Endometriosis

What is endometriosis

The endometrium is the inner lining of the uterus, which is shed each month (after it builds up) in the form of bleeding during the first week of the menstrual cycle.

In women with endometriosis, parts of the lining of the uterus travel to other organs and tissues outside the endometrium (and uterus) and this causes inflammation and pain as well as all the other symptoms of endometriosis.

Endometrial tissues can be found in any of the following areas:

• Pelvic cavity – most adhesions are found within the pelvic cavity, on the: ovaries, fallopian tubes, vagina, cervix, vulva, outer surface of the endometrium and all other areas within the pelvic cavity
• Abdominal cavity – some adhesions have also been found within the abdominal cavity, on the: outside of the stomach, colon, liver, and other areas within the abdominal cavity
• Thoracic cavity – rarely, adhesions have been found within the thoracic cavity on the: outside of the lungs, ribs

Endometrial tissue has been found in all areas in the body including the peripheral nerves, spinal column and the skin, except for the brain, heart and spleen. The endometrial tissue which travels outside the endometrium are called implants, as they implant on the body’s organs and they have adhesive quality because they act as an adhesive (or “glue”) which makes them sticky and this causes whatever tissue they are located on to stick to other nearby tissues and organs.

The endometrial adhesions, wherever they are, will expand and then bleed each month (as if they were inside the endometrium, ready for menstruation), as if they existed in the uterus, getting ready to implant an egg because they have eostrogen receptors and because of the effect that eostrogen has on these cells.

This constant expansion of the endometrial cells outside the endometrium causes great inflammation in the other organs where these lesions are located, plus it makes organs that should be separate, stick together, putting pressure on the whole pelvic region and this is what causes all the pain associated with endometriosis.

Endometriosis is classified according to the following:

• Stage I (minimal) – very little endometrial tissue outside the endometrium, with some implanted on one ovary and in the peritoneum. Implants are between 1-3cm deep and have some adhesion
• Stage II (mild) – some more endometrial tissue outside the endometrium, with some implanted on both ovaries and in the peritoneum. Implants are larger than 3cm deep and have some adhesion
• Stage III (moderate) – a lot more endometrial tissue in the peritoneum and both ovaries, as well as on the fallopian tubes. The pouch of Douglas (area between the uterus and anus) is partially obstructed. Implants are larger then 3cm deep, some with a little adhesion and others with deep adhesion
• Stage IV (severe) – a lot of endometrial tissue in the peritoneum, along the peritoneum and on both ovaries, as well as on the fallopian tubes. The implants are very deep and over 3cm deep with deep adhesion. The The pouch of Douglas (area between the uterus and anus) is totally obstructed

Facts about endometriosis

• Endometriosis is a much misdiagnosed, underdiagnosed and misunderstood disorder
• Endometriosis is a very common gynaecological disorder of women
• Endometriosis literally means “abnormal condition of the endometrium”, the inner lining of the uterus
• Experts believe that endometriosis affects anywhere between 1%-10% of all women of child bearing years, but the figures may be as high as 20% because not all women with pelvic pain visit a doctor or have investigative procedures to confirm or rule out this conditions
• Experts think endometriosis is due to an excessive amount of eostrogen (“eostrogen dominance”)
• Endometriosis causes pain in many women both during menstruation as well as when not menstruating
• Endometriosis can make sex painful for a woman, especially during penetration
• Endometriosis is named because it refer to the endometrium, the inner lining of the uterus, which is normally shed during the menstrual cycle but in women with endometriosis, this lining instead finds itself outside of the uterus and in and on surrounding body tissues and organs
• Endometrial implants have adhesive qualities, which makes them sticky and causes organs they implant to get stuck together or be obstructed (partially or totally)
• Some women with endometriosis have no pain at all nor other symptoms (asymptomatic), even if they have stage IV (severe) endometriosis
• Up to 30% of women with endometriosis experience no pain at all, no matter how severe or mild their condition
• Approximately 60% of women with endometriosis also develop cysts on their ovaries, usually on both
• About 30%-50% of women with endometriosis become infertile (unable to get pregnant)
• Some women experience a lot of pain and other symptoms even if they have stage I (minimal) endometriosis
• Endometriosis can often be diagnosed during another procedure, by accident

Symptoms of endometriosis

There are a number of symptoms of endometriosis, most of which are non-specific and so can be easily confused with other conditions:

• Anxiety
• Breast tenderness prior to menstruation
• Depression
• Difficulty getting pregnant
• Early onset menstruation, that starts at around age 11
• Heavy menstrual flow
• Fluid retention
• Infertility
• Irregular menstrual cycle
• Menstrual pain that gets worse as the period progresses
• Mood swings
• Pain at ovulation
• Pain during sex, especially during penetration
• Pain prior to menstruation
• Pain when passing stools
• Pelvic pain only on one side
• Pre-menstrual dysphoric disorder
• Pre-menstrual syndrome
• Severe menstrual pain

Health conditions aggravated by endometriosis

In addition to the symptoms above, there are a number of other health conditions which are either aggravated or possibly caused by endometriosis.

All of these are inflammatory conditions, which may be precipitated by the edometriosis, which is also an inflammatory condition:

• Allergic rhinitis (hay fever)
• Allergies
• Asthma
• Autoimmune disorders (such as lupus and thyroiditis)
• Candidiasis
• Chemical sensitivity
• Dermatitis
• Rashes
• Irritable bowel disorder
• Rheumatoid arthritis
• Sinusitis (especially if it is chronic)

Causes of endometriosis

While science is not sure why endometriosis occurs, there are a number of possible theories that have been identified and it could be that endometriosis is caused by a combination of these:

Oestrogen sensitivity

One theory about endometriosis is that some women with have an increased sensitivity to oestrogen and their bodies react in an abnormal to produce the uterine tissue implants outside the uterus. Experts think that these women’s bodies react in a different way to the oestrogen to cause the uterine tissue to be implanted on other tissues and organs outside the uterus, instead of it being expelled through the monthly bleeding out of the body. In addition to this, the eostrogen then makes the extra-uterine tissue behave as if it were inside the uterus and it bleeds on a cyclic basis (as if it was menstruating, but out of the uterus and into the pelvic cavity). This causes inflammation and all the symptoms associated with endometriosis.

Nutrient deficiencies

Endometriosis is an inflammatory condition and women who have this condition may have lower than normal levels of certain nutrients which mediate the body’s inflammatory response and allow the immune system to get rid of any extra-uterine (abnormal) tissue and reduce risk of endometriosis.

The nutrients mostly responsible for regulating the inflammatory processes (and cytokines) in the body and reducing likelihood of endometrial tissue implanting outside the uterus are those with potent antioxidant or anti-inflammatory properties:

• Glutathione
• Omega-3 fatty acids (DHA/EPA)
• Quercetin
• Vitamin A
• Vitamin C
• Vitamin E
• Zinc

Retrograde menstruation

Another theory about the cause of endometriosis proposed is that some of the lining of the endometrium, instead of flowing out of the uterus and outside the body (bleeding of menstruation), they may actually flow backwards up the fallopian tubes and towards the ovaries and into the pelvic and abdominal cavities and this may be the reason there are endometrial implants on the tissues and organs outside the endometrium. This is called retrograde menstruation.

Prevention of endometriosis

Non-preventable risk factors

Endometriosis is very difficult to prevent as the cause is not yet known. There are some definitely and known risk factors which are difficult to prevent:

• Family history – women who have immediate family members with endometriosis are at a much higher risk for also developing this condition, a risk factor which is not easily preventable
• Heavy menstrual bleeding – heavy menstrual bleeding exposes a woman to more circulating oestrogen and possible sensitivity to the that oestrogen in their body and as endometriosis is an oestrogen-dependent disorder, this makes it a difficult risk factor to prevent
• Hypothyroidism – women who have hypothyroidism have increased density of their oestrogen receptors on their cells and are also likely candidates for endometriosis too
• Menstrual cycle starting at early age – women who started their menstrual cycle at an early age may be exposed to more circulating oestrogen and possible sensitivity to the that oestrogen in their body and as endometriosis is an oestrogen-dependent disorder, this makes it a difficult risk factor to prevent
• Short menstrual cycle with heavy bleeding – women who have a shorter menstrual cycle together with heavy bleeding may be exposed to more circulating eostrogen and possible sensitivity to the that oestrogen in their body and as endometriosis is an oestrogen-dependent disorder, this makes it a difficult risk factor to prevent

Preventable risk factors

There may be ways to prevent worsening of symptoms of endometriosis from occurring or even reduce risk of developing this condition in the first place:

• Correct omega6:omega3 ratio in diet – experts believe that a diet lower in saturated fat and lower in processed foods may reduce levels of inflammation in the body, because this type of diet is high in the pro-inflammatory omega-6 fatty acids. The ratio of omega-6:omega3 fatty acids should be about 2:1 (or even 1:1), but in women who have a poor diet, it could be 15:1 or even higher and this places a greater risk on any type of inflammatory condition developing, not just endometriosis
• Exercise – studies show that women who exercise regularly, every day and have been doing so since a younger age (around age 16) tend to have less incidence of endometriosis. This could be because exercise ensures proper circulation and helps the immune system and other systems stay strong and healthy
• Exposure to certain environmental toxins – human and animal studies show that exposure to certain toxins (namely dioxin) may increase the risk of endometriosis development and this is because dioxin is an endocrine disrupter. An endocrine disrupt or is a substance which disrupts the proper function of the endocrine (hormonal) system so that the hormones no longer function in a healthy manner and a number of endocrine disorders can occur (endometriosis is one of them, but there are possibly links to cancer too)
• Obesity – women who are obese and/or have a higher fat ratio (higher than what is considered normal and healthy) have a much higher incidence of developing endometriosis. Experts believe this could be because these women have a higher intake of the inflammatory omega-6 fatty acids from foods that are high in saturated fat or are highly processed and have very little intake of the anti-inflammatory foods in omega-3 fatty acids or GLA and this increases the inflammation in their body, which may increase risk of endometriosis
• Lower saturated fat intake – experts believe that a diet lower in saturated fat may reduce levels of inflammation in the body, because this type of diet is high in the pro-inflammatory omega-6 fatty acids. The ratio of omega-6:omega3 fatty acids should be about 2:1 (or even 1:1), but in women who have a poor diet, it could be 15:1 or even higher and this places a greater risk on any type of inflammatory condition developing, not just endometriosis
• Reduce exposure to environmental toxins – there are a number of studies which suggest that women who are exposed to environmental toxins such as dioxin have a greater incidence of endometriosis. This is because dioxin (and other environmental toxins) is an endocrine (hormone) disruptor, which acts as a xenoestrogens and this means it blocks the normal function of the hormones in the body and causes abnormal hormone functions and this can cause endometriosis. Women should try to stay away from the environmental toxins known to be endocrine disruptors, especially plastics and PVC, which are the two most common ones
• Shorter menstrual cycle – women who have a shorter menstrual cycle, together with heavier menstrual bleeding are also at risk of developing endometriosis and this is because they have more exposure and possible sensitivity to the circulating eostrogen in their body, which is a risk factor for endometriosis, as it is an oestrogen disorder

Complications of endometriosis

There are a number of complications of endometriosis:

Cysts

Cysts are a common feature of endometriosis with up to 60% of all women with endometriosis developing cysts on the ovaries.

The endometrial implants on the ovaries can be small and red (blood coloured), clear or pink or darker red to brown or white, if they have been present a longer time. Younger women tend to have more red, clear or pink cysts, while older women tend to have cysts that are either white, red-brown, or black. In order to stop the endometrial implant from growing larger, the ovary creates a covering over the top of it and this is how the cysts are formed.

Chocolate cysts are the largest types of endometrial cysts, which can be up to 10cm wide. These cysts have fluid inside which is dark brown and looks like chocolate sauce, hence the name. An endometriosis cyst on an ovary is called an endometrioma.

The endometrial cysts on the ovaries will shed blood at each period.

Some of the endometrial cysts can rupture and bleed into the area around the ovaries, which can infect the whole peritoneum and require immediate emergency surgery (and antibiotics) as this could be life threatening. This is a rare scenario and usually only occurs with very large cysts. Most cysts are diagnosed before they get too large as most cysts cause some pain that require investigation.

Ectopic pregnancy

If the fallopian tubes and both ovaries are implanted with sticky endometrial implants, it can be very difficult (and probably impossible) for an egg to travel from the ovary, down the fallopian tubes and into the uterus in order to be fertilised by a sperm cell. This can cause the egg to become stuck, usually in the fallopian tube, where it can be fertilised by a sperm cell and become an ectopic (unviable) pregnancy.

An ectopic pregnancy is dangerous because it can cause the fallopian tube to burst and cause serious internal bleeding, which can be life threatening.

Infertility

The main complication of severe endometriosis is infertility. When the endometrial tissue implants on other organs, it causes havoc with the hormones because those endometrial tissues bleed cyclically (as if they were menstruating) and the blood cannot pass out of the cervix. In addition to this, if the fallopian tubes and both ovaries are implanted with sticky endometrial implants, it can be very difficult (and probably impossible) for an egg to travel from the ovary, down the fallopian tubes and into the uterus in order to be fertilised by a sperm cell.

Approximately 30-50% of women with endometriosis have a lot of difficulty trying to get pregnant. The older a woman is, the more severe the endometriosis, the more difficult to get pregnant.

Internal scarring

Another common complications of endometriosis is internal scarring, which occurs due to the endometrial tissue growing outside the endometrium, which bleeds every month. This internal bleeding causes inflammation and makes the body send clotting agents to stop the blood flow. After the bleeding has stopped, this will create scar tissue over the organ or tissue on which the endometrial implant sits. The scar tissue can build up on various organs in the pelvic region over time and this may cause some issues with the ability of those organs to function effectively.

Scarring, especially if it occurs on the ovaries or the fallopian tubes and impairs the ability of the egg to travel down the fallopian tubes and into the uterus for fertilisation, can greatly and adversely impair fertility.

When to see a doctor about endometriosis

Women who have any (or many) of the symptoms of endometriosis need to visit their doctor and discuss the possibility of this condition. Ensure you take a list of all your symptoms so that your doctor can be more informed about your condition.

Your doctor will send you to see a specialist (gynaecologist) who can examine you properly and perform the test needed to confirm (or rule out) endometriosis.

Women who experience any new menstrual (or pre-menstrual) symptoms of any severity should also visit their doctor for review.

Women who have endometriosis and who suddenly experience worsening of pain that is not relieved by pain medication need to see their doctor for a review.

Women who have any type of pelvic pain symptoms need to visit their doctor for diagnosis and review.

Diagnosis of endometriosis

Initial diagnosis of endometriosis involves the following:

• Medical history of symptoms – the doctor will ask a series of questions about severity and duration of symptoms, including the onset, to determine if there is a risk factor of endometriosis
• Physical examination – the doctor will perform a physical examination to determine if there are any obvious physical symptoms of endometriosis

Examinations

Your doctor can can also perform the following examination:

• Internal examination – you doctor inserts one digit into your vagina and puts their other hand on your pelvic area to feel the pelvic area from both the inside and outside and determine if there are any obvious signs of endometriosis (or other abnormalities)

The internal examination is completely voluntary and many women feel nervous about it, which is understandable. If you don’t want to have this test, you can say no, as it wont diagnose the endometriosis anyway, it only gives the doctor a very general impression of the uterus and other organs in the pelvic region.

Other diagnostic tests

Your doctor can also recommend you have the following tests:

• Pelvic ultrasound (external) – an ultrasound is a diagnostic test involves the clinician spreading some gel on the pelvic area and then moving a special instrument around the pelvic area to get a picture of the organs in this area
• Pelvic ultrasound (internal) – an intrauterine ultrasound is a diagnostic test and is usually performed at the same time as the external ultrasounds and involves the clinician inserting a special wand-like instrument into your vagina and up the cervix. This test cannot diagnose endometriosis, but it can provide a better view of the ovaries and determine if there are any cysts or other abnormalities that may need further investigation

Gynaecologists tests

If the doctor thinks it warrants further investigation, you may be referred to see a gynaecologist who can properly investigate the symptoms and definitely diagnose endometriosis (or rule it out).

A gynaecologist will complete the following tests:

• Medical history of symptoms – the gynaecologist will ask the same (or more detailed) series of questions
• Physical examination – you doctor inserts one digit into your vagina and puts their other hand on your pelvic area to feel the pelvic area from both the inside and outside and determine if there are any obvious signs of endometriosis (or other abnormalities)

Again, the internal examination is completely voluntary with the gynaecologist too. You can refuse it if you do not feel comfortable having this type of examination.

Diagnostic tests

Based on your symptoms (and physical examination if it is performed), the gynaecologist will recommend the following diagnostic procedure, which is the only definitive way to confirm (or rule out) endometriosis:

• Laparoscopy – in this test you will be given a general anaesthetic (although it can be sometimes performed under light sedation too). The gynaecologist will make some cuts in the abdominal wall in which a laparoscope (a thin fibre-optic rod with a light source and video camera at the end) is inserted inside.The abdominal cavity will be inflated with carbon dioxide to help separate the organs and make it easier to view the organs and any possible endometrial tissue that is outside the endometrium.The gynaecologist can also insert other instruments into the laparoscope (incision tools to remove the endometrial implants) and take video shots of the area both before and after incision (if there is to be any). Your gynaecologist will ask you for your written permission to be able to remove external endometrial or other abnormal tissue prior to having this procedure, including the possibility of a full abdominal incision if necessary.The length of this procedure will depend on what (if anything) the gynaecologist finds in the pelvic region. If there is little or no endometrial implants, this procedure can take about 30 minutes, but the more implants found, the longer the procedure. Once completed, the gynaecologist will remove the instruments and stitch up the incisions made.A laparoscopy is normally performed as a day procedure.After the procedure, it is normal to feel a little pain from the stitches (you will be given pain relievers to remedy this) and some shoulder/neck pain due to the carbon dioxide irritating the diaphragm and you may need to urinate more often than normal, because of the effect of the carbon dioxide on the bladder.

Conventional treatment of endometriosis

Conventional treatment of endometriosis depends on a number of factors – pain levels, severity of symptoms, age and future pregnancy plans.

Medication

There are a number of medications which are prescribed (either alone or in combination) for women with endometriosis, depending on their pain levels, severity of symptoms and whether or not they plan to become pregnant:

• Androgens – this is the synthetic version of the hormone testosterone and which helps to inhibit the activity of both eostrogen and progesterone in the body and reduce effects of endometriosis. This drug has a lot of side effects (it causes masculinisation, including facial hair growth, lowering of the voice and increased cholesterol levels), which may be intolerable for many women
• GnRH agonists – gonadotropin-releasing hormone agonists are drugs which switch off the signal to the pituitary gland to produce eostrogen and progesterone which can help to reduce progression of endometriosis. GnRH agonists are usually prescribed to be taken together with the contraceptive pill, but as GnRH agonists have very serious side effects (decrease in bone density and osteoporosis) they can only be prescribed for 6 months due to these side effects (even when taken in combination with the contraceptive pill). Examples are: Goserelin, Leuprolide, Nafarelin
• Oral contraceptives – combination estradiol and progestin medications (oral contraceptives) are given to women who are of child bearing years and who are not ready to become pregnant, as they help to greatly reduce progression of endometriosis and are often prescribed after surgery to remove the endometrial implants (to prevent further growth and progression). This traditional advice is refuted by a recent study which suggests that this is not necessary as recurrence of endometrial implants after surgical removal was similar whether or not oral contraceptives were used post surgery. There are a number of different types of oral contraceptives with different ratios of estradiol and progestin
• Painkillers – there are a number of painkillers that can be either prescribed or purchased without a prescription to help reduce pain levels, depending on the amount of pain:
  • Codeine-based painkillers – these are a stronger type of painkiller used for more severe pain. These painkillers can cause a number of gastrointestinal side effects
  • NSAIDs – non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to reduce the level of pain and may be the only medication prescribed for women with mild to moderate pain symptoms and few endometrial implants (as diagnosed by laparoscopy). NSAIDs should be taken prior to menstruation to relieve pain symptoms. There are a number of side effects of NSAIDs, which includes stomach upset, gastritis, ulcers and should be avoided by people with asthma
  • Other painkillers – there are a number of other painkillers which are stronger than the other types of painkillers and which need to be prescribed by a doctor as they are restricted in Australia (and other countries) and should not be purchased without a prescription
  • Paracetemol – these painkillers can be easily purchased from any supermarket or chemist and are recommended for mild pain
• Progestins – this is the synthetic version of the hormone progesterone, which is given to reduce the effects of eostrogen in the body and reduce effects of endometriosis. The most common form of progestin is: Medroxyprogesterone acetate

Lifestyle modifications

Doctors also recommend the following lifestyle modifications to help reduce symptoms:

• Warm bath – a warm bath is a great way to reduce stress and relax. If your doctor thinks your stress may be contributing to an exacerbation of your symptoms, s/he may recommend you try any number of stress reducing strategies to help reduce exacerbation of symptoms
• Hot water bottle – many women feel better if they use a hot water bottle to their stomach/pelvic area during menstruation, so your doctor may also recommend this strategy for less severe pain (or together with pain relief)
• Stress reduction – while stress wont cause endometriosis, it will exacerbate symptoms and make them (and everything else) feel worse. Most doctors will suggest some stress reduction techniques to help reduce an aggravating factor

Surgery

Surgery may be required after the initial laparoscopy, as it may be inadequate to remove larger or more prevalent endometrial implants that are present on various organs and tissues, which may be hindering their proper function. Surgery is only a temporary solution to endometriosis, as the implants will grow back again in most cases, although certain medication can slow its progress and are usually prescribed at the least, straight after surgery.

