This month, Choice Nutrition's Dr. Evan McCarvill (view biography) explains what Endometriosis is, and how this sometimes debilitating condition for those affected, can be managed!
What is Endometriosis?
The female reproductive system is a complex thing. And as such, it can be subject to certain complications and disorders that affect quality of life. Dysmenorrhoea, or pain during menstruation, is a common problem. While not necessarily the case, symptoms such as dysmenorrhoea, heavy or irregular bleeding, pelvic pain, pain during exercise, pain during urination and/or defecation, as well as bloating nausea and vomiting, can be associated with a certain condition of the female reproductive system known as endometriosis.
Endometriosis occurs when endometrial cells, which normally line the inner wall of the uterus, develop in abnormal locations in the pelvic cavity, such as on the ovaries, on the fallopian tubes, in the vagina, or on the cervix. These cells possess the same hormone receptors as normal endometrial cells, making endometriosis an estrogen-dependent disease, affecting women of menstruating age.
The cells respond to the normal monthly hormone cycle, resulting in microscopic internal bleeding, which in turn leads to the release of inflammatory cell signals called cytokines and prostaglandins, new blood vessel formation, and even fibroid formation. This is how the above-mentioned symptoms begin to occur (1). It is noteworthy that the condition usually diminishes with the onset of menopause, due to its estrogen-dependent nature.
While not normally life-threatening, the physical symptoms can be severe and debilitating in some cases, and the condition is often associated with infertility, with an incidence of some 20-50% among infertile women (2, 3).
How common is it?
It has been estimated that about 7-10% of the general female population suffers from endometriosis (4), so it is a fairly common problem. In fact, this figure may be a significant underestimation, as a confirmed diagnosis usually requires a biopsy, or direct visualization of the uterus via exploratory laparoscopy. Usually it's women undergoing surgery, or being evaluated for infertility, who receive this kind of testing.
Symptoms vary in severity. About a third of women with endometriosis have no symptoms at all (5). Therefore, some women may have the condition go undiscovered for years, and thus the true incidence in the population may be greater. Incidence can even be as high as 80% in women with chronic unexplained pelvic pain (6). One study even showed via laparoscopy that endometriosis could be found in 20-50% of women who had none of the typical symptoms (7). There appears to be a genetic component, as you are ten times more likely to develop endometriosis, if a first-degree relative has it (8).
What causes it?
Currently, the cause(s) of endometriosis is poorly understood, though there are some prominent hypotheses, including the notion that retrograde (i.e backflow) menstruation through the fallopian tubes transports viable endometrial cells and deposits them onto the pelvic organs, where their retained stem-cell properties enable them to survive and grow in these inappropriate locations.
However, it has also been shown that a great majority (90%) of women have retrograde menstruation, indicated by blood being present in the fluid of their abdominal cavities. But the majority of these women do not have endometriosis, so this is not a perfect explanation. Even so, conditions that increase retrograde menstruation, such as defects in the fallopian tubes, also seem to increase the risk of endometriosis, so there still seems to be a connection, even if it's an imperfect one (9).
There are likely multiple factors, both genetic and environmental, which are involved in the causation of the condition, which have yet to be elucidated. For instance, some research suggests that an imbalanced immune response to the displaced endometrial tissue may be involved.
Women with this condition seem to show an increased "humoral" immune response, and decreased "cell-mediated" immunity (10). "Cell-mediated" immunity is important for the body's defense against viruses and cancer. This is also the form of immunity that results in organ transplant rejection. While "humoral" (antibody-mediated) immunity is more involved in defense against bacteria, parasites, and the allergic response.
Normally, these are two forms of immune response that work in balance to defend the body against infectious agents. A dominance of "humoral", or antibody-mediated immunity is the kind of imbalance associated with conditions such as atopic eczema, asthma, lupus, and allergies. Thus, aiming to balance and modulate a healthy immune and inflammatory state in the body may be one way to help prevent the condition, and/or help to mitigate the symptoms if the condition already exists.
