The naturopathic approach to endometriosis
Endometriosis is a chronic inflammatory disease affecting around 10-15 % of women of reproductive age and is a common cause of infertility in the Western world.
This condition is characterised by the abnormal growth of functional endometrial glands and stroma in areas outside the wall of the uterus including the ovaries, fallopian tubes, uterosacral ligaments and the surface of the pelvic peritoneum. The displaced endometrial tissue responds to the cyclical changes in hormone levels and ends up thickening and shedding during menstruation. With no route outside the body, trapped blood and inflammation contribute to painful periods, non-menstrual pain, pain during sex and many other uncomfortable symptoms.
The conventional medical approach to “treating” endometriosis includes suppressing symptoms with painkillers and anti-inflammatory medication, hormone therapy including hormonal contraceptives (e.g. oral contraceptive pill), hormonal IUDs (e.g. Mirena) and aromatase inhibitors and laparoscopic surgery. Though many of these allopathic treatment options offer relief from symptoms, for some women, they produce an onslaught of side-effects which outweigh the benefits. This blog post provides a summary of naturopathic treatment options for endometriosis, though I would always recommend consulting with a naturopath for personalised care.
What causes Endometriosis?
The underlying cause of endometriosis is widely debated, though broadly speaking, it is known to involve the complex interplay between genetic, anatomical, immunological, hormonal and environmental factors. The main existing theories are:
Retrograde menstruation
Retrograde menstruation is the oldest theory explaining the location of ectopic endometrial tissue in endometriosis. This theory suggests that retrograde menstrual flow causes the transplantation of fragments of endometrial tissue into the peritoneal cavity through the fallopian tubes, and attachment of these fragments to various surfaces in the peritoneum, inducing an inflammatory response. How successful these ectopic implants become is dependent upon neoangiogenesis, immune dysfunction and reduced sensitivity to apoptosis (programmed cell death).
Immune dysfunction and oxidative stress
Impaired cell-mediated immune responses account for poor elimination of refluxed endometrial cells and increased capacity for cellular proliferation. In women with endometriosis, ectopic endometrial tissue displays resistance to being broken down by natural killer cells.
There have also been higher concentrations of macrophages (a type of white blood cell), as well as their secreted pro-inflammatory cytokines and angiogenic factors including vascular endothelial growth factor (VEGF), identified in their peritoneal fluid of women with endometriosis. Oxidative stress and the presence of bacterial lipopolysaccharide in the peritoneal fluid. via bacterial contamination from the genital tract, is thought to activate macrophages, stimulating their release of inflammatory mediators.
Excess oestrogen
An excess of oestrogen exists in endometriosis due to increased production, incomplete metabolism and poor elimination. Excess oestrogen triggers endometrial tissue proliferation and leads to the over-expression of cyclooxygenase 2, an enzyme responsible for causing inflammation, as well as activation of macrophages in the peritoneal cavity. Elevated oestrogen synthesis may be attributed to higher levels of oestrogen producing enzyme aromatase, found in adipose tissue.
A high ratio of oestrogen receptor beta to oestrogen receptor alpha has also been identified in endometriotic tissue, suppressing progesterone receptors and leading to progesterone resistance.
Endometriosis & diet
Factors involved in the pathogenesis of endometriosis, such as oxidative stress, inflammation, oestrogen activity, prostaglandin levels and toxin burden, are influenced by diet. There is an important role of nutrition in the onset and progression of this condition. Dietary recommendations for endometriosis include the following:
Refined sugar and carbohydrates
Research has shown that insulin is able to bind to its receptors in the endometrium and stimulate the proliferation of endometrial stromal cells, revealing the importance of glycaemic control as a consideration in endometriosis. High intake of refined carbohydrates and sugar can lead to hyperinsulinaemia, which reduces circulating sex hormone binding globulin and leads to higher levels of circulating oestrogens as well as a rise in insulin-like growth factor; resulting in increased proliferation of ectopic endometrium. Eliminating/reducing refined sugar and swapping from refined carbohydrates (e.g. white flour) to complex carbohydrates (e.g. wholegrains) is a key step in the treatment of endometriosis.
Vegetables and Fruit
A diet rich in colourful fresh vegetables, including some fruit, is anti-inflammatory, high in antioxidants and increases fibre intake. Adequate antioxidant intake is important in endometriosis as it counteracts the harmful free radicals that promote lipid peroxidation, implantation of endometrial tissue, angiogenesis and proliferation of endometrial lesions. A study by Mier-Cabrera et al. identified that women with endometriosis had lower dietary antioxidant consumption compared to women without endometriosis. These women were introduced a high antioxidant diet which included foods rich in vitamins A, C and E as well as zinc and selenium and their oxidative stress markers significantly decreased.
