Endometriosis: Lifestyle and Nutrition
The cornerstones of treatment for endometriosis should be lifestyle and nutritional approaches to enhance and consolidate standard therapies, and when appropriate they can be employed as first line therapy for some women. These approaches have not been well studied in the medical literature, however because these therapies generally enhance overall well being and health, they should be addressed with women, and further studied in a more formal fashion. Allopathic therapies for endometriosis include hormonal therapies and surgical excision, however they do not necessarily address the root cause of the problem. Some women will require surgery to establish a diagnosis, as well as for immediate treatment of significant pain. Surgery may also be consolidated with hormonal therapies, and also with lifestyle and nutritional approaches to minimize recurrent symptoms.
It has been estimated that 11% of all women may have some form of endometriosis; greater than 5 million women in the United States are estimated to have endometriosis. Some women have no symptoms of endometriosis and while others may have varying degrees of pain ranging from pain with menses to debilitating chronic pelvic and abdominal pain. Some women will also have infertility attributed to endometriosis. Endometriosis can become symptomatic in very young women in their teens, however it more commonly presents in women in their 20s and 30s. It may become evident in peri menopausal women in their 40s and 50s.
The condition endometriosis refers to tissue consisting of endometrial tissue in locations outside the lining of the uterus, where it is normally found. This is termed ectopic endometrial tissue. This endometrial tissue is not necessarily normal endometrial tissue, as it potentially undergoes cellular alterations that allows it to grow outside the lining of the uterus. The most common locations for this ectopic endometrial tissue are: the ovaries, under the ovaries, fallopian tubes, behind the uterus, bowels, and bladder. Endometriosis may also be found in the other spots outside the pelvis and abdomen, such as the lung and brain.
These ectopic endometrial implants may lead to significant levels of pain in women, and for some infertility. It is estimated that in women with pelvic pain, up to 75% will have endometriosis, and up to 50% of women with infertility will have endometriosis. Symptoms of endometriosis include: pelvic pain, heavy periods, spotting between periods, painful periods, pain with intercourse, bladder pain, abdominal pain, intestinal pain, constipation, nausea and depending on the location of the implants other symptoms. Endometriosis may cause painful urination, painful bowel movements, fatigue, and lack of energy. The amount of endometriosis however, does not correlate to the degree of pain that a woman may encounter and suffer. Pain due to endometriosis is not well understood; a small amount of endometriosis may cause a large amount of pain and some women with a large amount of endometriosis will have minimal to no pain. Pain may be due to the inflammation surrounding the implants which results from bleeding into these implants as they respond to monthly fluctuations in hormones. Scar tissue may also result from this chronic irritation, and this scar tissue may also lead to pain. This scar tissue can lead to the adherence of pelvic and other abdominal structures to one another; such as the bladder, rectum, ureters and other structures. Some endometriotic implants may also involve nerves, and these nerves can be irritated and sensitized by the inflammation. Endometriosis pain may become better after pregnancy, the reasons for this are currently not known.
Origins of Endometriosis
In order to understand a disease and craft treatments, the elucidation of the causes of the disease are important. The origins of endometriosis have remained elusive, and indeed as our environments and lifestyle change, the disease may also evolve.
Investigators have proposed that endometriosis results from retrograde menstrual flow. This is where endometrial tissue that normally flows through the cervix out outward during menses, flows in a reverse type fashion through the fallopian tubes. For some women this may be be cause, however many women have retrograde menstruation and not all develop endometriosis so there must be other factors contributing to development of symptomatic disease. Other factors which may be contributing to the development of symptomatic disease include: genetic factors (endometriosis can be found in familial clusters such as mothers, daughters and sisters), estrogen levels and metabolism (endometriosis can respond to anti estrogen therapies), progesterone levels and metabolism, immune system abnormalities (the immune system may fail to destroy the ectopic endometrial tissue), environmental exposures (such as dioxins and PCBs). Coelomic metaplasia, where the cells lining the abdomen convert into other types of tissue, may also contribute to endometriosis. Endometriosis may also result from direct transfer of tissue during surgery. Endometrial cells may possibly be transferred by the bloodstream (resulting in endometriosis of the lung and brain).
Standard Medicinal Therapies
While some forms of endometriosis, such as endometriomas (endometriosis of the ovaries) and adenomyosis (endometriosis of the wall of the uterus) may be detected with imaging such as ultrasound or MRI. The most common way that endometriosis is diagnosed is through surgery such as laparoscopy. After a diagnosis is made, treatment strategies can be reviewed and instituted. Treatment recommendations can be affected by age, symptoms, fertility desires, and amounts and locations of endometriotic implants. Pain medications can also be prescribed during treatments.
Effective treatment of endometriosis should employ a multidisciplinary approach. The cornerstone of treatments for endometriosis has been hormonal therapy along with surgery. However, many times after hormonal therapies are halted or after surgical excision, endometriosis may return to become symptomatic. Because the propensity to develop endometriosis is a chronic condition, treatment strategies should also consider and include lifestyle, nutrition, physical therapy, and other integrative approaches.
Hormonal therapies for endometriosis include: oral contraceptives (birth control pills); progestin treatment through oral progestins, injections, and IUDs; GnRH agonists either through a nasal spray, injection and most recently through the oral route. These hormonal therapies can lead to weight gain, mood issues, hot flashes, vaginal dryness and other estrogen deprivation symptoms for some women such as fatigue, joint pain and sleep disruption. Danzol, is a hormonal therapy which has been used for many years in the treatment of endometriosis, however it is associated with significant androgenic side effects such as oily skin, acne, deepening of the voice and other side effects such as fatigue, headaches, and dizziness. Other hormonal therapies being evaluated include: gestrinone and aromatase inhibitors.
Surgical therapies can provide immediate pain relief from endometriosis. Pre operative planning for surgical excision should include: goals of therapy, desire for future fertility, location and anticipated extent of disease, scope of surgery, and importantly methods to consolidate surgical therapies afterwards. Surgery will include removal of lesions and lysis of adhesions. Because the disease is a chronic condition and surgery does not treat the root cause of the disease, only the end product; even after extensive surgical therapies endometriosis can return. While conservative therapy with preservation of the uterus and the ovaries is favored, even after a hysterectomy and removal of the ovaries, endometriosis symptoms may return in up to 15% of women. Nerve interruption procedures can also be employed for relief of pain. These include pre sacral neurectomy and the LUNA procedure. Both of these procedures are associated with controversy and are generally not recommended as an initial approach. A progestin IUD may be inserted at the time of surgery for further hormonal consolidation.
Integrative approaches to the management of endometriosis include: nutritional approaches, lifestyle, physical therapy, acupuncture, mindfulness, aromatherapy, restorative sleep and others. Endometriosis has been linked to hormonal imbalances, stressors, nutritional deficiencies, and immune system disorders. These origins of endometriosis provide targets for management through integrative strategies. These holisitic approaches can help to manage inflammatory response, response to stressors, hormone processing, improvement in immune system function, and limiting environmental exposures. It has been demonstrated that attention to the HPA axis (hypothalamic - pituitary – adrenal axis) can help to mitigate endometriosis in animal models. Anti inflammatory approaches through nutrition may also be beneficial. It is very likely that because endometriosis is a complex disease process, these integrative approaches will not operate in isolation but should be combined in order to maximize their benefit. They can also be combined with traditional allopathic therapies.
Nutrition and Endometriosis
The foundation for nutritional approaches are to improve hormone balance, limit inflammation, improve liver function to improve detoxification, improve immune function, and limit potential toxic exposures. These nutritional strategies can be achieved through diet and targeted supplementation where deficiencies exist or enhancement can be beneficial.
- Nutrition Principles:
- Eat organic, when possible, in order to limit environmental exposures.
- Eat wild caught fish; increases EPA/DHA which can decrease inflammation and pain.
- Eat flax seed, hemp seeds and chia seeds which can help with hormone processing.
- Eat cruciferous vegetables which increases indole 3 carbinol and helps to support the liver to process hormones
- Eat avocados which are high in good fats, fiber and magnesium.
- Eat foods rich in unsaturated fats such as olive oil, nuts, seeds and oily fish.
- Limit alcohol: abstain for 2 months and then limit to 1 to 2 glasses per week. This helps liver function and detoxification. Alcohol is inflammatory.
- Limit saturated fats.
- Avoid non-organic dairy because they contain steroids and pesticides.
- Avoid red meats because they contain arachidonic acid which encourages the production of prostaglandins. PGE2 is inflammatory. If you do eat meat, eat grassfed organic in order to limit exposures.
- Avoid refined sugar. It is inflammatory.
- Achieve your optimal weight. Recommended in order to decrease endogenous estrogen.
- Multivitamin in order to correct for any unmeasured insufficiencies.
- Omega 3 Fish Oils 770mg EPA and 510mg DHA, in order to decrease inflammation.
- B vitamins in order to help with hepatic metabolism of estrogen; B6 may decrease menstrual pain. 50mg of B complex can be recommended.
- Vitamin E may help to relieve menstrual pain.
- Vitamin C and bioflavonoids in order to help with immune function. Bioflavonoids may help to relax smooth muscle and decrease inflammation at the time of menses.
- Magnesium can act as a smooth muscle relaxant.
- Zinc is important for the metabolism of fatty acids.
- Probiotic to decrease leaky gut and thus inflammation.
- Natural progesterone cream.
- Milk thistle (Silybum marianum) is proposed to act through the liver in order to balance hormones.
- Crampbark (Viburnum opulus), works as an antispasmoic and may help with menstrual pain.
- Agnus castus (Vitex/Chastetree berry) has been proposed to help normalize the pituitary gland. Proposed to help with “hormone balance”.
- Echinacea (Echinacea purpurea) is proposed to act through the immune system. It has been recommended to be used intermittently (10 days on 3 days off).
Limit Environmental Exposures
Excess estrogen can occur through environmental compounds that function as estrogens, so called xenoestrogens. Dioxins, found in pesticides, have been linked to endometriosis. When female rhesus monkeys are fed food containing dioxins, 79 percent developed endometriosis The severity of endometriosis correlated with the amount of dioxins consumed. Common sources of dioxins include personal care products. Always try to use organic personal care products.
Exercise inncreases pelvic blood flow, decrease stress, and increases endorphins. Regular exercise of 4 hours per week and lower levels of body fat can decrease the risk of endometriosis.
Increase blood flow, relax tensions in the pelvis.
May help to manage endometriosis. Appropriate referrals should be made.
Meditation and finding joy can help to manage stressors and the HPA axis. This can help the immune system, inflammation, pain, and others. Data on the efficacy of mindfulness and its impact on endometriosis is being elucidated. A good source for meditation techniques is headspce.com.
Aromatherapy and Essential Oils
While these have not been studied in the medical literature, they may be beneficial and also should be used with some significant and specific cautions. Essential oils should not be taken internally, they can be quite toxic and there is no regulation managing these essential oil products. Undiluted essential oils should not be applied directly to the skin. Individuals with seizure disorders or liver disorders should not use essential oils. Essential oils can be mixed with carrier oils such as coconut oil and others and used a massage oil. Mix 2-3 drops with 1 teaspoon of carrier oil. Essential oils should not be used in women seeking immediate fertility, pregnant, or around children. They can be toxic and should be used sparingly as recommended. A small patch test should always be used in order to assure that there are no allergies.
- Clary sage can help to balance hormones.
- Frankincense and sandalwood may help to decrease inflammation and help with healing.
- Basil can help with cramps.
- Geranium can help with cramps and well being.
- Eucalyptus radiata can help with inflammation.
- Lavender can help with well being, sleep, and scar tissue.
- Cypress can help with circulation.
- Bergamot, frankincense, geranium, neroli, rose, sandalwood, jasmine, patchouli, vetiver, and ylang ylang can help with stress management.
Sleep is important for a number of processes key in endometriosis. It is necessary for proper immune function, stress and HPA axis management, weight management, and others.