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We’re back with Part 4 of the Endo Uncovered series, and this one is all about surgery. How to think about it, how to prepare for it, and what Rachel wishes more women knew before going in.
Erin and Rachel are talking through some of the biggest questions that come up when someone is considering endometriosis surgery: How do you choose a surgeon? What’s the difference between excision and ablation? Is a hysterectomy really a cure for endometriosis?
Rachel shares about her own endometriosis surgery process, why excision is considered the gold standard, hysterectomy nuance, and exactly how she prepared her own body before surgery, from reducing alcohol and prioritizing protein to increasing iron-rich foods, vitamin C, omega-3s, pelvic floor PT, strength training, walking, and strategic supplementation.
If you are considering endometriosis surgery, preparing for surgery, recovering from surgery, or trying to understand what questions to ask, this conversation will help you feel more informed and grounded.
In this episode:
How your surgeon’s training and experience can influence recovery, outcomes, and recurrence risk
The vitamin C-rich foods, omega-3s, ginger, turmeric, and liver-supportive options Rachel used before and after surgery
The key difference between excision and ablation surgery
Why Rachel significantly reduced alcohol before her surgery
What’s coming next in the Endo Uncovered series: the MCAS, histamine, and endometriosis connection
Resources mentioned:
Manifest Your Health is the neuroscience-backed membership that helps you regulate your nervous system, integrate the parts of you that keep you stuck, and become the version of yourself your body can actually heal as.
Listen to Part 1, Part 2, and Part 3 of the Endo Uncovered series.
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Apply for 1:1 Endometriosis Support here if you’re navigating painful periods, suspected or diagnosed endometriosis, gut symptoms, hormone issues, or inflammation.
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Rachel:
I think the most important thing, whether it's having a hysterectomy or not, is understanding the reasoning for this recommendation. If a surgeon tells you that a hysterectomy will cure your endometriosis or keep it from ever coming back, that's not accurate information and it's not an appropriate reason to have the surgery. A lot of people think that having a hysterectomy will cure endo, but that's a little bit of a myth. Endometriosis is when tissue grows outside of the uterus, not inside of it. So removing the uterus doesn't remove the endometriosis. It can remove your monthly periods, it can absolutely help with some of that pain as well. But the disease process and the disease itself absolutely is still there.
Welcome to The Funk’tional Nutrition Podcast, spelled with a K because we do things a little differently around here. I'm your host, Erin Holt, and I've got 15 years of clinical experience as a functional nutritionist and mindset coach, creating a new model that I call Intuitive Functional Medicine™, where we combine root cause medicine with the innate intelligence of your body. This is where science meets self-trust. Your body already knows how to heal, and this show is going to show you how. If you're looking for new ways of thinking about your health, be sure to follow and share with a friend because you never know whose life you might change.
Erin:
All right, guys, welcome back. This is part 4 of our endometriosis series, so make sure you go back and listen to our last 3 episodes for the full story. In part 1, we talked about when to suspect endometriosis, what signs and symptoms to be looking for. In part 2, Rachel shared her whole story with endo, including her own health and period issues, her history with birth control use, her functional medicine approaches, and all of the things that led up to her endo diagnosis and her recent surgery. In part 3, we talked about what to do if you've been diagnosed with endo and how we approach our endometriosis clients in our practice. So be sure to go back to listen to 1, 2, and 3. Today we're going to be discussing a few different things. One, we're going to talk about things to consider when looking for an endometriosis surgeon.
Rachel just went through this whole thing, so she wanted to share it here live and direct, give you some pro tips. Number 2 is the difference between ablation and excision. Number 3 are strategies that will help prepare your body for surgery. And I do want to say that the stuff we're going to outline here, a lot of what we'll share will be effective ways to prepare your body for any type of surgery, not just endosurgery. So you might want to give this a listen. Anyway, so again, Rachel has firsthand experience with all of this, and she just went through the whole process. And you can go back to part 2 to listen to her entire story, including how she found her surgeon. But Rachel, I'm going to let you take it over from here since this is your wheelhouse.
Rachel:
So choosing a surgeon to perform surgery is really one of the most important decisions you can make on your endo journey. Your surgeon's experience and training can play a really big role in your recovery, your outcome, and your risk of recurrence. And consulting with a true excision specialist can help you discern if your symptoms are likely endo or not. Most surgeons, but not all of them, can identify irregularities on imaging or on a physical exam to help discern if surgery is warranted. And a majority of endometriosis cases, they go undiagnosed on routine ultrasounds and MRIs. But many of those endo specialists, they actually have the skills to perform transvaginal ultrasounds in the office. We've mentioned this before, but my surgeon, Dr. Cameron Najat, is able to identify endo on imaging.
He'll point it out to you on your exam, which I think is such a big deal. If you are considering getting surgery, you're like, do I even need to get opened up to find out if I have this or not? And so something to really be considering when you're looking into a surgeon is if they perform excision or ablation. The gold standard for endometriosis surgery is excision, and you want to see a surgeon who specializes in this technique. And an analogy that I heard is we want to think about endometriosis like a weed. We want to rip it out at the roots. We want to excise it rather than just shaving it off, which is what the ablation is. You're just kind of like shaving.
Erin:
So excision is ripping it out at the roots and ablation would be like shaving it.
Rachel:
Exactly. So when you move forwards with ablation and endo is only destroyed on the surface, the recurrence rate is higher compared to excision. Because excision results in a more complete removal. If the endo is actually removed more comprehensively, you're going to have better recovery, whereas if tissue's left behind, there's a likelihood things are going to, a higher likelihood things may grow back.
Erin:
So with ablation surgery, are people more likely to have to go back and get it done repeatedly?
Rachel:
Yes, from my understanding and the research.
Erin:
And then what about excision surgery? If somebody has that, is that like a one and done, or does sometimes It still grows back with that.
Rachel:
It still can grow back with excision surgery. Nothing is 100% a guarantee. However, with excision surgery, there is— research does show there's longer-term pain control. There's a reduced rate of recurrence with excision versus ablation.
Erin:
Okay. So when you were going in for yours, you were like, I definitely want to do excision based off of all of the research. Got it. Okay, cool. Cut it all out of me.
Rachel:
Yeah. So we're also looking for someone who isn't a general OB-GYN. OB-GYNs are amazing, but they only complete a handful of excision surgeries each year. They may not be able to identify all of the different ways that endo can present in the body. They might not know everywhere that it might be. Like, I had endo on my diaphragm, and is an OB-GYN going to be looking at your diaphragm when they're opening you up? Maybe, maybe not. Many endo experts and excision specialists do believe that having your surgery performed by a general OB-GYN Gyn can be more harmful than helpful as well.
Erin:
What would you be like Googling to find a surgeon?
Rachel:
You'd really want to be checking in to see, have they completed fellowship training or certification in gynecologic surgery? There's a MIGS fellowship that they can do. It's minimally invasive gynecologic surgery, or MIGS fellowship that they can do. And this is a program after residency where surgeons learn techniques involved in complex surgeries like endo. This is a quote from my surgeon directly. He specifically says, endometriosis surgery at times could be far more difficult than any cancer surgery. And this is because in many cases it involves many organs and delicate structures in women who are trying to preserve their fertility. So it's not just like, let's rip out all these organs. Let's try to preserve the ovaries and the fallopian tubes if we can, especially because, you know, a lot of women go through this process to optimize their fertility.
So the more experienced your surgeon is in doing the endometriosis surgery, the more likely it is that the disease is going to be fully recognized, identified, removed, and appropriately treated as well.
Erin:
How common are these surgeons? I don't think that's the right way that I'm trying to say it. But like, I know you were so lucky because Najat is close to where you are located in Northern California. But like, across the US, for example, like, how likely are people to find surgeons that excel in or have this like MIG certification or whatever?
Rachel:
I wish that there was a perfect database to find this. It is really challenging, and that's what a lot of women struggle with, especially in more rural areas. I'm in like an endo support Facebook group, and there are some women who are like in Kentucky, and they're like, I need help finding a surgeon. I know I need to travel, basically. So, you know, Najat would be kind of the Northern California excision specialist expert. There are a few in Southern California. There are definitely a few on the East Coast that, you know, I've referred out to and encouraged patients to seek out. There are a couple of different resources out there.
One is called Nancy's Nook. It's a Facebook group, actually. It's kind of like a support group for women with endometriosis. This is a newer resource. I can't say— I can't like vouch for these resources and say that I've used them, but another one is WULF Women, spelled W-U-L-F Women, and she is working to compile a database of surgeons that are endo experts. And then in this database that she's putting together, she's including, are they MIGS-certified, specialized, trained, things like that as well.
Erin:
Thank you for sharing all of that. And I probably should have led with this, but just to be clear, nothing that we're saying here is medical advice, and we're not experts ourselves. We're functional medicine practitioners that support clients with endometriosis from a functional medicine, nutrition, lifestyle perspective. But obviously, this is outside of our zone of genius. But Rachel was kind of like on her own figuring all of this stuff out. And she just learned so much for herself that she was like, we have to like talk about this on the podcast so I can share everything that I learned. So truly just like sharing Rachel's experience. But obviously, we don't want to present ourselves as like endometriosis surgeon specialists— not specialists, but experts.
More so just sharing information to help you guys as much as we can.
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Erin:
Let's talk about hysterectomies. Can you just take a quick moment to touch on this? Since we do see a fair amount of women come to our practice who have been told that the only way to manage their symptoms or their pain is with a hysterectomy?
Rachel:
I think the most important thing, whether it's having a hysterectomy or not, is understanding the reasoning for this recommendation. If a surgeon tells you that a hysterectomy will cure your endometriosis or keep it from ever coming back, that's not accurate information, and it's not an appropriate reason to have the surgery. A lot of people think that having a hysterectomy will cure endo, but That's a little bit of a myth. Endometriosis is when tissue grows outside of the uterus, not inside of it. So removing the uterus doesn't remove the endometriosis. It can remove your monthly periods. It can absolutely help with some of that pain as well, but the disease process and the disease itself absolutely is still there. If adenomyosis is present, then the uterus absolutely can be a source of pain, and a hysterectomy would provide symptom relief.
And in that case, a hysterectomy could be presented as a way to reduce pelvic pain. Adenomyosis is when endometriosis-like tissue basically grows into the muscles of the uterus as well.
Erin:
And, you know, I've certainly talked to enough women in my day who have had full hysterectomies for this and was like, it was the best decision of my life. And it like really, really helped. We have no skin in the game here. We're just presenting information so you have options, kind of like informed consent. The more information you have, the better. It's kind of our hot take on that. Okay, so let's say somebody does find a surgeon and they're like, really, they're ready to go, they're scheduled for surgery, how should they prepare for it for the best outcome?
Rachel:
So one of the hardest parts about preparing for surgery was how much fell out of my control. Focusing on the small things that I could do to support my body helped me feel more prepared and more calm during— I had like a 2-month waiting period between when I scheduled and went in for the procedure. So it felt empowering in that sense too.
Erin:
So you weren't like just like a sitting duck, just like waiting for something to happen? Are you Curious, do you consider yourself like kind of like a control freak or somebody with control issues?
Rachel:
Ish. My husband would tell you that I'm more controlling in our relationship, but it probably depends on the situation. It's 50/50, I guess.
Erin:
Do you know what Scott just said to me last week? He's like, you're kind of a control freak. I'm like, we've been together for 15 years. This isn't exactly like hot off the press intel. Like, no shit. I really feel as though a lot of people can relate to this. I think with health issues, especially when you've been dealing with health issues for a while, I think like weird control stuff can kind of like percolate. What specifically felt out of control? Like something was happening to you that you like had no like control over?
Rachel:
Yes, to a certain extent. Like when I met with my surgeon, I was informed during surgery, they might remove my appendix if it was affected, they might not.
Erin:
So you were like going in being like, I don't know what they're gonna take out of me.
Rachel:
Exactly. I don't even know.
Erin:
Wow.
Rachel:
Yeah. And again, you know, my surgeon was absolutely able to identify endo on imaging. He was like, oh, it's pretty severe, pretty bad. His PA or his co-surgeon told me, yeah, we're likely dealing with stage 3, stage 4. But again, they're not gonna officially know till they get in there. You don't know where it's going to be. It was recommended that I get an MRI prior to surgery to help set expectations, but again, it's not perfect in identifying endo. And I looked into the process, and basically my surgeon had recommended that I only get an MRI at 2 specific locations because only 2 specific radiologists near us are certified to even identify the endo on imaging. And long story short, I couldn't move forwards with it because the MRI, the soonest they had available, was like 2 days before my surgery or something, you know?
Erin:
Oh.
Rachel:
So I was like, okay, like, we'll just wait and see. what they see when they get in there as well. So it was like a lot of unknowns, a lot of uncertainty, like the most stressful thing ever. I mean, just uncertainty in general. Yeah.
And I, of course, binged tons of endo content on social media. And I do think it was really helpful. And it did help me prepare. And you definitely see women sharing more about not the bad side of recovery, but like, oh, wow, I'm like 3 weeks post-op and still like so exhausted and like not back to work yet and just not thriving. And everyone's healing journey is so, so different. I want to clarify that. But then you had some people being like, yeah, I was feeling good like 3 days post-op. So you just don't, you don't know, right?
Erin:
Yeah, I will just, I mean, you can speak more to your post-op experience. You did 2 episodes ago a little bit, but I was really surprised how like up and at 'em you were. I mean, we were like on a meeting. I'm like, can you fucking lay down, dude? Like, you know, you were just, I know I know it was uncomfortable and like you couldn't work out for a while, but I was, I guess I'm giving you like a pat on the back because I think the way that you approached, you know, and supported yourself like really set you up for success post-op. So can you talk to us a little bit about specific strategies that you used before your surgery?
Rachel:
Definitely. So from a nutrition perspective, we mentioned this in our last week podcast episode as well, but I recommend significantly reducing or eliminating alcohol prior to surgery. Endo is an estrogen-dependent condition, and alcohol intake can raise estrogen levels. Alcohol is a toxin. Your liver is going to have a lot more burden on it during surgery season. There's the anesthesia, the post-op meds. Your surgeon might recommend birth control. And if you reduce your alcohol, there's less liver burden.
We were at the IFM conference, I think the month before my surgery, and there's some—
Erin:
Yeah, I'm like, let's go out for drinks. Woo!
Rachel:
You're like, mocktails for me. So you—
Erin:
I can, I can vouch for her. She really upheld this. She's not telling you to do anything she wasn't willing to do herself.
Rachel:
This one was harder when we were at the conference, but I did pack like protein bars in my bag and things like that. But protein, 2 grams per kilogram of body weight pre and post-op. Protein is trending right now. Everyone's protein maxing, but this is actual medical nutrition therapy. 2 grams per kilogram of your body weight does help to support tissue repair post-op. The incisions themselves with excision surgery Or laparoscopic surgery are small, but there's a ton of internal incisions. I had 27 little things removed from me. So even though I only had 4 visible incisions on my abdomen, there's a lot more healing that needs to be done.
And high protein intake prior to surgery can help to promote muscle growth and can hopefully help to reduce some of that muscle loss post-op. I accomplished this with a combination of food and supplemental protein powder because I think I was Trying to hit like 150-something, 160-plus grams a day. Fish, meat, eggs, beans, hemp seeds sprinkled over soups and salads, bars. I love a quick protein powder. And then bone broth, like if we were making rice or grains, I would cook it in bone broth instead of regular broth. And then I also used bone broth post-op because I had to remain on like a liquid soft foods diet for a week. I was like, okay, I at least need to get in a little bit more protein, or try to at least. My big disclaimer, I tell my clients this all the time, is that 2 eggs is not enough protein for breakfast.
