnose it. Currently what they're doing is their validation studies where they're having clinics who are participating in this study to do a laparoscopy surgery and the blood test to see if the tissue biopsy is congruent with the blood.

results. So they're looking to see how sensitive and specific is this blood test and can it be used for early diagnosis of endometriosis, which is really fantastic. But aside from that, there's really no biomarkers.

Got it, well, keep us up to date on that test. Because that is super exciting. Okay, what about other, you know, I guess, complimentary potentially therapies? Is there anything that, you know, even from like a first principles, like maybe red light therapy, do you think that could be helpful in any way?

I think in theory it could be. We definitely lack research on that. So because there are no well-designed studies out there that really looks into seeing if it's going to help to reduce that inflammation. We can't definitively say that, but in theory, like if you have red light therapy at home, you should absolutely use it. You know, might as well use the tools that you have. We know that it's beneficial for so many other things and most likely it's not going to harm or worsen.

But that's the thing about scientific studies is that everything is falsifiable. So you never know what the data is going to show and sometimes you're going to get controversy there. But right now we just don't actually know if that will help treat it.

KAYLA BARNES-LENTZ (52:30.744)

Got it. What about anything else like supplementation? Is there any like theoretical reason to like more so support the liver with endometriosis or?

Actually, when it comes to supplementation for endometriosis, there's really good data on vitamin D, C, and E. Okay, so those are really powerful antioxidants that could, and just important vitamins in general to have in your nutrition and probably through additional supplementation. But there's pretty good research showing that supplementation of vitamin D, C, and E are really, really helpful for endometriosis.

What about anything like, cause I could assume that exercise might be a little bit more painful or something. Is there a good reason to think that, you know, maintaining a good exercise regime could be helpful or not really?

I think that for every aspect of health, exercise is important. So it doesn't even matter if we're talking about someone with a chronic disease versus not with a chronic disease. There is almost never a scenario with the exception of a few medical diagnoses where exercise is going to be harmful. So as long as you have good cardiopulmonary function and you're not dealing with some major joint or limb issues, then

you should absolutely implement a combination of resistance training and cardio.

KAYLA BARNES-LENTZ (53:56.184)

Thank you. If someone opts for the surgery, what do you recommend? Maybe like pre-op and post-op to help, you know, just healing, recovery.

I would say that post-op, most importantly, it wouldn't be a bad idea to still have different medications for hormonal suppression just to reduce the recurrence of it. So if you've had the excision surgery and they were able to remove most of the endometrial implants that were identified, that hormonal suppression added on post-op

can certainly help with the healing. And that's because even though we expect to be able to see all the endometrial implants through laparoscopy, sometimes you don't actually see it all. And certain things can be missed because it's just not visible to the naked eye. so hormonal suppression is really my go-to there. Aside from that pre-op and post-op, trying to implement as healthy of nutrition as possible

side.

DR. SASHA HAKMAN (55:04.918)

Reducing ultra-processed foods, more whole foods from really good sources, really high in vegetables and even fruits has been shown to be really helpful for endometriosis.

Are there any books or other thought leaders in this area that you can think of to recommend for resources for women?

there's different societies that have a lot of resources. So if you look at the American Society of Reproductive Medicine, if you look at the American American College of OBGYN, there are various different women's health societies that have plenty of resources. But I don't know that there's any like, I could be wrong. I don't know if there's any mainstream book.

specific to endometriosis that really go through everything in detail. It probably exists, I just don't even know about it.

Hopefully if you come across any. Okay, I'm gonna grab some of these questions. I think we answered a lot of them, can you focus on perimenopause next happening as young as 30 from a functional health stance? Okay, so let's table that. That seems as though like early, let's do another podcast on that at some point. So, can you put it into remission of a diet?

DR. SASHA HAKMAN (56:02.574)

So do.

DR. SASHA HAKMAN (56:08.226)

Yeah.

DR. SASHA HAKMAN (56:21.666)

whole different topic.

DR. SASHA HAKMAN (56:27.182)

I think that it's possible, but we don't fully know that yet. We know that some women, it'll get better over time and some rare cases and it's probably related to things like diet.

Got it. This person said had endo, then had a baby, no more endo symptoms, can pregnancy cure, so we covered that. Can you naturally remove or reduce a cyst?

That one's tough. Unfortunately, cysts will usually persist. In some cases, it can resolve with long-term hormonal suppression and or pregnancy. So basically stopping the whole process of ovulation.

Does surgery actually help?

If you go to the right surgeon, it absolutely can.

KAYLA BARNES-LENTZ (57:16.736)

Is it possible to get off birth control to, is it possible to get off birth control to help control endo? When I don't take it periods are awful.

So in that case, probably not.

Yeah, does using toxic skincare contribute to endo?

Probably.

how to deal with flares when you have to work.

DR. SASHA HAKMAN (57:40.526)

Oh yeah, that's a tough one. I would say get the right treatment so that you're not having these flares because it's hard to live life like that.

OCP as stopping of relapse of illness after surgery.

Yeah, so what this person's asking is after my surgery, should I go on birth control pills to stop basically the recurrence of it and keep staying remission? I would say yes. We sort of touched on that already.

Yeah, okay, we did. Can end be reversed?

We're still learning about the progression of the disease, but that seems to be pretty rare.

KAYLA BARNES-LENTZ (58:19.096)

My doctor thinks I may have it, wants to put me in birth control to see any other ways of confirming. Yeah.

And who knows, maybe in a year or two, blood test.

Is it possible that in endo, the ANS is chronically dysregulated?

ANS.

automatic nervous system.

DR. SASHA HAKMAN (58:38.154)

A, I thought A and S, okay. Is it possible that it's chronically dysregulated? Yeah. mean, very possible. It's not something that's been prioritized as research in this field, but it's something we just don't really know.

Could my endo be the cause of my HSCRP score of 10.1?

Yes.

Yeah, that's interesting. So that is a biomarker that maybe could be indicative.

Yeah. And yeah, CRP tends to be elevated with endometriosis. The only problem with that is that it's just so nonspecific. A lot of things will cause it to be elevated. So we can't look at that and say, you have endo.

KAYLA BARNES-LENTZ (59:20.364)

Yeah, that makes a lot of sense. Are people using medical cannabis as a treatment?

Not really. mean, the thing about cannabis is that that also has its own slew of problems long term that can contribute to worsening egg quality, fertility. But obviously, you know, for those who are really not caring about that because they're done having their families, they don't really care about egg quality, then it's probably not as big a deal. But there's still other long term health consequences of cannabis use.

Yeah, should we prioritize or avoid certain foods?

So we kind of touched on that prioritizing high fiber foods, unsaturated sources of protein, primarily plant, fish or seafood. Even shellfish has been shown to still be good. Avoiding too much red meat and in some studies they even suggested reducing poultry intake.

Okay, I wonder what role if any soy has in this.

DR. SASHA HAKMAN (01:00:34.866)

yeah, that's a good one. So that seems to be super controversial where some studies showing that soy can worsen it because of the phytoestrogens. But the reality is that we don't see an increased incidence in Asian countries where soy consumption is higher, but we do know the source of the soy is what's really important. So if you're consuming things like tofu, that's great. But if you're having ultra processed forms of soy, then probably not great.

That makes a lot of sense. What rule is the gut microbiome and detox pathways playing endo?

Gold.

DR. SASHA HAKMAN (01:01:11.394)

We don't know yet. Hopefully to be determined one day.

Okay.

I mean, yeah, from just my general thoughts, think better gut health always totally yields better overall health.

Yeah, I think it's now starting to be looked into because there's just a lot more interest in the gut microbiome and how it affects the whole system. I think there is going to be more research over time looking at disease progression and even disease incidence when it comes to a healthy versus unhealthy gut microbiome.

