Dr Nirala Jacobi:

Welcome back to part two of The SIBO Doctor Podcast, and let's jump right back into it. Just kind of mid-podcast summary in terms of what you're saying is it's an inflammatory condition that has its roots in some sort of microbial imbalance, possibly leaky gut, but hormonally there might not be any imbalances. Are you saying that hormones aren't at all involved, or partially involved?

Dr Lara Briden:

I can definitely respond to that. Endometriosis is not a hormonal condition. It's not a condition of hormone imbalance; that is not to say hormones aren't involved because they definitely are. I guess I would position it more that even just our normal hormone cycles are having a different effect in women with endometriosis compared to women who don't have endometriosis. So I'll give you a couple of examples. So one, we talked about the lesions are very sensitive to estrogen, even a normal amount of estrogen, so that's one thing. There's a whole side of things where estrogen interacts with histamine and mast cells, which we haven't dived into yet, but mast cell application-

Dr Nirala Jacobi:

We love doing that. We love talking about histamine and mast cells.

Dr Lara Briden:

That should ease into your question earlier of what gut pattern. Mast cell activation I would say is a big part of what's going on with endo. And then on the progesterone side of things, this is where it does get interesting. Progesterone generally should have an anti-endometriosis effect both in terms of downregulating the growth of the lesions themselves, and also modulating immune function. Remember we talked about, "Is this a type of autoimmune-type inflammation?" And if it is, in most cases of autoimmune-type immune dysfunction, progesterone has a beneficial immune modulating effect.

Dr Lara Briden:

So I think women with endometriosis, maybe some of them are not producing as much progesterone as they should, but that's true for many of us. And it's not so much that they're not making progesterone, it's that they are resistant to it. That's in the literature for sure, a progesterone resistance that's present with endometriosis, that could in part be epigenetic, possibly from dioxin exposure three generations ago, right?

Dr Nirala Jacobi:

Wow. That's blowing my mind.

Dr Lara Briden:

Yeah. And this inherited progesterone resistance, and so that potentially means the lesions are resistant to the downregulating effects of progesterone, but also the immune system could be resistant to the beneficial immune modulating effects of progesterone. So staying on the hormone side of things just for a minute, the standard conventional treatment is to give progestins, this goes back to our conversation earlier about contraceptive drugs are not hormones. So progestins, they also can be helpful for endometriosis, helping to downregulate it. But for what it's worth as a clinician, I'll say that progesterone works a lot better, and that would be progesterone preferably as an oral micronized capsule, which in Australia, New Zealand ... I don't know where all your listeners are from I guess depending on [crosstalk 00:04:16].

Dr Nirala Jacobi:

All over the world.

Dr Lara Briden:

All over the world.

Dr Nirala Jacobi:

Mm-hmm (affirmative)

Dr Lara Briden:

So depending where you are in the world as a naturopathic doctor, you can prescribe that or not, but you can also speak to their gynecologist about it. But what's been happening with a lot of my Sydney patients is they have had an opportunity to try Prometrium, which is the brand name of oral micronized progesterone that became available only at the end of 2016, so it hasn't been that long. And in New Zealand it's Utrogestan, in the States it's called Prometrium, in Canada it's Prometrium. In the UK it's Utrogestan, and that's real progesterone. That's well, as we call bioidentical or body identical progesterone. For what it's worth, that can be quite helpful for endometriosis. And that is more on the hormonal side of things. Even though I said it's not a hormonal condition, progesterone itself can still be ... giving it can still have an anti-inflammatory potentially lesion downregulating effect.

Dr Nirala Jacobi:

So you're basically using a transdermal application. Is Prometrium a transdermal or oral?

Dr Lara Briden:

Oral.

Dr Nirala Jacobi:

Okay. Is there a form that you prefer in terms of ... I hear that you can sort of saturate an area with transdermal progesterone and that you just don't get much absorption after some time; is that true?

Dr Lara Briden:

In that case with transdermal, you just have to rotate it around to different locations on the body. I'm not anti-transdermal. For certain things, I don't think it's ... That's a whole other topic. But what I'm talking about now is actually, I do think oral is preferable, if you can access it. It does seem to have a stronger effect. I think part of what's happening with the oral progesterone is the first pass in the liver, which is only portrayed as a bad thing, but for progesterone that's actually not ... it can be a good thing because more of it converts to allopregnanolone which is a neurosteroid which is quite calming for the nervous system. I actually think part of maybe why progesterone helps endometriosis so much is also it's potentially anti-pain effect; antiinflammatory, anti-pain, reducing the size of the lesions, reducing ... Progesterone, one of its natural effects is to mature and reduce or thin to some extent endometrial lining. It definitely acts on endometrial lining in a good way.

