Endometriosis is a somewhat mysterious condition, one that involves many factors, especially genetic or environmental, yet its etiology is largely unknown. With more research going into the study of Endometriosis, new understandings are emerging. With this more recent information coming forward there is a need to take a new approach to the treatment and management of the condition.

The Typical Presentation of Endometriosis

It is estimated that Endometriosis affects one in ten women who may present with a wide range of varying symptoms. The most common presentation is pain. The pain can range from mild to severe and can be described as a dragging pain in the pelvis. There may be pain present during intercourse or when going to the toilet to defecate. Abnormal bleeding may be present during menstruation, with clotting and a longer cycle overall. Premenstrual symptoms commonly associated with endometriosis include irritability and tension, breast tenderness, insomnia, bloating and constipation which resolves once the period comes (1).

Symptoms that may warrant further investigation:

• Intense period pain
• Pain during intercourse
• Pain worsening toward the end of the period
• Pain before periods and at ovulation
• Pelvic pain on one side
• Fertility issues
• A family history of endometriosis

What is Endometriosis?

Endometriosis is a condition where the endometrial tissue starts to grow outside its normal area within the uterus, lining the walls of the uterine cavity (1). How the endometrial tissue is relocated is unknown, with multiple theories yet to be confirmed. The lesions can be found almost anywhere in the body, but more commonly in the pelvic cavity including the fallopian tubes, ovaries, peritoneum, and bladder. Although not as common, they have also been found on the intestines, colon, rectum, vagina, on the skin, within the lungs, the spine, and brain! These lesions act as normal endometrial tissue, being stimulated by the hormone estrogen to swell and bleed with each menstrual cycle. This is known to be the primary cause of the pain experienced by sufferers, as the lesions and cysts by growing in the wrong place, cause pressure. They may also lead to the development of scar tissue. This can ultimately affect the function of other organs and result in complications such as infertility.

The Medical Approach

The medical approach is generally one of two options: Drugs or surgery. The drugs prescribed are oral contraceptive pills to supply the body with synthetic hormones to induce a pregnant or menopausal state. This means that they suppress ovulation and aim to reduce menstrual flow and further lesion stimulation. The most common surgical procedure is by laparoscopy to remove the endometrial lesions and cysts. Laparoscopy is considered the gold standard regarding diagnostic tools, meaning that at the same time as the diagnosis is made, the surgical removal of lesions can also be completed. Occasionally microsurgery might need to be undertaken to remove adhesions from fallopian tubes or walls of the pelvic cavity. The surgery is a somewhat invasive approach, and many women have reported still experiencing pain post-surgery, sometimes more severe than before.

How Functional Medicine can Help

Previously it was thought that hormonal correction should be the primary focus of treatment, due to the estrogen sensitivity of the endometrial lesions, This is no longer the Functional Medicine approach, as it is known that endometriosis is a multifaceted condition, so the path to treatment should be multidimensional as well. Taking a new approach to therapy for Endometriosis offers unique opportunities to explore the disease, and this means that treatment will differ from patient to patient depending on their symptoms:

1. Pain is the biggest complaint, and this is due to the inflammatory component of the condition. Targeting this first can bring great relief to a patient, and thankfully, is an area where natural remedies like nutritional medicine shine.
2. The Immune system must also be considered. More recent research has shown the significance of the body’s immune response to this disease, in cases of endometriosis, the immune system synthesizes inflammatory cytokines and autoantibodies that further inflame the lesions and stimulate their growth while reducing the activity of natural killer cells (3).
3. Oxidative stress has more recently become an area of focus with studies identifying a clear imbalance between reactive oxygen species (ROS) and antioxidants that are thought to play a role in the inflammatory nature of endometriosis. Production of ROS occurs due to standard metabolic functions, however, in cases of endometriosis, the ROS are thought to interfere with cell proliferation and have adverse effects within the peritoneal cavity (4).
4. Hormonal balancing is also to be considered, enhancing the body’s sensitivity to progesterone while supporting the body’s elimination and detoxification pathways to clear estrogens.

A New Approach to Treatment

Taking a new approach to the treatment of endometriosis can be an excellent opportunity to seek advice from a functional medicine practitioner. As a guide, the following interventions are supported by the current literature, making them appropriate considerations for use. Moving forward, a new approach to take towards treating endometriosis can, and should at least target one of the following. Ultimately any program should be tailored to the individual.

Managing Pain

The inflammatory nature of the condition is primarily responsible for the pain experienced. However, the severity of the pain itself is not a clear indication of the seriousness of the disease. Women with severe endometriosis might present with minimal pain, whereas a woman with intense, debilitating pain may only have a mild case. Specific herbal and nutritional remedies, as well as modified diet and lifestyle, can significantly reduce the discomfort and promote quality of life for those suffering.

• Turmeric: A common culinary herb, which has been shown to target endometrial tissue specifically, providing anti-inflammatory as well as analgesic properties. The curcumin in turmeric has been shown to suppress endometrial cell proliferation; it also addresses all areas of the inflammatory cascade that occurs in chronic inflammation (5).
• Evening primrose oil (EPO): consists of fatty acids that are beneficial for hormone health as they provide the building blocks for the cell membranes and steroid hormones. EPO may be used therapeutically in the management of endometriosis as it’s metabolized to produce series 1 prostaglandins (PGH1 specifically). These prostaglandins possess anti-inflammatory effects within the body as well as reduce excess collagen production, platelet aggregation, regulate T-lymphocyte function and reduce scar formation (6).
• Anti-inflammatory Diet: Ensuring the diet is used to reduce inflammation even further is paramount. The common culprits in a typical inflammatory diet are sugar, gluten, dairy and vegetable oils. However, the diet must be modified to suit the individual, identifying and removing any of the aggravating foods in their diet, or foods that may trigger an allergic response. This can range from high histamine foods, to FODMAPS and so on.
• Culinary Herbs: Considering the use of common culinary herbs is a simple and ineffective treatment. Ginger and cinnamon along with turmeric in foods and drinks can be used appropriately. These are known for their anti-inflammatory, pain relieving and blood stimulating properties that help to not only manage the pain but also reduce blood stagnation and prostaglandins (7).

Immune support

When it comes to enhancing immune function, the gut is always of primary focus. The immune response to endometriosis is not too dissimilar to other common autoimmune conditions each with intestinal hyperpermeability at their core.

• Zinc: Works to repair intestinal hyperpermeability and supports the immune system as well as reducing inflammation and promoting wound healing of endometrial lesions.
• Gluten: Removing gluten from the diet can further help, as gluten is known to increase intestinal permeability.
• Probiotics: Probiotic supplementation is of benefit, as the presence of lipopolysaccharides is linked to the presentation of endometriosis, these are endotoxins in the outer membrane of gram-negative bacteria (8).
• Sugar-free diet: Dietary application as per above, including anti-inflammatory foods, herbs and removing refined sugars as these are known to weaken the immune system.

Balancing Hormones

Balancing hormones can be done through two mechanisms. One is to support the body’s detoxification pathways, i.e., through liver and bowel, to assist in the clearance of estrogen, and Two is to provide nutrient cofactors that increase cellular sensitivity to progesterone.

• Hormone Synthesis: Zinc, vitamin B6, and magnesium work synergistically together to support the production of progesterone (9). Magnesium also plays a role in the detoxification of estrogen in the liver and bowel, with a deficiency contributing to estrogen excess via aromatization.
• Hormone Metabolism: The inclusion of cruciferous vegetables, like broccoli, support healthy estrogen metabolism.

Reducing Oxidative Stress

Oxidative stress occurs through some processes and is a crucial area of treatment targeting. The accumulation of iron within the pelvic region, environmental toxin exposure and the high estrogen/estrogen excess, are all are significant contributors to this (10).

• N-acetyl-cysteine (NAC) is a bioavailable form of cysteine that promotes glutathione synthesis (the body’s primary antioxidant). NAC provides not only anti-inflammatory and antioxidant actions but also targets pathways in the liver to promote detoxification. Clinical trials have also found that supplementation with NAC for 12 weeks resulted in decreased endometrial cyst size and reduced pain scores in participants (11).

There is a lot to consider when it comes to endometriosis that can leave both practitioners and patients feeling overwhelmed. For those suffering from this condition, it’s strongly advised to seek out care from a trained professional for the appropriate treatment and management of endometriosis. Considering functional medicine can be of great benefit, as this approach finds and treats the person as an individual and not just the disease.

References

1. http://www.abc.net.au/health/library/stories/2004/03/25/1829440.htm
2. Kennedy S, et al. ESHRE guideline for the diagnosis and treatment of endometriosis. Human Reprod 2005;20(10):2698-2704.
3. Králíčková, M., & Vetvicka, V. (2015). Immunological aspects of endometriosis: a review. Annals of Translational Medicine, 3(11), 153. http://doi.org/10.3978/j.issn.2305-5839.2015.06.08
4. Scutiero, G., Iannone, P., Bernardi, G., Bonaccorsi, G., Spadaro, S., Volta, C. A., … & Nappi, L. (2017). Oxidative stress and endometriosis: a systematic review of the literature. Oxidative medicine and cellular longevity, 2017.
5. Arablou, T., & Kolahdouz-Mohammadi, R. (2018). Curcumin and endometriosis: Review on potential roles and molecular mechanisms. Biomedicine & Pharmacotherapy, 97, 91-97.
6. Paxton, 2015, p.87 – Paxton, F., (2015). Foundations of naturopathic nutrition. Sydney: Allen & Unwin.
7. Khayat, S., Kheirkhah, M., Behboodi Moghadam, Z., Fanaei, H., Kasaeian, A., & Javadimehr, M. (2014). Effect of Treatment with Ginger on the Severity of Premenstrual Syndrome Symptoms. ISRN Obstetrics and Gynecology, 2014, 792708. http://doi.org/10.1155/2014/792708
8. Khan, K. N., Fujishita, A., Hiraki, K., Kitajima, M., Nakashima, M., Fushiki, S., & Kitawaki, J. (2018). Bacterial contamination hypothesis: a new concept in endometriosis. Reproductive Medicine and Biology, 17(2), 125–133. http://doi.org/10.1002/rmb2.12083
9. Trickey, R., (2011). Women, hormones & the menstrual cycle. Fairfield, Vic.: Melbourne Holistic Health Group.
10. Yamaguchi, K., Mandai, M., Toyokuni, S., Hamanishi, J., Higuchi, T., Takakura, K., & Fujii, S. (2008). Contents of endometriotic cysts, especially the high concentration of free iron, are a possible cause of carcinogenesis in the cysts through the iron-induced persistent oxidative stress. Clinical Cancer Research, 14(1), 32-40.
11. Porpora, M. G., Brunelli, R., Costa, G., Imperiale, L., Krasnowska, E. K., Lundeberg, T., … Parasassi, T. (2013). A Promise in the Treatment of Endometriosis: An Observational Cohort Study on Ovarian Endometrioma Reduction by N-Acetylcysteine. Evidence-Based Complementary and Alternative Medicine : eCAM, 2013, 240702. http://doi.org/10.1155/2013/240702