We sat down with Joel Evans, MD to talk about Functional Medicine options for common women’s health issues. This is the first in a series.
Before we get started, can you tell me about your background? My background really is one of a conventionally trained OB-GYN. As I became interested in helping my patients in every way I could, it became clear to me that all I was trained in simply wasn’t enough.
The best example of this was a 26-year-old woman who I had the misfortune of diagnosing with breast cancer. She asked: Does it matter what I eat? The answer I gave was, “I don’t know; ask your oncologist.”
Her oncologist was very well known, trained at Harvard, and the answer came back: “It doesn’t matter what you eat.”
She asked me if I believed that, and I said, “Let’s find out for sure. Let’s have you meet with a nutritionist.”
She met with a nutritionist, who said you must avoid all sugar; sugar goes directly to cancer cells. I went to the medical library to do some research on sugar and cancer. I was shocked to discover that there were over 10,000 papers on cancer and sugar!
It was at that point that I realized that there’s more to taking care of people than is taught in medical school. That’s when I learned about Functional Medicine and met Jeff Bland and started speaking for Metagenics way, way back in 2002 or 2003.
What kinds of patients do you typically see? I see patients that I’ve seen forever as an OB-GYN who come to me for GYN care. Then I see patients that come to me because they want a Functional Medicine doctor. I also see the most complicated issues that are referred to me by my colleagues and healthcare practitioners that have been through IFM that know that I have a level of expertise that justifies the referral.
The patients you said you’ve seen forever, do you help guide them into the Functional Medicine realm? Or are they just there for their usual visits? I always try to guide them into the Functional Medicine realm. When I do their routine blood work, it is far more expansive than that ordered by a traditional doctor. I look for the subtleties in thyroid function. I look for subtleties in adrenal function. I ask probing questions like, How’s your mood? How’s your energy? How are you sleeping?
By asking those broader questions about issues that most OB-GYNs don’t inquire, I can then target the blood work to address them. When I go over the results, my patients are getting Functional Medicine care without knowing the term.
Are they open to that? Most are open to that. There are very few, maybe 2 or 3% that aren’t. The vast majority are, which is why they refer their friends and relatives to see me. I’m able to help them in all areas of their health.
How would treatment for fibroids and endometriosis differ from traditional medicine to lifestyle medicine? For example, what tests do you use, and can you manage these conditions with lifestyle adjustments?This is a big question to answer! The treatments in conventional medicine for fibroids and endometriosis are treatments that most patients don’t want. If fibroids are diagnosed during a routine exam, and there are no symptoms, the conventional treatment is to do nothing. Most patients aren’t happy with that. From a Functional Medicine perspective, there are a lot of things that we can do to prevent them from growing and becoming symptomatic.
Rarely do you find endometriosis without symptoms other than if you’re doing a pelvic exam and you feel a cyst, get an ultrasound on the cyst, and find out that it has qualities that are consistent with endometriosis. In that case, the only conventional interventions are birth control pills or surgery to get that cyst removed and see if there are other endometriosis lesions in the pelvis, where they can be destroyed with laser or electrocautery.
If patients have symptoms of fibroids, it can be a feeling of fullness, it can be abnormal bleeding, or it can be pelvic pain. There really are no long-lasting conventional treatments for fibroids other than some type of surgical procedure done by radiologists where they block the blood flow to the uterus or block the blood flow to the fibroids and the fibroids shrink.
What I do, the Functional Medicine approach, is totally different. I looked at the underlying driver of fibroid and endometriosis growth, and that has to do with estrogen. The Functional Medicine approach ensures there is not too much estrogen coming into, or being produced, by the body and that estrogen is being eliminated properly.
What are the sources of estrogen entering the body?It can be from foreign substances, so we can be taking chemicals in, compounds that become or behave like estrogen—those are called xeno-estrogens—that’s why eating organic is so important. We can also be drinking estrogen from our water. They have found estrogens from medications in the water.
The other way we can have too much estrogen is that we can be producing too much. For example, we can make too much estrogen through an ovarian cyst. Visceral adipose tissue produces estrogen. In addition, we know the enzyme that makes estrogen, aromatase, is actually inside of endometriosis tissue and inside uterine fibroids. Anything that stimulates aromatase will produce more estrogen. Two direct stimulators of aromatase are insulin and inflammatory prostaglandins. Therefore, the Functional Medicine approach includes normalizing insulin levels and reducing inflammation.
Another thing to do is look at how the gut functions. If there are unhealthy bacteria in the microbiome, they can produce an enzyme called beta-glucuronidase that leads to reabsorption of estrogen from the intestine. We have to make sure that we move our bowels regularly, because if there’s constipation, that leads to increased estrogen absorption.
We also have to make sure our liver is functioning well, that our cytochrome P450 detoxification enzymes are functioning well because estrogen is eliminated through those pathways.
You have a special interest in hereditary breast and ovarian cancer. What kind of risk assessment and prevention tools do you use with your patients?There are standard questions that are put out by National Cancer Institute and the National Institute of Health that we use to find out if patients are at increased risk for BRCA.
Then there are other questions that we ask. Dense breasts put a woman at increased risk for breast cancer. I also look at risk factors for other hereditary cancer syndromes, such as Lynch syndrome, where women are at increased risk of colon and gynecologic cancer. I also look for other, nongenetic reasons patients might be at increased risk for breast cancer, like being overweight, having increased adipose tissue, elevated insulin levels, or even being under stress.
I then also do a test called BREVAGen™, which can give patients a five-year risk analysis of breast cancer. That’s what’s called a genomewide association study. By looking at the gene frequency of approximately 77 genes, they can come up with a very accurate five-year risk of breast cancer. That means they are candidates for risk reduction medications in addition to a thorough Functional Medicine breast cancer risk reduction protocol.
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