Endometriosis is a condition that causes tissues of the endometrium (uterine lining) to grow outside of the uterus. The endometrium is the inner mucosal lining of the uterus. It has two layers. The stratum functionale contains the excretory glands and is shed as menses during menstruation and is then built-up again by stimulation of the ovaries releasing hormones during the next cycle. The deeper layer that resides next to the myometrium is vascular (vessels that carry fluids) and serves to regenerate the stratum functionale after each menstruation ends. In this article, we’ll be discussing the causes and symptoms of endometriosis, how it effects fertility, medical options, and some natural therapies for endometriosis, including fertility cleansing, the natural fertility diet, systemic enzyme therapy, and supplementation with progesterone, dim, and maca root.

In women with endometriosis the displaced endometrial tissue (also known as implants) function and are influenced by hormones just as a normal endometrium is. This means that the implants function exactly like the endometrium; the tissues swell with blood as ovulation approaches, then begin to break down if pregnancy does not occur in order to prepare for menstruation. When the uterine lining is shed during menstruation the implants bleed, except the blood becomes trapped inside of the body. The accumulated blood causes localized inflammation and in many cases is painful. Over time the growth of the implants, the repeated internal bleeding and inflammation may cause the development of adhesions (scar tissue).

Endometriosis may attach to the ovaries, fallopian tubes, bowel, bladder, ligaments or other areas in the abdominal cavity. Rarely the endometrial cells will attach to other areas in the body including the lungs and nasal cavity. If adhesions develop, this may cause internal organs to become stuck to other internal parts of the body and may even cause displacement of organs and other tissues.

Endometriosis can have a huge impact on fertility, being blamed for 35-50% of fertility issues in women.

• Heavy menstruation with pain, large clots, long or abnormal length of cycles
• Lower abdominal pain, back pain, burning pain over the site of an implant
• Frequent or constant pain all month long
• Painful sexual intercourse
• Pain during bowel movement or urination
• Dysmenorrhea
• Ovarian swelling
• Swollen abdomen
• Infertility
• In rare cases, some women may experience bleeding after intercourse, bowel movements, or urination

Endometriosis can have a huge impact on fertility, being blamed for 35-50% of fertility issues in women. This is two to three times the rate of infertility in the general population.

Risk Factors

There are a variety of risk factors for the development of endometriosis. Here are the main risk factors:

• Too much estrogen/too little progesterone
• Genetic predisposition
• Too much conventional meat
• Radiation and EMF’s
• An abnormality in the immune system
• Exposure to environmental toxins
• Benign uterine fibroids

What Causes Endometriosis?

Doctors and scientists don’t really know for sure what causes endometriosis. Research shows that there are many different factors in the development of this condition, which makes it complex, with possibly many different origins. Because researchers cannot find one direct link to the cause, it also makes it very difficult to treat.

Genetic Predisposition

Genetic predisposition in women with a family history of mothers or sisters that have endometriosis are at a higher risk for developing endometriosis. Women who also have low progesterone often have a family history of low progesterone.

Genotyping studies have associated a link between endometriosis and individual genomic changes in certain chromosomes. This may have been passed down genetically from a parent. Changes in the chromosomes and gene expressions may also be caused by exposure to environmental factors or altered metabolism.

Lymphatic Flow Theory

This theory suggests that the endometrial tissue is spread throughout the body via the lymphatic system.

Retrograde Menstrual Flow Theory

Researchers and doctors suggest that endometrial tissue flows backward through the fallopian tubes and into the abdominal cavity causing the displacement of endometrial cells. These cells then attach to other areas of the abdominal cavity. This is the most widely accepted theory. It is recognized that other environmental, immunological, and hereditary factors may contribute to the development of endometriosis.

Low Progesterone and Estrogen Dominance

Low progesterone disrupts hormonal imbalance overall. When progesterone becomes low, estrogen usually becomes too high. Estrogen dominance and progesterone deficiency have been linked to the development of endometriosis.

Estrogen dominance may develop from exposure to and ingestion of xenoestrogens which are man-made toxins that mimic the body’s naturally produced estrogen. Xenoestrogens are found in and on many of the foods we eat, and may be a part of other chemicals we may be exposed to unknowingly or knowingly, on a daily basis. Some examples of xenoestrogens are pesticides, herbicides, fertilizers, dioxin (found in bleach), and plastics, all of which have been found to disrupt how the endocrine system functions. The endocrine system is responsible for hormonal balance. When the body has too much estrogen, the balance between estrogen and progesterone levels becomes tipped and low progesterone levels are often a result of the imbalance.

