Endometriosis: Theories, Evidence, and Treatment
Pamela Frank, BSc (Hons), ND
Endometriosis is a condition in which endometrial lining escapes the uterus, attaches to structures in the peritoneal cavity, and causes pain as the tissue grows in response to monthly fluctuations in estrogen. Endometrial tissue has been found in endometriosis patients as high as their lungs, where it can cause catamenial pneumothorax.1 Like the uterine lining, this tissue is sensitive to hormonal changes, growing in response to increases in estrogen levels. This growing tissue puts pressure on surrounding tissues and nerves, causes adhesion formation, and can bleed during menstruation. The pain can be present throughout a woman’s menstrual cycle, not just at menstruation, and can be both excruciating and debilitating. Conventional treatment usually involves hormonal suppression and/or laparoscopic surgery. 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.2
Endometriosis Pathogenesis Theories
- Sampson Hypothesis: Retrograde Menstrual Flow – This theory suggests that the cause of endometriosis is menstrual blood flowing in the wrong direction, out the fallopian tubes and into the abdomen. Anything that would encourage this backward flow is discouraged, eg, head stands, certain yoga poses on heavy flow days, and tampon use. Although retrograde menstruation appears to be a near-universal occurrence (76-90% of all women are estimated to experience this3), women with endometriosis have higher volumes of refluxed menstrual blood and endometrial tissue fragments than do women without the disorder. Some women appear to be at particular risk for developing endometriosis, perhaps through some of the mechanisms mentioned below.
- Tampon Use – Aside from the possibility of obstructing proper menstrual flow, there has also been research linking dioxin (a byproduct of bleach) to endometriosis. Bleached tampons may introduce dioxin into a woman’s system; however, a study by the Environmental Protection Agency concluded that personal care products and bleached coffee filters do not expose women to significant amounts of dioxin, whereas dietary intake from red meat and dairy products was significant.4
- Autoimmune/Altered Immunity – Some new research is suggesting that endometriosis may have an autoimmune component due to a high level of anti-endometrial antibodies found in endometriosis patients.5 Whether this is a result of endometriosis or a cause of it remains to be seen. It would be expected that the immune system would generate antibodies against endometrial tissue in a foreign location in an attempt to resolve endometriosis implants. A 1988 survey conducted in the United States found significantly more hypothyroidism, fibromyalgia, chronic fatigue syndrome, autoimmune diseases, allergies and asthma in women with endometriosis compared to the general population.6
- Estrogen Dominance – Typical North American diets, sedentary lifestyle, and our polluted environment set the stage for estrogen dominance, promoting estrogen’s influence on endometrial tissue.7,8 Studies in mice have shown that estrogen can promote B-cell activation and production of autoimmune antibodies.9 Estrogen dominance may contribute to altered immunity, which then contributes to development and/or progression of endometriosis. The one menstrual characteristic that has been linked to endometriosis is shortened cycle length, ie, less than 28 days,10 suggesting that progesterone insufficiency may contribute to this disorder.
- Excess Telomerase Activity – Telomerase is an enzyme in the lining of the uterus that has been shown to be overly active in women with endometriosis.11 The enzyme is normally more active through the follicular phase and less so through the luteal phase. As a result of increased telomerase activity, the lining of the womb may become more hostile to an early pregnancy, and the cells that are shed at this late stage in the menstrual cycle may be more “aggressive” and more able to survive and implant outside the uterus, causing pain in the pelvic or abdomen area.
- Coelomic Metaplasia – This theory proposes that cells that line the abdominal cavity can differentiate into endometrial tissue. Support for this theory is based on evidence of endometriosis lesions in a woman with complete uterine agenesis,12 and endometriosis in males.13
- Genetic Predisposition – Mothers and sisters of a woman with endometriosis are at a 7-fold increased risk of developing the disease.14
Naturopathic Approaches to Endometriosis
Naturopathic treatment goals for endometriosis include:
- Resolution of existing endometriosis tissue
- Moderation of endometrial tissue escape
- Pain relief
- Enhanced detoxification and excretion of excess estrogen and xenoestrogens
- Moderation of estrogen activity through proper diet, stress reduction, and exercise
Resolving Endometriosis Tissue
The immune system is responsible for identifying and resolving this anomalous tissue. Acupuncture can be used to help stimulate immune system activity in the abdomen and enhance resolution of endometrial implants.15
Castor oil packs (Ricinus communis) work to dissolve foreign tissue growth, including endometriosis. An article in the Journal of Naturopathic Medicine found that castor oil packs were effective as an anti-toxin and for enhanced immunological function.16
Acupuncture works amazingly well to relieve pain of any type, including endometriosis pain.17
Rosmarinus officinalis (rosemary) is a potent anti-inflammatory, possibly due to the polyphenol, rosmanol, and downregulation of NF-KappaB.18 Curcumin has been demonstrated to inhibit MMP-3 and induce regression of endometriotic lesions in a mouse model of endometriosis.19 And, as described below, resveratrol and melatonin may have analgesic effects in endometriosis.
Detoxification of Excess Estrogen and Xenoestrogens
Estrogen activity is increased when insulin levels are high, so maintaining steady blood sugar and increasing insulin sensitivity can modulate estrogen activity.20,21 Xenoestrogens can contribute to symptoms of estrogen dominance (Table 1).22
Table 1. Sources of Xenoestrogens
|Commercially raised, non-organic meats|
|Commercial dairy products|
|Bisphenol A (BPA)|
|Dryer sheets and fabric softeners|
|Personal care products containing parabens or phenoxyethanol|
|Air fresheners containing phthalates|
Progesterone Insufficiency/Luteal Phase Defect
Progesterone-based medication has been standard medical treatment for endometriosis. Supporting progesterone production through healthy diet, and also balancing the estrogen/progesterone ratio with herbs such as Vitex agnus-castus have been clinically helpful in endometriosis.