Dr Lara Briden:

It seems to be a stronger effect oral but I wouldn't discount ... I mean, if there are clinicians out there who are getting really good results with transdermal, that's certainly possible as well. You can also take it vaginally as a pessary, which is possibly in some cases quite good because it is quite close to the area, so you might get more, I would think, more progesterone actually just traveling to the pelvis, to the area where it's needed, not just through the blood supply that, but also just local saturation. But the only thing is I have had a couple cases where women using vaginal pessaries got sort of a skin reaction from that or an irritation from that, which I think after a few months ... I'm not saying that would happen every time, but maybe that's one of the reasons I have preferred oral.

Dr Nirala Jacobi:

Moving towards more the anti-inflammatory treatment aspects of this. But before we go into that, I just wanted to kind of remind the listeners about the reason why we're talking about endometriosis and SIBO. And so now we've always sort of looked at the link being purely adhesions and adhesions forming in the pelvic cavity and causing a kink in the garden hose, if you will, situation, attaching to the small bowel and therefore trapping bacteria in the upper gut where they're just not allowed to leave. And so what we usually do as SIBO practitioners is refer somebody with endometriosis to a very skilled visceral manipulation therapists. So I wanted to ask you about your opinion about that, but then moving into if it's an immune disorder how can we end a leaky gut?

Dr Nirala Jacobi:

I think we really do on this podcast, talk about leaky gut a lot. We talked about LPS a lot. We talk about those factors. I mean, it doesn't hurt to get your take on it at all. So I want to talk to you about your approach to that. So yeah, so let's kind of moving to the adhesion work and then into leaky gut work.

Dr Lara Briden:

Sure, yeah. So definitely referral to physical therapists, yes. I mean, I don't have a lot of knowledge of that myself. I have a few people I refer to. For what it's worth, this is very old school naturopathic. I don't know what your view is of this, but some of my patients, they do get results from castor oil packs. And I mean, probably in combination with some of the soft tissue manipulation, but I guess the castor oil, some of it does permeate the skin and potentially help to break down some of the scar tissues. So if anyone's out there who's used it or still like that treatment, I think it's worth mentioning.

Dr Nirala Jacobi:

I haven't used it but I've recommended it plenty in my time and it seems to be quite soothing but I haven't really found it to be useful to really break up extensive scar tissue or adhesions. For that, I really find sometimes referral to visceral manipulation therapy is quite miraculous to be honest. I've seen some really amazing things and sometimes nothing happens of course as with any therapies and depends on the extent of the scar formation. But any good visceral manipulation therapies has to work so that no new scar tissue forms obviously from the therapy. Because that's always the problem when you just do this sort of like a vigorous abdominal massage. It's like the antithesis of visceral manipulation in a way.

Dr Nirala Jacobi:

So there are actually a few people in Sydney that we refer to, and have had some really good results with not just adhesions from endometriosis but any sort of abdominal surgery has been shown to absolutely increase adhesion formation and the occurrence of SIBO. There's no doubt about that. So I do take that very seriously. So let's move then into immune modulation if you will and leaky gut treatments. Your favorite, how do you do it?

Dr Lara Briden:

Well, again there just like to be a little bit of an algorithm of what is going on with the gut. So obviously we're starting with the gut. I'm just thinking about very simple example. Like if someone's on a PPI, for example, like a Losec or something, then one of my first steps would be to help them find a way off that, which sometimes involves doing treatment for SIBO at the same time. But something like a low stomach acid or a proton-pump inhibitor I think is an upstream issue for the gut that needs to be addressed sooner rather than later. So I guess I might start there. Well, now we're speaking about endometriosis patients, but many times with the gut, I do think many people need to get off wheat and dairy possibly strictly if they have endo because of the immune side of things, but also just from the dairy side, the casein activation of mast cells.