- Family history of endometriosis
- Early onset of menses
- Short menstrual cycles (less than 27 days)
- Long duration of menstrual flow (more than 7 days)
- Heavy bleeding during menses
- Delayed childbearing, or no childbearing at all
- Defects in the uterus or fallopian tubes
Despite the elusiveness of the cause(s) of endometriosis, as of now, the fact that the cells are responsive to hormones is exploited as the mainstay of medical treatment. Usually this entails suppression of symptoms via hormone administration, such as combination oral contraceptive pills (COCPs), and/or surgical removal of the offending endometrial implants. Usually, surgery is reserved for the most severe cases. Endometriosis brings an increased risk of epithelial ovarian cancer, and it is believed that COCPs can help protect against this risk (11).
Although adequate symptom relief is experienced by the vast majority (up to 95% in some studies) of women who undergo medical management by means of hormonal suppression of ovulation, as many as half of them will have a return of symptoms within 5 years. Thus, to help further support quality of life, and/or to prevent recurrence of the condition, there are some natural approaches worthy of consideration.
As described above, the low level of internal bleeding that occurs as endometriosis implants respond to the normal menstrual cycle results in the release of pro-inflammatory cytokines and prostaglandins. The greater the pro-inflammatory signal that results from such compounds in the body, the greater the associated symptoms of pain and cramping. Thus, taking steps to lower the baseline level of chronic inflammation in the body can help to mitigate this.
1. Dietary approaches:
One basic way to do this is to eat according to an anti-inflammatory diet. Such a diet is predominantly plant-based, emphasizing fruits, vegetables, whole grains, nuts, fiber, and sources of Omega 3 fatty acids. The Mediterranean type diet, with its high ratio of omega-3 fatty acids to omega-6 fatty acids, is the most effective dietary pattern for reducing inflammation. Also, given how sugars and refined carbohydrates, such as from white flour breads and pastas, can promote an increased inflammatory state in the body, an anti-inflammatory diet should contain foods with a low glycemic load, emphasizing whole natural foods like fruits, vegetables, nuts, seeds, and berries (high in flavonoids). These foods also tend to be rich sources of phytonutrients that have antioxidant and anti-inflammatory properties that can help quench inflammatory triggers.
In a study on the Mediterranean diet involving 1500 men and 1500 women, the greatest adherence to the diet resulted significant reductions in inflammatory markers (in 20% lower CRP levels, 17% lower IL-6 levels, 15% lower homocysteine levels, 14% lower white blood cell counts, and 6% lower fibrinogen levels), compared with those with the least adherence (12).
It is generally understood that Omega-6 fatty acids, common in the Western diet, are pro-inflammatory to the body, while Omega-3 fatty acids are anti-inflammatory. Interestingly however, research has shown that omega 3 fatty acids have anti-inflammatory effects only when the basic diet is already very high in omega 6s, like the typical western diet. So really, it's not either/or omega-6 or omega-3 fatty acids that are pro-inflammatory or anti-inflammatory. Rather, it is the ratio between these two fatty acid groups that is important. The closer the proportions are; the more the ratio is 1:1 equal, the more anti-inflammatory the diet (13).
In the old days, people ate more fruits and vegetables, and so got more fiber, more complex carbohydrates, and more poly-unsaturated fatty acids, such as omega-3s. The ratio between omega 6 and omega 3 was close to 1:1, but over the last 150 years or so, the typical Western diet now has a ratio closer to 15:1 or 20:1 in favor of omega 6.
Foods rich in Omega-6 fatty acids, which are to be avoided or mitigated in the diet include: most factory-farmed meat, wheat, cottonseed oil, sunflower seed oil, corn oil, safflower oil, pumpkin seeds, cachews, and pecans.