Numerous studies have shown a correlation between dioxin exposure and the development of endometriosis. In a study using monkeys, it was shown that dioxin increased the severity and growth of endometrial tissues as well as promoted the survival of endometrial tissue outside of the uterus.

Dioxin is a group of highly toxic chemicals that are a by-product of industrial processing using chlorine to manufacture herbicides and pesticides, process pulp and bleached paper products (including the raw materials for feminine care products) as well as incinerate waste.

Dioxin is considered a Persistent Organic Pollutant, POP for short, that slowly over time accumulates in our bodies. This pollutant is carried in the air and in our water systems as well, which affects the entire food chain and planet. Dioxin is not only present in feminine care products, but in most paper products we use including napkins, paper towels, tissues, make-up removal pads, toilet paper, diapers, etc.

Immunological Factors

Immunological factors have been linked to the development of endometriosis and endometriosis-related infertility. In early endometriosis (stage 1 & 2) there are elevated levels of inflammatory mediators. Studies have shown elevated levels of cytokines, lymphocytes, and macrophages in the peritoneal fluid of women with early stage endometriosis.

Over time the immune system’s function appears to change and may increase the number of peritoneal macrophages, decrease T-cell activity and natural killer cells (NK), increase antibodies and alter cytokine network function. Overall this creates depressed immune function and a poor inflammatory response which may allow endometriotic tissues to implant elsewhere in the body more easily. This may also be why women with endometriosis have more pain and inflammation and are more susceptible to recurrent infections, especially yeast infections.

Oxidative Stress

Cell damage from free radicals has been suggested as the leading contributing factor for development of endometriosis. This may be due to dietary factors, exposure to chemical toxins, aging, and to immunological and inflammatory responses.

Free radicals are unstable molecules that can damage cell structures; this is known as oxidative stress. In normal everyday life, free radicals are produced from the activity in our bodies (for example free radicals are made during energy production) but chemicals in our surrounding environment can also create free radicals. It is said that each cell in our body is attacked about 10,000 times a day by free radicals, accelerating the aging process and allowing for tissue damage and the spread of disease. While we have mechanisms in place to rid the body of free radicals, this is not a perfect process and excess free radicals can accumulate.

How Does Endometriosis Affect Fertility?

Endometriosis is an estrogen dominant condition. When there is too much estrogen in the system, it causes hormonal imbalance. Proper hormonal balance is essential for healthy fertility.

Endometriosis also creates a situation of “congestion” where there are excess tissues growing in the uterus (as well as other areas of the body) which may make it harder for an embryo to attach properly for implantation.

Every month, the excess tissues bleed, which cause inflammation to occur and scar tissue to begin adhering to the uterus, fallopian tubes, the ovaries, and other organs. Amongst holistic healthcare practitioners, internal damage from endometriosis is known and referred to as chronic pelvic “congestion”. If endometrial cells attach to the ovaries or fallopian tubes this may alter normal ovulatory function or cause the fallopian tubes to become blocked.

As if that was not enough, some researchers suggest that the woman’s body may form antibodies against the misplaced endometrial tissue. The same antibodies may attack the uterine lining and cause miscarriages (up to three times the normal rate).
There are four stages of progression with endometriosis. As the disease progresses, fertility is negatively impacted in different ways. Stage I is considered the mildest, while Stage IV is considered the most severe and the most devastating to not only reproductive health, but the entire surrounding organs and tissues of the uterus.

Excerpt from Understanding the Different Stages of Endometriosis
By Elizabeth Willett, M.A., C.H.

The Four Sages of Endometriosis

Stage I or minimal – is characterized by a few isolated endometrial implants outside of the uterus and a minimal number of mild adhesions, if any.

Stage II or mild – is characterized by more and slightly deeper implants less than 5 cm in total and a minimal number of mild adhesions.

Stage III or moderate – is characterized by many deep implants, small endometriomas or cysts on one or both ovaries, and some filmy adhesions or scars.

Stage IV or severe – is characterized by multiple deep implants, large endometriomas or cysts (chocolate cysts) on either or both ovaries, and multiple dense (thick) adhesions often involving other organs.

Stage III and IV may require you to work with your healthcare provider to create the best plan for addressing your symptoms, which may include surgical procedures such as laparoscopy or excision surgery.

Medical Options for Endometriosis

If endometriosis is left untreated this condition has a serious negative impact on reproductive health. There are both medical options and natural therapies to help heal the body from endometriosis. Endometriosis is usually diagnosed by laparoscopic surgery.

Surgery
Doctors will often suggest laparoscopic or abdominal surgery to remove the endometrial lesions and scar tissue-damaged areas and to clip away adhesions if possible. The best surgical option today for endometriosis is the advanced surgical technique known as excision surgery. Excision surgery aims at removing the roots of the disease. In the case of severe endometriosis, a doctor may suggest a full hysterectomy (removal of uterus, cervix, ovaries and fallopian tubes) for women who do not want to get pregnant.

Hormonal and Pain Medications
Doctors may prescribe hormonal medications. The purpose is to stop the menstrual cycle and to prevent further growth of the endometrial tissues. This may also help to reduce pain. If pain is still present, they may prescribe pain medications. Hormonal medications alter the natural menstrual cycle and may prevent pregnancy. They all come with a variety of side effects. Medications are not always effective and once medications are stopped the endometriosis may come back or spread further. Your doctor can help you to determine which options may be best for your particular situation. Most times surgical options may be combined with natural therapies.

Natural Therapies for Endometriosis Infertility

Lifestyle changes are some of the most effective ways to help with endometriosis. These would be changing your diet, clearing out old tissues and congestion, balancing your hormones, and avoiding certain pollutants. The overall goal is to support proper function and health of the endometrium, endocrine and immune systems.

Step 1: Prepare your body with a cleanse

Cleansing specifically for fertility is an important first step if you are experiencing endometriosis. Cleansing using specific herbs helps the body to clear out old tissue, increase circulation to the reproductive system, support hormonal balance, and reduce inflammation and pain caused by endometriosis. There is a correlation between the body’s inability to remove excess toxins and waste products in women with endometriosis.

A fertility cleanse also aids the liver in removing excess estrogens from your system. Again, supporting proper hormonal balance is vital to reducing the spread of endometriosis. We find doing a Fertility Cleanse 2 times a year is important for supporting a healthy endometrium and hormonal balance.

Step 2: Eat a nutrient dense fertility diet

To begin, you will want to build a healthy foundation for your fertility by creating a baby-friendly body. Dietary changes specific to endometriosis are important. There are several types of food you may want to avoid because they have been linked to making endometriosis worse. Certain foods may trigger flare-ups, promote inflammation, or are “congesting” to the body, feeding the congestive nature of endometriosis, while other foods may increase hormonal imbalance.

Foods to Limit or Avoid
The following foods have been linked to the development of endometriosis or to making its symptoms worse:

Gluten, specifically wheat
Wheat has a direct link to making pain worse in women with endometriosis. Researchers are not sure why, but nutritionist Dian Mills says, “Wheat has been genetically modified…There is also problems with gluten sensitivity, and more people are becoming gluten sensitive and I find that when I’ve taken wheat out of the diet, in 80% of the women with endometriosis, their pain subsides.”

A study performed in 2009 on 120 women with endometriosis found 9 women who tested positive for markers that signal the possibility of celiac disease. Of those 9 women, 4 agreed to intestinal biopsy to confirm celiac disease and all 4 tested positive. Researchers concluded that celiac disease appears to be common in women with endometriosis, which may warrant further studies on the topic.

When you have Celiac disease, every time you eat something with gluten in it, your immune system goes into overdrive, which results in the production of toxins throughout the body. These toxins ultimately damage the villi found in the stomach. This destruction restricts the body’s ability to absorb the right nutrients which can actually starve the body of the vitamins and minerals it needs to work properly, eventually affecting every system in the body – including the reproductive system.

It is suggested to remove gluten or at least wheat from the diet for a minimum of 2 months to see if pain is reduced or eliminated.

Dairy products
Dairy products are “congesting” to the body. Consumption of dairy products should be limited to about 2 times a week at most. Choose organic raw dairy products when possible. Homogenized and pasteurized cows’ milk is the most congesting and hard to digest of all dairy products. Choose dairy milk alternatives, such as hemp, almond or brown rice milk instead. Organic raw unsweetened yogurt or kefir are the best choices for dairy products. Be sure that all dairy you do consume is organic or says it does not contain any added hormones.