Dr Lara Briden:

So we kind of go back to that mast cell activation even within the gut, I think is a driver. So I'm not a fan of a low FODMAP diet in the longterm, but I certainly would allow people to come off foods that are definitely bloating for them or fermenting for them. And then I often start with an antimicrobial. So I'm not sure quite how that fits in with some of your protocols currently, but I would ... for a lot of my endometriosis patients, especially if there's a lot of bloating, digestive bloating and what looks to me like a SIBO picture, I would probably, assuming there's no contraindications, do a course of a combination with berberine and oregano or myrrh or that kind of combination. Does that fit with some of your protocols currently?

Dr Nirala Jacobi:

Sure. We do it very differently.

Dr Lara Briden:

You do?

Dr Nirala Jacobi:

Yes, because we ... I mean, the fact that SIBO in a way, and especially if you have ... Well, let me back up. So you could have lots of different underlying causes and it really depends on the underlying driver of why that person developed SIBO. And one primary one is actually autoimmunity, which is antibody formation to the migrating motor complex.

Dr Lara Briden:

Yeah, I'm familiar with that.

Dr Nirala Jacobi:

Yeah. So one of the big recommendations we do ask people is not just to treat but to test, because to really understand what the recurrence rate is for that patient is, is really helpful because one of the things that happens in my clinic is that people get referred to me and they haven't really been assessed properly as to what's really happening and so just in my experience it draws out this whole process, whereas I often do ... I'm a big tester, so I do breath testing, I do stool testing and I personally get good results with that because then I can really target those treatments.

Dr Nirala Jacobi:

And especially if there's components of other drivers like hydrogen sulfide, which I find is often ... And like you said, histamine. Histamine is a huge deal when it comes to any sort of dyspepsia, functional gut disorders all the way from simple histamine intolerance and SIBO all the way to mast cell activation syndrome, which is really prevalent in chronic SIBO cases. So I'm somebody who likes to kind of ... I think you probably are the same as we're specialists in our field. So in our field we really understand that the ability to test and to really present it to the patient often also drives patient compliance. That's for sure what I see. It's like people are more compliant when they understand what's happening.

Dr Nirala Jacobi:

But I also understand and appreciate that when we're dealing with Gram-negative bacteria and SIBO, we can't actually assess those from ... we only know the byproducts, which is the gases. We don't actually know ... We know that there's a handful of bacteria that are very much associated with SIBO and they're all Gram-negative bacteria. They're mostly Gram-negative proteobacteria so like E. coli and proteobacteria or Proteus. So there's a number of these organisms that are commonly found that just happened to be Gram-negative, but we can't sample those very easily so we do breath tests.

Dr Lara Briden:

Yeah. I mean, I think it's a step one often, not step one, but step one might be just as you say, get to kind of an upstream driver of how they got there. But at some point I do find it useful to try to knock back some of those bacteria. I mean, knowing that that's not the whole solution because they could relapse and it's very true what you say about the motility complex other ways to kind of promote that motility longterm. But at least in the initial short term I find is often quite helpful to knock back those bacteria with ... I might do like a six or an eight week course about antimicrobial and it can give relief and not just to the bloating and the digestive discomfort but to the endo pain. Because of, I think just reducing the levels of LPS basically. Just kind of dialing that down and they start to get some relief.

Dr Lara Briden:

So I would do that usually with endo, not always with SIBO, but with endometriosis specifically, partly because of this autoimmune, if you will, side to it. Especially if there's any signs, like family history of gluten, celiac tendency like thyroid antibodies, which are to me ... I use thyroid antibodies almost as a vicarious gluten marker because they're so closely tied with gluten sensitivity. That's my experience.

Dr Nirala Jacobi:

That's a novel way of using it.

Dr Lara Briden:

Yeah. So here's an interesting statistic which I think I've got close to right. I'm going to say some numbers, so hopefully I've got these right. But if you check the celiac genotype or haplotype, which is actually a fair number of the population, then if you're positive for that, then I think it's still only about a one in 20 chance that you will get celiac disease. But there's a one in two chance that you'll get Hashimoto's thyroid disease with that haplotypes. And that's the same haplotype or genotype that's been quite closely correlated with endometriosis.

Dr Lara Briden:

So I'm kind of looking for signs of that autoimmunity, were there autoimmune in the family, are there autoimmune conditions going on. If that's there, then I really do potentially need them to get off strictly off gluten and A1 casein dairy and at the same time coming in with the antimicrobial, considering other food issues, which could be histamine, sometimes in some cases it's eggs. Eggs are another autoimmune-

Dr Nirala Jacobi:

Eggs are big.