Foods rich in Omega-3 fatty acids, which are to be encouraged in the diet include: Organic free-range pasture-fed meat, Walnuts, Brussel sprouts, Cauliflower, Flaxseeds, Sardines, Salmon, Herring, Anchovies.
In a previous article, I discussed the nature of Candida Overgrowth Syndrome, what it is, how it occurs, and what can be done about it. Essentially, it is an imbalanced overgrowth of a fungus, usually Candida albicans, within the otherwise healthy diversity of microbes living in our intestines.
While there is no hard research that has definitively made this connection, several practitioners have observed that some endometriosis patients experience symptomatic improvement while on an "anti-candida" program. This usually entails restricting refined carbohydrates and sugars in the diet, in accordance with the dietary principles discussed above, as well as anti-fungal medicines, prescription or otherwise (14).
It is not clear based on this information whether an anti-candida approach directly reduces endometriosis, or if the benefits are simply the result of an overall improvement of health. Regardless, it is worth consideration.
A connection with candida overgrowth would make some theoretical sense, for as I discussed in my previous article, this condition can result in hyperpermeability and chronic low-level inflammation of the intestinal mucosal lining (i.e leaky gut syndrome), which can have an impact on the sensitivity and function of the body's immune system (15).
As discussed above, there may be a connection between endometriosis, and a dominance of "humoral", or allergy-related immune function, sometimes resulting in hypersensitivities to certain foods or other environmental factors. Thus, taking steps to modulate healthy immune function, by balancing "humoral" and "cell-mediated" immunity, may be useful in some cases of endometriosis. This may include addressing any candidiasis and/or leaky gut syndrome, and perhaps also supplementation with immune-modulating plant beta-sterols (i.e. moducare , Choice Nutrition Online store password: "choice")
Please consult your healthcare provider before beginning any program involving supplementation or herbal therapies, especially if you are already taking prescription medications which may have the potential for interactions.
3. Herbal Therapies:
All supplements listed below are available in high grade pharmaceutical quality in our Choice Nutrition Online store, password is "choice".
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In mild to moderate cases of endometriosis, herbal therapy has a lot to offer. Herbal medicine categories that are relevant include the following:
- Cramp bark - Known scientifically as Vitex agnus-castus, this herb is a normalizer of female sex hormones and pituitary gland function. It tends to up-regulate progesterone, while downregulating estrogen. It is very useful for premenstrual symptoms, as well as rebalancing hormone activity after oral contraceptive use. It is commonly indicated for irregular or heavy menstrual bleeding, especially in cases of endometriosis. Contraindicated in pregnancy and lactation.
- Black Cohosh - Known scientifically as Cimicifuga (or Actea) racemosa, this herb serves as a relaxing uterine tonic, as well as a normalizer of female hormones, showing in rat studies the ability to lower serum luteinizing hormone (LH), which is also a goal in conventional treatment of endometriosis, as well as the ability to bind estrogen receptors. It competes with regular estrogen to bind with receptors, but binds them more weakly than actual estrogen. Thus does it effectively mitigate any excessive estrogen stimulation that may be contributing to symptoms. Black cohosh is useful in cases of hot flashes and premenstrual syndrome symptoms, as well as being indicated for endometriosis symptoms. Contraindicated in pregnancy, lactation, and estrogen-dependent tumors.
- Wild yam - Known scientifically as Dioscorea villosa, this herb is a source of raw material for the manufacture of synthetic contraceptive hormones and corticosteroids. As such, it naturally has hormone-normalizing, antispasmotic, as well as anti-inflammatory properties. It is indicated in cases of menstrual pains, ovarian and uterine pains, and even pains of pregnancy. Large doses should be avoided during pregnancy, except under the supervision of a skilled practitioner. Also contraindicated in cases of cancer.