It's 12 grams of protein.
Erin:
It's not, I know. And can I tell you, I've been like, this is like, this is a pep talk that I needed right now because I have not been prioritizing protein much. I've been kind of like definitely undereating protein a little bit, like out of like laziness, just like not taking the time to defrost. You know how it goes. And I can like notice my muscles getting smaller. Like, I really can. Like, I was like ripped, like, you know, a few months ago. And I'm like, just the summer and whatever, I just haven't been— I'm like, I need to eat more protein.
So even if you're not getting surgery, still eat your protein.
Rachel:
There is some research that suggests that if your exercise stays the same, your calories stay the same, but you shift to a more protein-forward diet, like protein makes up a greater percentage of your caloric intake, you can see positive body composition changes and increase muscle mass without changing your workouts, without changing your calories. So it's really cool.
Erin:
Eat your protein.
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Erin:
All right, what else other than protein?
Rachel:
Iron. We don't know what blood loss is going to look like during the surgery or post-op. I bled for like 3 to 4 weeks. Post-op. Pre-op anemia does increase surgical risk. Iron is involved in transporting oxygen to your tissues, so we want to make sure your tissues get enough oxygenation so you can recover well, you can heal well. Iron-rich foods pre-surgery that I leaned into: red meats, animal proteins, organ meats, shellfish. And then I did incorporate some of those plant-based foods too, like the leafy greens and legumes.
I just made an effort to pair them with vitamin C to enhance absorption.
Erin:
And we've talked about anti-inflammatory nutrition a bunch, but it's kind of a big deal post-op, or like around any type of operation or surgery, because it's kind of an inflammatory process, like going to kick up inflammation. So is there anything specific you did to reduce inflammation?
Rachel:
I tried to eat more of those vitamin C rich foods. I mean, I'm doing this all the time, but it was like an extra concerted effort. Vitamin C is involved in wound healing. It's a cofactor to help your body produce collagen. So I ate more strawberries, broccoli, and citrus fruits. Fish I ate twice a week for omega-3s, and then chia seeds, hemp seeds, flax seeds, walnuts. I tried to eat more of those during this season. Ginger and turmeric too, I would add it to smoothies.
Sometimes I would make like homemade shots. And then we were at the IFM conference, and that company Dose, they had like the turmeric liver shots. I bought a big bottle. I think I actually started it post-op, but your liver also needs support post-op too.
Erin:
Yeah, those are good. They're really good.
Rachel:
They're kind of expensive, but—
Erin:
Wicked expensive. But for a situation like this, I feel like worth it. Where do you get your fish, out of curiosity?
Rachel:
I get mine from a combination of Sprouts, the grocery store, or the farmer's market.
Erin:
It's like it has a decent fish market at your grocery store. I feel like fish can be like sometimes hard to find, especially if you're not right by the sea.
Rachel:
I know. I'm in California though, so.
Erin:
Yeah, you're right by the sea. Okay. I mean, I'm in New Hampshire. I'm really close to the sea too. What about supplements?
Rachel:
So big, big disclaimer, you really need to run all of the supplements you're on by your surgeon. Don't just take our advice from this podcast. Your surgeon will advise you on when to stop them prior to surgery. Before surgery, I did start a prenatal and a fish oil. I had 2 months to prep. I just wanted to fill in any nutrient gaps. I mean, an argument could be made to take zinc for immune system support and extra B vitamins for the red blood cell, and I was like, okay, There's— I can only eat so much. And so I got on the prenatal, got on my fish oil.