Dr Lara Briden:

Yeah, they're a big one for some people. I look for a history of childhood eczema to try to inform me if eggs are likely to be a problem. Now I'm going to be thinking a bit more about this nickel allergy. I'm going to actually be asking women about nickel allergies, like if they react to jewelry and thinking about that.

Dr Lara Briden:

What's interesting in this paper that we'll put in the notes, just to circle right back to this nickel allergy paper that I mentioned at the beginning. They acknowledge, they look at the list of foods that have nickel and kind of cross reference that with gluten free, dairy free and FODMAP. So wheat is quite high in nickel apparently. So you've got wheat in all three categories; wheat is gluten, FODMAP and high nickel. Then you got [crosstalk 00:18:46].

Dr Nirala Jacobi:

And glyphosate very often, right?

Dr Lara Briden:

Yeah, that too. I mean, you've got tomatoes which are quite high in nickel, especially if they're canned or tinned. And they're histamine. They don't talk about histamine in that paper, but there's a bit of overlap between these diets. So you get people ... it's like, whoa, they feel so much better off wheat, dairy and tomatoes. It's like, well, why is that? Is that nickel? Is that just the antigenic proteins, FODMAP thing?

Dr Nirala Jacobi:

Yeah, I look forward to reading that paper for sure because-

Dr Lara Briden:

Yeah, it's a-

Dr Nirala Jacobi:

Yeah, because I think there's some correlation, but it made me think besides removing gluten, dairy, tomatoes, and possibly egg, are you following ... and maybe low-FODMAP, but you're not doing an autoimmune paleo or any of those kinds of diets with endometriosis. Have you seen some success with that?

Dr Lara Briden:

I mean, that's the territory I'm in certainly when I'm thinking about eggs, if eggs are an issue. And I think maybe you can tell me about the autoimmune paleo. I was just head down doing my own stuff and suddenly I look up and there's this autoimmune paleo protocol and I'm like, well, where did that come from? I'm just trying to figure it out and maybe you know, where did that start? A lot of it is just wheat, dairy and eggs and things that would make sense to me as a naturopathic doctor that I've been doing for 25 years. But some of it's like, why is that on the list? I'm looking at this list, it's like, well, why those things? I'm just trying to understand how they ended up there.

Dr Nirala Jacobi:

I mean, I do sometimes use sort of those types of diets for short periods of time just to really rest the gut in a way. But they've also included lectins in there, which is sort of a controversial issue. And no legumes, no nuts, no ... basically it's just meat and vegetables, which I find really difficult. But I have clinically seen some improvement with inflammatory states. That definitely can happen, but not across the board. But I think some of it is you just have to try it out clinically but some people get very anxious around that amount of restriction for longterm. And the question I have is, I haven't seen any microbiome studies before and after, but we do know that just indiscriminately using ... maybe this is more related to the ketogenic diet, but using a lot of saturated fat actually increases the absorption of LPS. So I'm always very conscious-

Dr Lara Briden:

Yeah, for sure, endotoxins.

Dr Nirala Jacobi:

Yeah, so I am cautious around that when we're dealing with specific issues around LPS. I think there's a lot of different takes on this and I do think there's a degree of individuality that some diets definitely don't work for some people. Like for example, I just could never eat that much meat. I get so fatigued, I can't handle it. I'm much more sort of a natural vegetarian. And that's just my personal sort of body type. And I've definitely come across that where you can't just prescribe the same diet for everyone. Having said that, I do use the Bi-Phasic Diet which I've created for SIBO, but that is like you mentioned, you don't like to use low-FODMAP diets indefinitely and I totally agree with that.

Dr Nirala Jacobi:

I think that the goal of therapy is to have the widest possible plant based diet possible. So we know that irrefutably that plant based diets, meaning that the predominant intake of your diet should come from plants. That we know is the healthiest diet when we look at Blue Zones and when we look at cancer rates and when we look at longevity and we look at all those parameters. I think that to me is proof that something in plants in terms of bioflavonoids, polyphenols are so health promoting that just mono diets that focus on just one macro nutrient like protein or fat I just don't find is very balanced at all.

