What is Endometriosis?

70% of teens who experience chronic pelvic pain go on to be diagnosed with endometriosis

1 in 10 women have diagnosed endometriosis with half experiencing impaired fertility. Endometriosis causes whole body systemic inflammation, not just the uterus, and is characterised by the growth of misplaced endometrial cells (from the endometrium, lining of the uterus) outside of the uterus. These cells are responsive to the sex hormones that are part of the natural menstrual cycle. During ovulation, the endometrium and the misplaced cells thicken, but the misplaced cells cannot leave the body via normal menstruation. Instead, they bleed, which causes inflammation and pain. Over time this process can create scar tissue and adhesions where the uterus attaches to the ovaries, fallopian tubes and / or bowel and becomes incredibly painful.

“Normal” period pain

Usually, a bit of cramping in the lower pelvis or back occurs on the first day or so of your period and doesn’t interfere in your daily activities.  It is caused by prostaglandins released in your uterus and can improve with age or often after giving birth.

Abnormal period pain

Intense pain that doesn’t improve with pain killers – can be a throbbing, searing, burning or stabbing pain. Interferes with daily life to the degree of missing school or work. Can last for many days, can occur between periods. For some women the pain can be constant. This is caused by an underlying medical condition, such as endometriosis, and can get worse with age.

70% of women experience pain as a symptom of endometriosis, leaving 30% who don’t experience pain (but can still experience the impact on their fertility). Pain is also no indication as to the severity of the disease.

 

Other symptoms of endometriosis - May occur with or without period pain.

• Pain during intercourse
• Pelvic pain
• Ovulation pain
• Pain in lower back and thighs
• GIT issues
• Bladder issues
• Reduced fertility
• Nausea
• Fatigue
• PMS

 

Risk factors

• Obesity – inflammatory, oestrogenic
• MTHFR genetic defect – particularly on SNP C677T, reduces the body’s ability to clear xenoestrogens
• Genetic predisposition
• Delayed reproductive age
• Parasites / dysbiosis – inhibits oestrogen clearance

 

Causes

Unknown! But there are several theories:

Retrograde flow – the flow of blood back through fallopian tubes and into pelvic cavity instead of out through the vagina. Whilst probably normal to a degree, increased retrograde flow (due to a blockage – adhesions, congenital abnormality, etc - stopping menstrual blood from leaving the body) is associated with a higher risk of endometriosis. Some women report improvement in period pain when they stop using tampons for instance.

Increased exposure to oestrogens – for example, delayed pregnancy, early start to menarche, relatively high number of periods per year. Thought to be due to high levels of oestrogens possibly leading to thicker endometrium and therefore more likely to be endometrial cells in the pelvis due to a heavier period.

Increased local production of oestrogen due to aromatase activity present only in endometriosis – when tested, serum levels may come back as normal, but menstrual blood levels of oestradiol are elevated. This process also increases prostaglandins, resulting in pain and inflammation, and the prostaglandins further increase aromatase activity. 

Environmental toxins – dioxin exposure in the womb, these are industrial by-product that accumulates in meat, fish, eggs, cheese, butter, etc. 

Immuno ”incompetence” – dysregulation of immune system and an altered immune environment.

 

The immune system and endometriosis

The immune system has 2 main parts – Innate and Adaptive Immune systems

Innate immune response (involves cell enzymes, serum proteins, cytokines, macrophages, mast cells) has developed and evolved to protect the host from the surrounding environment in which a variety of toxins and infectious agents including bacteria, fungi, viruses and parasites are found.  It has the job of cleaning up misplaced endometrial cells, but with endometriosis this innate immune response does not occur. 

Within the peritoneal cavity of endometriosis sufferers there is an altered immune environment. NK cell activity is reduced, inflammatory cytokines are increased and regulatory cells are decreased.

Adaptive immune response (involves B cells, T cells, antibodies) is targeted against a previously recognized specific microorganism or antigen. Thus, when a given pathogen is new to the host, it is initially recognized by the innate immune system, after which the adaptive immune response is activated.  This is upregulated in women with endometriosis. Regulatory T-cells are reduced in women with endometriosis

Progesterone resistance usually accompanies endometriosis.  While progesterone would normally suppress an overactive adaptive immune system, for those with endometriosis the body is unable to control the adaptive immune system as it should.

Autoimmunity and endometriosis

Autoimmune conditions and endometriosis are highly correlated.  Endometriosis sufferers are more likely to have autoimmune conditions such as rheumatoid arthritis, lupus, MS, Hashimotos than those without it.

Auto-antibodies to the endometrium have been reported in a number of studies, although it is unclear whether an autoimmune response triggers the condition or endometriosis triggers an autoimmune response.  This high presence of autoantibodies may be the cause of endometriosis-related infertility that can persist even after it has been treated.

 

Digestive issues and endometriosis

Approx. 80% of women with endometriosis also have IBS.

Endometriosis lesions and adhesions can occur on the bowel causing mechanical digestive problems, leading to constipation, pain, bloating, poor nutrient absorption. Lesions and adhesions can also create locations for pathogens - including parasites and bacteria – to thrive. This can lead to bloating and other digestive problems. 

Digestive issues often caused by incorrect diet, can also worsen endometriosis symptoms. Intestinal permeability (often a precursor to autoimmunity) promotes inflammation, which worsens endometriosis symptoms. This can be aggravated by NSAID (non-steroidal anti-inflammatory drugs) use.

Proliferation of ‘gram-negative bacteria’, which produce toxic lipopolysdaccharides, impair P1 and P2 liver detoxification, and promote autoimmune disease and endometriosis.

Constipation pre-period reduces the capacity for oestrogen clearance via the bowel, can be aggravated by analgesics such as codeine, pathogenic bacteria, poor diet, dehydration, adhesions.

 

Nutritional support for endometriosis

The good news for sufferers is that since endometriosis is an inflammatory condition there is much we can do with our diet to reduce symptoms.  An effective health treatment plan will reduce immune system dysregulation, promote healthy digestive and excretory function, support liver for clearance of (xeno)oestrogens and ‘toxins’ and regulate blood sugar levels

 

Diet

Eat a diet full of plentiful anti-inflammatory foods

• Bitter green veggies (kale, sorrel, radicchio,), cruciferous vegetables (broccoli, cabbage), liver supporting vegetables (beetroot, carrots, onions, garlic, etc) and vegetables in general to promote digestion, help with P2 detox and reduce inflammation (5-10 cups per day)
• Include broccoli sprouts (approx 3 heaped tbsp) each day to help P1 detox and reduce chance of following an unhealthy oestrogen pathway
• Oily fish consumption (2-3 serves per week) for anti-inflammatory properties
• Non-gluten containing grains such as buckwheat, quinoa, basmati rice
• Goods fats such as olive oil, avocado (fruit and oil)
• Add in anti-inflammatory and liver supporting herbs and spices such as turmeric, cinnamon, ginger, parsley, coriander to each meal
• Eat 7-10 cups of vegetables per day (crowd out excess consumption of meat, grains, processed foods, etc, gain increased antioxidants and other beneficial properties of polyphenols, as well as aiding oestrogen and toxin clearance and liver support)
• Eat 1 pieces of low sugar fruit per day (berries or apple for liver support)
• Focus on veg rather than fruits to keep sugar consumption to a moderate level as veggies also contain important fibre

Avoid Pro-inflammatory Foods:

• Avoid dairy which is very often problematic in endometriosis
• Cut out processed foods, added sugar, trans fats, excessive animal fats
• Reduce consumption of red meat and saturated fats, particularly factory farmed (rather than grass fed and finished). Consumption of agricultural chemicals is associated with a higher prevalence of endometriosis. Saturated fats are linked to a rise in beta glucaronidase enzyme that causes oestrogen to recirculate rather than being excreted
• Keep nuts and seeds to a maximum of 1 handful per day (20 almonds) to minimise omega 6
• Avoid alcohol and minimise caffeine (less than 2 cups coffee per day) as they are associated with increased risk of endometriosis and associated infertility
• Avoid legumes due to lectins which increase intestinal permeability and can promote autoimmunity and immune dysregulation
• Replace all the above with extra servings of anti-inflammatory, fresh veggies!

 

Supplements

• Omega 3 – reduce pain and inflammation – 600mg EPA and 300mg DHA
• Vitamin E – reduces adhesion and inflammation – 500-1000 IU (under supervision, not pre or post op)
• Curcumin – reduces inflammation, suppresses local oestrogen production, reduces size and activity of lesions – 1 high dose cap with food (fat and black pepper for absorption)
• Grape seeds – antioxidant, reduces prostaglandins
• Probiotics – lactobacilli strains to reduce inflammatory gram-negative bacteria
• Vit B complex – support liver P1 detox and support methylation detox pathways
• Zinc – immune function and healing – 30-50mg / day
• Selenium – fatty acid metabolism – 200mcg / day
• Magnesium (200mg 2-3 x per day) and calcium (1000-1500mg / day) – hormone metabolism and inflammation modulation

 

Lifestyle and Complementary Therapy

• Exercise – 5 hrs / week associated
• Acupuncture – to help manage symptoms, regulate hormones, liver support
• Reduce exposure to exogenous toxins / xenoestrogens where possible ie cleaning products, self-care products, pesticides on foods
• Reduce cortisol levels – stress induces hormone dysregulation
• Address sleep hygiene for hormone regulation
• Herbal medicine, practitioner prescribed. Herbs are great for hormone regulation, liver support, immune modulation and pain management
• Heavy metal chelation if indicated – heavy metals overload the liver and impair oestrogen clearance and can increase systemic inflammation and exert adverse effects on hormones

 

Helpful Resources

Women, Hormones and the Menstrual Cycle by Ruth Trickey

Period Repair Manual by Lara Briden

Lara Briden’s Healthy Hormone Blog