• Dr. Jillian Smithers

The Truth About Endometriosis

What is Endometriosis?


Endometriosis is a condition characterized by the abnormal presence of endometrial tissue, which normally lines the inside of the uterus, called the endometrium, in other locations around the body. The tissue can be incorrectly implanted on the fallopian tubes, ovaries, intestines, and even in the urinary tract, respiratory system, or diaphragm in some cases.


The endometrium is the innermost lining of the uterus that fills with menstrual blood in response to hormones; therefore, endometrial tissue in other parts of the body will also respond to the same hormones and bleed regardless of where it is located. This leads to the development of inflammation and scar tissue, resulting in buildups of connective tissue, called adhesions, around the affected organs, causing severe pain.


Who Does Endometriosis Affect?


Endometriosis is common - affecting one in every ten women. It’s estimated to affect 200 million women worldwide. It can take women several years to get a proper diagnosis by their doctors because the symptoms are often overlooked and dismissed by the medical community. When a young woman comes in with pelvic pain, most often she’s going to be offered birth control and sent on her way with no lab testing or further look into what could be causing it. You may not know this, but periods should not be painful. That’s right; pelvic pain and cramping may be common, but they’re not normal.


Symptoms of Endometriosis


The number one symptom is pain - pain with periods, with sex, and even with urinating or having a bowel movement. This type of pain is not a cramp or a discomfort; it’s a debilitating pain potentially accommodated by vomiting, which can last more than 10 days out of the month because it can start before a woman’s period and then last through the entire time that she’s bleeding. Another thing that makes endo difficult to diagnose is that a woman can have pain at any time of the month and not just when she’s on her period because of the adhesions around other organs. That’s what causes the pain when urinating/defecating as well.


Other symptoms of endo can include diarrhea or constipation (especially around her period), abdominal bloating (especially around her period), heavy or irregular periods, and difficulty conceiving. It is estimated that 30 - 40% of women with endometriosis are subfertile. Since a lot of women are offered hormonal birth control as a treatment, we need way more research into the cause and treatments for this condition because birth control is not going to be a viable option for a woman looking to get pregnant.


Diagnosing Endometriosis


The diagnosis of endometriosis can take up to 12 years for some women. The gold standard of diagnosing it is through laparoscopy and biopsy. While this is a minimally invasive surgery, it can be expensive and a lot of women and their doctors aren’t too thrilled to undergo a surgery while in pain. Laparoscopy is also used as a treatment for endometriosis, which you can read about below.


Causes and Treatments


The treatment of endometriosis must be multifactorial. We need much more research to be done to identify causation, but we know that we must address estrogen dominance, immune system dysfunction/autoimmunity, leaky gut, and environmental toxicities, as they all play a role in this condition.


Estrogen dominance and endometriosis are closely related, but we’re actually not sure where this partnership begins. Estrogen can stimulate the immune system as well as the growth and proliferation of tissues, including endometrial tissue. Endometriosis, on the other hand, is accommodated by inflammation, which can then lead to estrogen dominance. So we’re really not sure whether it’s the estrogen dominance that’s leading to endometriosis, or endometriosis that’s leading to estrogen dominance.


Regardless of what the initiator is, the hormonal factor must be addressed. We also know that estrogen dominance plays a role in the development of autoimmune conditions, which is why we see much higher rates of these conditions in women than in men. In endo, we also see elevated inflammatory cytokines, the same that we see in autoimmune conditions. We also know that leaky gut, or intestinal hyperpermeability, is a risk factor for developing autoimmune conditions. Food sensitivities, certain medications (including birth control and NSAIDs, both often used by women with endo), alcohol, chronic stress, infections, and environmental factors all contribute to leaky gut.