Dr Lara Briden:

Well, I mean it's just the basic thing, you want to feed your microbiome in the lower guts and let them produce lots of nice short chain fatty acids to modulate immune function and do all the good things they're suppose to do. In my clinical style, I like to be, or I try to be ... my philosophy is to be quite practical. I'd been reluctant to hand someone a whole list of things they had to avoid if I wasn't sure why. I mean, I think just back to can someone digest legumes? That again comes back to, I don't know if it's ... Maybe, I guess it's on the autoimmune protocol. It could be lectins, but it's also FODMAPs and also actually legumes are one of the ... Back to this nickel thing. Not to keep beating this, but they're quite high in nickel.

Dr Nirala Jacobi:

This is fascinating.

Dr Lara Briden:

Yeah, so it's like why are we doing that? Well, I think big picture people should be able to eat legumes. I don't see the-

Dr Nirala Jacobi:

I agree with that.

Dr Lara Briden:

I don't think they should be on the list of, oh, those are always going to be bad. But if they're very bloating for someone, then-

Dr Nirala Jacobi:

Well, most of the time that happens to be an issue around a brush border enzymes and alpha-galactosidases and those types of enzymes that are really specific for that type of tougher outer sort of hull. And when you have microvilli damage, those brush border enzymes are going to be damaged. And so that's why we do see more incidents of histamine intolerance and intolerance to legumes and that should all be part of our gut rehab protocol so that people can digest these healthy foods.

Dr Lara Briden:

Yeah.

Dr Nirala Jacobi:

When we think about histamine intolerance, many of these foods are really healthy, like spinach and tomatoes and whatnot. So we really don't want to longterm reduce them. I think-

Dr Lara Briden:

Can I ask you a quick question, if you want to say, you've probably said this in your podcast before, but which are the ... off just the top of your head, the top two or three in terms of probiotics or taking a probiotic, which would be your first choices for histamine reducing rather than histamine liberating?

Dr Nirala Jacobi:

Yeah, so probably more like Lactobacillus rhamnosus, Lactobacillus plantarum 299v. Just off the top of my head, but I'm just ... I mean, I'm a big proponent of strain specific probiotics.

Dr Lara Briden:

Yeah, me too.

Dr Nirala Jacobi:

I will say that. I'm not just willy nilly, everybody take 10 different strains just for the heck of it. It's really about are you constipated? Are you bloated? Do you have visceral hypersensitivity? What are your symptoms? And this is what we provide or what we then target. And so in terms of inflammation however, I would be thinking definitely Lactobacillus rhamnosus. If we're thinking healing leaky gut, there are a few that are really involved or have been researched with intestinal permeability and rhamnosus looks really good. Lactobacillus paracasei I think is another, possibly Saccharomyces boulardii. I mean, when somebody has antibiotics, I will give them a multi-strain probiotic to ... Because we know this, that if you take 20 billion organism or a colony forming units of lactobacillus, you are somewhat protected from some of the damage that antibiotics exert. So you just have to follow the research.

Dr Lara Briden:

Yeah. Although to be fair, there was a bit of research suggesting the opposite, which I don't have it in front of me, but it was probably [crosstalk 00:27:11].

Dr Nirala Jacobi:

Yeah, is there always both sides?

Dr Lara Briden:

Yeah.

Dr Nirala Jacobi:

I remember that. It sort of refuted some of that, but I can say clinically that that does work. And for me, having done this for a long time, I do find that I rely more and more on my clinical outcomes rather than if a study says I've been doing it wrong all these years and yet I have good clinical outcomes.

Dr Lara Briden:

Well, that's tiny bit saying I've been doing it wrong. It would certainly give me pause. I feel like I'm interviewing you now, but I just want to ask about the strain Bacillus coagulans. Do you use that very much or do you have any insight into that? Because I know it can reduce LPS and reduce endotoxemia and-

Dr Nirala Jacobi:

Right. So what I'm waiting for, yes, I do use it. And you're talking about megaspore?

Dr Lara Briden:

Yeah.

Dr Nirala Jacobi:

So I do and I was very resistant for a long time because a lot of the studies were in-house studies. They were just generated by the company, which obviously always raises suspicion. But then reluctantly I started to use it and I used it for people that had multiple food sensitivities and they just could not tolerate any strain of probiotic I gave them, which often means there is a mucosal level of irritation and I wanted to see if their claims were really going to be born out in my patients. And I have to say that so far it works fairly well for people that are quite sensitive.

