• Painful menstruation, painful intercourse, and infertility
• Physical examination by a physician reveals one or more of the following: tenderness of the pelvic area, enlarged or tender ovaries, a uterus that tips backward and lacks mobility, and adhesions (abnormal scarring)
• Pelvic ultrasound detects endometrial tissue outside the uterus
• Definitive diagnosis: laparoscopy or laparotomy visualizing endometrial implants within the pelvic cavity
Endometriosis is a women’s health condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity, most commonly on the ovaries. Since the endometrial cells are under the influence of female hormones even when they reside outside the uterine lining, they can produce symptoms that often worsen at specific points during the menstrual cycle. Pelvic pain is a particularly bothersome symptom. Endometriosis lesions react to hormonal stimulation and may “bleed” at the time of menstruation. The blood accumulates locally, causes swelling, and triggers inflammatory responses, including the activation of pain-producing molecules known as cytokines.
Pain can also occur from adhesions (internal scar tissue) binding internal organs to each other, causing organ dislocation. Fallopian tubes, ovaries, the uterus, the bowels, and the bladder can be bound together in ways that are painful on a daily basis, not just during certain times of the menstrual cycle.
Endometriosis affects 10 to 15% of menstruating women between the ages of 24 and 40 years old.
Causes
The predominant theory of the cause of endometriosis is that during menses, blood flows backward and implants endometrial cells in the pelvic cavity. The problem found with this theory is that more than 90% of menstruating women without endometriosis have this backward flow. Typically their immune system is able to prevent implantation and growth of the endometrial cells outside the uterus, so defects in immune function may be responsible for the development of endometriosis. However, in some patients, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis. Women with endometriosis typically show alterations in immune function, particularly in those factors that are responsible for proper surveillance in the pelvic area.1
Other research suggests that estrogen-mimicking environmental toxins or radiation exposure increases the risk for endometriosis. Substances that have been shown to have estrogenic effects in the body include polychlorinated biphenyls (PCBs), pesticides, herbicides, certain plastics, heavy metals such as lead, and some kinds of household cleaners. However, these compounds are also known to adversely affect the immune system. Particularly incriminating are phthalates, used as plasticizers (substances added to plastics such as polyvinyl chloride to increase their flexibility, transparency, durability, and longevity).2 Phthalates are used in a large variety of products, from enteric coatings for pharmaceutical pills and nutritional supplements to viscosity control agents, gelling agents, film formers, stabilizers, dispersants, lubricants, binders, emulsifying agents, and suspending agents. Phthalates are being phased out of many products in the United States, Canada, and the European Union because of health concerns.
Risk factors for endometriosis include family history, lack of exercise from an early age, a high-fat diet, use of intrauterine devices, and increased or unbalanced estrogen levels. Women with a mother or a sister with endometriosis have an increased risk.1
Therapeutic Considerations
In most cases, endometriosis will cease after menopause. But in women in their reproductive years, endometriosis is merely managed. The most aggressive treatment is surgery. In younger women who may desire to get pregnant in the future, surgical treatment attempts to remove the stray endometrial tissue and preserve the ovaries. The dominant nonsurgical treatment is the use of hormonal medication that suppresses the natural menstrual cycle, plus pain medication to manage the discomfort. On occasions, naturopathic physicians will use natural progesterone therapy (a form of bioidentical hormone therapy) to help relieve the symptoms of endometriosis. Although progesterone creams may be available over the counter, we recommend being treated and monitored by a physician.
