Endometriosis – the hidden epidemic

How to survive diagnosis and treatment and help the body to heal itself, by endometriosis expert Dian Shepperson Mills.

What causes endometriosis?
The endometrium – the inside lining of the womb – sheds as a menstrual period in the monthly cycle. From day one to day 14 of the menstrual cycle, it is building up ready for conception around day 15, when most women ovulate. This process occurs in response to the hormone oestrogen, creating a nutrient-rich layer inside the womb ready to receive an embryo. When conception doesn’t occur, a period will shed this lining. However, some of the blood may drip inside the abdomen via the fallopian tubes. Here it can begin ‘seeding’ itself onto healthy tissue on the bowel, bladder and ovaries. With each period, this tissue then bleeds along with the womb lining, and the fluid it creates can become trapped inside the abdominal cavity, generating inflammation and pain.

The reason why this happens is little understood. Research reports that as that many as half of all menstruating women are affected by period pain, and 10% have such severe pain that it incapacitates them for three or four days each month.[4] How many of these have endometriosis is unknown, as diagnosis requires invasive techniques to determine the presence of rogue endometrial tissue. Where it is investigated, endometriosis is commonly found on the outside of the womb, ovaries, ligaments, bladder and bowel; large blood filled cysts may form on ovaries; and adhesions can stick organs together. Rarely it can grow on other organs, such as the lung, gums, kidneys, diaphragm, stomach, and liver.

The four key symptoms of endometriosis
1. Chronic/acute period pains
2. Ovulation pain
3. Pain on intercourse
4. Sub-fertility

Other reported symptoms
5. Abdominal bloating, IBS
6. Bladder pressure, urgency, interstitial cystitis
7. Extreme fatigue
8. Ovary pains, lower back pains
9. Chronic bowel symptoms, rectal bleeding, IBS
10. Low body temperature
11. Recurrent hormone imbalances
12. Pains at all times
13. Low moods and anxiety
14. Reduced immunity with frequent infections and sore throats

What’s strange about endometriosis is that small specks of endometrial tissue can cause enormous pain, while huge lumps may give no pain at all.

Approaching your GP
Not all GPs are very knowledgable about endometriosis. So it really helps to take a list of the main symptoms with you to show him/her what happens to you each month. Explaining what the pain is like is also important. “It hurts here,” often isn’t sufficient. Try to describe the pain – ie pinching, stabbing, wringing, dragging, searing, deep aches, burning, tearing, twinges, backache, left ovary or right ovary pains.

Does this correspond to the time of your period or when you ovulate mid-cycle? Do your bowel habits change when you ovulate? Do you become constipated or have diarrhoea before, during or after your period? Explain it all, write it down and go through exactly what happens when and how many days the pain lasts. Score the pain on a 0-10 scale. Keep a diary. The doctor is more likely to take it seriously if you can show pain is happening with the period and at ovulation.

Some women even get pain every day. Tell your GP which painkillers you take and how many are needed to stop the pain, or do they not even touch the pain? Ask to be referred to a gynaecologist with specialist interest in endometriosis. Aim to be assertive but not aggressive. If taking the oral contraceptive pill and painkillers at periods does not stop period pain, then you must see a specialist. When you get a referral, tell the specialist all the same points. Having a scan may show cysts and identify if organs are misaligned – but it will not show small spots of endometrioisis, only large lumps. These can only be identified by laparoscopy. Getting a diagnosis is a great relief to know what is causing the pain.

Surgical treatment of endometriosis
Gold standard diagnosis is done by laser laparoscopy, where any endometrial tissue is identified and simultaneously removed. Pharmaceutical treatments are the oral contraceptive pill to mimic pregnancy, GnRH analogues like Zoladex to mimic menopause, or use of the Mirena coil, as pregnancy and menopause are felt to halt the growth of endometrial tissue. Hysterectomy or removal of the ovaries may be done if the disease is severe, but usually the rogue tissue is just lasered away during a laparoscopy, or cut out by micro-surgery. Conservation of reproductive organs should also be the gold standard. It is bad practice to remove the womb and/or ovaries in women where they can be conserved by skilled surgery, and research suggests that future health and longevity can be impeded where full or partial hysterectomy occurs.