Dr Nirala Jacobi:

So I do sometimes use it for histamine intolerance particularly with salicylate intolerance, salicylate sensitivity. And I use it one every other day and it seems to be helpful, but it's not my only go to. But this company also makes something called these bovine immunoglobulins that I'm quite impressed with in terms of leaky gut and reactivity. So I do find that together they also work pretty well. Some of the other products that this company makes I'm unimpressed with, but so far these two really do deserve some accolades I think.

Dr Lara Briden:

So is that a colostrum type of-

Dr Nirala Jacobi:

It's not a colostrum, it's a bovine serum immunoglobulin.

Dr Lara Briden:

Oh, right. Okay.

Dr Nirala Jacobi:

Serum derived, and it used to be an IV application and it still is in some gastroenterology circles, but it is now also an oral supplementation. And I found that to be really helpful. I was actually going to ask you about bovine immunoglobulins for endometriosis. If it's really an inflammatory and immune dysfunction, that could be really helpful, I think.

Dr Lara Briden:

It is. Well, this is why I'm asking you all these questions about this kind of stuff. So yes, potentially probiotics or immunoglobulins are going to play a role. I mean, I've been using Bacillus coagulans a little bit. Certainly I've done the rhamnosus GG, that strain for endometriosis. With probiotics as you know it, the landscape is changing all the time and such different information. But I've been doing courses of different ones and I'm with you. I like to use single strain to try to get a result.

Dr Nirala Jacobi:

And they're hard to find sometimes because a lot of the research strains, like the research strain for hydrogen sulfide is Lp-8, Lactobacillus plantarum 8. And that's just not ... you can't find that. So we have to use 299V which is not the same strain, but we just hope that it's similar enough to have some effect for those types of conditions. So yeah, there's still a lot to ... And histamine is just forever more fascinating for me. And I've done a lot of research and a lot of presentations on histamine intolerance and I really do think this might be also a connection. I'm fascinated with its connection to endometriosis.

Dr Lara Briden:

Oh yeah. Well, and also just to loop back to talking about estrogen dominance, that phrase, which as I said, I don't use, I don't really like, but I think a lot of the time when people are describing their experience of estrogen dominance, whether it's pre-ovulatory or pre-menstrual or perimenopausal, a lot of what they're experiencing, like the fluid retention, the rashes, the headaches, that's histamine because estrogen stimulates mast cells. And at the same time, histamine stimulates estrogen release. So you get this feed forward amplification of histamine, estrogen, histamine, estrogen and can feel really awful and quite overstimulating and breast tenderness and irritability and the whole thing. That's a histamine picture.

Dr Nirala Jacobi:

And of course that begs the question, if it releases histamines we know that there are over 200 other mediators that mast cells release including heparin, right?

Dr Lara Briden:

Yes.

Dr Nirala Jacobi:

I mean, yeah, it's an endlessly fascinating conversation.

Dr Lara Briden:

Let's just stop there for a second about the heparin because, yes, I just figured that out a few years ago. The uterine lining is full of mast cells. So I would say yes, back to our topic of endometriosis has mast cells as well. But just on the topic of the actual uterine lining for a minute and heavy periods and the heavy flow of say perimenopause, there's a couple of reasons for that. Well, the heavy flow of perimenopause is first and foremost due to anovulatory cycles and losing progesterone. But secondarily mast cell activation in the uterine lining, yes, releases heparin, which is a blood thinner.

Dr Nirala Jacobi:

Right.

Dr Lara Briden:

Yes. And this is why clinically ... This goes back to what you were saying, it's always sort of nice after you've been doing something clinically for decades to figure out, oh, that's why that works. But this is why stopping dairy, because I think dairy is a pretty big mast cell release kind of histamine activator. Not in everyone, but I think in some people casein is pretty monstrous for that. So my experience has been for many women, stopping dairy lightens periods quite dramatically. And also things like turmeric or curcumin, which can stabilize mast cells lightens periods, also partly from reducing prostaglandins. But yeah, it kind of makes sense to me now that those things work. And there's this, I don't know if you've spoken to her, but Tania Dempsey, she's a gynecologist. She's just a GP in the States, has coauthored a paper on dysfunctional uterine bleeding And mast cell activation. And they were doing things like vaginal pessaries of antihistamines and things like that, which is pretty interesting to try to slow the bleeding. But anyway, yeah.