Research by Youseflu et al. in 2019 identified lower dietary soluble and insoluble fibre intake in women with endometriosis compared to a healthy control group. Other studies have found that a higher intake of fibre in the form of green leafy vegetables is protective against the development of endometriosis. Fibre intake is essential for achieving optimal intestinal transit time, reducing the amount of oestrogen and oestrogen metabolites that are reabsorbed from the colon and enhancing their excretion in faeces. Sex hormone binding globulin (SHBG) levels are also increased in high fibre diets, reducing levels of bioavailable oestrogen. High fibre diet has the additional benefit of balancing beneficial microorganisms in the large intestine, reducing the microorganisms that deconjugate oestrogen and allow its recirculation
Vegetables in the cruciferous family such as broccoli and cabbage have the additional benefit of being supportive to liver function by aiding phase 2 liver detoxification. Indole and diindolylmethane are the major bioactive constituents in cruciferous vegetables that act on enzymes that metabolise oestrogen. 3,3’-diindolylmethane (DIM) can reverse oestrogen effects in oestrogen-sensitive cells by inhibiting oestrogen receptor alpha signalling. It is also a powerful inducer of oestrogen 2-hydroxylase, decreasing the net level of oestrone and favouring the production of the less oestrogenic metabolite 2-hydroxyoestrogen over the strongly oestrogenic 16-hydroxyoestrone. Other therapeutic vegetables to consider eating are onions, garlic and leeks which contain organosulphur compounds that support liver detoxification and quercetin to reduce inflammation and oxidative stress.
Fats
Total fat consumption has not been associated with endometriosis risk, though certain types of dietary fats may exacerbate this condition. Trans-unsaturated fats, such as synthetic conjugated linoleic acid found in margarine, is associated with increased circulating markers of systemic inflammation such as IL-6. Prospective data from the Nurses’ Health Study II that spanned 12 years was analysed by Missmer et al. and revealed that women with the highest intake of trans-unsaturated fats were 48% more likely to be diagnosed with endometriosis. Their research also showed a 22% lower risk of endometriosis in those with the highest omega-3 fatty acid consumption. Omega-3 fatty acids found in fatty fish (e.g. salmon, sardines and mackerel) are able to regulate cytokines and prostaglandins, which gives them an anti-inflammatory effect. An in vitro study showed that eicosapentaenoic acid (EPA), an omega-3, significantly suppressed the survival of endometrial tissue cultured from women with endometriosis. The omega-3 to omega-6 ratio has also been established as a determinant of the severity of endometriosis, so not only is it important to boost omega-3 fatty acid containing foods but also reducing the intake of omega-6 containing inflammatory industrialised seed oils (e.g. canola, soybean, sunflower, safflower).
Endometriosis & toxins
We are exposed to toxins in the environment via the pesticide sprayed food we eat, inorganic industrialised meat and dairy we eat, what we apply to our skin, hair and nails, our cookware and the cleaning products we use. Exposure to environmental toxins is implicated in endometriosis due to their overburdening the liver, making it more difficult to fully metabolise oestrogen for clearance, but also the fact that many of these toxins are endocrine disrupting chemicals (EDC’s), that can mimic oestrogen and bind to its receptors in the body, having a “growth promoting” effect.
A number of studies have identified higher levels of circulating organochlorine chemicals in women with endometriosis. Exposure to organochlorine chemicals (including glyphosate, atrazine and 2,4-D) is predominantly through the pesticide and insecticide sprayed fruit and vegetables we eat and gets concentrated in the lipid content of meat and dairy products, which is why eating spray-free and organic produce (especially the dirty dozen) is such an important step in treating endometriosis. EDC’s commonly found in personal care products include parabens, pthalates and UV filters, signalling the importance of using natural skin, hair and nail care products. Plastics are also loaded with BPA, pthalates and phenol, which are EDC’s so use glass or stainless steel to store your food. Lastly, the non-stick coating on your pots and pans contains toxic PFC which is a potent EDC therefore get rid of teflon and swap to stainless steel and cast iron.
Physical activity & endometriosis
Several studies have shown a 40-80% reduction in the risk of endometriosis with regular physical activity (PA), though chronic pelvic pain may be whats preventing women with endometriosis from exercising in the first place. PA reduces oestrogen levels by increasing its elimination and decreasing its production. In addition, levels of SHBG increase with regular PA, reducing the amount of bioavailable oestrogen. Physical activity for healthy weight management is an essential consideration for endometriosis, since the activity of oestrogen-producing enzyme aromatase, is elevated with adiposity, obesity and hyperinsulinaemia. Regular PA can help to regulate blood sugar levels, reducing insulin resistance and hyperinsulinaemia, which are associated with increased proliferation in endometriosis, as well as reducing reducing inflammatory markers and increase levels of antioxidant glutathione.
