Endometriosis - what happens, risk factors, symptoms, complications, natural remedies
With one in ten Australian females being afflicted with Endometriosis, this is no small issue. And yet it is largely misunderstood and under-managed - even taking an average of seven to ten years for a diagnosis! The good news? There's plenty to learn about how we can help manage endo symptoms better, so let me give you the inside scoop. Just remember: This complex disease needs professional care at all times; don't try tackling it on your own!
what happens?
Your endometrium is a layer of tissue within the uterus, and is what thickens, and sheds each month during your menses. When you have endometriosis, tissue similar to that of the endometrium is found outside of the uterus, such as in the abdominal cavity, fallopian tubes, ovaries, or behind the uterus. It has even been found in the lungs and the brain!
That same tissue that is found outside of the uterus also goes through the growth and eventually breakdown that the endometrium does, leading to a bleed/period. So, each month, not only does the endometrium grow, the endometrial tissue found outside the endometrium also grows! Then, it is broken down by hormones, which leads to internal blood flow that can't leave our bodies. This causes inflammation and sometimes scarring! (Klemmt & Starzinski-Powitz, 2018).
Why this happens, is poorly understood and controversial within the literature, with several theories being proposed. They are:
Transplantation theory: is the most widely accepted theory (from 1927!), assuming that a small lesion is established and then proliferates, leading to a progressive disease. The establishment of the ‘lesion’ has multiple theories, including
Retrograde menstruation via the fallopian tubes, which is the backflow of menstrual contents back into the body. During backflow, fragments are suggested to implant and thus grow on the peritoneum and ovaries.
Lymphatic dissemination: suggests the abnormal tissue travels via the lymphatic system to sites outside of the endometrium.
Blood vessel dissemination: suggests the abnormal tissue travels via the vascular system to sites outside of the endometrium.
Direct implantation: suggests endometriosis arises from the invasion of endometrium through the uterine musculature.
In situ developement: suggesting that tissue misplacement happens at birth, by cervical mucus, tightness of the cervix, or malformations that impede normal drainage of ‘the mixture’ (which is theorised to be stem cells). The misplaced tissue lays dormant, due to the lack of estrogens in childhood, to grow rapidly after puberty.
Metaplasia/celomic theory: is the theory where normal peritoneal tissue “transforms” into abnormal endometrial tissue. Exogenous (created outside of the body) endocrine disrupting chemicals are suggested to play an important role in this transformation.
Induction theory: is similar to the metaplasia theory, suggesting endogenous (created in the body) stimulus promotes the transformation of normal peritoneal tissue into abnormal endometrial tissue. Endogenous stimulants include immune cells, endocrine cells, and stem cells.
Collectively, investigations involving the pathophysiology of endometriosis have revealed several hallmarks of disease:
Genetic predisposition,
Estrogen dependence,
Progesterone resistance,
Inflammation (Burney et al., 2012).
risk factors
Age: endometriosis is rare before menarche (your first period), and decreases after menopause. So you’re at the highest risk in your reproductive years (when all your hormones are flowing!).
Family history: there is increased risk in those with a mother or sisters with the disease. Just because your mum has it, or all your sisters and cousins have it, shouldn’t mean you need to "put up with it”.
Altered menstrual pattern: endometriosis is higher in women with early menarche, and short and heavy periods- a pattern which screams estrogen dominance.
Genetic factors: genetic polymorphisms are being considered in the literature at the moment, with endomestriosis having an overall heritability of approximately 50%. Numerous genes are involved in the pathogenesis of endometriosis, including genes involved in inflammation, cell cycle regulation, growth factors, hormone receptors and adhesion molecules. At present, 19 independent nucelotide polymorphisms (SNPs) have been associated with endometriosis. At this stage, it’s hard to transform this information into a clinical treatment, however the advances in genetics and relevant technology is exciting and one to keep your eye on.
Dioxin exposure: is a common environmental pollutant, found throughout the world, making them hard to avoid. WHO (2016) state that 90% of human exposure is through food - mainly meat and dairy products, fish and shellfish. Dioxins are mainly by-products of industrial processes (but can also be from natural sources, such as volcanic eruptions, and forest fires), examples being manufacturing herbicides and pesticides, and bleaching paper and other materials. Once they enter the body, they last a long time with their half life suggested to be 7-11 years. Dioxins modulate estrogen receptor signalling, adversely affecting the bodies response to hormones!