As a physician, my number one goal is to get women out of pain as we’re addressing the root causes of the condition. How we do that can change from person to person. We can use hormonal options like birth control or non-hormonal options like supplements, diet and lifestyle, and surgery. Oftentimes we’re using a combination of these things. Most of the women who come into my office have been offered hormonal birth control as the main treatment and are looking for other options, so I focus on using natural treatments to start reducing pain and lowering the pain medications that my patients are taking. I try to lower my patient’s intake of pain medication as soon as possible as NSAIDs have been linked to reversible infertility and can even prevent fertile women from ovulating, which increases estrogen dominance. Combine this with the 30-40% of women with endo who are subfertile plus the fact that NSAIDs contribute to leaky gut and we have a huge issue.


As with any chronic condition, it’s important that women understand that often working with a team of healthcare practitioners has the best results. With endometriosis, women often benefit from having a naturopathic doctor or functional medicine doctor to be her team leader to treat the cause while managing symptoms (especially pain relief), optimizing her diet, and balancing her hormones. A naturopathic doctor in certain states can order lab work and do acupuncture treatments as well. A study showed that acupuncture was actually more effective for endometriosis pain than hormonal treatments and also reduced the size of pelvic masses, lowered CA125 markers (a biomarker for several types of cancers and endometriosis), and reduced the recurrence rates of endometriosis. Other team members to consider include a counselor to manage the mental health aspects that come with being in chronic pain, a nutritionist to help optimize diet to lower inflammation and support hormones, a massage therapist to work on the adhesions that are causing pain, and a pelvic floor physiotherapist.


Hormonal Birth Control


Hormonal birth control is the most common endometriosis treatment used conventionally and can absolutely be used to reduce a woman’s pain, so it can be helpful in dealing with the effects on quality of life. With that being said, it’s imperative that women know when they are prescribed any hormonal birth control that they are not treating the root cause of the condition. That can be okay and is always the choice of the individual woman, but she must understand that it is used for managing symptoms, not treating the condition.


Non-Birth Control Options


In treating endometriosis, I most often use specific supplements combined with diet & lifestyle changes. These treatments are meant to address the hormonal aspect, support the immune system, repair the gut, and also reduce the pain. You can get out of pain naturally and effectively with the right plan.


Note: all of the supplements that I mention below can be found in my online store under the category “Endometriosis”.


Diet & Lifestyle


Follow an anti-inflammatory diet. Optimizing diet and nutrition is a very important piece of the holistic puzzle because we know that there is a strong inflammatory component. By eliminating inflammatory foods, we help to heal leaky gut as well as strengthen and restore the appropriate gut barrier that has been weakened by insults like medications, birth control, food sensitivities, infections, environmental toxins, etc. In supporting the gut, we strengthen the immune system and support hormone balance because estrogen is eliminated through our bowel movements. An anti-inflammatory diet involves cutting out the most common allergens: gluten, dairy, soy, corn, and eggs.


Increase veggies, especially cruciferous vegetables. Our daily goal is 5-9 servings/day, which equals out to be about 2-5 cups of veggies, which is easy to get in if you are conscious of it and spread it throughout the day. It definitely takes time to establish new routines, including eating more vegetables, so start small and work your way up! As you fill your plate with more fresh, nutrient-dense foods, you will automatically crowd out the inflammatory allergens listed above and won’t have to focus so much energy on avoidance.


Increase anti-inflammatory spices like turmeric. Turmeric is a potent anti-inflammatory that you’ve probably heard of over the years. It’s a yellow spice and its main active constituent is called curcumin. In terms of supplements, you can find many turmeric or curcumin supplements on the market, but absorbency is a huge issue. Like any supplement that you take, quality matters. Spending money on less expensive supplements doesn’t pay off in the end because they’re often not third party tested so we don’t even know what’s in the bottle and they're often far too low of a dose to offer any benefit. I once had a patient come in on a gut repair supplement and when I compared it to the one that I recommend and take personally, she would’ve had to take 24 capsules of hers to equal 1 teaspoon of mine - basically an entire bottle equalled one serving, that’s insane!