Yeah, that makes sense. Is seed cycling helpful?

DR. SASHA HAKMAN (01:01:53.166)

not really. mean, if we're really going to look at scientifically speaking, I know that it's, it's become really popular, but you know, if that is something that anecdotally you as an individual, feel like it helps then go for it. But, I think that there is also like even sinking your nutrition based on the part of your cycle. It can be very overwhelming for a lot of people.

So I would say just sort of, know, if you're really, really well versed in it you wanna do it, go for it, but it's not something you have to really start to learn about.

Yeah, I think, because I've really thought a lot about this too, as of late, like I don't do cycle or seed cycling. I think wouldn't the benefit come in because those seeds are providing the optimal levels of, you're increasing your nutrient status in that area. And we do know that there are some links of like nutritional deficiencies and like PMI. Totally. So that's like totally ideal behind it, right? Yeah.

I mean, I think that for PMS it makes sense. It could for endo, but once again, it just depends on the type of endometriosis you have. It's extremely variable from one woman to the next. And sometimes those endometrial implants could sort of like feed itself, so to speak. And so you can try everything you can in terms of lifestyle, seed cycling, whatever it is, but it...

may not actually improve at all and you still need drugs and sorry, I forgot to actually mention another very important drug that can be really helpful for suppression, but it can't really be used long term, which is Lupron or Antegnus. I think there was a question about that too, medications like Orlyssa, which are really, really great for suppressing endometriosis. But the thing about those, because it's essentially putting you in a form of medical menopause,

DR. SASHA HAKMAN (01:03:54.958)

there's a limitation to how long you want to be on it because the last thing you want is to reduce bone mineral density and become predisposed to things like osteopenia or osteoporosis in the future.

like using something like this and you're in a medical menopause as you said, would you not be losing eggs at that point? And you're still losing eggs every month.

You're still losing eggs every month, no matter what you do. Yeah. Sadly. All right.

okay. Is cycle syncing helpful? Is that the same thing as.

Yeah, kind of. think cycle syncing is referring more to nutrition and exercise. So just doing a variety of different types of foods based on where you're at in your cycle and different types of exercise. There's definitely merit to it, but it is very, very complicated. And I would say it probably causes more mental stress for a lot of women just trying to figure that out. Yeah. So.

KAYLA BARNES-LENTZ (01:04:54.99)

My opinion on that is definitely master the basics for sure. So I do some of that, right? Like I'll have slightly more red meat during the bleed phase or like we know we're more insulin sensitive in the first half and less in the second half. So I take that into consideration, but I think, yeah, just eating really healthy foods all the time is really like beneficial. Is it autoimmune was a question. kind of reviewed that. So essentially the answer is no, but still exploring.

No, there probably is some immune component to it, but not necessarily. We don't really know.

I'm not sure what this is. somatic therapy work for this? Things like human garage. Do you know what that is?

No, I've never heard of that to be honest. Somatic therapy sounds like it would be something more like, I don't know, with the mind and self-healing of some sort, but I don't know.

Yeah.

KAYLA BARNES-LENTZ (01:05:52.046)

Yeah, I don't know that one either. Okay, just general alternative treatments. We talked about all the conventional ones. Is there anything else that people are even trying for it? Like, I don't know, PRP or company.

Not right now. Okay. Yeah, that's not something that's been explored at the moment, but yeah, it's, we definitely need a ton more research on endometriosis to see what are alternative therapies, because I think a lot of the focus has been always on surgery and drugs. So it'll be interesting to see how that transforms over time. Hopefully it does.

Yeah, I mean definitely this seems like this is just so sad.

Yeah, it's very sad. It's very debilitating in many cases and it has a really massive emotional impact for a lot of women.

any benefits to using NAC.

DR. SASHA HAKMAN (01:06:43.042)

I mean, it definitely couldn't hurt. NAC is a great supplement. It's a strong antioxidant. you know, antioxidants are great. I'm all for it.

