Endometriosis - A Naturopathic Perspective

Endometriosis and Naturopathy Article

Article provided by: Claudette Wadsworth BA, BHlthSc, AdvND, DN, DRM, AdvNFM, MATMS in:
Bondi Junction, Sydney, Australia.
02 9369 1081
website: www.claudettewadsworth.com.au

Normally, the endometrium lines the inside of the uterus and is expelled during each menstrual period. Endometriosis is the presence of functioning endometrial tissue in an abnormal location, commonly found in sites throughout the pelvis, abdominal cavity and other parts of the body, eg. bowel, colon, rectum, ovary, bladder, lungs. Adenomyosis is endometrium growing between the fibres of the muscular wall of the uterus. Fragments of the endometrial tissue continue to respond to hormonal stimulation and they build up to form lesions - areas of inflammation and eventually cysts which act like a miniature uterus with bleeding occurring when the woman menstruates. As the blood cannot escape the cysts slowly increase in size and is filled with tarry blood. Scar tissue and adhesions to other pelvic organs also develop as the condition advances.

Endometriosis is the cause of up to 80% of pelvic pain or infertility. It is the most common cause of infertility in women over 25 years. It is estimated 10-20% of all women during their reproductive life are affected by endometriosis with or without symptoms, with a peak incidence at 25-35 years. Endometriosis can even occur in males. Some elderly males with prostate cancer who have had their testicles removed and been put on oestrogen drugs have been found to have endometriosis in their bladder or prostate.

Common Theories of Causation

• Relative oestrogen excess to progesterone ratio. Oestrogen is capable of stimulating a thicker endometrium and more serious pelvic contamination due to greater menstrual volume as well as affecting the immune system by diminishing natural killer cell activity.
• Retrograde flow is postulated as a causative theory where reflux of menstrual blood flows through and out of the fallopian tubes, adhering to other pelvic organs and growing inwards. However, almost all menstruating women who have patent (non-blocked) Fallopian tubes have some menstrual fluid in the pelvic cavity, but in the majority of women, endometriosis does not develop. Women who have a vaginal outflow blockage (either partial or complete), eg. congenital abnormalities, adhesions within the uterus or cervix, imperforate hymen or damage to the cervix such as by cauterization, may have excessive volume of refluxed endometrial cells and seem to have a higher incidence of endometriosis.
• Auto-immunity is another postulated theory. Auto-immune literally means that the body has antibodies to its own tissues. It is unknown, however, which condition precipitates the other. Immune systems of endometriosis patients have shown impairment of natural killer cells to destroy misplaced tissue, autoimmune antibodies to endometrial tissues as well as increased T-helper cell activity and reduced T- suppressor cell capacity. There is a direct correlation between the severity of endometriosis and the extent to which natural killer cell function is impaired. Endometriosis also secretes an unidentified substance that destabilizes surrounding capillaries and brings white blood cells to the region to release irritating chemicals, thereby showing increased numbers and activity of macrophages. Macrophages can prevent fertilization of eggs, reduce sperm motility, engulf and destroy sperm, eggs and embryo, increase adhesions and stimulate the growth of endometriosis.
• Endometrial cells are displaced through an embryonic mix-up when the embryo is just forming its tissues. Dysfunctional DNA genetic coding can lead to a more widespread distribution of these embryonic tracts in areas remote from the pelvis, eg. diaphragm or intestinal tract, thereby, being a congenital condition and present at birth. At puberty, the ovaries begin to produce oestrogen which acts on these tracts of tissue laid down as an embryo. They begin to change into endometriosis, with varying degrees of biologic activity and invasiveness depending on the strength of oestrogen stimulation.
• Endometriosis is a 20th century disease caused by toxic effects of xenoestrogens (synthetic environmental oestrogens or chemicals that mimic oestrogen, eg. dioxin) on tissues of the developing embryo or the developing human. Doctors before this century did not describe this condition, unlike all other female reproductive conditions, which is unusual given the severity of pains and the association with monthly periods. Recent research shows that animals exposed to certain environmental toxins develop spontaneous endometriosis. Xenoestrogens are much stronger than oestrogens made by the body, act as hormonal disrupters and have been prevalent in the environment only in modern times. Sources of xenoestrogen exposure include dioxin, pesticides and herbicides, growth hormones stored in animal fat, PCBs in plastics, especially when heated or used for hot drinks or food, waterways from the urine of women taking birth control pills containing synthetic oestrogen, nonylphenols - breakdown products of surfactants used in detergents, cosmetics and other toiletries, pesticides, herbicides and spermicides used in diaphragm jellies, condoms and vaginal gels. Higher levels of oestrogen can induce more oestrogen receptors in the metaplastic tracts, resulting in the full expression of the disease.
• Endometrial tissue may travel via the lymph and blood to distant places, eg. lungs and nose.
• Iatrogenic (caused be medical procedures) due to increased laparoscopy investigations that may cause damage or spread of endometrial lining.
• Bacterial invasion (eg. due to pelvic inflammatory disorder) leads to weakening and destruction of the endometrium, causing chronic endometriosis.
• Inflammatory prostaglandin excess causes inflammation, irritation and constriction of tissues. Women with endometriosis have been shown to have higher levels of inflammatory PG and low levels of anti- inflammatory PG. Prostaglandin and leukotriene imbalance affect ovulation, fertilization, embryo development and increase period pain.

Risk Factors

• Early menarche (menstruation starting at the earlier age), delayed pregnancy and short duration of breastfeeding: increased time of exposure to oestrogen
• Immediate family member (mother/sister) with endometriosis increases the risk 7 times
• Strenuous physical activity during menstruation increases risk; regular exercise is associated with a lower risk as exercise decreases rate of oestrogen production and insulin resistance
• IUD contraceptives increase risk as irritant and cause inflammation locally
• Caffeine and alcohol consumption increase risk

Signs and Symptoms

• Severe, painful periods which worsen towards the end of the period
• Infertility, decreased success rates for in vitro fertilization and increased miscarriage
• Stabbing pain on penetration sex
• Long and heavy periods (more than 7 days) with darker, brownish blood to start. Spotting and mid-cycle bleeding can be common
• Pain before period and at ovulation
• Feelings of pressure in pelvis, one-sided pelvic pain, pain during bowel movements
• PMS symptoms, including anxiety, mood swings, bloating, breast tenderness, constipation, food/sugar/chocolate cravings, headaches

Other Possibilities

• Higher incidence of endometriosis in women with liver disorders: the liver breaks down and removes oestrogen, other hormones and toxins from the blood circulation for excretion or inactivation
• Higher incidence of endometriosis in women with glandular fever: the glandular fever virus impairs the immune system, often long term, perhaps setting the scene for auto-immunity to occur
• Often there has been sexual, physical or psychological trauma to the woman

Diagnosis

• Based on symptom picture
• Pelvic examination
• Ultrasound
• Laparoscopy: the only way of a diagnosis of endometriosis can be absolutely confirmed

• Hormones to inhibit ovulation and suppress menstruation results in atrophy of the endometrium, eg. the Oral Contraceptive Pill: given continuously without a breakthrough bleed. Side effects include blood clots, stroke, heart attach, especially for smokers, abnormal cholesterol ratios. However, the Pill compares favourably with other drug regimes for endometriosis that have more serious side effects. The Pill is not as effective for advanced endometriosis and is not suitable for women who want to fall pregnant. Most women have a return of symptoms within 6 months of stopping the Pill.
• Progestogens: Prevera and Primolut N: side effects of nausea, bloating, acne, breast tenderness, weight gain, mood changes, increased facial and body hair, deepening voice related to the androgenising (male hormone) effects of the drugs as well as abnormal cholesterol ratios. Primolut N and the norethisterones must only be used for no more than 6-12 months. Provera and Duphaston (dydrogesterone) are given either in the last part of the cycle or continuously to produce a pregnancy-like state with no period. About 30% of women have spotting or breakthrough bleeding until the drug starts to work or the dose is adjusted. These drugs are relatively inexpensive and give significant pain relief. Fertility is not improved by these drugs, menstrual cycle may be delayed for many months and endometriosis may reoccur after stopping therapy.
• Danocrine (Danazol) is another progestogen which can cause pronounced androgenic (masculinizing) effects such as increased facial and body hair, loss or thinning of scalp hair, deepening of voice, weight gain, acne, severe mood changes, changes to sexual organs such as atrophy of breast tissue and hypertrophy of clitoris. Severe life-threatening strokes, blood clots and increased intracranial pressure has been reported; long term use may cause serious toxicity including jaundice and hepatitis. This drug needs to be carefully prescribed after due consideration of risks and benefits for each woman. For endometriosis, it is given in high doses of 200-800mg daily to stop ovulation, suppress the period and cause the endometrium to shrink. Spotting can be a problem but it improves period pain and other pelvic pain.
• GnRH agonists induce a temporary menopausal state. They are effective in reducing symptoms and the size of endometrial growths but obvious side effects are less severe. There is early and significant bone density loss, although this causes no symptoms until later in life but should be considered in the decision to use these drugs. On average, endometrial cysts return to their original size, 4 months after stopping treatment, so additional treatment is necessary. GnRH have no additional benefits in improving fertility.
• Laparoscopic removal of lesions and cysts: reduces or resolves both period pain and other pelvic pain significantly. However, there is increased risk of adhesions and scar tissue, fertility is not significantly improved and the endometriosis tends to reoccur with about 50% of women developing the condition again within 2-5 years.
• Hysterectomy, pregnancy.

Treatment length for endometriosis usually requires 6-12 months, depending on the severity and duration of the condition.

Dietary and lifestyle changes are essential for successful treatment and for maintenance of the condition long term to prevent reoccurrences. Herbal medicines and nutritional supplements are individually prescribed to:

• Balance hormones to improve the relative oestrogen excess and prevent reoccurrences by correcting underlying hormonal imbalance, rather than superseding the body's own hormones
• Ensure normal menstrual flow and uterine function
• Improve fertility if required
• Decrease constriction of blood vessels and muscular spasm, thereby decreasing pelvic congestion and pain
• Rebalance immune system dysfunction to address auto-immunity basis
• Improve liver function which breaks down and removes excess oestrogen, other hormones and toxins
• Soften and heal scar tissue and adhesions, and drain cysts
• Calm and nourish the nervous system to cope with chronic pain and anxiety as well as balance mood swings
• Decrease heavy bleeding and spotting
• Regulate bowel habits and decrease constipation. Women with endometriosis commonly experience irritable bowel syndrome symptoms which complicate their pain and hormonal imbalance. Anthraquinone laxatives should not be used as they will cause reflex spasm in the organs of the pelvic cavity. Painkillers with codeine will aggravate constipation.