Turmeric can be added into foods and drinks such as egg or tofu scrambles (if you are tolerant of egg or soy), added to rice or roasted vegetables, sprinkled on sauteed greens like kale or spinach, in soups, blended into a smoothie (just use a pinch or two!), in golden milk (simmered with coconut milk and honey), sprinkled on avocado, topped on a salad, and I’m sure many more ways! It’s important to note that turmeric’s absorbency and bioavailability is enhanced by black pepper, so you can add ½ teaspoon to ¼ cup of turmeric and store the mixture in a jar so that it’s ready for use at any time.



Eat to support sleep. We’ll be talking about sleep hygiene and its importance with melatonin below, but there are lots of foods that you can eat to support many different amino acids, minerals, and vitamins that are important for sleep. Tryptophan is an amino acid that gets converted into serotonin and then melatonin and is found in poultry, seafood, nuts and seeds, and legumes. Magnesium is known as the sleep mineral and is found in high amounts in dark leafy greens and nuts & seeds. Vitamin B6, or pyridoxine, helps to convert tryptophan to melatonin and can increase insomnia and decrease serotonin if deficient. It’s found in the highest amounts in sunflowers, pistachios, and flaxseeds. Lastly, melatonin is also found naturally occurring in certain foods like fruits and vegetables and nuts & seeds. It’s also important to cut out foods and drinks that can worsen sleep, such as, caffeine, spicy foods, alcohol, high fat meals, and too much water before bedtime.


Move your body. Exercise is amazing for so many things, but depending on the state of your adrenal glands, we often change what types of exercise we recommend. I typically recommend aiming for 10-15 minute HIIT sessions 3 times/week combined with gentler movements like yoga, walking, Tai Chi, Qi Gong, etc. If your adrenals are really depleted and you’re in HPA dysfunction (commonly called adrenal fatigue), then I recommend fewer to no HIIT sessions and only gentle movement 4-5 days/week. Movement is not only for stress reduction and generally health promoting, it also supports your lymph system and its detoxification, which is important for your hormones.


Reduce stress. In the hormone hierarchy, our adrenals are the foundation. That’s why stress is the root cause of many hormone imbalances, even with the thyroid gland and sex hormones. Stress reduction can be in the form of meditation, mindfulness, journaling, yoga, grounding, baths, saunas, laughter, massage, exercise, and supporting your adrenals glands with proper nutrition and potentially an adrenal support supplement. I prescribe almost all of my patients an adrenal support with herbs and nutrients intended to support healthy cortisol levels, nourish the HPA axis, and optimize catecholamine (dopamine, norepinephrine, and epinephrine) production.


Support the gut. Gut health has been a trendy topic for some time, but for good reason! The gut is the epicenter of everything - our immune system, neurotransmitters, hormone elimination, etc. We’ve already talked about nutrition adjustments that support gut health, but there’s also a time and place for a supplement. I like this supplement because it is a really comprehensive support for optimal gastrointestinal health and function by supporting and strengthening that gut barrier. This is really important because the lining of the gut needs to be permeable enough to allow micronutrients through into the bloodstream, but not overly permeable where larger molecules like toxins, allergens, and molds are gaining access to the blood stream.


Establish a bedtime routine to optimize melatonin levels. Sleep hygiene is important for all of us, but especially for anyone with a chronic health condition. You can start to optimize your sleep routine by limiting blue light at least 1 hour before bedtime, wearing amber glasses when looking at screens to block blue light, sleeping in a completely dark room, and taking a supplement.


Supplements

Melatonin has been shown to be effective in reducing the pain associated with endometriosis, from the menstrual pain to the pain with urination and defecation. It is also one of our main antioxidants in the body, so it has amazing systemic effects as well. I really like this supplement because it not only contains melatonin, but also 5-HTP, vitamin B6, inositol, and L-theanine for additional sleep support.


EGCG, the major component of green tea, is well-known for its significant antioxidant properties, but it may also be a promising treatment for endometriosis because it can actually prevent the growth of new endometrial lesions. This supplement also supports the immune and cardiac systems and is neuroprotective.


