Endometriosis Awareness
March is Endometriosis Awareness month. It’s been in the limelight a bit over this past year, but, given it affects at least 1 in 10 women, it deserves its own month. It’s one of the most common things I see in clinic as it features when I am working with women around fertility and also painful periods. It can be pretty debilitating for some women. There’s no cure, but there are some ways to alleviate symptoms, slow down the development of lesions and increase fertility.
What the heck is it??
Endometriosis is a condition where bits of endometrium (uterine lining) grow outside of the uterus, usually in the abdominal cavity but they can be anywhere (even in your nose!!), that swell and bleed in line with the menstrual cycle. Our immune system tends to respond to these lesions with cytokines and adhesions can form…this is where it can get a bit complicated, so I am going to gloss over the technical stuff… the important bit is that the result is often painful periods, chronic abdominal pain (sometimes with bowel movements or during sex, other times its just there all the time), adhesions, and heavy periods. In some cases (not all! In fact, not even most) endometriosis can also impair fertility.
So what causes it?
We are not 100% sure what causes some women to get endometriosis. It’s 2019 and our best answer is…we don’t really know for sure. But, there are a few different theories that are pretty convincing. One of the more recent and compelling of these is that the lesions are laid down during foetal development which then become active during puberty due to the influence of oestrogen. A couple of studies have found a a reflective number (around 11%) of female foetuses were found to have endometrial tissue present outside of the uterine cavity, which lends support to this theory [1] [2] . The oldest, but in my view least substantive theory is that it is caused by retrograde menstrual flow. Given that most women have some retrograde flow and only around 10% get endo, I am personally not sold on the retrograde flow theory, but there are plenty of people who
There is also a link environmental toxin exposure. Dioxins and others have been shown to be very elevated in women with endometriosis compared to control groups. These toxins are endocrine disrupters and may predispose adults to developing endometriosis, and there are a number of questions about prenatal exposure to toxins and development of endometriosis in female offspring[3].
Endometriosis used to be considered an endocrine disease with immune involvement due to its oestrogen dependance, but there is compelling evidence suggesting that endometriosis is actually an autoimmune disease. One review of the literature and research on endometriosis found that it could be classified as an autoimmune condition due to the prevalence of inflammatory cytokines and autoantibodies, and it was also found that there were higher prevalence of other autoimmune conditions alongside endometriosis[4]. Regardless of whether its classified as endocrine or autoimmune, both the hormones and the immune system are important aspects of this condition and both generally need to be addressed in any management plan.
How is it diagnosed?
We often suspect endometriosis from symptoms, but the only way to diagnose this is for a gynaecologist to go in via a laparoscopy and take a look. That’s pretty invasive, so its not the right call for everyone. The lesions can often be removed during this surgery, so if you are experiencing significant symptoms (ie pain or fertility issues) it can be very worthwhile.
How do we fix it?
There is no known cure for endometriosis. In women’s health we tend to talk about management. Treatment depends on your goals and individual circumstances. Some women are looking for a reduction in symptoms like painful periods or ongoing pelvic pain to improve quality of life, others are concerned about addressing the imbalance in their health and reducing reducing cancer risks, while others are wanting to assist their fertility. As with most things there are different approaches that will suit different people and their different circumstances.
Medical treatments include surgery and/or hormonal suppression. Hormonal management includes the pill, mirena IUD, Nuva ring, patches and implants. These to varying degrees will cut off your own hormones and slow development due to the oestrogen.
Surgical treatment can provide relief from symptoms and increase fertility, though it does nothing to prevent lesions from reforming, so it is frequently used in combination with other treatment. The average number of surgeries is 4. There is some evidence to suggest that surgical excision has better outcomes than ablation (burning)[5], so its worth discussing what form of removal with your gynaecologist if you are considering surgery.
Holistic approaches are usually multifaceted and can require ongoing treatment. Addressing inflammation and regulating oestrogen levels are usually the aim of such treatments as well as addressing the problematic symptoms such as pain & heavy bleeding. Generally an approach combining a number of modalities, such as lifestyle modifications, changes to diet, supplements, herbs etc, to best achieve the desired outcome. Any plan needs to be individualised to your requirements, but will usually involve trying to address the root of the problem to slow progression, rather than just addressing the symptoms.
If you are interested in exploring some alternative ways to
manage endometriosis symptoms, please get in touch and we can have a chat and
work out what would suit you.
[1] Signorile, P.G., Baldi, F., Bussani, R., et al., 2009. Ectopic endometrium in human fetuses is a common event and sustains the theory of mullerianosis in the pathogenesis of endometriosis, a disease that predisposes to cancer. J. Exp. Clin. Cancer Res.28, 49. https://www.ncbi.nlm.nih.gov/pubmed/19358700
[2] Signorile, P.G.,*, Baldi F., Bussani R., D’Armiento M., De Falco, Boccellino M., Quagliuolo L., Baldi A., 2010 New evidence of the presence of endometriosis in the human fetus. Reproductive BioMedicine Online 21, 142– 147 https://www.rbmojournal.com/article/S1472-6483(10)00179-3/pdf
[3] Wei, M., Chen, X., Zhao,Y., Cao, B., Zhao, W. 2016. Effects of Prenatal Environmental Exposures on the Development of Endometriosis in Female Offspring. https://www.ncbi.nlm.nih.gov/pubmed/26905420.
[4] Eisenberg VH, Zolti M, Soriano D. 2012. Is there an association between autoimmunity and endometriosis? https://www.ncbi.nlm.nih.gov/pubmed/22330229
[5] Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton-Smith P. 2017. Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis. J Minim Invasive Gynecol. 2017 Jul – Aug;24(5):747-756. https://www.ncbi.nlm.nih.gov/pubmed/28456617