Endometriosis is estimated to affect between 10–15% of people who menstruate and is characterised by the displacement of endometrial tissue growing outside the uterus. We explore natural remedies and herbs for endometriosis.
Understanding endometriosis
Endometriosis is a chronic, benign, oestrogen-dependent gynaecological condition characterised by displacement of endometrial tissue (usually lining the inside of the uterus) to ectopic locations (outside the usual place), in this case outside the uterine cavity (1,3). These endometrial tissues fix themselves and develop in ectopic locations including the bowel, bladder, fallopian tubes and occasionally respiratory and nasal passages. This is often accompanied by chronic inflammation, which can cause adhesions, scarring and pain in the affected sites (2).
The predominant features accompanying displaced endometrial tissue are chronic inflammation, immune system imbalances, and relative oestrogen excess (a relatively higher level of exposure to oestrogen compared to other women and in relation to progesterone levels) (3,4).
Endometriosis is estimated to affect 10–15% of menstruating women, and 70% of women with chronic pelvic pain — a common symptom (5,6). The process of diagnosis is often subject to significant delays in the UK, with the average time currently at 7.5 years (7). Endometriosis is estimated to be responsible for up to 25% of cases of infertility, although a definitive causative factor has not been confirmed. Although preliminary diagnosis is done based on clinical history, the ‘gold standard’ for a positive diagnosis is by surgical laparoscopy (keyhole surgery using a camera to observe the pelvic cavity) (2,8). Delays in diagnosis can be partly attributed to the fact that this invasive surgical method is not practical in all cases. It is usually a final resort following a series of other investigations such as pelvic examination, blood tests, urinalysis, and ultrasound scan, none of which typically give a conclusive diagnosis of endometriosis but are important in ruling out other conditions which present with similar symptoms (2).
Endometriosis has, until now, been widely overlooked as a health condition, in part due its largely invisible nature. However, endometriosis is now becoming more well-known and better researched, especially as diagnosed cases have risen significantly in recent years (9).
Despite this increase in research, endometriosis remains a somewhat complex condition which is difficult to diagnose and treat. However, there are some dietary and lifestyle factors associated with the risks of developing endometriosis, and whilst these do not usually occur in isolation, it shows promise for those who might be at risk. These considerations allow people to take preventative measures through appropriately implementing changes to increase overall health and reduce risk factors.
How does endometriosis work?
Endometriosis is (usually) cyclical, as ectopic endometrial deposits respond to monthly hormonal changes, including circulating oestrogens (oestradiol and oestrone) which stimulate endometrial tissue (2,9). Due to this hormonal component, endometrial tissue responds in the same way as the endometrium (lining of the womb) during the menstrual cycle. The most significant response is bleeding at the time of menstruation, which contributes to local inflammatory reactions, and formation of fibrous adhesions and endometrial cysts (10). This can also result in other symptoms such as nosebleeds or pink sputum if the endometrial tissue has migrated to the nasal or respiratory passages. In addition to this, endometrial deposits also respond to inflammatory mediators which are secreted by immune cells in the peritoneum (a membrane that lines the inside of the abdomen and pelvis), by increasing the number of cells at ectopic sites, which can cause them to develop further (10).
As a result, considering factors that contribute to inflammation and hormonal balance are important for people with endometriosis.
People with endometriosis can have higher levels of a substance called vascular endothelial growth factor (VEGF). VEGF regulates angiogenesis, a process involved in the development, growth, and specifically formation of new blood vessels to allow new tissues to receive nutrients and grow, including in endometriosis. VEGF can also trigger increased vascular permeability, which means large molecules enter the tissues, resulting in further inflammation.
Research suggests that endometrial lesions recruit their own neural and vascular (nerve and blood) supplies through a process called neuroangiogenesis, affecting local nerve cells involved in sensory pathways, which send pain signals to the central nervous system. This suggests that people with endometriosis may have increased pain perception in the affected areas (12).
The size or severity of the endometriosis deposits does not always relate to the severity of symptoms. Not everyone who has endometriosis will experience symptoms, but for those who do, they often involve different types of pelvic pain. In some women who are otherwise completely symptom free, endometriosis is only detected during investigations for infertility, or during an unrelated procedure such as laparoscopy for tubal ligation (sterilisation through tying the fallopian tubes) (2,11).
Infertility is thought to affect between 30–50 % of patients with endometriosis , which can be due to a variety of causes including structural changes of the reproductive organs due to endometrial deposits, adhesions, scarring, altered immune function, and hormonal changes which may affect egg quality and implantation of pregnancy (3,13).
