#397 ‒ Endometriosis and adenomyosis: diagnosis, fertility, reproductive aging, and emerging treatments | Renato Tomioka, M.D., Ph.D.

**Peter Attia** (0:11)
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My guest this week is Dr. Renato Tomioka, a leading expert in reproductive medicine and gynecologic surgery. Renato's clinical work sits at the intersection of three closely related fields, reproductive medicine, minimally invasive gynecologic surgery, and gynecologic endocrinology, a combination that makes him uniquely equipped to diagnose and treat some of the most consequential and under-recognized conditions women face today.
Endometriosis affects roughly 10 percent of reproductive-aged women, about 200 million women globally, and contributes to infertility in 30 to 50 percent of cases. Adenomyosis, its often overlooked counterpart, may be even more prevalent. Yet the average woman waits five to 12 years for a diagnosis, often because her pain has been dismissed as normal. In my conversation with Renato, we cover what endometriosis and adenomyosis actually are, and why they're so often missed, and how diagnosis has shifted from surgical laparoscopy towards MRI and specialized ultrasound. How Renato decides between hormonal therapy and surgery, and how those decisions change when fertility is part of the goal. Where IVF fits into the pathway for women with endometriosis, adenomyosis, or age-related fertility decline. How female age shapes egg quality and quantity, including the steep non-linear rise in chromosomal abnormalities after age 35
And the most common mistakes in surgical and fertility decisions, and what may be on the horizon for both endometriosis treatment and fertility preservation. So without further delay, I hope you enjoy my conversation with Dr. Renato Tomioka.
Renato, wonderful to see you. Thank you for coming to Austin. Today we're going to talk about two things that are related, but I want to talk about them in sort of this order. The first thing I want to do is talk about the diseases of the uterus, and I think most notably we'll talk about endometriosis, but also others. And then I want to talk about infertility, and obviously talk about some of the treatments for infertility. And of course, there's an overlap between those two. So let's start with the former. Orient us to what exactly this term is. I'm sure everybody's heard of endometriosis, but it's likely that not everybody understands exactly what it is.

**Renato Tomioka** (3:38)
So I believe the first point is to remember the layers of the uterus, right? So we have mainly three layers, the outside layer, it's called serosa, the middle part, which is the muscular layer, called myometrium, and the inner part where the embryo implants develop the placenta, which is called endometrium.
And this layer is very important because endometriosis is a disease, a chronic disease where an endometrial-like tissue, very similar to the endometriosis, outside the uterus. Instead of being inside that layer, it goes into the fallopian tubes on the ovaries, on the bowel, the bladder, sometimes the appendix and even the diaphragm. So that's endometriosis, very important disease. Around 10% of reproductive women globally have endometriosis, which means around 200 million women. And if you look into the data of infertile women, it's about 30 to 50% of women, they can have endometriosis.

**Peter Attia** (4:44)
So just to make sure I understand that, 30 to 50% of women who are struggling with fertility have endometriosis.

**Renato Tomioka** (4:51)
And the other way around, like if you have endometriosis, you have a chance of around 40% of being infertile.

**Peter Attia** (4:58)
So it's causal.

**Renato Tomioka** (4:59)
Yes.

**Peter Attia** (5:01)
Okay. So let's dig into this a little bit more. So first of all, you mentioned we have three layers in the uterus. The endometrial layer is the inner layer. That's the part that sheds every month during a woman's reproductive.

**Renato Tomioka** (5:13)
Very dynamic. Very dynamic, depending on the duration of the cycle, of course, where you are in the cycle.

**Peter Attia** (5:20)
Okay. You have a muscular layer.
And that's presumably functional. So during childbirth, the uterus needs to contract. So when a woman is experiencing contractions, that's what's contracting?