What helps to prevent or slow the growth of it returning after surgery?

It's always the same thing, hormonal suppression. Yeah, unfortunately, or fortunately, it just depends how you look at it. I'm personally a big fan of, you know, the birth control pill because I just see how it can be transformative for a lot of women.

Yeah, if I'm giving my honest opinion, think if I had this, would want to do, and of course, you know, mean, birth control is great, but I think just I would prefer a bioidentical. I would probably be one of those people. Yeah, that's fair.

Yeah.

DR. SASHA HAKMAN (01:07:27.628)

Yeah, I mean, I think everyone feels really differently about it based on their own experiences too. Like for me, because I never ovulated on my own, like birth control pills were life changing for me. So I'm like biased as just my personal experience with it. We know the safety profile is really great, but then also I was on it for 15 years and it probably saved my fertility because it's, believe it or not, very anti-inflammatory.

If you have things like PCOS or endometriosis and birth control pills work, then it works fantastic. It also came to mind there's so many different types. It's about getting on the right kind of birth control.

Yeah, yeah. And I mean, I'm definitely on the mindset, like, you know, there's people that are like, I'm never taking medication. I'm definitely not on that camp. You know, I can wrap a myosin, I do peptides, I get things from compounding pharmacies all the time. Right. So and if I had to be on really anything I would be because I think that preservation is more important than.

you just dying on this hill of like, I'm not going to be out of medication. Yes. And plus there's so many, you know, people are like, I would never take a statin, but then you're taking so much red rice yeast that it's like almost the same thing. one is regulated and one is not. So you should take the regulated one. Right. Be totally honest if you can't control it on your own, which obviously this is something that you can't. So yes.

And I'm definitely on team if there is lifestyle modification that could treat something we always start with that But in many cases that is not possible and you need drugs. Yeah, like I I really personally have Taken very little medications throughout my life for me. The one and only has always just been birth control pills because

KAYLA BARNES-LENTZ (01:08:59.662)

Yeah, always.

DR. SASHA HAKMAN (01:09:16.116)

I have what I thought was PCOS turns out to be non-clasical congenital adrenal hyperplasia, very complicated disease. But for me, it really helped me because without the birth control pills, it would have been really a struggle throughout all of my reproductive years. So I'm all about lifestyle modification first and foremost. Sometimes you just have to add in the meds in order to shut down the disease.

Yeah, I agree. And if anyone's like listening to this and just, you know, or has followed me for a long time, I just want to make that point really clear that although, you know, a lot of times I'm seeking out and I'm always putting lifestyle first. yeah, I would in no means would I not take a medication should I need it.

Yes, and it is not failure. Meds is not a form of failure because I know that a lot of patients look at it that way. Like I tried everything I tried. And like, don't, you know, put yourself into all this distress over just trying to have that title of saying, I don't need meds. Of course, none of us want to take meds long-term, but sometimes you just need it.

Absolutely not.

KAYLA BARNES-LENTZ (01:10:23.084)

Yeah, yeah, I agree. And I'm glad we just had that little chat about it. Because I don't really know if I've ever openly said that. mean, people could obviously find it out by looking at my protocol page and seeing that I'm taking different meds electively. But yeah, I think it's important.

Someone asked if I have endometriosis. No, I don't, but this was like an ultra highly requested podcast and I'm so excited to be able to, I wanna interview like a few people, know, just on all things women's health. I wanna go really deep into this because I don't know that there's a ton of coverage on it and with people that are like you, that are really like looking at the research, open-minded and just wanna give women the best information out there.

I think there's so many people, so many women that are living in small towns or not able to access this type of information. So that's why it's so important to me. continue to ask for things and I will continue to find the top people to bring the information to you. Let's see. Does access estrogen cause this?

