Endometriosis

What is Endometriosis?

Normally, the endometrium lines the inside of the uterus and is expelled during each menstrual period. When endometrial tissue grows in locations outside the uterus, endometriosis occur.

The cells of endometriosis that attach themselves to tissue outside the uterus are called endometriosis implants.

These implants are most commonly found on the ovaries, the Fallopian tubes, the outer wall of the uterus, the uterine or ovarian ligaments, the bowel and the bladder.

They can also be found in the vagina, cervix, and in rare cases they can occur outside the pelvis, on the liver, in old surgery scars, and even in or around the lung or brain.

Endometriosis may cause adhesions (fibrous scar tissue) and the uterus can become stuck to the ovaries, fallopian tubes and bowel.

 

What Causes Endometriosis?

Endometriosis is a perplexing complaint. No one knows for sure why it occurs, and so prevention is difficult. It causes a multitude of different symptoms, making it hard to diagnose. 

Possible causes include:

  • Relative oestrogen excess – relatively higher level of oestrogen might be stimulating thicker endometrium and more substantial pelvic contamination, because of increased menstrual volume. Studies have documented absence of progesterone receptors in women with endometriosis, which can contribute to relative oestrogen excess and increased prostaglandin E2. 
  • Aromatase activity (the enzyme needed to convert androgens to oestrogen) in the endometrium of women with endometriosis favour increased oestrogen production. Aromatase is not present in normal endometrium, but is expressed aberrantly in endometriosis, and is also capable of initiating an increase in PGE2.
  • Retrograde flow – Endometrial tissue is deposited in unusual locations by the backing up of menstrual flow into the Fallopian tubes and the pelvic and abdominal cavity during menstruation (termed retrograde menstruation). The cause of retrograde menstruation is not clearly understood, but it cannot be the sole cause of endometriosis. Many women have retrograde menstruation in varying degrees, yet not all of them develop endometriosis.
  • Prostaglandins – these substances are extremely important factors in the normal function of the reproductive tract and as a causative agents in disease. It has been suggested that young women with severe dysmenorrhoea may be more susceptible to endometriosis, as extreme uterine contractions associated with prostaglandins imbalance may increase retrograde flow.
  • The immune system – the immune system appears to be involved in the development of endometriosis. The number of white cells found in the peritoneal fluid increases in the early stages of endometriosis. These white cells normally engulf and/or destroy cells which should not be found in the fluid in the pelvic cavity.
  • Cellular change – some researchers believe that the cells which line the pelvic cavity alter and become identical to endometrial cells, then behave in the same way.

Researchers in the UK, Australia and USA have identified variations in the DNA of women with endometriosis that predispose them to developing the condition, which affects an estimated 176 million women worldwide during their reproductive years. (1)

Endometriosis tend to recur, and about half of all women with endometriosis develop the condition again within 5 years of completing a successful treatment.

It is also likely that direct transfer of endometrial tissues during surgery may be responsible for the endometriosis implants sometimes seen in surgical scars (for example, episiotomy or Cesarean section scars).

Transfer of endometrial cells via the bloodstream or lymphatic system is the most likely explanation for the rare cases of endometriosis that develop in the brain and other organs distant from the pelvis.

 

Risk Factors for developing endometriosis:

A number of dietary, inherited and lifestyle factors seem to contribute to the risk of developing endometriosis.

  • Starting to menstruate in an early age
  • History of heavy bleeding and long periods ( more than 7 days)
  • Having a first degree relative that has endometriosis
  • Genitourinary tract abnormality that increases retrograde flow
  • Exercise – women who engaged in strenuous exercise during menstruation had an increased risk of endometriosis, thought to be related to retrograde flow
  • Pregnancy – full term pregnancies are associated with reduced risk of endometriosis.

Endometriosis is found almost entirely in women of reproductive age and its development is strongly associated with presence of oestrogen. The disease is rare in post-menopausal women.

 

Symptoms:

Endometriosis is assosiated with a range of symptoms but is also asymptomatic in 30 % of cases.

The symptoms of endometriosis include:

  • Painful periods
  • Irregular or heavy menstrual bleeding
  • Pelvic pain
  • Lower back pain
  • Bloating
  • Pain during bowel movements and/or urination
  • Severe pre-menstrual symptoms
  • Painful sexual intercourse (dyspareunia)
  • Reduced fertility

The pain intensity can change from month to month, and vary greatly among women. Some women experience progressive worsening of symptoms, while others can have resolution of pain without treatment.

There is no relationship between severity of pain and how widespread the endometriosis is.

Unusual symptoms may include blood in the urine and headaches or sciatica, and are related to endometrial deposits in tissues as distant as the brain and the bladder.

 

How Is Endometriosis Diagnosed?

The condition is under-diagnosed and is often mistaken for dysmenorrhoea. A definitive diagnosis of endometriosis can only be made by laparoscopy and direct visualisation.

Laparoscopy is a surgical procedure performed under general anaesthetic, where a medical instrument with a video camera attached is used to examine your pelvic organs.

Ultrasound is a type of imaging using high frequency sound waves to show the contents of the pelvic cavity. Ultrasound will not reveal endometriosis, but it can be used to diagnose particular type of blood filled ovarian cysts (endometriomas) associated with endometriosis.

 

How Is Endometriosis Treated?