The role of oxidative stress
Studies have found a positive association between oxidative stress and endometriosis, suggesting that having too many oxidants in the body may affect the growth of endometrial tissue.[5] The presence of endometriosis also increases oxidative stress and a diet lacking antioxidants may contribute to excessive growth of endometrial cells.[6] Significantly, lower levels of vitamin E were found in the peritoneal fluid – the fluid that exists to cushion organs in the abdominal cavity where endometrial tissue often locates – than in blood plasma, suggesting that the peritoneal cavity has less antioxidant protection than blood, so the fluid containing the endometriosis might be more susceptible to oxidative stress.[7] Antioxidant nutrients like selenium, vitamins A, C and E may be supportive, plus proanthacyanadin in berries has antioxidant effects. Research has found that women with endometriosis have lower antioxidant intakes of vitamin C, vitamin E, selenium and zinc – and as endometriosis severity intensifies, an even lower intake of antioxidants is observed.[8]

Progesterone resistance
Many women with endometriosis have progesterone resistance, which is much like insulin resistance, where the body becomes less responsive to insulin. Progesterone resistance occurs when oestrogen and progesterone become out of balance, particularly when oestradiol, the more growth-promoting type of oestrogen, is not changed into oestrone, the more protective form of oestrogen. Women with endometriosis often show resistance of the endometrium to the effects of progesterone at certain times during the menstrual cycle. This is because there are low levels of a certain enzyme that facilitates its effect. Progesterone levels are able to rise 30 fold over the space of half an hour, so are difficult to measure accurately. Progesterone levels usually rise after ovulation to promote a successful pregnancy if conception has occurred.

Day 21 of the menstrual cycle is the normal reading taken to assess if levels are adequate. Low progesterone can indicate ovulation has not taken place and also that abnormal endometrium is present, and although progesterone does not seem to affect endometrial thickness, it does affect the quality and ability of the endometrium to hold onto the embryo as it tries to implant. The nutrients required for progesterone synthesis are magnesium, zinc, vitamin A, vitamin B6, amino acids and essential fats. It could be that these nutrients are deficient or poorly absorbed in women with low levels of progesterone. Progesterone is also produced in the ovary inside something called the corpus luteum. After an egg has been released from a follicle on the ovary at ovulation, the follicle seals up and fills with a golden liquid which produces progesterone – this is the corpus luteum.

In addition to sustaining pregnancy, progesterone is needed by the body as it causes the endometrium to shed once a month if conception hasn’t occured; it acts as an anti-depressant by calming the nervous system and balancing copper and zinc levels; it protects breast tissue and helps prevent breast cancer; it acts as a natural diuretic and aids thyroid action; it helps body fat to be used as energy and normalises blood sugar control; it stimulates bone growth and its effects are needed for a normal menstrual period. It may be that with all the oestrogenic chemicals in the food chain due to pollution and the widespread use of pesticides and chemicals in farming and food production, the fine balance between oestrogen and progesterone is disrupted.

To restore balance requires paying attention to what you eat. Having much less red meat and dairy foods seems to be important, as is eating organic whenever possible. In the case of endometriosis, it’s recommended to not only avoid sources of oestrogen, but also the much weaker phytoestrogens found in foods like soya, wheat and citrus, as well as in the herbs black cohosh, dong quai and red clover. It may also not be a good idea to have too much folic acid, ie above 400mcg a day. The herb vitex agnus castus can help to balance oestrogen and progesterone over three to six months, but must be stopped if you become pregnant. No hormone-influencing herbs should be taken if you are on the pill or taking HRT or the GnRH analogues for endometriosis, as they have affects which might disrupt each other. All supplements are best stopped five days before any operation.

Oestrogen dominance
Endometriosis develops in the presence of excessive oestrogen. Research found that 79% of a group of monkeys developed endometriosis after exposure to certain types of dioxins – toxic oestrogenic chemicals found in the environment as the byproduct of industrial processes and rubbish incineration – in their food. The severity of endometriosis was directly related to the amount of the toxic oestrogenic chemicals, called TCDD, the monkeys were exposed to. They also showed immune abnormalities similar to those observed in women with endometriosis. According to the World Health Organisation: “In Belgium the incidence of endometriosis in women presenting at clinics with infertility is 60-80%, while TCDD concentrations in breast milk are the highest in the world.” More infertile women with endometriosis had detectable high TCDD levels in their blood than the fertile women tested without the disease. Women with endometriosis should therefore avoid fatty foods that may be high in oestrogenic toxins to reduce their exposure.[9] Unless organic food is consumed, oestrogenic pesticides are found in plant and animal foods, as they adhere to the fat molecules.

