Endometriosis is an estrogen-dependent, inflammatory condition characterized by the growth of the endometrium or lining of the uterus in ectopic locations, usually within the pelvis. Although we aren’t exactly sure what causes endometriosis, it is thought to be associated with retrograde menstruation. This is where menstrual tissue flows backward, through the fallopian tubes and into the pelvic and abdominal peritoneum. Other beliefs regarding the etiology of endometriosis include the idea that this condition may come about when surgical procedures such as episiotomy and caesarian section transfer endometrial tissue into ectopic locations and the idea that peritoneal cells may differentiate into endometrial cells. Despite the fact that we aren’t exactly sure how endometriosis comes about, we are sure about one thing: This condition can be extremely debilitating and can significantly impair our patients’ quality of life. As integrative practitioners, it is important for us to be able to assist our patients in navigating this complex condition and to help them find the right treatment options for them while mitigating risk for any associated unwanted side effects.
The incidence and symptomatology of endometriosis
Endometriosis is a common women’s health problem. In fact, it’s estimated that 10% of the female population in America will be affected by endometriosis during their reproductive years, with an incidence of 2-4%.[1] The condition is a very common cause of chronic pelvic pain. Aside from chronic pelvic pain, common symptoms of endometriosis include dyspareunia, infertility, and menstrual irregularities such as dysmenorrhea, menorrhagia, and metrorrhagia, also referred to as intermenstrual bleeding.
Conventional treatment for endometriosis
The most common treatment options for endometriosis include:
Over-the-counter non-steroidal anti-inflammatory drugs, such as ibuprofen and naproxen
Hormonal contraceptives, including oral contraceptive pills, patches, and vaginal rings to help control estrogen levels and prevent abnormal thickening of the uterine lining
Gonadotropin-releasing hormone (GnRH) agonists and antagonists to block the production of luteinizing hormone and follicular stimulating hormone in order to decrease estrogen levels and prevent menstruation
Progestin intrauterine devices, implants, injections, or pills to prevent menstruation and the growth of ectopic endometrial tissue thereby reduce the associated pain and symptoms in this population
Aromatase inhibitors to reduce estrogen levels and prevent build-up of the endometrium and the pain and symptoms associated therewith
Surgery to remove ectopic endometrial tissue while preserving the uterus and ovaries. This type of surgery is known as conservative surgery. In some cases, hysterectomy with oophorectomy is still performed; however, medicine is moving away from this approach because of associated symptoms.
An integrative approach to endometriosis
There are adverse effects associated with the current conventional means of treating endometriosis. This is problematic because these adverse effects limits their long-term use and conventional therapies tend to need to be taken long-term since symptoms usually return after cessation of these therapies. Therefore, as practitioners, it is in our and our patients’ best interest for us to familiarize ourselves with integrative therapies that have more tolerable side effect profiles. This includes nutritional therapies and botanical products.
In my clinical experience, plant-based diets tend to be highly beneficial in the treatment of endometriosis.[2] This is likely because plant-based foods contain anti-inflammatory components that modulate immunological and inflammatory body processes.[3] Furthermore, research demonstrates that the ratio of the omega-3 fatty acid eicosapentaenoic acid (EPA) to the omega-6 fatty acid arachadonic acid (AA) is a relevant factor in indicating the severity of disease in endometriosis.[4]
Although plant-based foods contain comparatively low amounts of EPA, they also contain virtually no pre-formed AA. Animal-based foods, on the other hand, are much higher in pre-formed AA, with grain-fed meat having, on average, an up to five times higher omega-6 to omega-3 ratio than grass-fed meats.[5] Therefore, I typically recommend completely plant-based diets for my patients with endometriosis, and I have seen stellar results with this dietary intervention alone. If compliance is difficult for this dietary intervention, I recommend a mostly plant-based diet with some fish. If that is also too difficult, I recommend that they at least choose grass-fed meats over grain-fed meats.
How to use integrative medicine to support patients taking conventional medicine for endometriosis
In cases where the severity of our patients’ condition requires conventional therapies, we can still provide integrative support. For example, research demonstrates that oral contraceptive pills deplete various nutrients, including vitamins B2, B6, B9 (folate), B12, C, and E, and the minerals magnesium, selenium, and zinc.[6] We can make recommendations to replenish these nutrients using oral supplementation, or we can assist our patients by recommending and administering intravenous nutrient therapy to restore these nutrients.
Furthermore, research demonstrates that pycnogenol, a natural nuclear factor-kappa B inhibitor, enhances the efficacy of oral contraceptives in the treatment of endometriosis.[7] Individuals who took pycnogenol along with oral contraceptive pills reported significantly greater decreases in pain scores compared to individuals on oral contraceptives alone.
Resveratrol is another natural constituent that may help potentiate the effects of oral contraception in the treatment of endometriosis. Research concluded “the addition of 30 mg of resveratrol to the contraceptive regimen resulted in a significant reduction in pain scores, with 82% of patients reporting complete resolution of dysmenorrhea and pelvic pain after 2 months of use.”[8]
Conclusion
In conclusion, endometriosis is a fairly common reproductive health concern. Conventional therapies are able to control pain and other associated symptoms for many patients; however, they are associated with unwanted side effects in many cases and symptoms often return with cessation of the therapy. As integrative practitioners, we can make dietary recommendations to address endometriosis-related concerns and use our integrative approach to support our patients who are using conventional therapies.
References
Fourquet, J., Sinaii, N., Stratton, P., Khayel, F., Alvarez-Garriga, C., Bayona, M., Ballweg, M. L., & Flores, I. (2015). Characteristics of women with endometriosis from the USA and Puerto Rico. Journal of endometriosis and pelvic pain disorders, 7(4), 129–135. https://doi.org/10.5301/je.5000224
Ilhan, M., Gürağaç Dereli, F. T., & Akkol, E. K. (2019). Novel Drug Targets with Traditional Herbal Medicines for Overcoming Endometriosis. Current drug delivery, 16(5), 386–399. https://doi.org/10.2174/1567201816666181227112421
Watzl, B. (2008). Anti-inflammatory effects of plant-based foods and of their constituents. Int J Vitam Nutr Res. 78(6),293-298. doi: 10.1024/0300-9831.78.6.293
Khanaki, K., Nouri, M., Ardekani, A. M., Ghassemzadeh, A., Shahnazi, V., Sadeghi, M. R., Darabi, M., Mehdizadeh, A., Dolatkhah, H., Saremi, A., Imani, A. R., & Rahimipour, A. (2012). Evaluation of the relationship between endometriosis and omega-3 and omega-6 polyunsaturated fatty acids. Iranian biomedical journal, 16(1), 38–43. https://doi.org/10.6091/ibj.1025.2012
Beezhold, B. L., & Johnston, C. S. (2012). Restriction of meat, fish, and poultry in omnivores improves mood: a pilot randomized controlled trial. Nutrition journal, 11, 9. https://doi.org/10.1186/1475-2891-11-9
Palmery, Maura & Saraceno, A & Vaiarelli, Alberto & Carlomagno, Gianfranco. (2013). Oral contraceptives and changes in nutritional requirements. European review for medical and pharmacological sciences. 17. 1804-13.
Maia, H., Jr, Haddad, C., & Casoy, J. (2013). Combining oral contraceptives with a natural nuclear factor-kappa B inhibitor for the treatment of endometriosis-related pain. International journal of women's health, 6, 35–39. https://doi.org/10.2147/IJWH.S55210
Maia, H., Jr, Haddad, C., Pinheiro, N., & Casoy, J. (2012). Advantages of the association of resveratrol with oral contraceptives for management of endometriosis-related pain. International journal of women's health, 4, 543–549. https://doi.org/10.2147/IJWH.S36825