Surgery can consist of:

• Hysterectomy – this is a last resort surgery, for women who either have such extensive endometrial implants that it is impossible to treat without removal of either the uterus or the ovaries or both, or for women who are past child-bearing years and want to have a permanent solution for the endometriosis. A hysterectomy will usually induce early menopause, so doctors now will not perform it so casually as it is not without risk
• Laparotomy – if more extensive surgery is required, as detected into the initial laparoscopy, a laparotomy will be performed. In this surgery, an incision (cut) is made into the abdominal wall in order for the surgeon to access the abdominal and pelvic cavities to view the regions with the extensive endometrial implants so that they can be removed. This surgery can involve any of the following as part of the surgery:
  • Electrocautery – a special device is used which produce heat by way of an electrical current and this allows the surgeon to cut out and remove the endometrial implants
  • Laser ablation – the use of a laser to cut out and remove endometrial implants quickly and concisely

Alternative / complementary treatment of endometriosis

Women who suspect they have endometriosis, should visit their doctor for diagnosis and confirmation.

The alternative/complementary strategies discussed here should be used as an adjunct to treatment (after removal of the endometrial implants) and to boost the immune system and reduce further risk of endometrial implants, but only with the permission of a doctor that it is safe to do so, given that some women may be taking medications or have other health conditions that may interact with some alternative/complementary strategies.

Herbs

There are a number of excellent herbs which may help to provide relief for symptoms:

• Black cohosh (Actaea rcaemosa/Cimicifuga racemosa) – the herb black cohosh has been traditionally used to treat menopause symptoms and to balance the female hormones which may help to reduce symptoms. This herb may be especially beneficial for women who have had a hysterectomy. Due to the effect that black cohosh has on eostrogen, it should not be used in women with female-type eostrogen-dependent cancers, without approval from a doctor, it should not be used by women who are also taking the contraceptive pill and it should not be used for longer than six months
• Chasteberry (Vitex agnus-castus) – the herb chasteberry has been traditionally used by herbalists to normalise eostrogen levels (by inducing the pituitary gland to produce more luteinising hormone (LH) and increasing production of progesterone). Chasteberry also helps to promote ovulation, which may help women who have trouble conceiving. Studies show that when women are supplemented with chasteberry, their progesterone levels became normal, but these studies may not have been reliable, so NCCAM is funding studies on chasteberry
• Dong Quai (Angelica sinesis) – the herb dong quai has been used in Traditional Chinese Medicine (TCM) for centuries as treatment for menstrual related problems. Studies show dong quai has substances which help to relax smooth muscles (such as the uterus), reduce menstrual pain and normalise eostrogen levels
• Milk thistle (Silybum marianum) – the potent antioxidant milk thistle (St Mary’s Thistle) helps to protect the liver from the damage caused by free radicals due to the inflammation of endometriosis. Many studies show that milk thistle reduces oxidative damage to the liver and protects it from dysfunction and damage as good as, or better than any known medicatƒions
• White peony (Paenoia lactiflora) – the herb white peony has been used in Traditional Chinese Medicine (TCM) for centuries to reduce uterine spasm and pain due to endometriosis during menstruation. One study suggests that this herb does have anti-inflammatory properties which may reduce prostaglandin activity and reduce pain symptoms of endometriosis. While TCM is a respected form of herbal medicine, there are not enough published studies to verify these results on a larger scale, but they are currently ongoing

Vitamins

There are a number of vitamins which may help to provide relief for symptoms:

• Bioflavonoids – the potent antioxidant bioflavonoids help to keep the immune system functioning normally and healthy. Bioflavonoids, together with vitamin C, are needed to help reduce the damage from free radicals, which are produced in inflammatory conditions such as endometriosis
• Vitamin A – the potent antioxidant vitamin A helps to keep the immune system functioning normally and healthy. Vitamin A is needed to help reduce the damage from free radicals, which are produced in inflammatory conditions such as endometriosis
• Vitamin C – the potent antioxidant vitamin C helps to keep the immune system functioning normally and healthy. Vitamin C is needed to help reduce the damage from free radicals, which are produced in inflammatory conditions such as endometriosis. In addition to this, vitamin C helps the body get rid of excess eostrogen
• Vitamin E – the potent antioxidant vitamin E helps to keep the immune system functioning normally and healthy. Vitamin E is needed to help reduce the damage from free radicals, which are produced in inflammatory conditions such as endometriosis. Studies show vitamin E helps to inhibit arachidonic acid to prevent increase in prostaglandins. In addition to this, vitamin E is needed for healthy circulation so it may assist with removal of the endometrial implants

Minerals

There are a number of minerals which may help to provide relief for symptoms:

• Calcium – the mineral calcium is especially needed during menstruation because it helps to reduce pelvic cramping and pain because calcium helps to ensure muscle tone is normal and healthy (and not spasming)
• Iron – women who suffer heavy bleeding during menstruation will need to replenish their iron levels to avoid risk of iron deficiency and anaemia
• Magnesium – the mineral magnesium helps to relax all smooth muscles (it is a natural muscle relaxant), which means it is required in conditions such as endometriosis, where the uterine wall is contracting in spasms, to reduce these spasms and reduce pain symptoms. Magnesium is also indicated for women with PMS (or PMDD) too
• Zinc – the potent antioxidant zinc helps to keep the immune system functioning normally and healthy. Zinc is needed to help reduce the damage from free radicals, which are produced in inflammatory conditions such as endometriosis. Zinc also stimulates the gonadotropin-releasing hormones (GnRH) which promote ovulation

Other nutrients

There are a number of other nutrients which may help to provide relief for symptoms:

• Evening primrose oil – evening primrose oil has high content of GLA (gamma-linoleic acid), which is an excellent anti-inflammatory omega-6 fatty acid. Evening primrose oil inhibits the formation of the inflammatory prostaglandins released during menstruation, reduces inflammation in the pelvic region in general and helps to reduce pain symptoms
• Fish oil – a number of studies suggest the anti-inflammatory properties of omega-3 fatty acids in fish oil (DHA/EPA) have a beneficial effect in women with endometriosis, by reducing inflammation, reducing the prevalence of endometrial implants and reducing symptoms
• Glutathione – the potent antioxidant amino acid glutathione helps to reduce free radical activity in the body, which occurs when there is an increased amount of inflammation in conditions such as endometriosis. Studies show that this antioxidant also helps the liver detoxify from free radicals and other toxins produced during inflammation
• Quercetin – the potent antioxidant quercetin is actually a flavonoid, which is especially needed to reduce the allergic response to inflammation and as many women who have endometriosis have allergy symptoms, it may be beneficial as it has anti-inflammatory properties

Dietary modifications

There are a number of dietary modification strategies which may help to provide relief for symptoms:

• Adequate intake of poly and mono unsaturated fats – ensure that your diet has adequate amounts of these healthy fats, which contain the anti-inflammatory omega-3 fatty acids. Most beneficial are: olive oil, sunflower oil and safflower oil
• Decrease saturated fat intake – excessive intake of saturated fats, from fatty meat and especially from fried foods and processed foods has a pro-inflammatory effect on the body, which increases inflammation and can make symptoms much worse
• Decrease sugar intake – excessive sugar intake can increase inflammation in the body, by increasing the number of prostaglandins present and this is bad news if you have endometriosis, as it means you have high levels of inflammation and the excessive sugar intake can only make it worse. The simplest and easiest way to cut down on sugar intake is to limit intake of processed foods and always read labels
• Don’t smoke cigarettes – smoking cigarettes will only increase inflammation in the body, increase symptoms and increase risk of infertility, which is already a risk for women with endometriosis, so smoking greatly increases that risk. If you smoke, give it up and do not be exposed to other people’s second hand cigarette smoke as it has exactly the same effect as if you were smoking the cigarettes (but unfiltered, so it makes it worse) yourself
• Increase intake of plant foods – increase your intake of vegetables, fruits, legumes, grains, nuts and seeds to provide more adequate nutrients for your body, reduce inflammation and reduce symptoms
• Limit alcohol intake – excessive alcohol intake (beyond the recommended amounts) increases inflammation in the body and can exacerbate symptoms. It is recommended to have only 1 standard alcoholic drink 4-5 days per week at the most, for women with endometriosis. In addition to this, high alcohol intake is associated with infertility and birth defects
• Limit caffeine intake – excessive caffeine intake increases inflammation, is a diuretic and is associated with infertility too. Sources of caffeine: coffee, tea (green, white and black), chocolate, energy drinks, some soft drinks

Lifestyle modifications

There are a number of lifestyle modifications which may help to provide relief for symptoms:

• Avoid xenoestrogens – there are a number of chemicals used today that have eostrogenic effects on the body (they are called xenoestrogens). These xenoestrogens disrupt the endocrine (hormone) system, by attaching to the hormone receptors on cells, or by otherwise blocking the body’s natural hormones from performing their function properly. A number of health concerns are indicated for xenoeostrogens: endometriosis, cancer, infertility, ovarian dysfunction, so they should be avoided as much as possible. The most common xenoestrogens are: dioxin, plastics, pesticides, PCB’s, PVC, alkyl phenols, cadmium and lead
• Exercise regularly – try to ensure that you exercise for at least 30-45 minutes every day (preferably longer and more intense workouts). Alternate workouts with cardiovascular training and fitness training to strengthen every part of the body, increase circulation, boost the immune system and reduce incidence of endometrial implants. Studies show that regular exercise is associated with a 40%-80% reduction in risk for endometriosis

Alternative treatments

• Acupuncture – several studies suggest that acupuncture (traditional Chinese or Japanese) may be a useful, effective and safe strategy for reducing pelvic pain (as well as fatigue, headaches and nausea) in young women diagnosed with endometriosis
• Progesterone cream – some studies suggest a beneficial effect from using a bio-identical progesterone cream (usually made from wild yam) to help normalise levels of all hormone and reduce eostrogen levels if too high. Since endometriosis is an eostrogen-dominant condition, normalising oestrogen levels may help to reduce pain symptoms of endometriosis. A bio-identical progesterone cream has much fewer side effects than progestin, the synthetic version of progesterone

Always ensure that you notify your medical practitioner of any supplements that you want to take – it may interfere with other medication or conditions you have. Confirm with your doctor it is safe to take before you try it.

Living with endometriosis

Self care strategies

There are a number of strategies which are recommended to help deal with endometriosis:

• Check for food intolerance – studies show that women with endometriosis have a higher incidence of a number of food intolerance (or allergies) and this may either be a contributing factor, or be caused by the endometriosis. In either case, it is well worth finding out if there are any food intolerance (gluten intolerance, lactose intolerance, among others)
• Decrease intake of saturated fats – these foods create more inflammation in the body, so it would be beneficial in helping reduce some of your symptoms by reducing any foods high in saturated fat. These include: fried foods, high fat meats, junk foods, processed foods
• Decrease intake of sugar – this is because sugar has an inflammatory effect on the body by increasing levels of prostaglandins and these are the substances with cause inflammation as part of the healing process. Try to avoid processed and junk foods as they usually contain high levels of sugar
• Exercise regularly – you need to start exercising more and regularly. Studies show that women who exercise regularly and since teenage years, have less incidence of endometriosis. Aim to do 30-45 minutes of exercise every day, alternating cardiovascular workouts with strength training
• Fish oil supplement – consider taking a fish oil supplement (but discuss this with your doctor before trying it as it may interact with your other medication). Many studies have suggested that a fish oil supplement with DHA/EPA helps to reduce the inflammation associated with endometriosis and reduces the number of endometrial implants outside the uterus
• Increase intake of essential fatty acids – increase intake of foods which are rich in omega-3 essential fatty acids and GLA (gamma-linoleic acid) both of which help to reduce inflammation in any part of the body. Foods rich in these nutrients are: evening primrose oil, flaxseed oil, oily fish (mackerel, salmon, sardines, trout, tuna), pecans, safflower oil, sunflower oil, walnuts. These foods should be part of a healthy diet, even if you take supplements too
• Increase intake of fresh vegetables – increase intake of vegetables to have about 6-7 portions of vegetables each day. Aim to have one salad every day, filled with lots of dark green leafy and dark red/purple (ie purple cabbage) vegetables . This helps provide the body with adequate antioxidants to help the immune system function better
• Increase intake of fibre – studies show that a diet rich in adequate soluble and non-soluble fibre helps to remove any excessive levels of eostrogen and this may assist with reducing symptoms of endometriosis. Aim to have 30g of fibre each day, but if you have not been recently eating many foods high in fibre, start adding a few more fibre-rich foods in your diet each day, slowly, a little at a time and build up to an adequate supply. Psyllium is an excellent fibre which is well tolerated in most people and it also helps to ensure the gastrointestinal system is functioning correctly and in a healthy manner
• Pain medication – make sure to take some pain medication to reduce level of pain (which is due to inflammation because of the endometrial implants) and visit your doctor to discuss further treatment if pain is unbearable even despite using pain relief
• Reduce alcohol intake – if you drink a lot of alcohol it can worsen the inflammation and pain you experience. While it may seem that alcohol provides a certain numbness and reduction of pain symptoms in the short term, over the longer tem it will make your condition much worse, so try to limit your alcohol intake to the standard recommended at the very most (1 standard drink 4-5 nights a week)
• Rest – if you are in pain, especially during menstruation, it is important just to rest as that is the most appropriate way to help your body recover more quickly from the pain
• Try acupuncture – several studies show that acupuncture may be a more safer and effective way to treat pelvic pain associated with endometriosis than medications (that are not without possible side effects and complications, especially in the stronger painkiller categories). Talk to your doctor about trying acupuncture for your pain symptoms

Caring for someone with endometriosis

Partner

If you have a partner with endometriosis, there are a number of strategies you can use to help them:

• Healthy diet – try to encourage your partner to eat more foods which will reduce inflammation (fish, walnuts, pecans) and reduce intake of foods that will increase inflammation (highly saturated foods, processed and junk foods) as this will help improve some of their symptoms
• Reduce alcohol intake – especially if it is more than the standard drinks recommended by health experts, it can cause not just general problems with health, but also inflammation in the body which will only further exacerbate your partner’s symptoms, so encourage her to drink less and be supportive by reducing your alcohol intake too. Try not to have more than 1 standard drink 4-5 nights a week
• Sex – if your partner has pain on deeper penetration, try to be sensitive to them and do not enter her so deeply . Sex should be a enjoyable experience and if your partner is in pain, she will not be enjoying it
• Support – try to provide support and loving care for your partner, especially if you know they are experiencing a great deal of pain and discomfort from their condition. Try to be as understanding as you can be to their situation

Friends

If you have a friend with endometriosis, there are a number of strategies you can use to help them:

• Don’t drink alcohol – try to ensure your social interactions with your friend do not involve alcohol, as it can make their symptoms much worse over the long term
• Support – try to provide support and loving care for your friend, especially if you know they are experiencing a great deal of pain and discomfort from their condition. Try to be as understanding as you can be to their situation

Parents

If you have a daughter with endometriosis, there are a number of strategies you can use to help them:

• Exercise – try to encourage your daughter to exercise every day, for at least 30 minutes, but longer is preferable. Studies show that women who exercise regularly as girls and continue to do so into their 30’s and 40’s have much less incidence of endometriosis
• Healthy diet – try to encourage your daughter to eat more foods which will reduce inflammation (fish, walnuts, pecans) and reduce intake of foods that will increase inflammation (highly saturated foods, processed and junk foods) as this will help improve some of their symptoms
• Support – try to provide support and loving care for your daughter, especially if you know they are experiencing a great deal of pain and discomfort from their condition. Try to be as understanding as you can be to their situation

