Ljupka Peev Naturopath, Nutrition, Herbal Medicine for women's health and fertility.
Endometriosis

ENDOMETRIOSIS

Endometriosis is an inflammatory condition, where cells and tissues that normally line the uterus (endometrium) are found outside of the uterus, usually in the pelvic or abdominal cavity. This tissue may be found on the ovaries, the intestines, the outside of the uterus wall, the fallopian tubes, or other abdominal organs, where it undergoes the same cyclical changes in response to hormones, such as oestrogen, as it does in the uterus. It grows and sheds, causing bleeding and inflammation. It may also cause scarring and adhesions of organs and tissues.

 

Signs & symptoms
How common is endometriosis?
How is endometriosis diagnosed?
Causes
Risk factors
Effects on fertility
Medical treatment
Natural therapies
Self-help
References

 

What are the signs & symptoms?

Some women may have no signs or symptoms of endometriosis. More commonly, however, women may experience pain that is worse immediately before menstruation. Pain can also present at other times during the menstrual cycle, such as at ovulation, or it may occur during or after sexual intercourse, when moving the bowels, or when urinating. The pain may be back pain or abdominal pain. It is important to note that severity of pain is not an indicator for severity of disease.

Other symptoms of endometriosis may include diarrhoea or constipation, particularly during menstruation, abdominal bloating, heavy or irregular periods, fatigue, or infertility.

Period Pain

How common is endometriosis?

The exact incidence of endometriosis is not known but it is estimated to occur in about 10% of menstruating women. [1]

Endometriosis can be found in about 20-40% of women with infertility.[2]

These figures may be higher, given that some women may not experience any symptoms, and thus not present for investigation or diagnosis.

 

How is endometriosis diagnosed?

The only was to definitively diagnose endometriosis is by laparoscopy (also known as keyhole surgery). This is a procedure performed under general anaesthetic, where a small cut is made in the belly button and two other areas of the abdomen and a small camera (laparoscope) is inserted so that the surgeon may view inside the pelvic and abdominal cavity to locate and identify any endometriosis. A sample of the endometrial tissue is taken for investigation and usually the surgeon will also remove any endometrial tissue that is found.

Other tests, such as blood tests or ultrasound, might be used before laparoscopy to help assess if endometriosis is likely, but these tests as yet cannot definitively diagnose the condition.

 

What is the causes of endometriosis?

The exact cause of endometriosis is unknown but there are many reasons or theories to explain why it may occur.

Retrograde menstruation  This is the backward flow of menstruation through the fallopian tubes and into the pelvic cavity. This occurs in most women and the cells are simply absorbed or broken down by the body. In women with endometriosis, the cells that make it into the pelvic cavity attach themselves onto other tissue and organs and grow there. Why this happens is unknown, but it is thought that there may be immune or hormonal dysfunction allowing this to occur.

Immune system dysfunction  Abnormalities of the immune response have been found in some women with endometriosis and may play a role in the development of endometriosis.

Inflammation  Women with endometriosis often have increased levels of inflammatory markers in the body, although it is not clear if this contributes to, or is a consequence of the disease.

Metaplasia  Metaplasia is where one type of cell or tissue is able to change into another type of tissue. It is thought that some cells around the ovaries and in the pelvic cavity are able to change into endometrial cells like those lining the uterus.

Surgical procedures  Endometriosis can sometimes be found in surgical scars and it is thought that surgical procedures such as Caesarian sections may transfer endometrial tissue from the uterus to other areas.

 

What are the risk factors for endometriosis?

  • Family history (mother, sister, aunt) of endometriosis
  • Shorter menstrual cycles (less than 27 days) with longer bleeding (more than 7 days)
  • Heavy periods
  • Early menarche – first menstrual bleed before 12 years of age
  • Never given birth
  • Pelvic infection or a history of pelvic infection
  • Defects in the uterus or fallopian tubes that prevent the normal passage of menstrual flow

 

What are the effects of endometriosis on fertility?

It is important to note that although endometriosis can be a cause of infertility, many women with endometriosis are still able to conceive without difficulty and carry a pregnancy to full term. Also, not all women who have difficulty conceiving have endometriosis.

Exactly how endometriosis causes infertility or difficulty conceiving is not completely understood, but anatomical and hormonal factors may provide some reason. There may be obstruction of the fallopian tube/s, thus preventing the egg from meeting the sperm, or hormonal imbalances that effect conception or normal embryo development.

 

Medical treatment

Treatment of endometriosis will differ depending on the severity of the disease and symptoms, and whether pregnancy is the aim.

The aim of treatment is to manage pain and slow or stop the progression of endometriosis. There is no “cure” for endometriosis except for hysterectomy and removal of the ovaries, however there are many treatment options available for the management of symptoms.

Medical treatment options include:

  • Pain medication such as non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen
  • Hormone therapy to reduce menstrual flow, prevent ovulation and menstruation, or reduce oestrogen levels.
  • Surgery to remove endometrial tissue from outside of the uterus.
  • Assisted reproductive technologies such as intra-uterine insemination (IUI) or IVF in women still having difficulty conceiving after surgery.

