Endometriosis: What we Know
Endometriosis is one of the most common reproductive disorders, affecting nearly 10 percent of all women in their reproductive years, and a leading cause of infertility. It is devastating. Patients have described it to me like “someone scraping the inside of my uterus with a rusted knife”. Not only is there intense pelvic pain, these women can struggle with extremely painful periods, pain with intercourse and infertility.
What is it? In short, endometriosis is when the uterine lining grows outside of the uterus, forming “endometriotic lesions”. Usually it is confined to the pelvic area (tubes, ovaries, rectum, bladder, and other pelvic tissues, but there are some cases where it has grown on the lungs or even the spine!). In a healthy normal cycle, hormones fluctuate to encourage the thickening of the endometrium in preparation for an embryo, however with endometriosis, the misplaced tissue also grows. When menstruation occurs, this tissue is trapped and cannot flow outside body through the vagina, instead it flows wherever it can, causing inflammation and pain. Eventually, this tissue can cause scarring in the fallopian tubes or ovaries, which complicates fertility.
Symptoms:
The actual amount of endometriosis often doesn’t determine how severe the symptoms are. Some women with a large amount of tissue feel no discomfort, while others with even a small amount of misplaced tissue experience severe pain.
Painful periods
Lower abdominal pain or low back pain, often throughout the cycle
Pain with bowel movements
Menstrual irregularities, including spotting and heavy bleeding during periods
Pain with intercourse
Bloating, nausea, constipation, diarrhea
Pain with urination
Ovarian cysts (sometimes “chocolate cysts” occur too, otherwise called “endometriomas”)
Diagnosis
The only way to truly confirm the condition is by undergoing a surgical laparoscopy with biopsies of the affected areas (described as “raised flame-like patches, whitish opacifications, yellow-brown discolorations, translucent blebs, or reddish or reddish-blue irregularly-shaped islands”). Sometimes treatment will begin without the formal diagnosis, because laparoscopy carries its own risks of scar tissue and is often only performed in severe cases. Surgery can be used both as a diagnostic tool and as treatment to remove the lesions.
Sometimes, it can take years to receive a diagnosis.
Cause
Endometriosis results when misplaced endometrial cells implant, grow, and elicit an inflammatory response. Its origins are multifactorial including abnormal endometrial tissue growth, faulty immune system, imbalanced cell growth/death, hormone imbalances, and genetic factors.
The Main Theory
Some researchers believe endometriosis may be triggered by endometrial cells loosened during menstruation “backing up” through the fallopian tubes into the pelvis, a process called retrograde menstruation. This theory, called Sampson’s Theory, has originated because of women who have reproductive defects that block menses have an increased risk of developing endometriosis, and that endometriosis has been induced in animal models by injecting endometrium tissue into the abdomen. In this theory, after the endometrial tissue enters the abdominal cavity, it must survive the defenses of the body, attach to a surface, and then modify the surrounding tissues to establish a lesion. This theory is difficult to prove, but is the most widely accepted.
There are some faults with this theory, including that endometriosis can be present in a fetus, despite not gone through puberty/menstruation, endometriosis is commonly developed in a surgical scar (e.g. from a c-section), endometriosis has been shown to transport to other parts of the body (see lungs/spine above) through the lymphatic system. There is a strong genetic inheritance component to the condition. Other theories hold that endometriosis involves a faulty immune system, hormones, or genetic factors.
Risk factors
Anyone can develop endometriosis, but some risk factors increase the possibility of developing the condition. These include:
Never giving birth
Genetics: One or more relatives having the condition. The risk is approximately 6 times higher when there is a close relative with severe endometriosis
Early puberty (before age 11) or late menopause
Heavy periods, longer periods (lasting more than 7 days) or menstrual cycles of less than 27 days
Being taller than 68 inches
Exposure to severe physical and/or sexual abuse in childhood or adolescence
Caffeine, alcohol consumption, and trans unsaturated fat consumption
Lack of exercise
Exposure to certain chemicals, including phthalates
Comorbidities
Other health conditions have been linked to endometriosis, including cardiovascular disease, allergies, asthma, and some chemical sensitivities, some autoimmune diseases, chronic fatigue syndrome, and ovarian and breast cancer. Cardiovascular disease (chronic inflammation and increased oxidative stress are present in the pathogenesis of both atherosclerosis and endometriosis)
Standard treatments
Conventional care care focuses to reduce pain, and suppress hormones. The hormone suppression (or hysterectomy with oophorectomy) is to stop “feeding” the endometriosis lesions hormones that encourage it to grow.
Pain medications: over the counter anti inflammatories to help combat the pain
Hormones: this may be the birth control pill, Depo-Provera shot, an IUD (but these can make your periods more irregular or heavy), or Lupron are the most common hormonal interventions
Laparoscopy: This surgery seeks to remove the endometrial tissues, often by cauterizing or surgically removing the endometrial lesions. Laparoscopy is the only true way to confirm the diagnosis of endometriosis. The rate of recurrence of endometriosis after laparoscopic surgery is estimated to be between 40-50% within 5 years; approximately 21.5% of women experience recurrence within 2 years.