It could worsen it. Could it cause it? Maybe. I mean, these are very specific questions that we don't necessarily have the answer to. We, you know, discussed the theory of why we think that it forms in the first place and that there's also a genetic predisposition. But if you do have androgen excess, though it's rare to have that with endometriosis, if you do have that, it'll certainly worsen it tremendously.

So let's see, is comorbidity with autoimmune conditions like Crohn's common?

DR. SASHA HAKMAN (01:12:05.582)

I mean, you see it sometimes, but I don't think it's more than, you know, the general population. You can probably find some sort of association study, but at end of the day, those are not powerful studies to see what the prevalence is. Endometriosis doesn't cause things like Crohn's, but it's sort of intuitive to think that if you have an autoimmune disorder or you have some sort of inflammatory disorder, it will make whatever predisposition you have.

a lot worse or more likely to end up having something like endometriosis.

Yeah, that makes sense. For someone with an endocyst and a polyp, can you keep it from getting worse?

Well, I'd say for the polyp, just get that removed, get it out. So this is basically mostly benign growth of the lining of the uterus, which can cause heavier bleeding than usual, it can cause intermenstrual spotting and or bleeding, and removing it is really non-invasive. So this is where we go in with a camera through the cervix, so there's no incisions, and then you essentially just grasp the polyp, patients go home that day.

Many will go back to work the next day. So the downtime is very, little and it's out of there. So with the polyp, I would remove that. And what was the second part of the question?

KAYLA BARNES-LENTZ (01:13:24.952)

So it's for someone with an endocyst and a polyp. Can you get that from getting worse?

The endocyst, they're probably referring to as an endometrioma. Once again, hormonal suppression will prevent it from getting worse.

Then your Lyssa, you said that's a good one, right? Yeah.

Orlyssa is great. So Lupron is a shot that you get for either monthly or every three months. Orlyssa is a daily pill that you take, so it's easier to just stop it and reverse it as opposed to the Depo Lupron. They work in different ways, but in similar ways. What they're essentially doing is they're blocking the release of gonadotropins from the brain. So follicle stimulating hormone and luteinizing hormone so that you don't have an ovulatory cycle.

That way you're not making estrogen and that way you're not sort of the endometrial implants.

KAYLA BARNES-LENTZ (01:14:16.728)

Got it. Lap surgery one year ago for endometriosis, taking chase tree. Can you speak to this?

It's probably not going to help you. mean, I doubt it'll cause any harm. know that that's a, Vitex is a really common supplement people take for reproductive purposes, but there's more data on things like vitamin D, E, and C.

Can postpartum endometriosis turn into endometriosis?

can postpartum endometriosis.

Yeah, turn into endometriosis.

DR. SASHA HAKMAN (01:14:53.55)

I mean, it's part of endometriosis. Sorry. Yeah.

Okay, and me try this turn and me got it got it got

Okay, so those are two totally different things. So endometritis is chronic inflammation inside the lining of the uterus, typically due to some sort of bacteria. So the treatment for that is antibiotics. And then usually that will cure it. The most common antibiotic we use is doxycycline. Sometimes you'll get rebiopsy to confirm with a test of cure. And then other times you just leave it alone. Endometriosis, totally different. That's the presence of endometrial cells outside of the uterus.

Can I still have endo if receptiva is negative? Have ruled out everything else. Okay.

So Receptiva is a test that I actually very commonly do as a fertility specialist. It's really only fertility specialists that do this test. What we're doing here is we're doing what's called a mock cycle for an embryo transfer. So we're preparing the uterine lining for a transfer, except on the day of the embryo transfer, instead of the transfer, we're doing an endometrial biopsy, okay, the day that we would normally put an embryo back in the uterus.

