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Endometriosis feels like it's a big, shiney new discover now that it's finally getting attention - but this has been something that women (and a very small proportion of men) have been suffering from for decades. It's not an easy diagnosis, but the more information we put out there, the more accessible the treatment options and healthcare around this become.
So let's get our heads around what endometriosis is and what's this gut connection!
So what is Endometriosis?
Endometriosis is currently defined as an inflammatory disease in which bits of tissue that are similar to uterine lining (glands and stroma cells) grows throughout the abdominal cavity on structures such as ovaries and intestines. It causes pain (sometimes severe), scarring, and infertility. This pain is inflammation driven via the production of cytokines and therefore prostaglandins. It can be all the time or just around ovulation and your period. Some women even experience pain with intercourse too. Fertility issues, irregular periods, dark blood, clotting… and often they also have high oestrogen due to the self producing tissue (I'll get into this later). Due to these hormonal and inflammatory changes, occassionally women will also present with anxiety and mood disorders.
The scar tissue is described a few ways; dark brown endometrial fluid and are sometimes referred to as "chocolate cysts." The presence of cysts - called endometriomas - (around the ovaries) indicates a more severe stage of endometriosis. Surrounding tissue can become irritated, eventually developing scar tissue and adhesions — bands of fibrous tissue that can cause pelvic tissues and organs to stick to each other
So why does this happen?
There are several theories, as I say theories, as it currently hasn't been proven. This is something we chat more about in the podcast.
Retrograde menstruation (tissue goes the wrong way down fallopian). This is observed in 90% of all women but it doesn't always develop into endometriosis.
Coelomic metaplasia - transformation of healthy peritoneal tissue (uterine lining) into ectopic endometrial tissue due to common origin cells
Müllerian remnant - cellular debris from embryonic Müllerian duct transform into endometriotic tissue by the influence of sex hormones rising at the beginning of puberty
Still largely unknown - potentially many casues, including LPS production in the gut.
HOW does it progress to Endometriosis?
“Inflammation plays a key role in the pathophysiology of the disease, mainly by altering the function of immune cells (macrophages, natural killer, and T cells) and increasing levels of pro-inflammatory mediators (cytokines) in the peritoneal cavity, endometrium, and blood. These immune alterations inhibit apoptotic (cell death) pathways and promote adhesion and proliferation of endometriotic cells. [1]” The microbiome (good bacteria) also plays a role. For example, women with endometriosis have a high level of gram-negative bacteria and the bacterial toxin LPS (lipopolysaccharide) in their pelvis, which can actively promote endometriosis and may be an initiating cause of endometriosis. See - Endometriosis is a disease of immune dysfunction. Lara Briden, a leading naturopath, is trying to change the face of endometriosis from 'hormonal condition' to 'inflammatory condition'. “We have shown that IL-1β, IL-6, and TNF-α serum levels are significantly higher in women with endometriosis compared to women free of disease.” Praccies you may want to look into regulation of matrix metalloproteinases (MMPs) too.
How does endo promote self growth? The Oestrogen-Inflammation Feedback Loop.
Note: Endometriotic tissue (in endo) =/= Normal endometrium/endometrial tissue
For the general population: [4,5]
“Endometriotic tissues have the ability to synthesize E2 (our main oestrogen during reproductive years) new from cholesterol, because there is a high expression of two of the most important enzymes involved in the process of oestrogen production: aromatase (CYP19A1) and steroidogenic acute regulatory protein. Additionally endometriotic tissue in this case have more oestrogen receptors than regular endometrium tissue, making it more sensitive to oestrogen.
“Inflammation and estrogen production in endometriosis are linked by a positive feedback cycle in which the chronic overexpression of aromatase and COX2 (involved in prostaglandin production) supports the sustained production of estradiol and prostaglandin E2 (PGE2) in endometriotic tissue.
For praccies:
"E2 and Oestrogen Receptor-β stimulated PGE2 formation, whereas PGE2 stimulated estradiol synthesis. Selective or nonselective COX inhibitors (i.e. turmeric and antispasmodics) that disrupt PGE2 synthesis effectively reduce pelvic pain in endometriosis."
"Moreover, in uterine microvascular endothelial cells, ERβ mediated estradiol-stimulated COX2 expression and PGE2 production.”
“The overproduction of estradiol in endometriosis drives ERβ signaling to support endometriotic tissue survival and inflammation. Additionally, ERβ may have estradiol-independent pathologic actions.”
This loop depends on responsiveness of ER, heightened by endo pathology - proliferative signaling mechanism mediated by the estrogen-E2 receptors axis
What else do we see?
We ideally want to make sure you’re ovulating to get that progesterone to effects it’s anti-inflammatory actions and immune modulation effects. BUT we also see a lot of gut disturbances, and this is what we chat more about in the podcast I recently did - here.
sensitivies (IBS/dysbiosis/SIBO)
changes in bowel motions (diarrhoea, constipation) even just with the cycle
gas, nausea
the classic endo bloat
pain with some foods
increased food sensitivies
Lowered diversity of the gut microbiome
differences in abundance of 12 genus belonging to the classes Bacilli, Bacteroidia, Clostridia, Coriobacteriia, and Gammaproteobacter between endometriosis patients and controls
an Escherichia/Shigella-dominant gut
With most clients I see, we implement a low gluten and dairy diet. As these have been shown to impact the progression and symptoms associated with endo (including the disruption to gut health). “dairy products intake was associated with a reduction in endometriosis, with significant effects when the average daily intake ≥3 servings”. So reducing or cutting these out can help. The rest can be super individual depending on your symptom picture and if gut testing is necessary. We may look at a low FODMAP diet while completing a whole gut protocol, but a practitioner is best to judge. Options here to improve your gut include:
PHGG - go SLOW - if this causes issues, come see me as you have deeper issues.
Glutamine 5g
FODMAP/Mediterranean diet - see more foods below
Saccharomyces boulardii (SB)
NAC to a degree
Getting diagnosed:
I should note that endometriosis cannot be formally diagnosed without a laproscopy. Some GPs may refer for ultrasounds, but these are not fine enough to pick up early stage endo.
You will need to find the right specialist and the right U/S tech to even consider diagnosing with an ultrasound.
Treatment options for Endometriosis:
Ginger
Cramp bark (and many others)
Green tea
Resveratrol
N-Acetyl Cystine - “NAC was found to both prevent the growth of cysts as well as reduce the size of existing cysts.”
Food to eat MORE of:
Parsley
Turmeric
Ginger
Phyto-oestrogen
Alternative therapies you should consider using:
Acupuncture
Vitamin D
Relaxing - managing stress, exertion
Heat/ tens machine / bath
Also consider pelvic floor tone, new study showed stretching that pelvic area and connecting muscles can improve pain.
I thoroughly hoped this help enlighten you, and gave you some options to consider with your practitioner. Should you need any guidance or have questions - feel free to DM @mickayla_naturopath or email me - mickayla@rosemarynaturopathy.com.au
I would encourage you to listen to the podcast to learn more about treatment options and in depth chats on the gut relationship with Endometriosis!
References: