Endometriosis! Now What? Part 1

Have you been diagnosed with Endometriosis? Or do you think you may have it? And now you’re wondering… What is it? What causes it? What can I do about it? Does it affect my fertility? This three-part Endometriosis series will hopefully answer these questions!

What is Endometriosis?

The lining of your uterus, the endometrium, normally grows every month and is cyclically shed as your period. However, Endometriosis is a chronic inflammatory condition characterized by endometrial tissue located OUTSIDE of the uterus.¹ This abnormal tissue may show up on your bladder, bowel, fallopian tubes, ovaries, in the abdomen, or even distant places such as your lungs, diaphragm, spine, or spleen.

Distribution¹⁸

• Uterosacral ligaments 63%
• Ovaries
  • Superficial 56%
  • Deep 20%
• Ovarian fossa 33%
• Anterior vesical pouch 22%
• Pouch of Douglas 19%
• Intestines 5%

This displaced endometrial tissue is VERY estrogen-sensitive, so each month, as you move through the rhythm of your menstrual cycle and your estrogen levels naturally increase and decrease, the displaced tissue responds by growing and shedding just as your uterine endometrial tissue would. The bleeding and shedding of this tissue in places it’s not supposed to be is very irritating to the surrounding area and creates inflammation, irritation, and pain. Over time, recurrent inflammation can also cause adhesions and scarring.

Women aged 25-35 are most likely to be diagnosed¹. You may experience no symptoms or have severely debilitating pain. Interestingly, symptoms are generally not correlated with either the number or size of lesions. Strange, I know!

Most Common Symptoms

• Pelvic pain⁷
• Menstrual pain^{5, 7}
• Pain with intercourse⁵
• Infertility/Subfertility^{7, 8}
• Pain with pooping
• Constipation
• Diarrhea
• Urinary frequency, urgency, and pain⁵
• Abnormal uterine bleeding
• Low back pain
• Chronic fatigue

How is it Diagnosed?

I wish I could say this was an easy peasy diagnosis, but it’s not and unfortunately, the average time to diagnosis is 6-9 years!^9-13 The delay is often related to the overlap of symptoms with other gynecological, gastrointestinal, and urinary conditions. Symptoms are often suppressed with hormones and non-invasive diagnostic techniques, while available, are still not readily accessible. This doesn’t mean your doctor can’t work with a presumptive diagnosis.

There are no Endo lab markers that can be assessed via blood to make a definitive diagnosis. Serum cancer antigen (CA) 125 can be elevated, but this marker can be increased for many other reasons. I will run this if I’m highly suspicious of endo and looking to make a case for additional diagnostics but it’s traditionally used as a monitor once a definitive diagnosis has been made.

The use of advanced ultrasound, MRI, and CT have definitely become more sophisticated over the last several years in identifying the potential for endometrial tissue, but are unfortunately only being used by a small number of highly specialized physicians. The use of these details to make a presumptive diagnosis is undoubtedly sufficient to initiate therapeutic options. With that said, your doctor will be looking out for deep nodules on your bladder, the tissue between your rectum and vagina, and on your ovaries to suggest the presence of Endometriosis.

Exploratory laparoscopic surgery is still used to make a definitive diagnosis. This involves inserting a camera and tool (to cut and remove tissue) into your abdomen. Lesions will be assessed visually and removed. It is ESSENTIAL to find a surgeon very well versed in surgical excision or ablation of endometrial lesions. This surgery can be used for diagnosis and treatment.

Endometriosis is staged I-IV according to the standards set by the American Society for Reproductive Medicine

What Causes Endometriosis?

About 1 in 10 reproductive-age women are affected with endometriosis! You would think we would have a better handle on the cause, but unfortunately, it’s still poorly understood. It appears the cause is multifactorial, including:

• Altered immunity
• Imbalanced cell growth & Oxidative stress
• Altered hormone signaling & metabolism
• Genetic
• Retrograde menstruation
• Leftover embryonic cells

Wow, that’s a mouthful! I’ll try to break it down.

