Lara Briden's Podcast

The hidden story of endometriosis: Pain, lesions, and the microbiome

• Lara Briden • Season 4 • Episode 17

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If you’ve been diagnosed with endometriosis, the big question is: What type of lesions?

In this episode, Lara challenges long-held assumptions to explore:

  • the three types of endometriosis lesions, 
  • emerging evidence that superficial lesions may not explain pain or other symptoms, 
  • alternative explanations for pelvic pain and infertility, including pelvic congestion, immune dysfunction, and gut microbiome imbalance, and 
  • an update on the bacterial contamination hypothesis.

Links:

Broadly speaking, there are three types of endometriosis lesions: endometriomas, deep infiltrating lesions, and superficial lesions. In this episode, I’ll bring you some research updates about the first two types. I’ll also make the case that superficial lesions alone, without the other types, may not be the explanation for your pelvic pain or other symptoms. 

Welcome back to the podcast. I’m your host, Lara Briden, a naturopathic doctor and author of the books Period Repair Manual, Hormone Repair Manual, and Metabolism Repair for Women.

Okay, so let’s get into it. 

Endometriomas, also called chocolate cysts or endometriotic cysts, are endometriosis lesions that form on the ovaries. 

Deep, infiltrating lesions are invasive lesions that penetrate more than 5 mm into tissue, and they include rectovaginal nodules, which form in the space between the vagina and the rectum.

Endometriomas and deep infiltrating lesions typically occur together, so if you have an endometrioma, you likely have deep, infiltrating lesions as well. 

Now, endometriomas and/or deep infiltrating lesions can definitely be the explanation for symptoms like pain and infertility. And they can be serious enough to require surgery. Although it is also worth pointing out that even those types of lesions can, in some cases, regress on their own or with non-surgical treatments, including, I would argue, immune and antimicrobial treatments, which I’ll come to a little later.

First, though, we need to talk about superficial lesions, and the unsettling possibility that for some women, possibly many women, the superficial type of endometriosis lesions may NOT be the explanation for pain, infertility, or other symptoms. Although, to be fair, there are different sub-types of superficial lesions, so some could explain symptoms, while others do not. 

Unfortunately, a hyperfocus on innocent superficial lesions could be a major distraction from the actual cause or causes for your pain or other symptoms, such as interstitial cystitis (a bladder condition), fibromyalgia, pelvic floor tension, or a super-common, but frequently missed condition called pelvic congestion syndrome, which is essentially varicose veins, but inside the pelvis. For more information about that, see my article, “Could pelvic congestion syndrome explain your pelvic pain?” The link is in the show notes.

Now, it is entirely possible to have one of those conditions as the main cause of your pain or other symptoms, but ALSO to have superficial endometriosis lesions. And that’s because superficial endometriosis lesions may be a lot more common than we realised. For example, a 1991 study looked at women undergoing surgery for tubal sterilization and found that 43 percent of them had superficial lesions despite having no symptoms. That citation is in the show notes.

There hasn’t been much definitive data since then, so we don’t know if it’s really true that 43% of healthy women have superficial lesions, but there is a growing consensus that it's a fair number of women. In fact, according to a 2019 article in the British Journal of Obstetrics and Gynaecology, at least some superficial endometriosis lesions could simply be just a physiological phenomenon or a normal feature of menstruation. The citation is in the show notes.

By physiological or normal, they mean that at least some of what’s currently classified as superficial endometriosis lesions are essentially just harmless deposits of endometrial-like tissue that come with having periods. And that the immune system will likely eventually clean up. As Dr Peta Wright says on page 36 of her book Healing Pelvic Pain, “I would even argue that superficial endometriosis may not be a disease at all.” She likens the detection of superficial lesions to finding a post-party mess if a landlord were to do a spot inspection of a rental property. Sure, there’s a mess on that particular day, but in a few weeks, after the residents—or the immune system—has had a chance to clean, everything will be fine again.

So, if you’ve been diagnosed with endometriosis, your first question should be: What type of endometriosis lesions do you have?  And I don’t mean what stage of endometriosis, because that’s something else. I mean, what type of lesions?— like we talked about before. Are they endometriomas and/or deep infiltrating lesions? If so, that could very well be the explanation for your symptoms.

 Or are they only superficial lesions? Because in that case, your pain or other symptoms could be caused by something else. You just happen to also coincidentally have superficial lesions, like many women do. 

As you know, there are two main ways to detect endometriosis lesions: specialised transvaginal ultrasound and surgery. There’s also MRI, but that’s less common.

Specialised transvaginal ultrasound or MRI can really only detect endometriomas and deep infiltrating lesions. But that’s okay because those are the lesions that need to be detected. Of course, sometimes ultrasound can miss those. There’s always nuance and complexity with a topic like this.  

Of course, surgery can detect endometriomas and deep infiltrating lesions. But it can also detect superficial lesions. In fact, surgery is the main way to detect superficial lesions. But the big question is: How helpful is the detection of those superficial lesions? Since they may not be the explanation for your symptoms anyway. Because, just to say again: even if you have superficial lesions, the explanation for your pain or other symptoms— and the thing that needs treating!— could be something entirely different.

Hopefully, obvious explanations like fibroids, adenomyosis, and infection have already been ruled out by your doctor. But you may need to actively look for hidden causes or explanations like pelvic congestion syndrome, fibromyalgia, or pelvic floor tension, like I mentioned earlier. Or you may need to look more generally at the nervous system, especially the autonomic nervous system, because it can contribute to pelvic pain and fertility problems. So can the immune system. And so can the gut.