The natural approach to endometriosis is designed to achieve the following goals:
• Reduce inflammation
• Enhance detoxification mechanisms
• Reduce bothersome symptoms
The strategies discussed in the chapter “Silent Inflammation” are extremely important in endometriosis. Especially important is eating the right type of fats. The consumption of trans-fatty acids appears to increase the risk of endometriosis, while long-chain omega-3 fatty acids from fish oils appear to be protective. Twelve years of prospective data from the Nurses Health Study II, which began in 1989, were analyzed for the association between dietary fat and many health problems, including endometriosis. Those women who consumed the most trans-fatty acids were 48% more likely to be diagnosed with endometriosis. In contrast, those women with the highest consumption of long-chain omega-3 fatty acids were 22% less likely to be diagnosed with endometriosis.3
One study looked directly at the effect of essential fatty acid ratios on production of inflammatory cytokines by endometrial cells.4 The test tube study took endometrial cells from women with and without endometriosis attending an infertility clinic. The cell cultures were provided with nutrients and supplemented with various ratios of omega-3 polyunsaturated fatty acids and omega-6 polyunsaturated fatty acids (found in meat and dairy products, and in soy, safflower, corn, and sunflower oil). They found that the higher the ratio of omega-6 to omega-3 fatty acids, the greater the secretion of an inflammatory compound, interleukin-8, in cells from women both with and without endometriosis, with the cells from women with endometriosis secreting significantly higher levels.5
The importance of a high-fiber diet in enhancing detoxification cannot be overstated. Foods high in fiber are associated with the growth of friendly microorganisms within the large intestine. Studies show that a high intake of fiber and a predominantly vegetarian diet lead to a decrease of biologically active free estrogens in blood plasma.6 Increasing the intake of high-fiber foods, especially vegetables, also helps clear excess estrogen from the body. Foods that are particularly helpful in this regard are vegetables in the brassica family, such as broccoli, brussels sprouts, cabbage, and cauliflower.7 Other liver-cleansing foods are beets, carrots, artichokes, lemons, dandelion greens, watercress, and burdock root. Onions, garlic, and leeks contain organosulfur and flavonoid compounds, which enhance the immune system and encourage the production of liver enzymes that have a role in detoxification.8 See the chapter “Detoxification and Internal Cleansing” for more discussion.
Last, the isoflavones in soy products and the lignans in flaxseed may also be important in a dietary approach to endometriosis. These foods counter the effects of excess estrogen. A Japanese study demonstrated that moderate soy intake was associated with a decreased risk of premenopausal hysterectomy. Since some of the surgeries were due to endometriosis, these results led the authors to conclude that moderate soy intake may decrease the risk for endometriosis.9
Foods to decrease include dairy products, red meat, sugar, caffeine, and alcohol. The Environmental Protection Agency estimates that 90% of human pesticide exposure occurs through food, primarily meat and dairy products.10 Dairy products (except nonfat versions) also tip the ratio of omega-6 to omega-3 fatty acids toward inflammation.
Dietary therapy can be very helpful in endometriosis. In a two-month study of 50 women with endometriosis, a significant reduction in symptoms occurred when the intake of higher-glycemic carbohydrates and caffeine was decreased and the intake of omega-3 and omega-9 fatty acids (e.g., from olive oil) was increased.11 Caffeine is a particular problem for many women with endometriosis. In one study, women consuming an average of more than 150 to 225 mg of caffeine per day (about the amount in 1 to 11/2 cups of coffee) had a 20% increased risk of endometriosis, while those consuming more than 225 mg had a 60% increase.12
Lipotropic Supplements
Historically, naturopaths have used lipotropic factors such as inositol, methionine, and choline in cases of endometriosis. Lipotropic supplements usually are a combination of vitamins and herbs designed to support the liver’s functions of removing fat, detoxifying the body’s wastes, detoxifying external toxins, and metabolizing and excreting estrogens. These lipotropic products vary in formulation depending on the manufacturer, but they are all similar. Many now contain anticancer phytonutrients found in brassica-family vegetables, such as indole-3-carbinol (I3C), di-indoylmethane (DIM), and sulfurophane. Research has shown that these compounds help to break down cancer-causing forms of estrogens to non-cancer-causing forms, making them especially important for women with endometriosis.7
Grape Seed or Pine Bark Extract
Extracts from grape seed and the bark of the maritime pine (Pycnogenol) are rich sources of proanthocyanidins, one of the most beneficial groups of plant flavonoids. Because Pycnogenol was shown to inhibit inflammation in a test tube study, researchers sought to evaluate its role in a study of 58 women with endometriosis. The women were randomly assigned to receive either Pycnogenol 30 mg twice per day for 48 weeks or an antihormonal drug, leuprorelin acetate, given by intramuscular injection every four weeks for 24 weeks. After four weeks on Pycnogenol, patients slowly but steadily improved, with their symptoms decreasing from severe to moderate. Overall, this group experienced a 33% reduction in symptoms of endometriosis. The leuprorelin group had a greater response within the treatment period but relapsed after 24 weeks. The Pycnogenol group maintained regular menses and normal estrogen levels during treatment; in contrast, the leuprorelin group had suppressed menstruation and drastically lowered estrogen levels (which were expected). In addition, five women in the trial taking Pycnogenol became pregnant.13
Many traditional herbal medicines used to treat women with endometriosis contain phytoestrogens. However, their activity is certainly less that the effects of dietary phytoestrogens such as soy and flax. So we recommend focusing on dietary phytoestrogens rather than botanical sources.