Red meat, especially commercially raised beef
A study published in 2004 (Human Reproduction) compared 504 women under the age of 65 who had endometriosis to 504 women under the age of 65 who had no known fertility problems to see if there was a dietary link to the development of this disease. They found that women who ate beef or other red meat seven times a week or more were 100 percent more likely to have endometriosis than women who ate red meat three times a week or less. The study did not mention what the connection between red meat consumption and endometriosis is, but that it does exist. It may very well be that most red meat contains a variety of xenohormones and antibiotics which are known to be toxic to the the human body. See Non-organic foods below for more information on how non-organic meats affect fertility.

Pork
The same study from above showed that women who ate ham three or more times per week were 80 percent more likely to have endometriosis than those who ate it less than once a week. Pork is one of the fattiest meats a person could consume, which means pigs store more toxins than other animals.

Soy
Soy foods are highly processed and contain concentrated amounts of isoflavones. The isoflavones are known to be phytoestrogenic. In fact, soy contains more concentrations of isoflavones than any other phytoestrogen, which may contribute to estrogen dominance. Most soy is genetically modified and not organic, both of which have been linked to numerous infertility cases.

Non-organic foods
We have learned that exposure and consumption of pesticides, herbicides, synthetic fertilizers, and GMO foods can create hormonal imbalance through endocrine disruption and suppressed immune function. Conventional fruits and vegetables are regularly sprayed with these chemicals and then, not only do we eat them daily, but so do animals that are raised for meat.

If you eat non-organic meats, you are being doubly exposed to these toxins. This is because xenohormones become more concentrated as they move up the food chain. Xenohormones are often stored in the fat cells of animals. The fattier the meats you are consuming the more xenohormones you are consuming. For example, if you are eating 80% lean/20% fat beef, you may be consuming 20% toxins that cow has stored in its fat. What was that non-organic cow eating? Well, conventional beef is raised in feedlots. They are fed corn and soy feed. This is GMO corn and soy, sprayed with pesticides, fertilizers and possibly herbicides. The cows eat this everyday. Then, on top of that, the animals live in horrible living conditions and are given antibiotics to stave off the spread of disease.

Foods to Focus On

Fresh Vegetables and Fruits
These foods should make up most of your diet. The study from 2004 that linked red meat consumption to endometriosis also suggested that women who eat green vegetables 13 times or more per week (roughly twice a day) were 70 percent less likely to have endometriosis than those who consume green vegetables less than six times per week.

Women who ate fresh fruit 14 times or more per week (at least twice a day) were 40 percent less likely to have endometriosis than those who ate fruit and vegetables less than six times per week.

This study suggests that there may be a link between eating a healthy diet low in red meat and high in fruit and vegetables and a reduced risk of developing endometriosis.

The current advice is to eat at least five 80g portions of fruit and vegetables every day.

The Importance of Fiber
Your main focus and one of the first things you should do right now is eat more fiber. Fiber helps the body to get rid of excess estrogens.

Some good sources of fiber are:

• Dark leafy greens
• Broccoli
• Swiss chard
• Quinoa
• Chia seeds
• Beans

Essential Fatty Acids
Make sure to eat a diet high in essential fatty acids, specifically omega 3, 6 and 9 which have been shown to help reduce inflammation in the body. Reducing inflammation will help to lessen the pain that endometriosis can cause. Especially focus on Omega 3s, as they support hormonal balance. A diet high in Omega 3 EFAs and lower in trans fatty acids improves cellular integrity, which helps to protect cells in the body from oxidative stress.

Good sources of omegas are:

• Omega 3: Flax seeds (ground), cage free organic eggs, wild Alaskan salmon and Cod Liver Oil
• Omega 6: Borage Oil, Evening Primrose Oil
• Omega 9: fresh seeds and nuts, avocado and sunflower oil

If you are not getting enough essential fatty acids from the foods you eat, you may want to consider taking a complete omega supplement or at least one high in omega 3.