The gut is interesting because there’s growing evidence that it can play a huge role in pelvic pain and infertility, whether that involves endometriosis lesions or not. That’s explained in a 2024 Nature article called “The gut microbiome and chronic pain.” It explores how the gut microbiota, and their associated metabolites (like short-chain fatty acids and bile salts), are altered in people who have pain syndromes like fibromyalgia and endometriosis. The article even mentions the potential value of a wheat-free/dairy-free diet, all while somewhat blurring the lines between endometriosis and other chronic pain conditions like fibromyalgia and IBS. 

The article also makes the very important point that there’s no one-size-fits-all approach to treatment for gut inflammation and pain. That’s the topic. But, broadly, if you have gut problems, you want to consider things like tood sensitivities, especially sensitivity to A1 casein or normal cow’s dairy, plus subclinical deficiencies of nutrients like vitamin A and zinc, especially if you’ve been trying to follow an exclusively plant-based diet, because those important gut nutrients are mostly absent from plant foods. Another gut consideration is SIBO or small intestinal bacterial overgrowth, the topic of episode 12 of this podcast.
 
And that brings us to a quick update on the “bacterial contamination hypothesis of endometriosis.” As you might recall from episode 4 of this podcast, the bacterial contamination hypothesis was first proposed in a 2018 paper—link in the show notes— which explained how LPS toxin from gram-negative bacteria in the pelvis can drive inflammation and immune dysfunction. The bacterial toxins are believed to enter the pelvis via retrograde menstruation, intestinal permeability or both. Importantly, intestinal permeability is typically the result of things like gluten sensitivity, dysbiosis, SIBO, and nutrient deficiencies, especially zinc and vitamin A, which I just mentioned.

Back in episode 4, I proposed natural antimicrobial treatments for endometriosis, such as berberine, N-acetyl cysteine and maybe iodine, but you need to be really careful with iodine, so review my books for some iodine safety tips. 

Okay. 

Since that 2018 paper, there’s been a newer 2023 paper linking bacteria to endometriosis, but via a different mechanism. This research—link in the show notes— found that Fusobacterium infection of endometrial cells activates growth factors and fibroblasts, which promote endometriosis lesions. In an animal study, they were able to shrink lesions with antibiotics.

So, there are at least two mechanisms by which bacteria or the microbiome could play a role in the development of the serious type of endometriosis lesions. And there are probably more mechanisms. Making the gut microbiome a great target for treatment. 

For context, the growing understanding of the possible role of the microbiome does not negate the role of other things, such as hormones or immune dysfunction. If you’re watching the video, this is an image from a 2024 paper called “Emerging bacterial factors for understanding pathogenesis of endometriosis,” —link in the show notes— where the role of bacteria is put into context with all the other potential factors, including hormones and immune dysregulation. 

So, what does this all mean? 

Well, Step one: If you have symptoms, such as pelvic pain, that suggest endometriosis, it probably makes sense to undergo the specialised transvaginal ultrasound. If lesions are visible, then it’s because they’re deep infiltrating lesions or endometriomas. 

And for those types of lesions, various treatment options should be on the table, including surgery in some cases, and also possibly natural antimicrobial treatments. Because, although the microbiome research has not yet translated to new medical treatments, it can help to inform the use of natural antimicrobial treatments such as diet changes, and the berberine, N-acetylcysteine, and iodine that I mentioned.

But if lesions are not visible on the specialised transvaginal ultrasound, then Step 2 is to consider other explanations for pelvic pain or other symptoms. For example, you could ask your doctor about pelvic congestion syndrome. Or consult a pelvic physiotherapist about pelvic floor tension. You could definitely work with the nervous system and address any gut issues. And if infertility is your main concern, then please thoroughly assess the male side of things, even if the basic semen analysis was deemed “good enough.” In my experience, there’s often a lot of room for improvement when it comes to sperm and semen. For example, did you know that semen has a microbiome? And for other treatment ideas, consult Dr Peta Wright’s book, Healing Pelvic Pain.

And remember that surgery to detect superficial lesions may not add clarity or bring you any closer to the right treatment. In fact, it could just be a massive distraction. I wish it were not like this. I wish we did not have a century-old paradigm that treats superficial lesions as a disease when they are quite possibly a normal finding.

In the words of the Faculty of Pain Medicine, associated with the Australian and New Zealand College of Anaesthetists, “The long-held paradigm that endometriosis lesions are a direct cause of persistent pelvic pain is no longer tenable.” Instead, they propose that the treatment of women’s pelvic pain should align with the best practice that exists for other persistent pain states, which consists of multidimensional whole-person care, with the goal of relieving pain, whether endometriosis lesions are present or not. The link to that document is in the show notes. Lots in the show notes today.

So, really, this is about acknowledging that women’s symptoms are real. Your symptoms are real. That’s true whether endometriosis lesions are present or not. But finding a solution for those symptoms could require looking beyond the lesions.

I hope that’s been helpful, and thanks so much for listening! Or watching. 
Please share and leave a review. You can also leave a comment on the YouTube video or on the blog post associated with this episode at LaraBriden.com. And I’ll see you next time when I’ll revisit PCOS or polycystic ovary syndrome.