Magnesium lowers something called prostaglandins, which are substances that cause cramping and, when they’re too high, increase the severity of menstrual cramps. Magnesium is involved in hundreds of pathways around the body, so it’s something that we want to make sure we have plenty of in our system. I like to run lab tests to check for magnesium levels when applicable, so if you’re concerned about a magnesium deficiency, you can ask your doctor to order a “RBC Magnesium” test. That looks at the magnesium that’s inside your red blood cells, not just circulating around. I spoke about magnesium-rich foods above, which are great to incorporate, but I also often prescribe a magnesium supplement for period cramps. My favorite types of magnesium are magnesium malate and magnesium glycinate. There are actually nine different types, so it's important to know what you want to take the magnesium for to decide on a form. I typically have patients take magnesium malate in a sustained release tablet in the morning because it increases energy and magnesium glycinate in either a capsule or powder at bedtime to help soothe anxiety and support sleep. Both forms will help lower pain due to endometriosis.


Hormone balancing herbs support optimal hormone balance and are great for women with endometriosis because they support the proper elimination of excess estrogens through liver and gut detoxification pathways. With endo being closely related to estrogen dominance, this is super important to make sure that we're breaking down our estrogens properly. They also protect and support beneficial estrogenic activity, and to support progesterone production to reduce estrogen dominance. I personally take this supplement to balance my own hormones.


B vitamins are well known for increasing energy, but they’re also really important for your hormones! They’re involved in liver detoxification, how your liver breaks down estrogen, and the production of hormones. Each B vitamin has different, but supportive, roles, so a B Complex is great because it supplies all of those vitamins and not a single one. I often use this B Complex because it’s important to get adequate B5 to support our adrenal glands and B6 to produce progesterone and melatonin.


Surgery


For some women with endometriosis, surgery is the best option. A type of operation called a laparoscopy is not only used to diagnose endo, but also to remove adhesions caused by the condition as well. The goal of this surgery is to reduce endometriosis-associated pain by removing all visible endometriosis lesions and any associated adhesions. A surgeon can use a technique called an excision to cut away the endometrial implants from the surrounding tissue and then send them for biopsy to confirm that it is endometriosis and not cancer. They can also burn the implants, but care must be taken to ensure that the implant is not only destroyed, but also that no underlying tissue (bowel, bladder, etc.) is damaged.


Any woman with severely painful periods should see a physician for a full workup to investigate the root cause. If this is also vomiting due to pain, avoidance of work/social activities/sex due to pain, pain with urination/defecation, or pain between periods, that is even more important.


Remember that you are the only one who knows what’s normal for your body. Anytime you feel that something is off, you are probably right. If you feel dismissed or like your doctor isn’t listening to you, then it’s time to find someone who will because your concerns need to be heard.


References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942279/

http://endometriosis.org/

https://www.ncbi.nlm.nih.gov/pubmed/22330229

https://www.nhs.uk/conditions/leaky-gut-syndrome/

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0186616&type=printable

https://www.ncbi.nlm.nih.gov/pubmed/15726771

https://academic.oup.com/rheumatology/article/39/8/880/1784112

https://www.pharmaceutical-journal.com/news-and-analysis/news/nsaid-use-may-prevent-fertile-women-from-ovulating/20068779.article?firstPass=false

https://www.ncbi.nlm.nih.gov/pubmed/23252791

https://www.ncbi.nlm.nih.gov/pubmed/25165691

https://www.ncbi.nlm.nih.gov/pubmed/26256952

https://www.ncbi.nlm.nih.gov/pubmed/22748101

https://www.ncbi.nlm.nih.gov/pubmed/23081870

https://www.alaskasleep.com/blog/foods-for-sleep-list-best-worst-foods-getting-sleep

https://www.ncbi.nlm.nih.gov/pubmed/18603648


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