Step 3: Avoid Exposure to Environmental Toxins

We have learned that exposure to certain environmental toxins may contribute to the development of endometriosis or make it worse. Some toxins are known to be endocrine disruptors. Endocrine disruptors, also known as xenohormones, are human-made chemicals. These chemicals have the ability to interfere with the natural functions and development of our bodies. The main function of the endocrine system is to serve as our body’s message center. Hormones deliver messages and the endocrine system coordinates hormones.

Ways to support healthy endocrine function and avoid xenohormones:

• Eat organic foods
• Avoid exposure to pesticides, herbicides and synthetic fertilizers
• Use natural feminine care products
• Use organic, natural body care products, including makeup
• Avoid food preservatives and dyes
• Use low VOC paints
• Use recycled unbleached paper products
• Use non-chlorinated oxygen-based bleach in the laundry
• Avoid plastics

Step 4: Systemic Enzyme Therapy

Systemic Enzyme Therapy is one of the most effective natural therapies for helping the body to deal with endometriosis. Specific systemic enzymes can help to reduce “pelvic stagnation” caused by endometriosis. How do they do this? Systemic enzymes help with endometriosis by supporting the body’s natural ability to:

• reduce inflammation and pain
• break down fibrin, the substance that makes up scar tissue and adhesion
• increase circulation to the reproductive organs
• mediate immune system response

Systemic Enzyme Therapy may help to reduce the inflammation caused from the scar tissue irritating the surrounding organs and may reduce the pain that sometimes comes from having endometriosis.

The blood cleansing actions of this therapy help to bring proper circulation to the reproductive system and get the “stagnant blood” cleared out, bringing fresh oxygenated blood to your uterus and ovaries.

It is best to start the Systemic Enzyme Therapy in conjunction with fertility cleansing. For endometriosis, you will want to stay on a systemic enzyme blend for many months so that the “pelvic stagnation” can be cleared. It can take many months to be effective, we find that focusing on this type of therapy for a minimum of 3-6 months is best, though it may take longer depending on the severity of the case.

Step 5: Supportive Herbs and Supplements for Hormonal Balance and Creating a Healthy Endometrium

Herbs and supplements can be very helpful for women with endometriosis. Many of these natural therapies support the body in eliminating excess hormones, endometrial tissues and inflammation, while promoting the reduction in endometrial growth.

Progesterone
If you have endometriosis, Dr. John Lee recommends using progesterone cream from days 8 to 26 of your cycle, to reduce the effects of estrogen on the body (estrogen stimulates endometrial growth). Take a short week off to refresh your receptor sites. He has had success with controlling symptoms within six months. Once the outbreaks of endometriosis are tolerable reduce the usage to days 12 until the end of the menstrual cycle.

DIM
DIM helps to balance the hormones helps to balance the hormones by breaking down excess estrogen and removing it from the body. Endometriosis is an estrogen dominant condition. Cleansing the body of excess estrogen should help the body to reduce the growth of excess endometrial tissues.

Women’s Best Friend
Women’s Best Friend helps the body to reduce pelvic discomfort so you start feeling better right away. Women’s Best Friend goes to the source of the problem, helping to reduce excess estrogen that fuels abnormal growths, and stimulates liver activity for improved estrogen metabolism. It works with your body’s natural detoxification processes to clear congested endometrial tissues while reducing symptoms like abnormal bleeding.

Key herbs in Women’s Best Friend that make this product so effective:

Goldenseal Root (Hydrastis canadensis)– This herb is extremely antibiotic, antimicrobial and anti-inflammatory. It works to heal any infection in the reproductive system, while also reducing pain and inflammation from foreign tissue growth. Reduction in inflammation may help to prevent scar tissue and adhesion.

Jamaican Dogwood (Piscidia erythrina)– This herb is extremely antispasmodic and analgesic. It reduces muscular cramps and spasm. This is an herb that is often relied on by herbalists for women who have unrelenting pain disturbing daily life activities and debilitating pain.

Wild Yam (Dioscorea villosa)– Helps to promote normal hormone levels and overall balance within the reproductive system. Wild Yam may also help the uterus to work more efficiently during menses.

Cramp Bark (Viburnum opulus)– This is one of the most effective herbs for reducing uterine spasm and cramping. Cramp Bark has been shown to relax the smooth muscles of the body, especially those of the uterus.

Peony Root (Paeonia officinalis)– Peony has been found to aid in increasing progesterone levels, lowering testosterone and balancing estrogen. Overall, this herb has excellent hormone-balancing support.