4. Traditional Chinese Medicine:
One other way I like to approach metabolic and hormone-based conditions such as endometriosis, is by employing principles of Traditional Chinese Medicine. This is a form of Eastern medicine with centuries of tradition and clinical practice behind it. It employs a model of the human body grounded in ancient Chinese metaphysical philosophy, which is different from the mechanistic model of Western medicine. Functions of internal organs and systems are considered to be influenced by the healthy circulation of a form of energy called "Chi" (or Qi) and Blood throughout the body, as well as by balance of Yin and Yang, which are thought of as two fundamental forces governing the entire universe in macrocosm, as well as the human body in microcosm.
When Qi and Blood stagnate and don't flow properly through certain organs and systems, possibly as a result of diet and lifestyle factors, invasion of outside influences which would be the equivalent of infectious or contagious conditions, or even by the influence of habitual mental/emotional factors, there can be dysfunction of these organs and systems, resulting in clinical symptoms. Acupuncture is one of the traditional therapies used in this system to re-balance and regulate the desired healthy internal function.
In one study, 67 participants with endometriosis underwent auricular (in the ear) acupuncture for their condition, and their menstrual pain scores were over 90% improved from what they were at the beginning of the study. The result was a highly statistically significant improvement, though admittedly the sample size was small, and there was no control group (16). While these data have some limitations, they are encouraging, and certainly serve as grounds for more conclusive research. In the meantime, acupuncture is a safe and accessible therapy which may bring significant relief.
In another trial, which did have a control group using sham acupuncture, involved 101 women between ages 20-40 years, randomly assigned to either the true acupuncture or sham groups, who received 10 acupuncture treatments over the course of 5 weeks, before switching groups and repeating the same process. This was in addition to conventional pain management treatments. The first group, receiving the true acupuncture, experienced a significant reduction of pain intensity, as measured using a 10-point visual analogue scale (VAS), after the first 10 treatments. The second group experienced improvement only after the crossover, where they began to receive the true acupuncture as well (17). These data also indicate that specific acupuncture points can serve as an effective therapy for endometrial pain, though confirmation is needed through further study.
And so, if you suffer from endometriosis, or if you know someone who does, I hope this has helped you gain some insight into the nature of the condition, and some of the options you have to prevent or manage it.
As always, feel free to contact us in case you have any questions or concerns, or to book an appointment.
DO NOT ACCEPT ILLNESS!
Yours in health,
Dr. Evan McCarvill, B.Sc., Doctor of Naturopathic Medicine (ND)
- Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. Comprehensive Gynecology. Philadelphia, PA: Mosby; 5th ed. 2007:chap 19.
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- Modugno F, Ness RB, Allen GO, Schildkraut JM, Davis FG, Goodman MT. Oral contraceptive use, reproductive history, and risk of epithelial ovarian cancer in women with and without endometriosis. Am J Obstet Gynecol. 2004 Sep. 191(3):733-40.
- Chrysohoou C, et al. Adherence to the Mediterranean diet attenuates inflammation and coagulation process in healthy adults: The ATTICA Study. J Am Coll Cardiol. 2004: 44(1): 152-158.
- Pischon T, et al. Habitual dietary intake of omega-3 and omega-6 fatty acids in relation to inflammatory markers among US men and women. Circulation. 2003; 108(2): 155-60.
- Crook W. The Yeast Connection and the Woman. Jackson, TN, Professional Books, 1995:133-143.
- Yamaguchi N, et al. Gastrointestinal Candida colonisation promotes sensitization against food antigens by affecting the mucosal barrier in mice. Gut. 2006; 55:954-960. [PubMed: 16423887.
- Zhu, Z, Kindreth D, Hamilton, Ewan D, McNicol. Acupuncture for Pain in Endometriosis. Sao Paulo Med J. 2013. 131(6).
- Katharina Rubi-Klein, Kucera-Sliutz E, Nissel H, Bijak M, Stockenhuber D, Fink M, Wolkenstein E. Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis? A randomized controlled cross-over trial. Eur J of Obst & Gyn & Reproductive Biology. 2010. 153(1): 90-93