Wednesday, March 20, 2024



In the spirit and support of Endometriosis Awareness Month (March 2024), the Women's Health Collaborative proudly introduces the remarkable work and generous report of BARBARA BARTLIK, MD (NYC). Our editors met with Dr. Bartlik, a NYC colleague of the IHRC (Integrative Health Research Center), led by our own imaging diagnostic director Dr. Robert Bard. Dr. Bartlik is a psychiatrist, sex therapist, and integrative medicine specialist in Manhattan who has over three decades of experience in clinical practice. She uses mainstream medications, psychotherapy, cutting-edge technologies, and natural therapies, such as dietary modification, detoxification, and supplementation with vitamins, minerals, botanicals and essential fatty acids. Whether the problem is psychiatric (ADHD, anxiety, bipolar disorder, depression, OCD, PTSD, schizophrenia) or medical (autoimmune issues, dementia, fatigue, hormonal-related problems, insomnia, pain, sexual dysfunction, weight management), this integrative approach is effective and tends to minimize adverse effects.


AN INTEGRATIVE PSYCHIATRY APPROACH TO REDUCING PAIN DUE TO ENDOMETRIOSIS  By: Dr. Barbara Bartlik  |  Edited by: Dr. Roberta Kline (Part of the 2024 WHC EndoSpace feature series)

Women with endometriosis can suffer from many of the same mental health issues as other women. However, they can also suffer from additional problems caused by pain due to endometriosis, which can lead to depression, anxiety, sexual dysfunction, and sleep problems.

Because women with endometriosis may be prescribed medications to manage their symptoms, it’s important to be aware of options and their potential benefits and risks.  Psychiatric medications often prescribed for women with endometriosis include selective serotonin reuptake inhibitor (SSRI), serotonin and norepinephrine inhibitor (SNRI), and tricyclic antidepressants; benzodiazepines, sleep medications, mood stabilizers, anticonvulsant medications, and atypical antipsychotics. Antidepressants can help because they reduce depression, which exacerbates pain 

[1]. Fluoxetine [2], an SSRI antidepressant, and gabapentin[3] and pregabalin [4], both anticonvulsants have been shown to relieve chronic pelvic pain. Duloxetine[5], venlafaxine [6], and desvenlafaxine [7], all of which are SNRI antidepressants, can relieve various types of pain. Reports show that tricyclic antidepressants doxepin[8], amitriptyline, and imipramine, out of fashion for years as first-line treatment for depression, are now making a comeback to relieve pain [9].

All the antidepressants mentioned above can cause side effects of sexual dysfunction, weight gain, fatigue, and more. Bupropion, a unique antidepressant, relieves neuropathic pain and is less likely to cause these side effects, but it is more likely to increase anxiety [10]. Benzodiazepines prescribed for the treatment of anxiety, muscle cramps, and insomnia can also be effective in relieving pain, but they can cause sedation and lead to addiction[11]. Sedative-hypnotics such as zolpidem aid sleep, but they, too, are habit-forming and can cause memory problems [12]. The second-generation antipsychotics, quetiapine[13] and olanzapine[14], reduce pain scores and aid sleep but are associated with significant weight gain and sexual dysfunction[15]. Sometimes, when there is severe acute pain, opiates may be prescribed, although other less addictive solutions may also be sought.

Research shows that women with endometriosis have increased oxidative stress in their bodies[16]. Therefore, minimizing exposure to toxic substances that cause oxidative stress is important. That is not easy since toxins are ubiquitous and difficult to avoid. They are in food, air, water, household and personal care products, mold, and more. Many of these toxins mimic hormones and damage the endocrine system. I advise endometriosis patients to eat a clean, antibiotic-free, hormone-free, organic, pesticide-free Paleolithic diet, which also minimizes alcohol, dairy, gluten, genetically modified organisms (GMOs), highly processed foods, seed oils, soy, and sugar. Become familiar with the Dirty Dozen and Clean Fifteen lists, guides produced by the Environmental Working Group ( to help consumers choose produce low in pesticides. Eat wild-caught fish, free-range poultry and eggs, and grass-fed beef where possible.

Women with endometriosis tend to have higher estrogen levels[17], and estrogen stimulates endometrial lesions to grow. The liver can detoxify unwanted estrogens and remove them from the body, but only if it has adequate protein. Amino acids from protein attach to unwanted hormones, which allows these and toxic chemicals to be excreted through the bowel. Without enough protein, hormones and toxins build up and cause many health problems.

Read labels carefully to avoid additives and toxic ingredients. If it needs to be clarified if a product contains toxins, contact the manufacturer directly to obtain more information. Get rid of plastic containers and transition to glassware and stainless steel. Don’t use plastic bottles that contain endocrine-disrupting phthalates and bisphenol A (BPA). Avoid using Teflon or other chemically-coated pans that contain forever chemicals that remain in the body.