Endometriosis is associated with a higher risk of developing other conditions such as ovarian cancer, breast and other cancers, as well as autoimmune and atopic disorders, which highlights the importance of early diagnosis, treatment, and management (5).
Understanding the root
Endometriosis is a mysterious health condition and the exact root cause remains unclear, but it is well accepted that immunological factors and inflammation are key features. For anyone with a serious health condition or persistent symptoms, consultation with a health practitioner is always recommended.
A common hypothesis for the development of endometriosis is retrograde menstruation (backward menstrual blood flow through the fallopian tubes into the peritoneal cavity), with subsequent implantation of endometrial cells (5).
However, retrograde menstruation is observed among healthy menstruating women and might even be universal among all menstruating women, whereas endometriosis affects only around 10–15% of menstruating women, suggesting that other factors aside from retrograde menstruation are involved (5).
In simple terms, it seems that many women may have endometrial tissue present outside the uterine cavity (the womb) which does not progress or become problematic for health, perhaps due to healthy immune and inflammatory response, or lack of other risk factors (4).
There are several risk factors proposed to be associated with the development of endometriosis, as follows (2,3,4,14).
Factors associated with increased risk
- Heredity (mother or sibling with endometriosis)
- Earlier age of menarche (before age 11)
- Shorter menstrual cycle length (less than 27 days)
- Taller height
- Low BMI
- Alcohol use (daily)
- Caffeine
- Lack of exercise
- High fat diet
Factors associated with decreased risk
- Parity (the number of times an individual has given birth)
- Current oral contraceptive use (although this often returns if the contraceptive pill is stopped, and oral contraceptives often have other side effects and implications)
- Smoking
- Higher body mass index
- Regular exercise
- Fish and omega 3 fatty acids
In summary, the root of endometriosis is likely to be a combination of retrograde menstrual flow, other risk factors, coupled with circumstances suitable for its development such as immune system imbalances, high levels of pro-inflammatory markers, and relative oestrogen excess. Relative oestrogen excess can be associated with heavier menstrual volume, increasing likelihood of retrograde flow, and shorter menstrual cycle length (4).
Whilst a clear cause of endometriosis remains elusive, it proves difficult to treat the condition at its root. However, there are many strategies that can help to manage this complex condition, such as improving immune function, reducing inflammation, balancing hormone health, and supporting optimal liver function to ensure metabolism of hormones, alongside additional support to help provide symptomatic relief.
Signs and symptoms
- Pelvic pain
- Acute pain before menstruation
- Painful periods (dysmenorrhoea) which may be accompanied by vomiting / diarrhoea / fainting
- Painful ovulation
- Pressure on lower back
- Intermenstrual bleeding
- Bleeding from nose, bladder, or bowels
- Fatigue
- Painful intercourse (dyspareunia)
- Painful defecation (dyschezia)
- Painful urination (dysuria)
- Infertility
Accompanying symptoms (usually in addition to one or more from above):
- Symptoms of depression and anxiety
- Nausea
- Dizziness
- Headaches
Herbal solutions
Reducing endometriosis inflammation
- Gotu kola (Centella asiatica) is used for its anti-inflammatory properties as well as to reduce formation of adhesions and encourage tissue healing (10,16).
- Liquorice (Glycyrrhiza glabra), rehmannia (Rehmannia glutinosa), and ginger(Zingiber officinale) for anti-inflammatory properties.
- Marigold (Calendula officinalis), echinacea (Echinacea purpurea), and poke root (Phytolacca decandra) to support lymph, reduce congestion and inflammation (10,15).
- Curcumin is a constituent of turmeric (Curcuma longa). It stimulates microcirculation and possesses several pharmacological activities such as antioxidant, anti-inflammatory, and antiproliferative (10).
- Borage, evening primrose, flaxseedand pumpkin seed oils are full of essential fatty acids that help to decrease tissue inflammatory responses.
- Castor oil packs for external use.
Reducing menstrual cramping
- Cramp bark (Viburnum opulus), blue cohosh (Caulophyllum thalictroides), dang gui (Angelica sinensis), raspberry leaf (Rubus ideaus), ginger for dysmenorrhoea and chronic pelvic pain (10,16).
- Lady’s mantle (Alchemilla vulgaris) as a uterine tonic and astringent for menorrhagia (10,15).
- Motherwort (Leonurus cardiaca) may be helpful as an emmenagogue to promote more efficient menstruation if the flow is thick and heavy, this may also reduce bleeding time (4). It is also helpful for reducing spasms, and as a nervine tonic (14,15).