For women with endometriosis, the type of PA as well as the point in the menstrual cycle that the PA takes place is an important consideration. Aerobic PA can provide pain relief by acting as an analgesic through its modulating action on the central and peripheral nervous systems, neuroendocrine effects and the release of endogenous opioids. Strenuous exercise during menstruation (but not during other stages of the cycle) can increase the risk of endometriosis and is therefore not recommended.
Herbal medicine & Endometriosis
A range of herbs are used in endometriosis to balance hormones, support liver function and bile flow, modulate immune function, reduce angiogenesis, induce apoptosis, reduce inflammation and pain. Though clinical studies are lacking, the herbs that have been researched with in vivo and in vitro experimentation are Vitex agnus-castus, Zingiber officinale, Curcuma longa and Camellia sinensis. I highly recommend consulting with a qualified naturopath, for a herbal formula specifically tailored to you.
Vitex agnus-castus - Chaste tree berry
Vitex agnus-castus has been used for menstrual irregularities for many years and is thought to normalise the oestrogen-to-progesterone ratio by enhancing progesterone production, binding or both. Berries of this tree have hormone modulating properties through their weak binding affinity for oestrogen receptors and ability to modulate the expression of hormone sensitive genes. Chaste tree also works as a dopamine agonist, inhibiting prolactin. This is supportive of fertility in endometriosis, since there is evidence that hyperprolactinaemia may contribute to infertility.
Zingiber officinale - Ginger
The rhizome of the ginger plant functions as pain relief in dysmenorrhea, due to its anti-inflammatory, antispasmodic and analgesic actions. Studies have revealed that constituents of ginger are able to inhibit the COX and LOX enzymes, suppressing the production of prostaglandins, thromboxane and leukotrienes that are associated with dysmenorrhea and elevated in women with endometriosis. A small clinical trial comparing ginger to NSAIDs (e.g. ibuprofen) revealed equal reductions in dysmenorrhea (painful periods) when 250 mg ginger was taken 4 times per day, over the first 3 days of the menstrual cycle.
Curcuma longa - Turmeric
Curcumin is an active constituent of turmeric with anti-inflammatory, analgesic, antioxidant and anti-angiogenic actions that are beneficial for the treatment of endometriosis. Curcumin down-regulates the cytokines that promote inflammation as well as suppressing the expression of vascular cell adhesion molecules in endometriotic stromal cells. In a study by Zhang et al., endometrial stromal cells and epithelial cells isolated from a group of women with endometriosis were cultured in a medium containing different concentrations of curcumin, revealing a dose dependent reduction in the proliferation of endometriotic cells, linked to reduced estradiol levels and the induction of apoptosis. In a mouse model of endometriosis, Jana et al. identified that curcumin has the ability to regress endometriosis by down-regulating MMP-3, an enzyme that supports the invasion and proliferation of ectopic endometrial tissue within the peritoneum. Curcumin has also been shown to inhibit angiogenesis and the progression of endometriosis by reducing microvessel density and the expression of the protein VEGF.
Camellia sinensis - Green tea
Though studies exploring the role of green tea in endometriosis are lacking, its major constituent Epigallocatechin-3-gallate (EGCG) is a potent antioxidant and anti-angiogenic. In a mouse model of endometriosis administered EGCG, vitamin E (antioxidant) or saline, EGCG was able to reduce the size of endometriotic lesions and the diameter and density of endometrial microvessels. The expression of VEGF mRNA was decreased in the EGCG group, supporting its role in reducing vascularisation of endometriotic lesions. There was also more obvious apoptosis in the lesions after treatment with EGCG, which has been attributed to suppression of NF-kB activation and activation of killer caspases.
Takeaways from this blog post
Endometriosis is a complex condition that involves immune dysregulation, inflammation and a dominance of circulating oestrogen.
This condition can be supported by making shifts towards a low toxin lifestyle and an anti-inflammatory and organic diet:
Eating organic produce, especially the dirty dozen, meat and dairy
Swapping from storing food in plastic containers to glass or stainless steel
Eliminating chemical personal care products that contain toxic EDC’s and using natural ones with ingredients like shea butter, cacao butter, coconut oil, beeswax and plant extracts
Throwing out your non-stick teflon pots and pans and using stainless steel or cast iron
Increasing fresh non-starchy vegetables and fruit
Eliminating inflammatory trans fats (e.g. margarine) and high omega-6 industrialised vegetable oils (e.g. sunflower, canola, soybean) from your diet
Boosting omega-3 fatty acids by eating more fatty fish (e.g. sardines, salmon), pasture raised eggs, walnuts and flaxseed
Including ginger and turmeric in your diet
Drinking green tea daily
Including regular graded physical activity, though being mindful of avoiding strenuous physical activity when you’re menstruating
For a personalised, carefully tailored treatment plan to support you naturopathically to bring down inflammation, balance hormones, support detoxification and regulate your immune system to alleviate the symptoms of endometriosis, get in touch.