The Medical Approach 

  • Surgery is the most common treatment for endometriosis and is most frequently done by laparoscopy or laparotomy. Endometrial lesions are ablated by heat or laser diathermy. Surgery to remove implants seems to reduce pain considerably, and is also used as a way of improving fertility.
  • Anti-inflammatory drugs – Ibuprofen, Naproxen are commonly prescribed for pelvic pain and menstrual cramping. These medications have no effect on the endometrial implants.
  • Gonadotropin-releasing hormone analogs (GnRH analogs) suppress oestrogen production by the ovaries and as a result menstrual periods stop, mimicking menopause. This treatment leads to regression of the implants with marked pain relief. Side effects include hot flashes, vaginal dryness, irregular bleeding, mood changes, fatigue and osteoporosis. 
  • Danazol increases serum testosterone, relieves pain and resolves implants. 
  • Oral contraceptive pills (estrogen and progesterone in combination) are also used to treat endometriosis.
  • In very severe or chronic cases a hysterectomy may be needed.  

 

The Natural Medicine Approach

Endometriosis is a very complex disease and disrupts many areas of a woman’s life.

Natural medicines are aiming to improve relative oestrogen excess, regulate prostaglandin synthesis and the immune system to ensure normal uterine function and menstruation, and improve fertility.

Modern lifestyle seems to impair oestrogen clearance via the liver and bowel, and women today are over-exposed to the stimulatory effects of oestrogen. Mediherb LivStim Phytosynergist liquid and Mediherb LivCo contain herbs that increase bowel flow and liver metabolism of hormones, and can improve oestrogen clearance.

Herbal Liver detoxification formula is also designed to enhance liver detoxification.

Women with endometriosis experience many different problems with ovulation. Ovulation can either be delayed or the follicle might not develop properly. One of the causes of infertility is thought to be the Luteinised unruptured follicle syndrome, where the follicle develops, but the egg is not expelled. MediHerb Tribulus Forte is a tonic herb and when used in the upper end of the dose in the follicular phase of the menstrual cycle can improve ovulation rates.

Female Reproductive herbal formula is designed to help support healthy reproductive system. Rehmania and Dong Quai are traditionally used to regulate menstruation. Dong Quai provides both antispasmodic and stimulating activity on the uterine muscle. Ginger helps to reduce inflammation. Shatavari has been used traditionally as an uterine tonic.

MediHerb EndoFem contains Dong Quai, Peony, Calendula and Ladies Mantle. Calendula helps to reduce muscle spasm, reduces inflammation and lessens menstrual bleeding. Dong Quai helps to initiate regular uterine contractions. Paeonia helps to modulate hormoanl balance.

Flordis Premular contains Vitex and helps improve menstrual irregularities, premenstrual syndrome and infertility. It is a difficult herb to use , as it may cause ovulatory hyperstimulation and should be prescribed by a practitioner.

MediHerb Cramplex is used to reduce spams, menstrual cramping and pain.

Menstrual support (MenstroCare) is a combination of Chinese herbs that helps maintain healthy hormonal balance, helps relief PMS and irregular menstruation. Chaste tree has been shown to assist in healthy balance of oestrogen and progesterone, and normalise menstrual cycle.

Oestrogen Detoxification provides powerful support for oestrogen metabolism.

Antioxidant Superfoods is a great tasting powder containing a broad range of nutrients and phytochemiclas which provide antioxidant support. Research suggests that exposure to environmental toxins, and free radical damage, may contribute to the development of endometriosis.

High Potency EPA and  MediHerb Evening Primrose Oil alter prostaglandins and leukotrine levels and may improve fertility, reduce inflammation and bleeding tendencies.

Supplementation with Vitamin E improves the symptoms of endometriosis, possibly due to its antioxidant activity and maybe also due to its effects on prostaglandin metabolism which reduces bleeding. Vitamin E has also shown to reduce adhesion formation.

 

Lifestyle and dietary Changes:

  • Buy hormone-free animal products (eggs, poultry, meats, dairy).
  • Avoid heated plastics, plastic lined items and Styrofoam (microwave, oven, sun).
  • Eat high fibre diet, more cruciferous vegetables like broccoli, cauliflower, Brussels' sprouts, and cabbage. They help excrete excess oestrogen.
  • Purchase “organic” locally grown produce, free from pesticides, herbicides, chemical sprays or synthetic fertilisers.
  • Reduce sugar, caffeine and alcohol intake, and avoid saturated fats and refined foods.
  • Include bitter foods in your diet – endive, chicory, silverbeet, radicchio, mustard greens, dandelion leaf, grapefruit 
  • Increase intake of whole grains, fresh vegetables, and vegetable proteins (legumes such as soy).
  • Eat diet rich in Omega-3 (eg. cold water fish, nuts and seeds) and low in animal fats.
  • Exercise regularly ( avoid exercise during your period) to stimulate pelvic circulation and improve general fitness.

 

Endometriosis is difficult to diagnose and can cause a whole range of complex and really debilitating symptoms.

An Emed E- Consult is an easy and cost effective way to discuss your case and obtain a Personalised Health Prescription from a qualified Naturopath. 

 

 

References:

1. Painter JL, et al. Genome-wide association study identifies a locus at 7p15.2 associated with endometriosis. Nature Genetics doi: 10.1038/ng.731

 

Further Reading: