The Naturopathic View: Endometriosis - by Judith Fiore (Fall 2010)

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ENDOMETRIOSIS

by Judith Fiore, ND
Fall 2010
 
Endometriosis is a troubling reproductive condition where the primary complaint is pain. For some women, the pain can be almost unbearable, and can profoundly affect their efforts to lead a healthy and normal life. In a woman who does not have endometriosis, the endometrium lines the inside of the uterus and is expelled during each menstrual period.  Women with endometriosis, however, have functioning endometrial tissue in an abnormal location. This endometrial tissue is often found throughout the pelvis and abdominal cavity; it responds to hormonal stimulation and may eventually form blood-filled cysts, known as “chocolate cysts”. Scar tissue and adhesions to other pelvic organs also develop as the endometriosis advances.1

While pain is the number one symptom for this troubling condition, there is a surprisingly high percentage of women who report no symptoms other than infertility. It is estimated that 10-20 percent of all women are affected by endometriosis during their reproductive lives, with or without symptoms, with a peak incidence at 25-35 years.2 Endometriosis is also estimated to be the most common cause of infertility in women over 25 years of age.3 The percentage of women with endometriosis who are having difficulty conceiving ranges from 35 to 50 percent.4 It is considered to be one of the top causes of female infertility.
 
Symptoms of endometriosis include, but are not limited to:
Pain before and during menstrual periods
Pain at the time of ovulation
Pain during or after sexual activity
Heavy or irregular bleeding
Fatigue
Pain with bowel movements during menses
 
There are a number of possible causes, including the possibility that retrograde flow of menstrual blood through and out the fallopian tubes will adhere to other pelvic organs such as the ovaries, vagina, cervix, fallopian tubes, bladder, rectum, walls of the abdominal cavity and so on.5 However, almost all menstruating women who have open fallopian tubes have some menstrual fluid in the pelvic cavity, but in the majority of women, endometriosis does not develop. On the other hand, women who have a vaginal outflow blockage due to problems within the uterus and cervix may have a high amount of refluxed endometrial cells and seem to have a higher incidence of endometriosis.

Autoimmunity, where the body develops antibodies to its own tissues, is another theory. It is thought that these antibodies, combined with a decrease in lymphatic activity, allow the endometrial tissue to proliferate.6 Autoantibodies against ovarian and endocrine tissue have been found in significant amounts in women with endometriosis.7

Exposure to environmental pollutants such as dioxin is also being studied for a possible link with endometriosis.8,9 It is known that animals exposed to environmental toxins develop spontaneous endometriosis.10 In our modern world, we are living in a chemical “soup” of various toxins in our air, water and soil. If these studies hold true, it makes sense that we need to take steps to limit our contact with environmental toxins.

The exact cause of endometriosis is probably multi-faceted, with women who are considered to have a genetic predisposition to the disease most at risk. It has been found that endometriosis is six to seven times more prevalent amongst close relatives, like sisters, mothers and daughters, than in the general population.11

Nutritional Help

There are nutritional therapies that can be used to help reduce the symptoms of endometriosis and that are easily applied if a woman is undergoing fertility treatment. This is where an awareness of potential exposure to environmental toxins is valuable. Eating organic foods, particularly organically raised animal products such as chicken, beef, turkey and dairy, can go a long way to reducing exposure. It is also a good idea to eat several vegetarian meals weekly, to help reduce the amount of saturated fats in the diet.
 
A popular dietary approach to endometriosis is a vegan diet, which is completely free of all animal products, including eggs and dairy. There have been investigations showing that avoiding red meats and increasing the consumption of green vegetables has had a positive effect.12 This approach does appear to reduce the pain that women were reporting.12,13 It is known that a low-fat, high-fibre diet will decrease circulating estrogens in the body14, and vegan females tend to excrete two to three times more estrogen in their feces than women who eat meats and dairy. However, it may not be the best approach for everyone for a number of reasons, and not only because it affects levels of iron and B12. I would recommend that you consult with a naturopathic doctor or registered nutritionist to design the best way of eating for you and your fertility.

Another dietary approach that has had increasing acceptance is the avoidance of wheat and other grains that contain gluten. Gluten is a protein found in grains such as wheat, rye, and barley. Gluten comprises about 80% of the protein present in these grains.  Because wheat flour makes up the majority of starches that are eaten in the typical modern diet, it is surmised that the demands placed on the digestive system to break down gluten can eventually lead to gluten sensitivity or gluten intolerance in some people. With this type of sensitivity, it is believed that inflammatory-based diseases like endometriosis would improve if gluten-containing grains were eliminated from the diet.16 There has been scant research into this area, but I will say that in my clinical experience my endometriosis patients do seem to experience reduced pain when they follow a gluten-free diet.  

Vitamin E, Magnesium and Omega-3 Fatty Acids

Vitamin E is an antioxidant that is vital in protecting the body and DNA against damage from free radicals. Vitamin E has been found to be helpful in reducing the pain associated with endometriosis and decreasing the amount of bleeding.17 It can be taken as a supplement, and it is also a component of leafy green vegetables, eggs, whole grains, seeds and nuts.

Magnesium is known as a nutrient that plays an important role in relaxing smooth muscle. It is commonly given to pregnant women who are having contractions and are at risk for pre-term delivery.18  Because magnesium is able to calm uterine contractions, it has been studied for its role in reducing the pain of menstrual cramping19 and has been found to be effective for pain relief, reducing the need for additional medication. Other than the common side effect of loose stools, magnesium at therapeutic dosage is considered safe and is well tolerated by most people.

Omega-3 Fatty Acids have been shown to be effective over time for pain relief.19,21  This is because of the anti-inflammatory effects of omega-3 oils; fish oil in particular is considered to be the best supplement to take. If taken daily and in the recommended dosage, fish oil can have excellent effect in the long run.22 Be sure to look for a good quality fish oil, one that is molecularly distilled to remove heavy metals, mercury and other toxins, and that is third party tested for purity.
 
Acupuncture

In almost all cases, a Traditional Chinese Medicine (TCM) practitioner will view endometriosis as a problem of blood stasis, which means that the blood flow is static and not moving properly through the reproductive system. Acupuncture treatment helps move the blood, and the TCM approach has been shown to be as effective as conventional pharmaceutical therapy for endometriosis.23,24 This could be very helpful if you are trying to conceive and wish to avoid drugs that may affect your fertility.  

Acupuncture points are chosen according to the individual’s TCM diagnosis and can vary from person to person. The acupuncture points commonly used in the treatment of endometriosis are located on the ears, abdomen, wrists, feet, legs, and back. Needles are usually retained for 20 to 45 minutes. Acupuncture patients typically report how relaxed they feel, and how much their pain is alleviated by the treatment. I recommend that acupuncture treatments for women with endometriosis be done at least twice weekly for the first month or two, and then once a week as maintenance.
 
Lifestyle

Excessive exercise is considered to be a contributing factor to worsening  endometriosis.25  I recommend exercise to my patients, but I caution them not to overdo it. I prefer activities that do not overly stress the pelvis. Running and lifting heavy weights are best avoided; other forms of exercise such as swimming, biking, yoga, low-impact aerobics and walking are better options. Whatever form of exercise you enjoy, try to move your body at least four days a week.

Other lifestyle factors, such as smoking25 and alcohol consumption26,27, can have an exacerbating effect on endometriosis symptoms (caffeine and chocolate also tend to aggravate symptoms). Case-control studies have shown that alcohol in particular can have serious  effects for women who are dependent on it or abuse it. Anovulation, ovarian damage, luteal phase defect, and recurrent miscarriage are some of the issues that can be seen with endometriosis and can also be related to alcohol abuse. Bottom line: don't smoke, and don't consume more than three drinks weekly. If possible, it's best to avoid alcohol completely.

The Use of NSAIDs

Owing to the intense pain experienced by many sufferers of endometriosis, the use of analgesic medications like NSAIDs (non-steroidal anti-inflammatory drugs) is common.  Unfortunately, NSAIDs can delay or inhibit ovulation.28,29 Therefore, it is not unusual to see women dealing with endometriosis who also have ovulatory problems, further compounding their difficulties with conception. What I have seen in my practice is that by changing the diet and having regular acupuncture to decrease the level of pain experienced, the dependency on NSAIDs can be reduced. Often these medications will need to be taken for only a day or two, which can allow ovulation to occur at a normal time in the cycle.
 
The Final Word

In my experience of treating endometriosis, it is vital that a treatment plan be based on a very healthy diet and also include dietary supplements shown to be beneficial for endometriosis. We may never learn the cause of this difficult condition, and there may never be a cure, but I have seen patients suffering from endometriosis improve significantly with acupuncture and nutritional help. It is my hope that if you are dealing with endometriosis, you will seek out naturopathic care, nutritional help, and acupuncture treatment to allow you to manage this disease and hopefully, in my opinion, improve your fertility.

References:

1. Speroff L and Fritz MA. Clinical Gynecologic Endocrinology and Infertility, 7th ed. Philadelphia, Pa.:Lippincott Williams & Wilkins; 2005; chap. 29.
2. Farquhar C., Endometriosis (review). BMJ 2000; 320:1449-52.
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7. Sidell N, Han SW, Parthasarathy S. Regulation and modulation of abnormal immune responses in endometriosis, Ann NY Acad Sci 2002; 955:159.
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13. Sesti F, Pietropolli A, et al. Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for endometriosis stage III-IV. A randomized comparative trial. Fertility and Sterility 2007; 88(6):1541-1547.
14. Rose DP, Lubin M, Connolly JM. Effects of diet supplementation with wheat bran on serum estrogen levels in the follicular and luteal phases of the menstrual cycle. Nutrition 1997;13(6):535-9.
15. Goldin BR, Adlercreutz H, et al. Estrogen excretion patterns and plasma levels in vegetarian and omnivorous women. The New England Journal of Medicine 1982;307(25):1542-1547.
16. Aguiar FM, Melo SB, et al. Serological testing for celiac disease in women with endometriosis. A pilot study. Clin Exp Obstet Gynecol 2009;36(1):23-5.
17. Ziaei S, Zakeri M, and Kazemnejad A. A randomized controlled trial of Vitamin E in the treatment of primary dysmenorrhoea. BJOG 2005; 112:466-469.
18. Meloni A, Melis M, Alba E, Deiana S. Medical therapy in the management of preterm birth. Journal of Maternal Health. 2009; informahealthcare.com
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28. Smith G, Roberts R, Hall C, Nuki G. Reversible ovulatory failure associated with the development of luteinized unruptured follicles in women with inflammatory arthritis taking non-steroidal anti-inflammatory drugs. Br J Rheumatol 1996;35:458.
29. Gaytán M, Morales C, Bellido C, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) and ovulation: lessons from morphology. Histol Histopathol 2006 May;21(5):541-56.

About the author
Judith Fiore, ND, is a registered naturopathic doctor in Ontario whose practice in downtown Toronto is dedicated to improving the fertility of women and men. She supports many fertility patients, most notably patients with TCART, CreAte, Lifequest, Toronto West Fertility Centre and Mount Sinai RBU. She lectures frequently on integrating naturopathic medicine with medical fertility treatment, and she is the head of the Acupuncture Examinations Committee for the Board of Directors of Drugless Therapy – Naturopathy.  She can be reached at 416-231-4477, or please visit her clinic website: www.naturalfertility.ca