DR. SASHA HAKMAN (01:16:04.834)

With that biopsy, when we send it out for Receptiva, Receptiva is the company or the test that's doing, looking at BCL6. BCL6 is a marker for endometriosis that has affected the lining of the uterus. And if you are positive for BCL6, implantation rates are as low as 17%. And then the treatment is either surgery, so excision of the endometriosis,

Or you give Lupron for two months, two to three months, or even Oralyssa, although I don't know if Oralyssa was technically part of their validation study, but it really just works the same, so probably just as fine. And that's in hopes of improving your implantation rates. Now, if you did this test and you're negative and there's still very strong clinical suspicion for endometriosis, the next step would just be the laparoscopy surgery. So it is possible.

But usually what I have found is when you're negative for BCL6, there likely is something else going on.

Okay, thank you.

Was that confusing?

KAYLA BARNES-LENTZ (01:17:16.27)

No, think no. Okay, good. Best way to reduce prostaglandin for pain relief other than pills.

good question. I'll let you know when I find out. actually don't know. I don't know if there's a way to, I mean, through new, there's probably some dietary things you can do, but, once again, taking things like NSAIDs is really going to be, the best bang for your buck. Yeah.

Please cover why it's important not to get ablation surgery. I don't know if that means like just not getting it at all, because that seems like maybe not the best option, but I think when you talk to ablation versus.

Excision, yeah, mean, excision's been shown to be superior to ablation. I think that people do ablation because it's easier and faster, but it really, yeah, you're not really removing the implants. so I think that's a key. Ablation is really good for superficial endometriosis. So sometimes the lesions are really teeny tiny, you know, superficial on top of an organ. And so you can just sort of like burn that off. But if you're very

That's if you're really well trained to look at certain implants, knowing that one is superficial versus deep. With the deep implants, you really, really want to excise them.

KAYLA BARNES-LENTZ (01:18:39.382)

Why can't you see these implants on imaging?

It's really hard to see. Some of them are very subtle and like I said, they're superficial. so you're not going to see, mean, ultrasound is terrible test to try to look for endometriosis because when you're doing ultrasound, you're really just, you know, there aren't ways to look at the peritoneum or on the outside of the ovary that will really demonstrate

superficial implants. Now, if there's an endometrioma, that's obvious on ultrasound, you'll see that. And when you see it, you know that you're pretty much like automatically stage three endometriosis and there's four different stages. So it's really hard to see on ultrasound. With MRI, sometimes you can see these implants, especially if it's more deeper infiltrated into the tissue. But once again, if it's superficial, if you have filmy adhesions, which are still consistent with endometriosis, you can easily miss that.

And once again, the severity of the stage of endometriosis doesn't necessarily correlate with pain. So you could be stage one endo where you have very superficial implants, very filmy adhesions. It's barely taking over anatomically, but it's causing you tremendous pain versus those where I've seen their stage four endometriosis. They have thick, dense adhesions. It is everywhere. It's all over the ovaries, the fallopian tubes, and they have...

no pain whatsoever. And sometimes the only reason they found out is because of their infertility.

KAYLA BARNES-LENTZ (01:20:17.251)

Wow.

Okay.

is endometriosis linked to breast cancer?

No, but it is linked to ovarian

HRT for perimenopause safe for pigolendo.

DR. SASHA HAKMAN (01:20:33.474)

Generally, yes. So if you're in menopause, your ovaries are no longer really playing any role. When we're doing HRT in menopause, you are given really the lowest dose that is effective for your symptoms of hot flashes and whatever else. The dose is so small that it really shouldn't worsen endometriosis. So hence like when you're on

a combination oral contraceptive pill that has estrogen. You're not necessarily feeding the endometriosis. So same thing in menopause, you can do HRT.

how to increase fertility if you have endometriosis.

The biggest, biggest thing that you can do to improve your fertility is until you start trying, suppressing it as much as humanly possible. So this is where doing things like birth control pills and other medications to suppress it can actually significantly protect your fertility.

how to differentiate between PCOS and Endo, how to know if you have both.