Efficient detoxification of hormones and xenoestrogens requires nutritional support of liver function.
Phase I detoxification requires:
- Vitamins: B2, B3, B6, B12, folic acid (in the form of 5-methyl-tetrahydrofolate (5-MTHF), beta-carotene, vitamin A, C, E
- Minerals: Copper, manganese, selenium, zinc
Phase II detoxification requires:
- Cysteine, methionine
Endometriosis patients often have concomitant bowel issues or IBS.23 Reducing bowel inflammation can ease endometriosis associated pain. A healthy digestive tract also allows more efficient excretion of estrogen or xenoestrogens. One study demonstrated that Lactobacillus gasseri OLL2809 suppressed development of endometriosis via activation of natural killer cells.24
A clean, whole foods, low-glycemic index, low-glycemic load diet that is free from immune-suppressing foods like sugar, processed carbohydrates, red meat, dairy, GMO foods, and additives and preservatives is essential to expedite resolution of endometriosis tissue (Table 2).
Table 2. Dietary Recommendations
|Foods to Avoid|
|Foods to Emphasize|
Traditional Chinese Medicine
A Traditional Chinese herbal formula containing Ramulus Cinnamomi, Poria, Cortex Moutan, Radix Paeoniae Rubra, and Semen Persicae plays an important role in the regression of endometriotic implants via immunological regulation in a rat model. Rats were given either a low-dose (480 mg/kg/day) or high-dose (1920 mg/kg/day) treatment.32
Supplements for Endometriosis
- Pinus maritima (pycnogenol): Pycnogenol is a powerful antioxidant from the bark of the pine tree. It is known to improve egg and sperm health. A 2007 study revealed a 33% reduction in endometriosis symptoms after 48 weeks of 60 mg of pycnogenol per day.33
- Resveratrol: Supplementation with 30 mg per day of resveratrol along with an oral contraceptive was found to significantly improve and even resolve dysmenorrhea and pelvic pain in endometriosis patients.34
- Melatonin: A study found that 10 mg per night of melatonin had an analgesic effect on endometriosis-associated chronic pelvic pain and improved sleep quality. Additionally, melatonin was found to modulate the secretion of brain-derived neurotrophic factor and pain through distinct mechanisms.35
- N-acetylcysteine (NAC): Supplementation with 600 mg TID of NAC was found to decrease endometrial cyst mean diameter, compared to a significant increase in cyst diameter in untreated patients.36
- Indole-3-carbinol (I3C): I3C may help endometriosis by increasing phase II liver enzyme activity, particularly glutathione-S-transferase (GST).37
- Calcium-D-glucarate: Glucuronidation occurs during the second phase of liver detoxification and is the process of conjugating hormones, carcinogens, or other lipid‑soluble toxins with glucuronic acid so that they can be excreted via the biliary tract. Bacterial β‑glucuronidase in the gut can deconjugate these complexes, making it possible for the toxins to be reabsorbed into the body. Calcium-D‑glucarate has the ability to reduce the β‑glucuronidase activity of intestinal bacteria, thereby allowing more efficient toxin and conjugated hormone excretion.38
- Vitamin D3: In a rat model of endometriosis, administration of vitamin D3 resulted in a significant reduction in the cross-sectional area of endometriosis cysts.39
- Curcumin: In a mouse model of endometriosis, curcumin was shown to reduce inflammation through inhibition of NFkappaB and to cause regression of endometriotic lesions.19
A Typical Protocol for Endometriosis
As discussed, the diet should consist of clean, organic, whole foods that are low-glycemic index, low-glycemic load, and high fiber, and free from immune-suppressing foods like sugar, processed carbs, red meat, dairy, GMO foods, and additives and preservatives. In addition, the following treatments are often helpful:
- B Complex with 5-MTHF – 1 capsule BID with food
- I3C – 400 mg once per day with food for one month, then reassess
- Calcium-D-glucarate – 650 mg per day with food for one month, then reassess
- Melatonin – 3-10 mg 1-2 hours before bed
- NAC – 600 mg TID with food for 3 months
- Pycnogenol – 60 mg once per day with food
- Resveratrol – 30 mg per day with food
- Curcumin (sustained-release) – 1000 mg BID
- Vitex agnus-castus – 1 tsp TID
- Probiotics – at least 50 billion CFU 2-3 times per day with food
- Vitamin D3 – 1000 IU TID with food
- Castor oil packs nightly over the lower abdomen
- Acupuncture – once per week for 6 weeks, then monthly between cycle days 6 and 13
Pamela Frank, BSc (Hons), ND has 14 years of experience as an naturopathic physician and 20 years as a medical laboratory technologist. She is clinic director of Forces of Nature Wellness in Toronto and was twice voted “Best Naturopath in Toronto.” Pamela maintains a busy practice with particular expertise in women’s health issues, PCOS, PMS, menopause, acne, infertility, uterine fibroids, and endometriosis. Other passions include her family, new puppy Odie, tennis, running, cycling, volleyball and healthy cooking. For more information, visit: www.NaturopathToronto.ca.
- Haga T, Kurihara M, Kataoka H, Ebana H. Clinical-Pathological Findings of Catamenial Pneumothorax: Comparison between Recurrent Cases and Non-Recurrent Cases. Ann Thorac Cardiovasc Surg. 2013 May 23. [Epub ahead of print]
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