Immune factors: endometriosis has been correlated with other autoimmune disease, such as rheumatoid arthritis, systemic lupus erythematosus, thyroid disease, celiac, inflammatory bowel disease and multiple sclerosis. This is due to it sharing pathophysiological similarities, being elevated cytokines, decreased cell apoptosis, and T- and B- cell abnormalities. Unfortunately, the quality of evidence is poor due to the high risk of bias identified in the studies (Shigesi et al., 2019). However, this definitely makes my mind think about all the wonderful immune modulating therapies we have at our fingertips! And, if it could provide some relief to this disease?!
symptoms
Painful periods (dysmenorrhea), and pain not associated with menstruation. Pain is not normal!! If you are in severe pain every month, reliant on pain medication, stuck in bed, and/or unable to work - then please go and talk to your GP about endometriosis.
Heavy periods. Again, not normal!! A normal period is anywhere up to 80mL. A soaked, regular pad or tampon holds about 5mL, and a super tampon holds 10mL. So, 80mL is 16 fully soaked pads or tampons, or 8 fully soaked super tampons. If you are bleeding more than this, again, please go and talk to your GP about endometriosis. It is also a considerable amount of blood to be losing every month, which can lead to anaemia.
Pain during sexual intercourse (dyspareunia).
Intermenstrual bleeding (Liu, 2019).
Other symptoms depend on the location of misplaced tissue:
Large intestine: pain during defecation, abdominal bloating, diarrhoea or constipation, rectal bleeding, nausea, vomiting.
Bladder: dysuria, hematuria, suprapubic or pelvic pain (particularly during urination), urinary frequency, urge incontinence.
Ovaries: formation of an endometrioma with occasional ruptures or leaks, causing acute abdominal pain and peritoneal signs, hot flushes prior to menstruation/at ovulation/conception/implantation.
Adnexal structures: adnexal adhesions, leading to pelvic mass or pain.
Extrapelvic structures: vague abdominal pain (Liu, 2019).
Further symptoms include: headaches, chronic fatigue, fainting, dizzy spells, depression, anxiety, back pain, pain in legs and thighs, anaemia, and hypoglycemia.
complications
Infertility.
Miscarriage.
Endometrioma rupture.
Endometrioma infection.
Malignant transformation - rare (1%).
naturopathy vs conventional
The main treatment methods of endometriosis via the conventional route is symptom management. This is done by surgical removal of the ectopic tissue, and or hormonal treatment to suppress ovarian function to avoid the cyclical effects on the tissue (via the oral contraceptive pill, mirena etc). Some women find the hormonal interventions extremely beneficial in minimising their pain, however some don’t. Sometimes, it is also recommeded to have a hysterectomy, however as the lesions can be found outside of the uterus, this may not provide any pain relief at all (Shigesi et al., 2019).
Naturopathic treatment involves symptom management, and exploring the root cause. A naturopath consultation involves looking at your diet, lifestyle, as well as the effects of/on other systems in the body, and how they contribute to your presentation. The health of the gastrointestinal tract, liver, immune system and eliminatory channels will be of high interest. Furthermore, complementary medicine has some great and extremely effective herbal and nutritional pain management herbal interventions, which are favoured in those with endometriosis.
key interventions
Again, I can’t stress this enough.. this will depend on the individual! And, this is a complex disease. Please don’t try and treat it yourself. You need to get professional care, and don’t be discouraged by that!
Some interventions that could be used in naturopathic treatments include:
For pain: The top of the list when treating endometriosis - pain is a very complex, and subjective experience which makes it difficult to pin down. Endometriotic type pain is associated with active inflammation, making it ‘nociceptive’ - meaning, pain that arises from damage to non-neural tissue. Other types of pain associated with endometriosis include neuropathic pain and muscular pain. Pain can be extremely stressful, so it is not uncommon to see dysfunction of the hypothalamic-pituitary-axis, which is a central component of the stress response (Coxon et al., 2018). Some common interventions for pain include:
Increase anti-inflammatories & antioxidant rich foods: as found in fatty fish (salmon, mackeral, sardines), nuts and seeds, cold pressed oils, turmeric, ginger, berries, citrus fruits, pineapple, papaya and green tea. Consider supplementing with fish oil or cod liver oil.
Decrease inflammatory foods: such as refined sugars, takeaway, saturated fats and deep fried foods, excessive caffeine, alcohol and refined carbohydrates; such as bread, pastries and pies.
Herbal & Nutritional interventions include those with anti-inflammatory, anti-oxidant, antispasmodic, anodyne and antiprostaglandin properties. We have some amazing herbs and nutrients at our fingertips that have been preferred by case subjects in the literature. As always, herbs and nutrients can have adverse effects if self-prescribed. A naturopath will work with you to tailor a treatment plan that is safe and specific to your presentation.
Engage with other physicians such as acupuncturists and physiotherapists. Hypertonic pelvic floor is something that contributes to spasms and pain in endometriosis, and can be supported by a physio.
