Understanding Endometriosis
Endometriosis is a chronic, benign, oestrogen-dependent gynaecological condition characterised by displacement of endometrial tissues (that normally lines the inner body of the uterus) to ectopic locations (meaning outside the usual place) in this case outside the uterine cavity (1,3). These endometrial tissues fix themselves and develop in the ectopic locations, accompanied by chronic inflammation (2).
The main features of the condition which accompany displaced endometrial tissue seem to be 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 (5), and 70% of women with chronic pelvic pain (6) a common symptom. Delays in diagnosing endometriosis are common, in the UK the average time to diagnosis is 7.5 years (7). Although preliminary diagnosis is done based on clinical history (2), the ‘gold standard’ for sure diagnosis is by surgical laparoscopy (which is looking inside the pelvic cavity with a camera) (8). Delays in diagnosis are perhaps at least partly because this invasive surgical method is not practical in all cases and is usually only resorted to after a series of other investigations have been carried out such as pelvic examination, blood tests, urinalysis, and ultrasound scan, none of which typically give a conclusive diagnosis of endometriosis but can be important in ruling out other conditions which present with similar symptoms (2).
Although a much-overlooked health condition perhaps due to its ‘invisible’ nature, endometriosis is becoming more well-known and better researched, especially as diagnosed cases have risen significantly in recent years (9).
Despite the increase in research though, 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 does show promise for those who might be at risk, to be able to take preventative measures through appropriately changing those of the habits which are implicated and beneficial for overall health.
How does endometriosis work?
Endometriosis is (usually) cyclical, meaning that ectopic endometrial deposits respond to monthly hormonal changes (9), including circulating oestrogens (estradiol and estrone) which stimulate endometrial tissue (2). Since endometriosis deposits respond to cyclical hormone changes, they behave in the same way as the endometrium (the lining of the womb) during the menstrual cycle, bleeding at the time of menstruation, which may contribute to local inflammatory reactions, and formation of fibrous adhesions and endometrial cysts (10). In addition to this endometriosis deposits also respond to inflammatory mediators (messengers in the body that promote inflammatory responses) 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).
This means that paying attention to inflammation and factors which may contribute to this is important for people with endometriosis, as well as factors which affect hormone balance.
People with endometriosis can have higher levels of a substance called Vascular Endothelial Growth Factor (VEGF). VEGF is the regulator of 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 disease states such as endometriosis. VEGF can also trigger increased vascular permeability, which means large molecules enter the tissues, resulting in further inflammation.
Some research suggests that endometriosis lesions recruit their own neural and vascular (nerve and blood) supplies through a process called neuroangiogenesis, and that this affects nerve cells in the area involved in sensory pathways which send pain signals to the central nervous system. This may mean that people with endometriosis 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 (2), or during an unrelated procedure such as laparoscopy for tubal ligation (sterilization through tying the fallopian tubes) (11).
Infertility is thought to affect between 30 – 50 % of patients with endometriosis (13), which can be because of different causes including structural changes of the reproductive organs due to endometrial deposits, adhesions, and scarring, by altered immune function, and hormonal changes which may affect egg quality and implantation of pregnancy (3).
Endometriosis is associated with a higher risk than in the general female population of developing other conditions such as ovarian cancer, and increased risk of breast and other cancers, as well as autoimmune and atopic disorders (5), which highlights the importance of early diagnosis, treatment, and management.
Understanding the root
Endometriosis is a mysterious health condition and the exact root cause remains unclear, but it is well accepted that ectopic displacement of endometrial tissue and inflammation are key features. If you have a serious health condition or persistent symptoms, it is always best to speak to a health practitioner.
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 (5), suggesting that other factors aside from retrograde menstruation are involved.
In simple terms, it seems that many women may have endometrial tissue present outside the uterine cavity (the womb), but that in some women this does not seem to 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 sister 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
- Current oral contraceptive use (although this often returns if 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, and 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).
While a clear cause of endometriosis remains elusive, it of course proves difficult to treat the condition at its root. However, there are many strategies which 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 manage any presenting symptoms.
