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

Peter Attia

Jun 22, 2026

Episode description

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Renato Tomioka is a leading expert in reproductive medicine and gynecologic surgery whose unique skills allow him to diagnose and treat some of the most impactful yet frequently overlooked conditions affecting women's health. In this episode, Renato explores endometriosis and adenomyosis, explaining what these conditions are, why they often go undiagnosed for years despite affecting millions of women worldwide, and how advances in MRI and specialized ultrasound are transforming diagnosis beyond traditional surgical laparoscopy. He discusses the decision-making process behind hormonal therapy versus surgery, how treatment strategies change when fertility preservation is a priority, and where IVF fits into the care pathway for women with endometriosis, adenomyosis, or age-related fertility decline. Renato also examines the profound effects of female age on egg quality and quantity, including the accelerating rise in chromosomal abnormalities after age 35, highlights common mistakes in both surgical and fertility management, and shares promising developments on the horizon for treating these conditions and preserving fertility.

Follow Dr. Tomioka's work: Instagram: @dr.renatotomioka; Website: Renato Tomioka, M.D., Ph.D.

We discuss:

0:00:00 - Intro
0:00:11 - Endometriosis: definition, prevalence, infertility risk, and theories of disease development
0:09:03 - The biology of endometriosis: estrogen dependence, progesterone resistance, and tumor-like growth mechanisms
0:13:25 - Adenomyosis explained: how it differs from endometriosis, why it develops, and its impact on reproductive health
0:18:52 - Recognizing endometriosis and adenomyosis: the "6 Ds" of endometriosis and key differences in clinical presentation
0:22:09 - Uterine fibroids: classification, symptoms, and the importance of fibroid location

Mindsip insights from this episode:

Recognize endometriosis lesions as estrogen-producing entities

Endometriosis lesions can have somatic mutations in oncogenic genes like KRAS, causing them to produce their own estrogen and grow independently, similar to benign tumors.

#cancer

#estrogen

Preserve ovarian reserve by harvesting eggs before surgery

Surgically removing endometriomas can reduce a woman's ovarian reserve (AMH) by 40-50%, so it's often better to harvest eggs before such a procedure.

#fertility

Understand egg aneuploidy risk in young women

The risk of egg aneuploidy is non-linear and surprisingly high even in young women, with a 31-year-old having a 30-35% rate, which then rises exponentially after age 35.

#fertility

Enhance IVF success with adenomyosis treatment using GNRH agonist

For women with adenomyosis and failed IVF, a 2-4 month treatment with a GNRH agonist like Lupron before embryo transfer can significantly increase success rates.

#fertility

Utilize frozen eggs to enhance family planning options

Only about 10% of women who freeze their eggs ever come back to use them, often because they get pregnant naturally.

#fertility

Utilize specialized ultrasound for accurate endometriosis diagnosis

A standard transvaginal ultrasound is not sensitive enough to rule out endometriosis; a specialized protocol with bowel prep is required for an accurate diagnosis.

#diagnosis

#ultrasound

Address three layers of endometriosis pain for effective relief

Endometriosis pain has three layers: nociceptive (from the lesion), neuropathic (nerve infiltration), and nociplastic (central sensitization), which is why surgery alone may not resolve the pain.

#pain

Reduce ovulatory cycles to lower endometriosis risk

Modern women experience a fourfold increase in ovulatory cycles compared to women 200 years ago, which is a likely cause for the rising prevalence of endometriosis.

#risk

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