Support your stress response by engaging in activities that make you feel relaxed, such as meditation, yoga, pilates, reading, singing, dancing, swimming, going for nature walks. There are also some very effective herbs and nutraceuticals that support your hypothalamic-pituitary-axis.
To reduce inflammation, and thus scar formation: Inflammation is a main contributor to pain and scar tissue formation. Interventions include:
Increase anti-inflammatories & antioxidant rich foods, and decrease inflammatory foods, as seen above. Again, consider supplementing with fish oil or cod liver oil.
Key herbal interventions and nutritional interventions include those with anti-inflammatory, tissue healing, immune modulating, and lymphatic properties. It is important to work with your naturopath to assess what herbs are right for your individual presentation. But examples could include calendula, gotu kola, yarrow, zinc & vitamin C.
For hormonal imbalances: Oestrogen dominance and progesterone insufficiency/resistance are a huge contributor to case presentation. Interventions include:
Assess the environment to determine if there are any environmental toxins disrupting the endocrine system, and exacerbating symptoms. Environmental toxins can be found in the water you’re drinking, cosmetics, perfumes, household products, pesticides and herbicides found in food, road or air pollutants, aircons.. the list goes on!
Addressing adrenal function due to cortisol having an inverse relationship with estrogen. The adrenals secrete adrenaline and cortisol, and with prolonged stress, they eventually crash, leading to adrenal exhaustion. If the adrenals are in overdrive, the body diverts progesterone to the adrenals to support cortisol production, due to progesterone being the precursor. This can support estrogen dominance by causing estrogen to be “unopposed”. Meaning, the estrogen:progesterone ratio is out. Furthermore, excessive cortisol actually blocks progesterone receptors, further contributing to low progesterone. There are many neutraceuticals and herbal interventions to support adrenal function, and again it is essential to be working with your practitioner to identify what ones are right for you.
Address weight and the conversion of adipose tissue to estrogen. Adipose tissue in those with excess weight significantly contributes to the body pool of estrogen. Tips include:
Reassess macronutrient intake to ensure you are not going over your energy in/energy out ratio.
Reduce your intake of calorie dense foods such as chocolate, pastries, takeout.
Exercise at least 3-4 times per week with exercises that increase your heart rate.
Assess liver function to enhance the clearance of estrogen. Ensure you are eating enough fibre, to support the binding and elimination of estrogens via the liver. Did you know the recommended daily intake for fibre is 35g/day? A lot of us do not meet that mark, and can contribute to constipation and the reabsorption of estrogens. Bitter foods stimulate the liver, and can be found in rocket, endive, broccoli sprouts, and lemons.
Assess gastrointestinal function as alterations in the microbiome can contribute to estrogen excess, called the ‘estrobolome’. Furthermore, alterations in bowel clearance can contribute to estrogen excess due to a process called enterohepatic circulation. This is when the bowels aren’t cleared frequently, leading to reabsorption of toxins and in this case, estrogen, leading to bodily excess. Key things a naturopath will look out for is dysbiosis (alterations of the gut bacteria), food intolerances, food excess or deficiencies, malabsorption and leaky gut, and altered motility.
If you have any further questions or things to add - I would love to hear from you! Please leave a comment, reach out on social media, or send me an e-mail :)
references
Burney, R. O., & Giudice, L. C. (2012). Pathogenesis and pathophysiology of endometriosis. Fertility and sterility, 98(3), 511–519. doi:10.1016/j.fertnstert.2012.06.029
Coxon, L., Horne, A. W., & Vincent, K. (2018). Pathophysiology of endometriosis-associated pain: A review of pelvic and central nervous system mechanisms. Best Practice & Research Clinical Obstetrics & Gynaecology. doi:10.1016/j.bpobgyn.2018.01.014
Klemmt, P., & Starzinski-Powitz, A. (2018). Molecular and Cellular Pathogenesis of Endometriosis. Current women's health reviews, 14(2), 106–116. doi:10.2174/1573404813666170306163448
Lie, J. (2019). Endometriosis. MSD Manual. Retrieved from https://www.msdmanuals.com/en-au/professional/gynecology-and-obstetrics/endometriosis/endometriosis.
Shigesi, N., Kvaskoff, M., Kirtley, S., Feng, Q., Fang, H., Knight, J. C., … Becker, C. M. (2019). The association between endometriosis and autoimmune diseases: a systematic review and meta-analysis. Human reproduction update, 25(4), 486–503. doi:10.1093/humupd/dmz014
The Department of Health. (2018). National Action Plan for Endometriosis. Retrieved from https://www1.health.gov.au/internet/main/publishing.nsf/Content/endometriosis
WHO. (2016). Dioxins and their effects on Human health. Retrieved from https://www.who.int/news-room/fact-sheets/detail/dioxins-and-their-effects-on-human-health