DR. SASHA HAKMAN (01:21:38.712)

So these are two totally different things. I see it often confused. think that, a lot of women think that PCOS, because it stands for polycystic ovary syndrome, that it's a disease of cysts in the ovaries. It's just a very, very poorly named disease. It has nothing to do with cysts. It just means that there's tons of follicles throughout the ovary, particularly in the periphery of the ovary. With PCOS, the problem is that

Your brain is secreting so much luteinizing hormone, which is a hormone that you just need to surge for about 24 hours to release an egg. But if you have high LH, what it's doing is it's increasing ovarian testosterone and insulin levels, which can lean to insulin resistance, leads to irregular periods, lack of ovulation, sometimes no periods at all. And so it's a metabolic and endocrine disease.

Endometriosis, once again, is the presence of endometrial cells located outside of the uterus.

KAYLA BARNES-LENTZ (01:22:41.558)

All right, someone asked about bioidentical hormones. We already covered that. Are there any supplements that help to specifically slow the growth of the lining? Is there anything outside of what you've already mentioned?

I mean, there's reports of using things like aromatase inhibitors, which we use for various reasons, but I don't think that it's really commonly done. Same with different testosterone analogs that could be used to help, but those also come with their fair share of side effects too.

Can you touch on, this is not obviously related to endometriosis, but the question is, let's see here.

KAYLA BARNES-LENTZ (01:23:25.166)

about weight gain with endo and bad PMDD. A little bit about PMDD, not super familiar with that either.

Yeah, so PMDD is more of a mood disorders around your period. so typically for that, what we'll do is treat either with SSRIs, so antidepressants around that time and or birth control pills. There's different ways of managing that. It is different than endometriosis, a whole different thing altogether.

but sometimes the treatment can overlap.

Any good tips for pain and vomiting?

Vomiting, have not heard too much of as a complaint. I mean, it's certainly possible, but once again, when it comes to the pain of endometriosis, it's really treating the endo. So whether it's hormonal suppression or surgery, long-term end-side use just during the period, if you are still cycling, then those things can help. So it's just a matter of sitting with an endo specialist and discussing all your treatment options.

KAYLA BARNES-LENTZ (01:24:33.774)

repeat raw carrot salad recipe. Do you believe that this could help?

I mean, this is one of those things where we go back to the basics of just healthy nutrition is really great. There isn't going to be a specific recipe that's gonna cure endometriosis.

Yeah, I think the idea behind that is maybe like reducing estrogen is that like the raw carrots.

I mean, carrots have so much benefit. mean, the carotene is so great, but eating carrots is not going to cure endometriosis. It's not going to help your symptoms. I mean, that in a combination with just an overall healthy, nutritious diet based on what the studies show can help endometriosis in general, but it's not like a particular ingredient is going to suppress your estrogen levels so much.

because at that point it's almost like a drug.

KAYLA BARNES-LENTZ (01:25:26.062)

Yeah, that makes sense. Okay, this is really sad. four, it's up on my lungs, not on any meds or birth control suggestions. The same person said, I, according to them, they did 24 months slash rounds of Lupron injections in 2010 to 2012 long-term concerns.

Not long-term, I would check bone density. That would be my main advice because two years is a really long time. So I'd check your bone density to make sure that that has at least come back to what it was and it's in a decent range. But aside from that, there wouldn't be any long-term detrimental effects of being on this medication for a long time. But if symptoms have recurred, then I would say it's time to really

revisit the idea of possibly doing surgery or just long-term suppression with something like norethondrone acetate, is a progesterone pill. I'm telling you, had such, such great success with patients on this pill.

Okay. Well, I think that's about it. That's like the gist of all the questions that we got. Thank you so much for coming on the pod today and just talking about all this with us. We'll link to, of course, your website and any resources and other podcasts that we've done. So I'm sure Sasha will be a returning guest because we have lots of email questions. So thank you so much for being here.

Thanks for having me again. And just a last little note here, if you're struggling with endometriosis, please don't give up. Find the right doctor who can really help you along this journey to get you to a place that you need to be.

KAYLA BARNES-LENTZ (01:27:08.046)

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