Vitex or chasteberry (Vitex agnus-castus) has traditionally been used as a treatment for hormone imbalances in women. Through action on the pituitary gland, it increases progesterone production by means of an increase in luteinizing hormone, with the effect of making estrogen less available. This herb is useful for fibroids and premenstrual syndrome, and it may also have an effect in endometriosis.14
QUICK REVIEW
• Endometriosis is a women’s health condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity.
• Risk factors for endometriosis include family history, lack of exercise from an early age, a high-fat diet, use of intrauterine devices, and increased or unbalanced estrogen levels.
• The natural approach to endometriosis is designed to reduce inflammation, enhance detoxification mechanisms, and reduce bothersome symptoms.
• The consumption of trans-fatty acids appears to increase the risk of endometriosis, while long-chain omega-3 fatty acids from fish oils appear to be protective.
• Increasing the intake of high-fiber foods, especially vegetables of the brassica family, helps clear excess estrogen from the body.
• A significant reduction in symptoms occurs with a decreased intake of higher-glycemic carbohydrates, an increased intake of omega-3 and omega-9 fatty acids, and a decreased intake of caffeine.
• Pycnogenol showed an ability to reduce endometriosis symptoms by 33% in one clinical trial.
• Vitex extract may reduce estrogen’s effect on endometrial tissue.
TREATMENT SUMMARY
The natural approach to endometriosis is designed to reduce inflammation, enhance detoxification mechanisms, and reduce bothersome symptoms.
Follow the guidelines in the chapter “A Health-Promoting Diet.” Consume a diet low in fat and high in fiber, whole grains, flaxseed, soy foods, and vegetables in the cabbage family, and avoid overconsumption of meat and dairy products, omega-6 fatty acids, saturated fats, sugar, caffeine, and alcohol. Soy isoflavone intake should be approximately 45 mg per day. Ground flaxseed at a dosage of 1 to 2 tablespoons per day is also recommended.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin B6: 25 to 50 mg per day
Folic acid: 800 to 2,000 mcg per day
Vitamin B12: 800 mcg per day
Vitamin C: 500 to 1,000 mg per day
Vitamin E (mixed tocopherols): 100 to 200 IU per day
Magnesium (bound to aspartate, citrate, fumarate, malate, or succinate): 200 to 300 mg three times per day
Selenium: 100 to 200 mcg per day
Zinc: 30 to 45 mg per day
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Flaxseed oil: 1 tbsp per day
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or more per day
• Specialty supplements, one of the following:
Lipotropic formula providing 1,000 mg betaine, 1,000 mg choline, and 1,000 mg cysteine or methionine
SAM-e: 200 to 400 mg per day
• One or a combination of the following:
Indole-3-carbinol: 300 to 600 mg per day
Di-indoylmethane (DIM): 100 to 200 mg per day taken with food
• Vitex (chasteberry): In tablet or capsule form (often standardized to contain 0.5% agnuside), 175 to 225 mg per day; in liquid form, 2 to 4 ml (1/2 to 1 tsp) per day