To purchase a kit with these ingredients including Systemic Enzyme Therapy click here…

Additional Supplements that are helpful for endometriosis…

Whole Food Prenatal Multivitamin
A major part of increasing egg health and preparing the uterine lining is to take a whole food multivitamin that contains all of the key nutrients for optimal fertility health. Making sure your body has all of the nutrients necessary is a lot easier when you are taking a multivitamin. My favorite is the 100% whole food Fertile Woman One Daily from Fertilica™. Synthetic multivitamins don’t have the same effect. If you decide to change your diet to reduce endometriosis, you will need to make sure your body is supported nutritionally as your body adjusts to the dietary changes. For women that have gluten or wheat intolerance, the digestive system may be damaged, which makes absorption of nutrients from the diet difficult; it is vital you supplement with a multivitamin to ensure you make up for lost nutrients in foods.

Pycnogenol: Pycnogenol is a powerful antioxidant that comes from the bark of the pine tree, Pinus maritima. It has been shown to help women with endometriosis, improve egg health, and increase sperm health. Antioxidants are important in restoring and protecting cellular health and DNA. Pycnogenol is a therapeutic alternative to Gn-RHa in the treatment of endometriosis.

Bee propolis
Bee Propolis is a resinous mixture of tree sap, tree buds, tree leaves and other botanical sources that the bees make to seal small openings in their hives. A study published in Fertility and Sterility (2003;80:S32) showed that 60% of women with endometriosis-related infertility who took 500mg of bee propolis twice a day for 9 months became pregnant as opposed to 20% in the placebo group. Endometriosis pain, scar tissue and adhesion formation is thought to be triggered by inflammation responses in the body. Bee propolis has been shown to be extremely anti-inflammatory which may help to reduce the inflammation associated with endometriosis. Bee propolis may also contain immunomodulating properties which may prove beneficial for autoimmune-related fertility issues. Some doctors theorize that endometriosis may be an autoimmune disorder.

Maca
Maca is an incredible fertility super food. It helps to balance the hormones, but does not contain any hormones itself. Maca is able to do this through nourishing and balancing the endocrine system. Maca may be a useful tool for preparing women with endometriosis for pregnancy because healthy hormonal balance contributes to healthy fertility.

Summary

Endometriosis is a complex fertility issue that has been shown to potentially have multiple causes. There are a variety of steps that need to be taken to heal and reduce the effects it can have on fertility and quality of life. The following 5 steps can help you to support a healthy endometrium!

1. Diet is your foundation. There are many foods that contribute to the spread and pain of endometriosis; limit those. Choose foods that support estrogen metabolism and reduce inflammation.

2. Avoid exposure to environmental toxins. Exposure to certain toxins may make endometriosis worse.

3. Fertility Cleansing is vital to supporting hormonal balance and uterine health.

4. Systemic Enzyme Therapy supports both proper inflammatory response and immune function. It also aids in the breakdown of scar tissue and adhesion.

5. Use supportive herbs and supplements for hormonal balance and to create a healthy endometrium.

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Hethir Rodriguez - Certified Herbalist, Nutritionist, Birth Doula

Hethir Rodriguez is the Founder and President of Natural Fertility Info.com. She has been a Certified Herbalist for over 19 years, holds a Bachelors degree (BS) in Nutrition Sciences and is a Certified Birth Doula and Massage Therapist specializing in fertility massage. Since founding Natural Fertility Info.com in 2007, Hethir’s research, articles, and guides have been read by over 40,000,000 people, currently averaging at over 1,000,000+ readers per month.  Hethir has dedicated her life to helping provide a source for high quality, research based information and support for those on their journey to becoming parents.

Dr. Christine Traxler M.D., OB/GYN

Dr. Traxler is a University-trained obstetrician/gynecologist, working with patients in Minnesota for over 20 years. She is a professional medical writer; having authored multiple books on pregnancy and childbirth; textbooks and coursework for medical students and other healthcare providers; and has written over 1000 articles on medical, health, and wellness topics.  Dr. Traxler attended the University of Minnesota College of Biological Sciences and University of Minnesota Medical School,  earning a degree in biochemistry with summa cum laude honors in 1981,  and receiving her Medical Doctorate degree (MD) in 1986.