Always peel vegetables which are not organic. The body’s clearance system for oestrogen, cholesterol and toxins is the liver. These steroid hormones should be broken down by the liver, after which they no longer have much hormonal effect. Ensuring effective liver clearance of hormones is key to the management of endometriosis. If not cleared and levels are too high, oestrogen can have profound effects in the body and on the menstrual cycle. It causes the womb lining to thicken and can prolong menstruation time. It stimulates the nervous system, causing copper levels to increase and zinc to decrease, and it stimulates high levels of adrenal corticosteroid hormones. In excess, oestrogen encourages spontaneous abortion. It stimulates breast tissue and has been linked to breast cancer when unopposed at high levels. High oestrogen reduces thyroxine hormone and may produce hypothyroid states. It causes body fat deposits to increase and impairs blood sugar control, leading to weight gain.

Nutrients that encourage oestrogenic activity are copper, calcium and folic acid, plus high levels of vitamin C and E and some essential fats. As with all nutrition, moderation seems to be the key. Diets high in saturated fat are seen to increase concentrations of serum oestrogen.[10] Other research showed that women who eat meat once a day are up to twice as likely to have endometriosis compared to those who eat less red meat and more fruit and vegetables.[11] Studies have shown that women with the highest intake of red meat increase their risk of endometriosis by between 80 and 100%, while those with the highest intake of fresh fruit and vegetables lowered their risk of endometriosis by about 40%. So reducing consumption of foods that are high in saturated fats and replacing them with fruit and vegetables such as broccoli, cauliflower and cabbage which contain indoles, appears to improve oestrogen metabolism.

Women in Japan have the highest levels of endometriosis in the world, although they have low levels of breast cancer.[12] It is felt that this may be due to high levels of oestrogenic chemicals – dioxins, PCBs and phthalaytes – in their food chain. It may also be due to high levels of dietary phyto-oestrogens from soya products. The birth rate in Japan is the lowest in the world. Research at Cinncinnatti and Auckland zoos showed that the wild cat breeding programmes did not work when the animals ate a very high level of soya protein in the diet. When two-thirds was exchanged for chicken, the animals fell pregnant naturally. We also know that high levels of peas in the diets of Tibetan men reduce fertility, due to the phyto-oestrogens. So eat pulses in moderation.

Dietary fibre increases excretion of excess oestrogen from the body. Some fibres such as the lignins found in rye and seeds are synthesised by gut flora to form anti-oestrogenic compounds, which are protective against cancers.[13] Soluble fibre binds to oestrogen and inhibits its re-absorption. Rich in oats, seeds, fruits and vegetables, soluble fibre also promotes synthesis of a hormone known as Sex-Hormone-Binding-Globulin (SHBG), which is a unique transport system for oestrogen. While oestrogen is bound to SHBG, it cannot exert any biological effect within the body.[14] But if fibre intake is low, then the oestrogen can have a biological effect, triggering the endometriosis implants to grow. A vegetarian, low-fat diet reduces period pain and increases SHBG.[15] Bifido bacteria in the gut encourages oestrogen clearance by inhibiting an enzyme known as beta glucoronidase. This enzyme, when high, encourages the deactivated safe oestrogen to become reactivated so that it can be sent back into circulation (not a good idea with endometriosis).

The best vegetables to eat are those from the cruciferous family, all rich in B vitamins and magnesium, such as cabbage, sprouts, broccoli, cauliflower, kale, turnip, swede, radish, horseradish, mustard and cress. These contain three unique compounds – indoles, dithiolthiones and isothiocynates – which influence enzymes that help eliminate excess oestrogen.[16] Grandmas are right when they say “Eat up your greens”! To help your ovaries and uterus work effectively, make sure that you eat four portions of vegetables every day. Avoiding the bad saturated animal fats, hydrogenated and damaged ‘trans’ fats, and eating cold-pressed oils is also important.