Hysterectomy: removal of both ovaries and the uterus, the ovaries are often removed to result in an early menopause (they are removed to reduce your body’s natural production of hormones in hope that the endometriosis lesions will no longer grow).
Naturopathic Perspective & Treatments
The theory of retrograde menstruation (mentioned above) doesn’t hold as a comprehensive explanation of endometriosis, because most women experience retrograde menstruation (76-90%) but only 10% of women develop endometriosis. Endometriosis is thought to be a “perfect storm” of multiple factors resulting in the altered immune function and hormones, which then encourages the growth of the misplaced endometrial tissue. The goal of naturopathic treatment is to look at each individual contributing factor and address it thoroughly as possible to address the underlying dysfunctions that cause endometriosis and its symptoms.
Hormone Imbalance
Endometriosis is a hormonally responsive condition, as these lesions contain hormone receptors. Women with endometriosis tend to have higher levels of estrogens and androgens and lower levels of progesterone. To further compound the issue, endometriosis lesions have the ability to produce more estrogen through an enzyme, called aromatase. Estradiol (the strongest estrogen) arises mainly from the ovaries and adrenals via aromatase. In the endometrium of healthy women, the activity of aromatase is undetectable, but in women with endometriosis the endometrium and the endometriosis lesions are able to produce aromatase at high amounts, which produces more estrogens.
Progesterone resistance and low progesterone is another issue with endometriosis. Progesterone, which is produced in the second half of the cycle, inhibits the action of estrogen and prepares the endometrium for implantation, but studies show that endometriotic lesions do not contain as many progesterone receptors, so, unlike the uterine endometrium, these lesions will continue to grow in the presence of progesterone.
Cross-talk between the endocrine (hormonal) system and immune system can impact the progression of endometriosis. Sex hormones can alter the immune response. In women with endometriosis, both estrogen and progesterone can promote a pro-inflammatory environment, but hormone-inflammation response is not found to be the case in healthy women.
The Immune System
The research is clear that women with endometriosis have altered immune function. Surveys show that women with endometriosis have significantly more hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma compared to the general population.
In endometriosis, the local immune system in the pelvis is altered with an increase in inflammatory chemicals (called “cytokines” and “chemokines”), and a decrease in anti-inflammatory cell activity. These inflammatory signals found in the abdominal cavity can encourage endometrial growth. The role of these immune cells and chemical signals is a complicated process and not quite entirely understood. There is a possibility that endometriosis has an autoimmune component due to a high level of “anti-endometrial antibodies”, but may be a secondary response of the immune system in an attempt to resolve endometriosis implants.
Endocrine Disruptors & Toxins
Environmental causes must be considered because endometriosis is a hormone responsive disease. Environmental exposures that affect a woman’s hormonal system need to be considered and addressed. In labs, endometriosis has been induced experimentally with exposure to dioxin (a toxic substance found in emissions and the breakdown of chemicals such as bleach) and has been linked with exposure to many toxic chemicals. Exposure to these chemicals occur through air, food, water, personal care products and plastics.
Women with endometriosis have been documented having higher levels of dioxins, pthalates, bisphenol A (BPA), pesticides, insecticides, formaldehyde, and cadmium. Many of these toxins can bind to hormones receptors, triggering additional endometrial growth; while others are thought to disrupt the immune system, increasing inflammation and reducing the immune system’s ability to clear the endometriosis lesions.
It is not clear if women with endometriosis have been exposed to higher amounts of these chemicals or if there is an impaired function in removing these compounds.
How Endometriosis affects fertility
The reason for infertility appears to involve physical distortions from pelvic adhesions and endometriomas, hormone imbalances affecting the receptivity of the endometrium, and production of substances that are "hostile" to normal ovarian function, ovulation, fertilization, and implantation.
What ELSE can you do?
Since endometriosis is a condition that involves estrogen dominance, immune dysregulation, and toxin exposure, treatment is aimed at addressing each of these, individually. Read more here.
Additional Sources:
Frank, P. (2013). Endometriosis: Theories, Evidence, and Treatment – Naturopathic Doctor News and Review. [online] Ndnr.com. Available at: https://ndnr.com/womens-health/endometriosis-theories-evidence-and-treatment/
Marchese, P (2011). Breast Cancer and Endometriosis — Naturopathic Doctor News and Review. [online] Ndnr.com. Available at: https://ndnr.com/womens-health/environmental-links-to-breast-cancer-and-endometriosis/
Nezhat, Camran et al. “Bilateral thoracic endometriosis affecting the lung and diaphragm.” JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 16,1 (2012): 140-2. doi:10.4293/108680812X13291597716384
Ahn, Soo Hyun et al. “Pathophysiology and Immune Dysfunction in Endometriosis.” BioMed research international vol. 2015 (2015): 795976. doi:10.1155/2015/795976
Schenken, R. (2019). UpToDate. [online] Uptodate.com. Available at: https://www.uptodate.com/contents/endometriosis-pathogenesis-clinical-features-and-diagnosis [Accessed 30 Feb. 2019].
Greene, Alexis D et al. “Endometriosis: where are we and where are we going?.” Reproduction (Cambridge, England) vol. 152,3 (2016): R63-78. doi:10.1530/REP-16-0052