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 inflammation
- Centella asiatica (gotu kola) is used for its anti-inflammatory properties and to reduce formation of adhesions (10, 16)
- Glycyrrhiza glabra (liquorice), Rehmania, and Zingiber (ginger) for anti-inflammatory properties.
- Calendula officinalis (marigold), Echinacea, and Phytolacca decandra (poke root) to support lymph, reduce congestion and inflammation (10, 15).
- Curcumin is an extract from Curcuma longa (turmeric). It stimulates microcirculation and possesses several pharmacological activities such as antioxidant, anti-inflammatory, and antiproliferative (10)
- Borage oil, evening primrose oil, flaxseed oil, pumpkin seed oil are full of essential fatty acids that help to decrease tissue inflammatory responses.
- Castor oil packs for external use
Reducing menstrual cramping
- Viburnum opulus (cramp bark), Caulophyllum (blue cohosh), Angelica sinensis (dong gui), Rubus ideaus (raspberry leaf), Zingiber officinale (ginger) for dysmenorrhoea and chronic pelvic pain (10, 16)
- Alchemilla vulgaris (ladies mantle) as a uterine tonic and astringent for menorrhagia (10, 15).
- Leonorus cardiaca (motherwort) may be helpful as an emmenagogue to promote more efficient menstruation if the flow is thick and heavy, this may reduce bleeding time (4), it is also helpful for reducing spasms, and as a nervine tonic (14, 15).
Hormonal regulation
- Vitex agnus castus (chaste berry) a hormone regulator indicated in relative oestrogen excess, perhaps because it has an indirect effect on increasing progesterone (15, 16)
- Taraxacum officinale (dandelion root), Schizandra, and Silybum (St Mary’s Thistle) to support liver function and breakdown of oestrogen (14, 16)
Reducing pain and spasm
- Paeonia lactiflora reduces cramps in dysmenorrhoea due to antispasmodic effect (4), also anti-inflammatory and oestrogen modulating (15)
- Pulsatilla pratensis for management of ovarian pain (10, 16).
Other support
- Thuja to control tissue growth (16)
- Withania somnifera (ashwagandha), Rhodiola, and Rehmania may be beneficial as adaptogens to support stress responses.
- Prickly Ash as a circulatory stimulant may help to reduce pelvic congestion (14).
- Commiphora mukul (myrrh or guggul) traditionally used in Ayurveda to regulate menstruation, is nutritive, healing to mucous membranes, and indicated in endometriosis (17).
- Hypericum perforatum (St John’s wort) may be helpful in providing nervous system support for mood changes associated with endometriosis (4).
Holistic solutions
Dietary and lifestyle
Some of the risk factors associated endometriosis are modifiable lifestyle habits, such as:
- caffeine and alcohol intake (which may be reduced).
- regular exercise associated with decreased risk (can be adopted).
A small observational study of women with endometriosis who had made dietary changes found they experienced decreased symptoms of endometriosis (especially pain and fatigue), increased wellbeing, and gained a greater understanding of their bodies after adopting an individually adapted diet (18). This suggests that knowing your own body and self-involvement in care options for managing endometriosis are important. 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 ‘clean’ 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 and phytonutrients (20) including plenty of vegetables and fruits, for fibre which helps hormone balance (3) and antioxidants .
- Reducing foods which contribute to inflammation (processed and fried foods, red meat, sugar, alcohol, dairy) (14).
Cabbage family vegetables help to favourably balance oestrogen levels, so eating more cabbage, broccoli, brussels sprouts, cauliflower may be beneficial.
Vitamin C: improves immunity, decreases fatigue and capillary fragility (14).
Vitamin E: helps correct progesterone / oestrogen ratios, and inhibit 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 chemicals that disrupt your hormones. These are also known as endocrine disruptors and include (14):
- Pesticides
- DBP
- DEHP
- BPA
- Bisphenol A
- Phthalates
- Dioxins
- Pesticides
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. doi: 10.3390/ijms221910554.
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- 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. [PubMed: 15980014].
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- Missmer, S.A, Hankinson, S.E, Spiegelman, D, Barbieri, R.L, Marshall, L.M, Hunter, D.J. Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric, and lifestyle factors. Am. J. Epidemiol. 2004;160:784–796.
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