References

• Agarwal A, Gupta S, Sharma RK. Role of oxidative stress in female reproduction. Reprod Biol Endocrinol. 2005 Jul 14;3:28
• Buck GM, Sever LE, Batt RE, Mendola P. Life-style factors and female infertility. Epidemiology. 1997 Jul;8(4):435-41
• Cooke K, Trickey R. Endometriosis: Natural and Medical Solutions. Allan and Unwin, Australia 2002
• Cooke K, Trickey R. Women’s Trouble: Natural and Medical Solutions. Allan and Unwin, Australia 1998
• Covens AL, Christopher P, Casper RF. The effect of dietary supplementation with fish oil fatty acids on surgically induced endometriosis in the rabbit. Fertil Steril. 1988 Apr;49(4):698-703
• Cramer DW, Missmer SA. The epidemiology of endometriosis. Ann N Y Acad Sci. 2002 Mar;955:11-22; discussion 34-6, 396-406
• Dhillon PK, Holt VL. Recreational physical activity and endometrioma risk. Am J Epidemiol. 2003 Jul 15;158(2):156-6
• Eskenazi B, Mocarelli P, Warner M, Samuels S, Vercellini P, Olive D, et al. Serum dioxin concentrations and endometriosis: a cohort study in Seveso, Italy. Environ Health Perspect. 2002 Jul;110(7):629-34
• Evans S, Marsh J, Taylor M. Endometriosis and Other Pelvic Pain. Lothain Books, Australia 2005
• Fugh-Berman A, Kronenberg F. Complementary and alternative medicine (CAM) in reproductive-age women: a review of randomized controlled trials. Reprod Toxicol. 2003 Mar-Apr;17(2):137-52
• Gazvani MR, Smith L, Haggarty P, Fowler PA, Templeton A. High omega-3:omega-6 fatty acid ratios in culture medium reduce endometrial-cell survival in combined endometrial gland and stromal cell cultures from women with and without endometriosis. Fertil Steril. 2001 Oct;76(4):717-22
• Geller SE, Studee L. Botanical and dietary supplements for menopausal symptoms: what works, what does not. J Womens Health (Larchmt). 2005 Sep;14(7):634-49
• Heilier JF, Donnez J, Lison D. Organochlorines and endometriosis: a mini-review. Chemosphere. 2008 Mar;71(2):203-10. Epub 2007 Nov 19
• Heilier JF, Nackers F, Verougstraete V, Tonglet R, Lison D, Donnez J. Increased dioxin-like compounds in the serum of women with peritoneal endometriosis and deep endometriotic (adenomyotic) nodules. Fertil Steril. 2005 Aug;84(2):305-12
• Highfield ES, Laufer MR, Schnyer RN, Kerr CE, Thomas P, Wayne PM. Adolescent endometriosis-related pelvic pain treated with acupuncture: two case reports. J Altern Complement Med. 2006 Apr;12(3):317-22
• Jackson LW, Schisterman EF, Dey-Rao R, Browne R, Armstrong D. Oxidative stress and endometriosis. Hum Reprod. 2005 Jul;20(7):2014-20. Epub 2005 Apr 7
• Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Ann Intern Med. 2002 Nov 19;137(10):805-13
• Lundeberg T, Lund I. Is there a role for acupuncture in endometriosis pain, or ‘endometrialgia’? Acupunct Med. 2008 Jun;26(2):94-110
• Mier-Cabrera J, Aburto-Soto T, Burrola-Méndez S, Jiménez-Zamudio L, Tolentino MC, et al. Women with endometriosis improved their peripheral antioxidant markers after the application of a high antioxidant diet. Reprod Biol Endocrinol. 2009 May 28;7:54
• Morris KA. Living Well With Endometriosis: What Your Doctor Doesn’t Tell You… That You Need to Know. HarperCollins Publishers, USA 2006
• Netsu S, Konno R, Odagiri K, Soma M, Fujiwara H, Suzuki M. Oral eicosapentaenoic acid supplementation as possible therapy for endometriosis. Fertil Steril. 2008 Oct;90(4 Suppl):1496-502. Epub 2007 Dec 3
• O’Callaghan D. Endometriosis–an update. Aust Fam Physician. 2006 Nov;35(11):864-7
• Osiecki H. The Physicans Handbook of Clininical Nutrition, 6th Edition. Bioconcepts Publishing QLD, 2001
• Porpora MG, Ingelido AM, di Domenico A, et al. Increased levels of polychlorobiphenyls in Italian women with endometriosis. Chemosphere. 2006 May;63(8):1361-7. Epub 2005 Nov 11
• Rier S, Foster WG. Environmental dioxins and endometriosis. Semin Reprod Med. 2003 May;21(2):145-54
• Rier SE. The potential role of exposure to environmental toxicants in the pathophysiology of endometriosis. Ann N Y Acad Sci. 2002 Mar;955:201-12; discussion 230-2, 396-406
• Rier SE et al. Endometriosis in Rhesus Monkeys (Macaca Mulatta) Following Chronic Exposure to 2,3,7,8,-tetrachlorodibenzo-p-dioxin. Fundamental and Applied Toxicology, 1993 Vol.21, pp.433-441
• Rier SE, Martin DC, Bowman RE, Becker JL. Immunoresponsiveness in endometriosis: implications of estrogenic toxicants. Environ Health Perspect. 1995 Oct;103 Suppl 7:151-6
• Sesti F, Capozzolo T, Pietropolli A, Marziali M, Bollea MR, Piccione E. Recurrence rate of endometrioma after laparoscopic cystectomy: a comparative randomized trial between post-operative hormonal suppression treatment or dietary therapy vs. placebo. Eur J Obstet Gynecol Reprod Biol. 2009 Nov;147(1):72-7. Epub 2009 Aug 7
• Sesti F, Pietropolli A, Capozzolo T, Broccoli P, Pierangeli S, Bollea MR, Piccione E. Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for endometriosis stage III-IV. A randomized comparative trial. Fertil Steril. 2007 Dec;88(6):1541-7. Epub 2007 Apr 16
• Wayne PM, Kerr CE, Schnyer RN, Legedza AT, Savetsky-German J, et al. Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial. J Pediatr Adolesc Gynecol. 2008 Oct;21(5):247-57
• Wieser F, Cohen M, Gaeddert A, Yu J, Burks-Wicks C, Berga SL, Taylor RN. Evolution of medical treatment for endometriosis: back to the roots? Hum Reprod Update. 2007 Sep-Oct;13(5):487-99. Epub 2007 Jun 16

Last reviewed and updated: 6 May 2025