Research suggests that the antioxidants curcumin, melatonin, N-acetylcysteine, and vitamins C and E show promising results for endometriosis patients[18]. Nutrients that reduce menstrual pain are also helpful, such as a combination of magnesium and vitamin B6[19]. Vitamin D is another nutrient that can help reduce pelvic pain [20]. In addition, anti-inflammatory supplements such as omega-3 fatty acids can be helpful because women suffering from endometriosis have elevated inflammatory markers on blood tests [21][24].

 The discomfort and pain experienced by women with endometriosis can dampen sexual feelings and make sexual pleasure more difficult to achieve. Sexual activities may have to be adjusted to reduce pain during sex and after. The woman’s partner may also be adversely affected. It is essential to remain flexible and open. Erotica and vibrators can boost the sexual response, which helps to overcome the pain. Numerous oral nutritional supplements and topical creams can stimulate desire and arousal. Two FDA-approved pharmaceuticals are available for low libido in premenopausal women (bremelanotide, flibanserin). Sexual problems can lead to both psychological and relationship problems, so it is important to get help. Consult a trained professional.

The utilizing of non-invasive transcutaneous electrical nerve stimulation (TENS) can help alleviate pelvic pain and augment the sexual response [22][23]. In addition, device-based energy medicine modalities such as pulsed electromagnetic field (PEMF), noncoagulative multipolar radiofrequency, and red-light therapy alleviate pelvic pain, increase blood flow, promote collagen formation, stimulate cell growth and repair, and reduce inflammation [24][25]. Studies have shown that they are effective in treating sexual problems [26][27] and may help with a range of psychiatric issues [28]. These devices are painless, non-invasive, and are viable alternatives to pharmaceuticals and surgery.



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2)        Patetsos, E., & Horjales-Araujo, E. (2016). Treating Chronic Pain with SSRIs: What Do We Know?. Pain research & management, 2016, 2020915.

3)        Sator-Katzenschlager SM, Scharbert G, Kress HG, Frickey N, Ellend A, Gleiss A, Kozek-Langenecker SA. Chronic pelvic pain treated with gabapentin and amitriptyline: a randomized controlled pilot study. Wien Klin Wochenschr. 2005 Nov;117(21-22):761-8. doi: 10.1007/s00508-005-0464-2. PMID: 16416358.

4)        Guan Y, Ding X, Cheng Y, Fan D, Tan L, Wang Y, Zhao Z, Hong Z, Zhou D, Pan X, Chen S, Martin A, Tang H, Cui L. Efficacy of pregabalin for peripheral neuropathic pain: results of an 8-week, flexible-dose, double-blind, placebo-controlled study conducted in China. Clin Ther. 2011 Feb;33(2):159-66. doi: 10.1016/j.clinthera.2011.02.007. Epub 2011 Mar 27.

5)        Skljarevski, V., Zhang, S., Iyengar, S., D'Souza, D., Alaka, K., Chappell, A., & Wernicke, J. (2011). Efficacy of Duloxetine in Patients with Chronic Pain Conditions. Current drug therapy, 6(4), 296–303.

6)        Aiyer R, Barkin RL, Bhatia A. Treatment of Neuropathic Pain with Venlafaxine: A Systematic Review. Pain Med. 2017 Oct 1;18(10):1999-2012. doi: 10.1093/pm/pnw261. PMID: 27837032.

7)        Allen, R., Sharma, U., & Barlas, S. (2014). Clinical experience with desvenlafaxine in treatment of pain associated with diabetic peripheral neuropathy. Journal of pain research, 7, 339–351.

8)        Hameroff SR, Weiss JL, Lerman JC, Cork RC, Watts KS, Crago BR, Neuman CP, Womble JR, Davis TP. Doxepin's effects on chronic pain and depression: a controlled study. J Clin Psychiatry. 1984 Mar;45(3 Pt 2):47-53. PMID: 6321454.

9)        Sansone RA, Sansone LA. Pain, pain, go away: antidepressants and pain management. Psychiatry (Edgmont). 2008 Dec;5(12):16-9. PMID: 19724772; PMCID: PMC2729622.

10)     Semenchuk MR, Sherman S, Davis B. Double-blind, randomized trial of bupropion SR for the treatment of neuropathic pain. Neurology. 2001 Nov 13;57(9):1583-8. doi: 10.1212/wnl.57.9.1583. PMID: 11706096.

11)     Edinoff, A. N., Nix, C. A., Hollier, J., Sagrera, C. E., Delacroix, B. M., Abubakar, T., Cornett, E. M., Kaye, A. M., & Kaye, A. D. (2021). Benzodiazepines: Uses, Dangers, and Clinical Considerations. Neurology international, 13(4), 594–607.

12)     Chien, C. C., Huanga, H. T., Lung, F. W., & Lin, C. H. (2011). Zolpidem withdrawal delirium, seizure, and acute psychosis: Case reports and literature review. Journal of Substance Use, 16(4), 330–338.

13)     McIntyre, A., Paisley, D., Kouassi, E. and Gendron, A. (2014), Quetiapine Fumarate Extended-Release for the Treatment of Major Depression With Comorbid Fibromyalgia Syndrome: A Double-Blind, Randomized, Placebo-Controlled Study. Arthritis & Rheumatology, 66: 451-461.

14)     Freedenfeld, R.N., Murray, M., Fuchs, P.N. and Kiser, R.S. (2006), Decreased Pain and Improved Quality of Life in Fibromyalgia Patients Treated with Olanzapine, an Atypical Neuroleptic. Pain Practice, 6: 112-118.

15)     Nagaraj, Anil Kumar M. Senior Resident; Pai, Nagesh B. Clinical Associate Professor1; Rao, Satheesh Professor and Head2. A comparative study of sexual dysfunction involving risperidone, quetiapine, and olanzapine. Indian Journal of Psychiatry 51(4):p 265-271, Oct–Dec 2009. | DOI: 10.4103/0019-5545.58291

16)     Scutiero, G., Iannone, P., Bernardi, G., Bonaccorsi, G., Spadaro, S., Volta, C. A., Greco, P., & Nappi, L. (2017). Oxidative Stress and Endometriosis: A Systematic Review of the Literature. Oxidative medicine and cellular longevity, 2017, 7265238.

17)     Chantalat, E., Valera, M. C., Vaysse, C., Noirrit, E., Rusidze, M., Weyl, A., Vergriete, K., Buscail, E., Lluel, P., Fontaine, C., Arnal, J. F., & Lenfant, F. (2020). Estrogen Receptors and Endometriosis. International journal of molecular sciences, 21(8), 2815.

18)     Clower, L., Fleshman, T., Geldenhuys, W. J., & Santanam, N. (2022). Targeting Oxidative Stress Involved in Endometriosis and Its Pain. Biomolecules, 12(8), 1055.

19)     Fathizadeh, N., Ebrahimi, E., Valiani, M., Tavakoli, N., & Yar, M. H. (2010). Evaluating the effect of magnesium and magnesium plus vitamin B6 supplement on the severity of premenstrual syndrome. Iranian journal of nursing and midwifery research, 15(Suppl 1), 401–405.

20)     Xie, B., Liao, M., Huang, Y., Hang, F., Ma, N., Hu, Q., Wang, J., Jin, Y., & Qin, A. (2024). Association between vitamin D and endometriosis among American women: National Health and Nutrition Examination Survey. PloS one, 19(1), e0296190.

21)     Meng-Hsing Wu, Kuei-Yang Hsiao, Shaw-Jenq Tsai,Endometriosis and possible inflammation markers,Gynecology and Minimally Invasive Therapy,Volume 4, Issue 3,2015,Pages 61-67,ISSN 2213-3070,

22)     Lauren L. Zimmerman, Priyanka Gupta, Florence O’Gara, Nicholas B. Langhals, Mitchell B. Berger, Tim M. Bruns,Transcutaneous Electrical Nerve Stimulation to Improve Female Sexual Dysfunction Symptoms: A Pilot Study,Neuromodulation: Technology at the Neural Interface,Volume 21, Issue 7,2018,Pages 707-713,ISSN 1094-7159,

23)     Murina, F., & Di Francesco, S. (2014). Transcutaneous electrical nerve stimulation. In Electrical Stimulation for Pelvic Floor Disorders (pp. 105-117). Cham: Springer International Publishing.

24)     Rebecca Wall, R Paul Ross, Gerald F Fitzgerald, Catherine Stanton, Fatty acids from fish: the anti-inflammatory potential of long-chain omega-3 fatty acids, Nutrition Reviews, Volume 68, Issue 5, 1 May 2010, Pages 280–289,

25)     Stewart GMWheatley-Guy CMJohnson BDShen WKKim C-HImpact of pulsed electromagnetic field therapy on vascular function and blood pressure in hypertensive individualsJ Clin Hypertens20202210831089

26)     Bossini L, Caterini C, Koukouna D, Casolaro I, Roggi M, Di Volo S, Fargnoli F, Ponchietti R, Benbow J, Fagiolini A. Rola fototerapii w leczeniu osób z zaburzeniami czynności seksualnych--weryfikacja wynik6w badania pilotaiowego [Light therapy as a treatment for sexual dysfunctions--beyond a pilot study]. Psychiatr Pol. 2013 Nov-Dec;47(6):1113-22. Polish. PMID: 25007542.

27)     Kolodchenko Y. Nonablative, Noncoagulative Multipolar Radiofrequency and Pulsed Electromagnetic Field Treatment Improves Vaginal Laxity and Sexual Function. Womens Health Rep (New Rochelle). 2021 Jul 27;2(1):285-294. doi: 10.1089/whr.2021.0020. PMID: 34327510; PMCID: PMC8317596.

28)     Larsen ER, Licht RW, Nielsen RE, Lolk A, Borck B, Sørensen C, Christensen EM, Bizik G, Ravn J, Martiny K, Vinberg M, Jankuviené O, Jørgensen PB, Videbech P, Bech P. Transcranial pulsed electromagnetic fields for treatment-resistant depression: A multicenter 8-week single-arm cohort study. Eur Psychiatry. 2020 Feb 18;63(1):e18. doi: 10.1192/j.eurpsy.2020.3. PMID: 32093804; PMCID: PMC7315871.



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