 

Natural therapies

The aims of treatment with natural therapies are much the same as for medical treatment:

  • reduce pain
  • reduce inflammation
  • slow or stop progression
  • reduce the risk of adhesions
  • increase fertility.

Herbal and nutritional medicine can be used to successfully address all of these aspects, helping to reduce symptoms and progression of endometriosis and improving quality of life.

Preventing ovulation is not in the realm of natural therapies, however hormonal regulation can be achieved using herbal medicines, as well as nutritional measures. Herbal medicines may also be used to support the function of the immune system.

Herbal and nutritional medicine may be used alongside medical treatments to optimise outcomes and reduce potential drug side-effects. This must only be done via consultation with a qualified herbalist in order to prevent any negative interactions and ensure safety.

 

Self-help

Adopting lifestyle and dietary changes can help to improve the symptoms of endometriosis and reduce its progression.

Exercise  Women who exercise regularly have a reduced risk of endometriosis and may experience less pain. However, it is advised that women do not engage in strenuous exercise during menstruation as this may increase their risk.[3]

Diet A healthy diet will help to reduce inflammation and pain, and may potentially slow the progression of endometriosis.

Incorporating omega-3 essential fatty acids found in oily fish has been shown to reduce inflammation in the body and reduce pain associated with endometriosis.[4] This may also be achieved with supplementation, however there is great variability in quality of fish oil supplements and the anti-inflammatory properties have been shown to be dose-dependant, therefore professional advice should be sought.

Including green vegetables and fresh fruit has been shown to reduce the risk of endometriosis, while daily consumption of beef, red meat or ham has been shown to increase the risk of endometriosis.[5] The increased risk associated with meat products may be due to the saturated fat component and associated increase in inflammation.

A diet high in fibre is essential for healthy bowel flora and function, along with adequate fluid intake and may also be beneficial in managing endometriosis.

Caffeine  A higher caffeine intake may effect fertility in women with endometriosis. A study found that women with endometriosis who consumed more than 5 grams of caffeine per month (equivalent to 2 or more cups of coffee, or 4 or more cups of tea per day) had a higher risk of infertility.[6]

Alcohol  Women with endometriosis who consume more than one standard alcoholic drink per day may be at higher risk of infertility.[7]

Maintain an ideal body weight  It is now well known that obesity causes inflammation, which is a crucial factor in the progression of endometriosis. Thus, maintaining an ideal body weight is of utmost importance to its management. Women who are obese have been found to have a higher rate of recurrence of endometriosis after laparoscopic surgery.[8]

Being overweight or obese also affects the chances of conception. Women with a body mass index (BMI) of 29 (kg/m2) or higher have lower pregnancy rates compared to women with a BMI below 29. Also, for each increase in BMI there is an associated 4% reduction in pregnancy rate per year.[9]  Reducing weight in overweight or obese women will increase their chances of conception and reduce pregnancy complications.

Reaching and maintaining an ideal body weight requires lifestyle and dietary changes that are adhered to for life. Your naturopath may be able to assist you in providing dietary and supplemental advice, lifestyle counseling, as well as monitoring progress and improving your motivation.


References

[1] Wheeler JM. 1989. ‘Epidemiology of endometriosis-associated infertility’, J Reprod Med, 34(1):41-6.

[2] Strathy, J.H. Molgaard, C.A. Coulam, C.B. et al, 1982, ‘Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women’, Fertil Steril, 38(6):667-72. Ozkan, S. Murk, W. Arici, A. 2008, ‘Endometriosis and infertility: epidemiology and evidence-based treatments’, Ann N Y Acad Sci, 1127:92-100.

[3] Vitonis, A.F. Hankinson, S.E. Hornstein, M.D. et al, 2010, ‘Adult physical activity and endometriosis risk’, Epidemiology, 21(1):16-23.

[4] Harel, Z. Biro, F.M. Kottenhahn, R.K. et al, 1996, ‘Supplementation with omega-3 polyunsaturated fatty acids in the management of dysmenorrhoea in adolescents’, Am J Obstet Gynecol, 174(4):1335-8. Netsu, S. Konno, R. Odagiri, K. et al, 2007, ‘Oral eicosa-pentaenoic acid supplementation as possible therapy for endometriosis’, Fertil Steril, 90(4 Suppl):1496-502.

[5] Parazzini, F. Chiaffarino, F. Surace, M. et al, 2004, ‘Selected food intake and risk of endometriosis’, Hum Reprod, 19(8):1755-9.

[6] Grodstein, F. Goldman, M.B. Ryan, L. et al, ‘Relation of female infertility to consumption of caffeinated beverages’, Am J Epidemiol, 137(12):1353-60.

[7] Grodstein, F. Goldman, M.B. Cramer, D.W. 1994, ‘Infertility in women and moderate alcohol use’, Am J Public Health, 84(9):1429-32.

[8] Nezhat, C. Hajhosseini, B. King, L.P, 2011, ‘Laparoscopic management of bowel endometriosis: predictors of severe disease and recurrence’, JSLS, 15(4):431-8.

[9] Mutsaerts, M.A. Groen, H. ter Bogt, N.C. 2010, ‘The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial’, BMC Womens Health, 10:22.

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