I stopped this like 10-ish days prior to surgery. I was taking my NAC consistently, and there's so much research regarding NAC. I also stopped this pre-op. And then after surgery, I brought in phosphatidylcholine, the one from Quicksilver Scientific. I loved it. It's really good for cell membrane support, liver support. It helps to support the healthy consistency and thickness of your bile. And it was crazy, I would take this and within a few minutes I was like, My vision is clearer.
It was weird. I'm like, but I was— I also had taken so many medications too. I can see.
Erin:
Is it liquid? Do you take it?
Rachel:
Yeah, yeah, it's liposomal, so you hold it under your tongue. I mean, it's rapidly absorbed in your system, and I think it— that's why it rapidly affected me. So that was motivating to continue with that. I did a bottle of that. I added collagen to my coffee just to like, you know, bump up my amino intake and wound healing support. I took electrolytes for hydration. And then a few weeks post-op, I just got back on my normal supplement stack and I added in CoQ10 because I wanted to give my mitochondria eggs a little bit of extra support too.
Erin:
Can you be so for real with me? When you add collagen to coffee, do you taste it?
Rachel:
I use creamer in my coffee, so you don't taste it. Yeah, I like—
Erin:
I can't—
Rachel:
I try to sneak it. My husband jokes that I'm always adding like potions stuff to his food. I tried to add it to his coffee without saying anything. And he likes his coffee black. So he can tell he doesn't like it.
Erin:
Okay.
All right. What about physical medicine that you did? Or like anything like movement or like moving and shaking outside of like putting things into your mouth?
Rachel:
I highly, highly recommend pelvic floor PT prior to surgery. So chronic pelvic pain can cause the muscles to stay in high alert. And working on your pelvic floor prior to surgery also just helps to support that, like, tissue awareness, brain-pelvic floor connection, reducing some of that tension before incisions are introduced. If you can't get in to see pelvic floor PT, if it's not in the budget, even doing diaphragmatic breathing prior to surgery can be so, so helpful as well. In terms of strength training, if you're able to, I highly recommend it. We want good muscle mass prior to surgery. Building muscle helps your body handle the stress of the operation, it speeds up your recovery, and then your body will Probably be breaking down some muscle just to fuel that healing and repair that tissue. So the more muscle you have prior to surgery, it means a safer reserve.
And this is my personal experience, but one of my recommendations, if you're getting laparoscopic surgery, you're not recommended to use your core and you're not supposed to use your core for a while after surgery. And I am so thankful that my arms were strong post-op because it kind of hurts to scoot. You can't like— You don't realize how much you use your core for everything. And we have like a— our couch has like a chaise lounge. And so I was tucked in the back of this corner, but it like hurt to scoot. My husband tried to pull me. I'm like, this hurts too much. I just basically would use my arms to like— he would brace his arms and I would pull myself up off of it.
Or I would like basically day 2, day 3 and on, I would do like tricep pushups or tricep, whatever they're called, to like get myself off of the bed. And we were like, wow, I'm so strong. So that—
Erin:
All that Pilates is paying off.
Rachel:
I guess so. I will say I did Pilates and I did like barre arms at home, and I made a concerted effort to do more upper body prior to surgery as well. In terms of working out too, I would recommend avoiding high-intensity workouts or lifts immediately prior to your surgery. We don't want to increase the amount of inflammatory cytokines in circulation. I'm talking like a day or two pre-op. It's fine if you want to do it before then. And then I'm a big fan of walking as well, just to support circulation and to support blood flow as well. And that's a wrap for this episode.
Erin:
Make sure you tune in to our next episode where we'll be chatting about the MCAS histamine endometriosis connection. Everyone's going to be so excited for that one. All right, thanks, Rachel.
Rachel:
Thank you.
Thanks for joining me for this episode of the Funk’tional Nutrition Podcast. Please keep in mind, this podcast is created for educational purposes only and should never be used as a replacement for medical diagnosis or treatment. If you got something from today's show, don't forget, subscribe, leave a review, share with a friend, and keep coming back for more. Take care of you. Bye.