Altered Immunity, Imbalanced Cellular Growth & Oxidative Stress²

The cells within endometrial lesions don’t play by the rules! They grow and spread faster, attach more deeply to surrounding tissue, and stay around longer than normal cells. They produce a ton of inflammation but are also more sensitive to it, which means more pain, scarring, and adhesions. All of this makes endometriosis harder to treat and more likely to progress.

Women with endometriosis have also been shown to have altered immune cell activity. This allows endometrial lesions to grow and implant in places this tissue shouldn’t be. There is even debate as to whether endometriosis is actually an autoimmune disease.¹⁸

Altered Hormone Signaling & Metabolism

As if things couldn’t get more complicated, endometriosis lesions increase estrogen production within themselves, making the cells grow like crazy. Unfortunately, the tissue also manages to resist progesterone’s friendly effects, which would normally buffer growth.

Your gut changes in response to endometriosis, and your endometriosis changes in response to your gut! There is a vicious cycle of alterations in gut permeability and microbes, causing inflammation, which fuels the fire and likely your symptoms.^3,4

Genetics

If your mom or sister has Endo, you are 6-7x more likely also to have it. This is likely related to inherited detoxification genetics affecting hormone metabolism. Meaning, you are likely less able to clear estrogen from your body, making it more available to stimulate endometriosis tissue growth.

Retrograde Menstruation

About 90% of women have some menstrual blood that moves up through the uterus, out of the fallopian tubes, into the abdominal cavity. However, most women do not develop Endometriosis, suggesting that additional factors have to be involved.⁵ Additionally, seeding may occur via blood, lymph dissemination.¹⁸

Leftover Embryonic Cells

When the reproductive organs are forming some of the cells can get misplaced and remain in the abdominal cavity (or other places). They begin to grow as they would within the uterus and become endometrial lesions.⁶

What Increases My Risk?

• prolonged exposure to (endogenous) estrogen¹⁴
  • 1st menstrual cycle before 12 years of age
  • late menopause
  • shorter menstrual cycles, less than 27 days
  • constipation
  • lack of dietary fiber
  • genetics
• heavy menstrual bleeding
• obstruction of menstrual flow
• environmental exposures (exogenous estrogen)^16,17
  • diethylstilbesterol (DES) while in utero
  • dioxins
  • POPs (persistent organic pollutants)
  • PCBs
• height greater than 68 inches
• low body mass index
• exposure to severe physical or sexual abuse as a child or teen
• high consumption of fat (esp. trans fat), fried foods
• IUD use
• history of D & C
• fewer than two pregnancies
• nutrient deficiency
• excess caffeine
• excess alcohol consumption
• inflammation & oxidative stress

What Decreases My Risk?

• late-onset of menstruation (after 14 years of age)¹⁴
• increased consumption of omega-3 fatty acids¹⁵
• multiple pregnancies or births
• extended intervals of lactation
• dietary fiber
• adequate nutrition
• healthy GI and reproductive microbiome

Endometriosis! Now What? Parts 2 & 3

Check out Part 2 and Part 3 of this Endometriosis Blog Series for a discussion on conventional and naturopathic therapeutic options and endometriosis-associated infertility!

Additional Resources

Naturopathic, Integrative & Functional Medicine Providers

If you’re looking for help with endometriosis and interested in working with me I’m available via virtual consult. Schedule a FREE 15-Minute Discovery Call today! Alternatively, if you would like to find a practitioner in your area, see the resources below.

• Dr. Tamara Darragh
• American Association of Naturopathic Physicians
• The Institute for Functional Medicine

Endometriosis Resources

• Nancy’s Nook Endometriosis Education (Facebook Group): This group is serious about educating individuals and practitioners about Endo. They have a helpful list of surgeons across the US that specialize in excision surgery.
• Endometriosis.org
• American College of Obstetricians and Gynecologists: Frequently Asked Questions About Endometriosis
• Endometriosis Association