How to reduce pain
Pain reduces quality of life. Research showed that women with severe pain, infertility and endometriosis had raised levels of PGE2 pro-inflammatory prostaglandins (from arachidonic acid) in their peritoneal fluid in the abdominal cavity; this is the trigger for inflammation.[17]

Where pain is present, painkillers may need to be taken, but research links the use of pain-killing non-steroidal anti-inflammatory drugs (NSAIDS) to infertility via suppressing ovulation, and this can then encourage endometriosis, so it becomes a vicious cycle. Specifically, the use of NSAIDs may give rise to a condition called ‘luteinized unruptured follicle syndrome’ (LUF), which is the clinical name given when ovulation doesn’t occur. In LUF syndrome, women will have the normal sequence of endocrine events and a normal menstrual period, but their ovary will not release an egg. Steroid hormone concentrations in the peritoneal fluid are much lower after the ovulatory cycle where LUF syndrome exists – and it is felt that this may facilitate the development of endometriosis.[18]

Some nutrients play a role in relieving pain including the essential fats, vitamin C, E, K, some of the B vitamins, zinc, selenium and magnesium. Research looking at the effects of fish oils on endometrial implants showed positive results in that the sites of endometrial tissue shrank when fish oils were fed to rabbits with surgically induced endometriosis.[19] Studies, looking at the use of omega-3 fish oils in subjects with severe menstrual pain showed that they were effective at reducing pain.[20] Magnesium is also known for its relaxing effects on muscle tissue and can help with dysmenorrhoea and lower back pain.[21] Vitamin E can help reduce painful cramps and also reduce blood loss.[22] For the B vitamins, Vitamin B6 (pyrodixine) can have analgesic effects by helping to relieve the pain associated with premenstrual syndrome.

Vitamin B12 has been shown in three independent trials to have an analgesic effect too when injected intramuscularly.[23] And when vitamin B12 is taken with vitamin B1 and B6, they can together produce significant pain relief and reduce inflammation, comparable to the action of standard pain relief but without the side effects.[24] It is known from research that high doses of thiamine (B1) can suppress pain transmission. There appears to be some relationship between thiamine (B1) and morphine.[25] In one study, 100mg vitamin B1 was given for three months to 556 girls with period pain and 87% felt completely cured and 8% relieved – only 5% experienced no effect.[26] The use of yeast-free B vitamins seems to be crucial for women with endometriosis as regular use of multivitamin supplements may decrease the risk of ovulatory infertility.[27] The conclusion being that a high potency multi-vitamin-mineral supplement will increase fertility by supporting ovulation.

Nutritional help
To help reduce endometriosis, follow a low-GL diet and identify and avoid hidden allergens.

The careful choice of nutritional supplements may help to improve reproductive health. Harvard University and the American Dietetics Association both advise that a multi-vitamin-mineral should be taken each day.[28] Research at the University of Leeds suggests that women taking a multi-vitamin capsule every day may double their chance of getting pregnant, as it is felt that better quality eggs are produced by the ovary.[29]

Suggested daily supplement programme
• Multi vitamin and mineral capsule
• Magnesium citrate 200mg
• Bioacidophilus (16 billion viable organisms)
• Pesticide-free omega-3 fish oil 1000mg

Choose supplements that are hypoallergenic and free of yeast, gluten, lactose, sugar and dairy products. Consult a doctor before you try to get pregnant.

Optional extras
• Slippery elm 300mg – to soothe and heal the gut membrane
Chromium polynicotinate 100ug – to balance blood sugar
• Zinc citrate 20mg – for immune support
• Cold pressed Omega-6 Evening primrose oil 1000mg – to aid hormone balance

Note, evening primrose oil should not be taken by anyone prone to epilepsy.

How effective is the natural approach?
In a recent research trial involving 198 women with diagnosed endometriosis who had visited the Endometriosis and Fertility Clinic and followed the approaches outlined in this Special Report, those who had reported sub-fertility had a 52% success rate in falling pregnant; 86% reported pain reduction; and 26% who had not reported fertility problems fell pregnant.[30]

About the author
Dian Shepperson Mills is the founder and lead nutritionist at the Endometriosis and Fertility Clinic. She has researched the relationship between endometriosis and diet for ten years, works closely with physicians in Europe and North America and has given lectures worldwide. Her research interests also include fertility, polycystic ovaries, and premenstrual syndrome. Dian is the Chair of the Nutrition Special Interest Group for the American Society of Reproductive Medicine (ASRM), a trustee of the Charity Endometriosis SHE Trust UK (www.shetrust.org.uk) and an advisor to the International Endometriosis Association USA. For more information, read Dian’s book Endometriosis: a Key to Healing and Fertility Through Nutrition, co-authored with Michael Vernon.


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