Hormonal regulation
- Agnus castus (Vitex agnus castus) is a hormone regulator indicated in relative oestrogen excess, as it has been shownto exert an indirect effect on increasing progesterone (15,16).
- Dandelion root (Taraxacum officinale) , schisandra (Schisandra chinensis), and milk thistle (Silybum marianum) to support liver function and breakdown of oestrogen (14,16).
Reducing pain and spasm
- Peony (Paeonia lactiflora) reduces cramps in dysmenorrhoea due to its antispasmodic effect (4). It is also anti-inflammatory and an oestrogen modulator (15).
- Pasqueflower (Pulsatilla vulgaris) for management of ovarian pain (10,16).
Other support
- Thuja (Thuja occidentalis) to control tissue growth due to its antiproliferative effects (16).
- Ashwagandha (Withania somnifera), rhodiola (Rhodiola rosea), and rehmannia may be beneficial as adaptogens to support stress responses.
- Prickly ash (Zanthoxylum americanum) as a circulatory stimulant may help to reduce pelvic congestion (14).
- Myrrh or guggul (Commiphora mukul/ C. molmol) is traditionally used in Ayurveda to regulate menstruation, as a nutritive, and healing to mucous membranes, thereby indicating it in endometriosis (17).
- St John’s wort (Hypericum perforatum) may be helpful in providing nervous system support for mood changes associated with endometriosis (4).
Holistic solutions
Diet and lifestyle
Some of the risk factors associated with endometriosis are modifiable lifestyle habits, which can be mitigated by:
- A reduction in caffeine and alcohol intake
- An increase in regular exercise
A small observational study of women with endometriosis who had made dietary changes found they experienced decreased symptoms of pain and fatigue, increased wellbeing, and gained a greater understanding of their bodies after adopting an individually adapted diet (18). The main dietary changes from this study were:
Excluding or decreasing the amount of:
- Gluten
- Dairy products
Adding more:
- Vegetables and fruit
- Cooking food from scratch with fresh ingredients
Other dietary recommendations:
A diet high in omega 3 fatty acids is associated with a significantly lower risk of endometriosis, whilst a high intake of trans fats and red meat is associated with a higher risk of endometriosis (3,19).
Anti-inflammatory diet
This will naturally be helpful in an inflammatory condition, the basis is:
- Increasing foods with an anti-inflammatory effect in the body, which generally includes a variety of whole, plant-based foods rich in healthy fats, antioxidants and phytonutrients including plenty of vegetables and fruits (20). An increase in fibre also helps with hormonal balance as it helps with elimination of excess hormones (3).
- Reducing foods which contribute to inflammation including processed and fried foods, red meat, sugar, alcohol and dairy (14).
- Cabbage family (brassicaceae) vegetables help to favourably balance oestrogen levels, so eating more cabbage, broccoli, brussels sprouts and cauliflower may also be beneficial.
- Vitamin C improves immunity, decreases fatigue and capillary fragility (14).
- Vitamin E helps correct progesterone:oestrogen ratios, and inhibits some inflammatory pathways (14).
- Acupuncture has been found to be effective in reducing pain associated with endometriosis (21).
- Sufficient sleep, rest, and stress management will all benefit a healthy immune system, healthy inflammatory responses, and healthy hormone balance.
Avoid endocrine disruptors
Avoid endocrine disruptors (chemicals which affect hormonal concentrations) such as (14):
- Pesticides
- DBP
- DEHP
- BPA
- Bisphenol A
- Phthalates
- Dioxins
References
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- Smolarz B, Szyłło K, and Romanowicz H. Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature). Int J Mol Sci. 2021 Oct; 22(19): 10554. https://doi.org/10.3390/ijms221910554
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- Carter JE. Combined hysteroscopic and laparoscopic findings in patients with chronic pelvic pain. J Am Assoc Gynecol Laparosc. 1994;2:43–47. https://doi.org/10.1016/s1074-3804(05)80830-8
- National Institute for Health and Clinical Excellence. Endometriosis: Diagnosis and Management. Full Guideline 2017. https://www.nice.org.uk/guidance/ng73. Accessed 4 June 2022.
- Kennedy S, Bergqvist A, Chapron C, D’Hooghe T, Dunselman G, Greb R, et al. Special Interest Group for Endometriosis and Endometrium Guideline Development Group. ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod. 2005;20(10):2698–704. https://doi.org/10.1093/humrep/dei135
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