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References

1. Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of Endometriosis. Nat Rev Endocrinol. 2019;15(11):666-682. 
2. Scutiero G, Iannone P, Bernardi G, Bonaccorsi G, Spadaro S, Volta CA, Greco P, Nappi L. Oxidative Stress and Endometriosis: A Systematic Review of the Literature. Oxid Med Cell Longev. 2017;2017:7265238. doi: 10.1155/2017/7265238. Epub 2017 Sep 19. PMID: 29057034; PMCID: PMC5625949.
3. Yuan M, Li D, Zhang Z, Sun H, An M, Wang G. Endometriosis induces gut microbiota alterations in mice. Hum Reprod. 2018 Apr 1;33(4):607-616. doi: 10.1093/humrep/dex372. PMID: 29462324.
4. Leonardi M, Hicks C, El-Assaad F, El-Omar E, Condous G. Endometriosis and the microbiome: a systematic review. BJOG. 2020 Jan;127(2):239-249. doi: 10.1111/1471-0528.15916. Epub 2019 Sep 19. PMID: 31454452.
5. Vercellini P, et al. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014 May;10(5):261-75.
6. Makiyan Z. Endometriosis origin from primordial germ cells. Organogenesis. 2017;13(3):95-102. doi:10.1080/15476278.2017.1323162
7. Sinaii N, et al. Differences in characteristics among 1,000 women with Endometriosis based on the extent of disease. Fertil Steril. 2008;89(3):538.
8. Donnez J, Donnez O, Orellana R, Binda MM, Dolmans MM. Endometriosis and infertility. Panminerva Med. 2016 Jun;58(2):143-50. Epub 2016 Feb 2. PMID: 26837776.
9. Husby GK, et al. Diagnostic delay in women with pain and Endometriosis. Acta Obstet Gynecol Scand. 2003;82(7):649.
10. Pugsley Z, Ballard K. Management of Endometriosis in general practice: the pathway to diagnosis. Br J Gen Pract. 2007 Jun;57(539):470-6.
11. Hadfield R, et al. Delay in the diagnosis of Endometriosis: a survey of women from the USA and the UK. Hum Reprod. 1996 Apr;11(4):878-80.
12. Ballard K, et al. What’s the delay? A qualitative study of women’s experiences of reaching a diagnosis of Endometriosis. Fertil Steril. 2006;86(5):1296.
13. Staal AH, et al. Diagnostic Delay of Endometriosis in the Netherlands. Gynecol Obstet Invest. 2016;81(4):321.
14. Schenken RS. Endometriosis: Pathogenesis, clinical features, and diagnosis. UpToDate. https://www.uptodate.com/contents/endometriosis-pathogenesis-clinical-features-and-diagnosis?search=endometriosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Accessed June 29, 2020.
15. Missmer SA, et al. A prospective study of dietary fat consumption and endometriosis risk. Hum Reprod. 2010 Jun;25(6):1528-35.
16. Yao M, Hu T, Wang Y, Du Y, Hu C, Wu R. Polychlorinated biphenyls and its potential role in endometriosis. Environ Pollut. 2017 Oct;229:837-845. doi: 10.1016/j.envpol.2017.06.088. Epub 2017 Jul 31. PMID: 28774553.
17. Piazza MJ, Urbanetz AA. Environmental toxins and the impact of other endocrine disrupting chemicals in women’s reproductive health. JBRA Assist Reprod. 2019 Apr 30;23(2):154-164. doi: 10.5935/1518-0557.20190016. PMID: 30875185; PMCID: PMC6501744.
18. Hechtman L. Chapter 18: The Female Reproductive System. Clinical Naturopathic Medicine. 2nd ed. Elsevier Australia, 2019:855-882.

Disclaimer: This website and post include general information about nutrition, health, and fertility. This content is not medical advice. It is not a replacement for medical advice, diagnosis, or treatment of any health condition or illness. With that said, if the reader or any other person has a medical condition, concern, or illness, they should consult with their personal doctor or another appropriately licensed healthcare provider. The reader should also never disregard professional medical advice or delay in seeking advice because of something discussed in this information. It is imperative to consult your doctor or another appropriately licensed healthcare provider before implementing any changes to your diet, fitness routine, lifestyle, medications, or nutritional supplements. 

Information provided in this document and the use of any products or services related to this document by you does not create a doctor-patient relationship between you and Tamara Darragh, ND, DC. Statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.