Dr Nirala Jacobi:

Yeah, I think that mast cells are going to be ... or that whole aspect of mast cell migration into different mucosal tissues is going to be quite fruitful in terms of therapeutic applications because we definitely, we see that. I mean, that is one reason why SIBO has histamine intolerance besides the microvilli. But we do see mass cell migration into the lamina propria of the small intestine. So I guess anytime that you have an irritated mucosal surface, it makes sense that mast cells would migrate to help flush out the irritating offender also. But also your comment about casein what they also found, they have finally found an IgG receptor on mast cells. IgG food allergies are back in the discussion room in terms of possibly contributing to mast cell degranulation. We always thought of IgE, right?

Dr Lara Briden:

Yeah.

Dr Nirala Jacobi:

We just thought that IgE is associated with histamine release, but now we really are validating these types of food sensitivities potentially that could definitely be also tied to endometriosis. Oh my God, it feels like we're just getting started.

Dr Lara Briden:

I know, just scratching the surface. To be fair, the research is a work in progress. So one of the big problems with endometriosis we can kind of finish with this is the lack of research. And that's a more of a political thing. The fact that it's a women's disease just meant that it just has not received the attention that it should have. I mean, yes it's been researched but I feel like there's so much more to learn and understand and not get locked into one paradigm. They were locked in this paradigm of retrograde menstruation, cut it out kind of thing.

Dr Lara Briden:

The disease was first described by surgeons. So of course the focus was always on the presence of the lesions and how to slice those out, which I'm not against removing them but that can cause adhesions and other things. I guess if the disease had first been described by immunologists, maybe it would be quite a different conversation about this disease. It's like that old analogy of all the blind people looking at an elephant in a room, so one person is describing this. So it's a disease we can come at from different angles. With everything but especially with endometriosis, I am constantly open to new ideas, new angles into this because, yeah, I wouldn't say ... I mean, I have described some treatments for you. We didn't actually go into my full protocols, but those are on my blog and in my book. And those are still a work in progress. I would be quite happy to have some new treatment come on board for this disease because it's ...

Dr Nirala Jacobi:

Well, it just seems like you've mentioned so many underlying drivers that are common to SIBO and are common to other inflammatory conditions. So it does always comes back to what do we know about mucosal immunity? What do we know about microbiome interfacing with that mucosal immunity? What about dysbiosis? What about all these different factors that all of us are finding are central to our respective specialties in a way. It's really fascinating to me. And yeah, so where can people actually find you and the book and all of that and just bear in mind, it's also in the show notes. So all of your contact details will be found in the show notes.

Dr Lara Briden:

Thank you. Yeah, my book is Period Repair Manual and it's online, it's on Kindle, it could be in your local bookshop. It's published by Pan Macmillan. It's out there. And on Amazon of course. And then my blog is larabriden.com and all of my social media is @LaraBriden. I'm very easy to find, it's just my name.

Dr Nirala Jacobi:

Are you still seeing patients or?

Dr Lara Briden:

I'm seeing patients one day a week in my Christ church consulting rooms now.

Dr Nirala Jacobi:

Right. So you have fled the continent twice.

Dr Lara Briden:

Well, I have, but to be fair I'm still very connected to Australia. I was saying to you earlier, I'm coming there a couple of times this year.

Dr Nirala Jacobi:

Great, wonderful.

Dr Lara Briden:

I was in Australia for almost ... Well, not almost, for 20 years and a lot of my naturopathic community is there and yeah, so I still feel very connected.

Dr Nirala Jacobi:

Well, this has been so stimulating and I have a lot of new thoughts. I definitely want to start thinking about nickel more. I want to investigate that. So we'll have those research studies for you in the show notes, I'm hoping. And thank you so much for your time and for your wisdom and your insight into endometriosis. I'm sure people are going to find this super useful, so thanks so much for your time.

Dr Lara Briden:

Thank you for having me.

Speaker 3:

Thank you for listening to the SIBO Doctor Podcast. We hope you found the information in this episode useful in the treatment of your SIBO patients. Thanks to our sponsors, sibotest.com a breath testing service with easy online ordering and Quin Tron maker of outstanding breath testing equipment. Tune in again for another episode of the SIBO Doctor Podcast. Thanks again for listening.