I want to start off by saying painful periods are NOT normal. I repeat, painful periods are not normal. Many women believe that dealing with menstrual cramps during their cycle is par for the course of being a woman. This is a false belief that is so easily accepted because of the the large percentage of woman who suffer from severe menstrual cramps. I will delve deeper menstrual cramps in another blog. However, today I wanted to talk all about endometriosis.
What is Endometriosis?
Endometriosis is a condition in which endometrial-like tissue, normally found in the inner lining of the uterus (the Endometrium), grows in areas outside of the uterus. This tissue can be found on your ovaries, fallopian tubes, rectum, bladder, and even in c-section scars. The endometrial-like tissue responds to both estrogen and progesterone when they are secreted during menstruation. This tissue continues to function as it does in the uterus. It thickens, breaks down, and bleeds during menstruation leading to inflammation and scarring (1). There is a similar condition to endometriosis known as adenomyosis, in which endometrial tissue is found in the myometrium of the uterus (the smooth muscle of the uterus). Both endometriosis and adenomyosis are very similar in pathophysiology.
Who gets Endometriosis?
The number of women diagnosed with endometriosis is on the rise. Today, there are more than 176 million woman world wide who have been diagnosed. Many women are misdiagnosed and improperly treated for many years before the correct diagnosis is made. The average time from onset of symptoms to diagnosis of women with endometriosis ranges from five to ten years (1). Endometriosis is present in 10% of reproductive aged women, and the average age at diagnosis is between 25-29. Adolescents are also effected by this condition. More than half of women under 20 years old who experience pelvic pain or dyspareunia (painful intercourse) have endometriosis (4).
Typically, around age 50, estrogen levels rapidly decrease and women who are post-menopausal notice a resolution in their symptoms. However, because of the use of iatrogenic or endogenous hormones, for example, post menopausal women using hormone replacement therapy, the disease can still be active and cause problems. In rare cases, men who are on long-term estrogen therapy have developed endometriosis (3).
Theories on the cause of Endometriosis
There are many theories on the etiology of endometriosis, sadly, none of these theories have been proven or can fully explain all of the mechanisms associated with the development of the condition (3). So in essence, the cause is still unknown and is likely a combination of many of the factors described below.
1. Retrograde Menstruation
One theory on the cause of endometriosis is retrograde menstruation, or the back flow of endometriotic tissue through the fallopian tubes and into the pelvic cavity. This retrograde flow, along with potential hematogenous (blood vessels) or lymphatic circulation, may result in the seeding and growth of endometrial tissue in ectopic sites (lung, brain, eye, etc.) (4). However, research has found that at least 90% of women have retrograde flow, and because many do not develop endometriosis, this theory may be missing a piece of the puzzle, such as hormonal, inflammatory, and immunological dysfunction. This theory also fails to explain how men have developed the condition when treated with estrogen.
2. Immunological Origin
The immune system/endometriosis connection is complex. I will briefly discuss some of the known immune abnormalities found in women with endometriosis, however, I will go further in depth in another blog. One of the roles of our immune system is to remove debris from retrograde menstruation. However, in women with endometriosis it has been found that there is reduced surveillance and clearance of endometrial cells by the immune system, allowing for implantation into ectopic sites (5). Research has also identified an increase in inflammation, and the concentration of immune cells (IL-1, IL-6, IL-8, and TNF-α), within the peritoneal cavity promoting adhesions and angiogenesis (5). The combination of these mentioned factors favor the growth and survival of ectopic endometrial cells.
3. Metaplasia Theory
In the Metaplasia theory, it is thought that extrauterine cells abnormally transform into endometrial cells via immunological and/or hormonal factors (6). These cells are thought to have originated from the abdominal peritoneum. In the Mullerian Metaplasia theory, it has also been hypothesized that endometriosis is the result of residual embryonic cells from the Wolffian or Mullerian ducts that develop into endometriotic lesions that are responsive to estrogen (6). This theory could explain why pre-pubertal girls are diagnosed with endometriosis. Nonetheless, it fails to account for lesions found outside of the Mullerian duct (6).
Although endometriosis has been a condition that has been around for over 100 years, there is still no clear cause. In addition to the above mentioned theories, environmental factors and genetics are also thought to play a role in the development of the condition.
Known Risk Factors
Although, the origin of endometriosis is not quite understood there are some risk factors that have been identified. Below are a list of women with an increased risk (7):
Early age at menarche: Woman who have their first period before the age of 10
Women who have a short menstrual cycle (<27 days), and long menstrual flow (>7 days)
Women with a first degree relative have a 6x higher risk of developing endometriosis
Women with a higher body mass index (BMI), lack of exercise, and a high fat diet. (Fat in the body produces estrogen)
Conversely, there is a decreased incidence of the condition in (7):
Smokers (Smoking decreases estrogen levels)
Women who exercise consistently from an early age
Women who eat a low fat, and low red meat diet
Endometriosis affects an estimated 1 in 10 women during their reproductive years, typically between the ages of 15 to 49. Many women are asymptomatic when the disease first begins, and the first sign for some may be infertility. Other symptoms include:
Painful menstrual periods
Pain with intercourse (Dyspareunia)
Pelvic and/or low back pain
Painful bowel movements (especially during menses)
Painful urination (especially during menses)
Pain with exercising
How is Endometriosis Diagnosed?
In office, a physical exam can reveal pelvic tenderness, enlarged/tender ovaries, a uterus that tips backward and lacks mobility (retroverted uterus), fixed pelvic structures, and adhesions within the pelvic cavity. This can lead your physician to recommend further testing to identify what is going on. Currently, the only definitive way to diagnose endometriosis is through laparoscopic biopsy. Laparoscopy is a surgery in which a small incision is made in the pelvic area and a biopsy of the endometriotic tissue is taken. Laparoscopy is considered the, "gold standard", however, it is invasive and should be done by a surgeon who specializes in endometriosis, otherwise a missed diagnosis could occur.
Ultrasound can also be used to identify the consistency of an endometrioma within an ovary. MRI's are able to detect endometriomas outside of the ovary, however, due to their cost they are not often used. CA-125 is a blood marker that has been found to be positive in women with stage III and IV of the condition. However, this test is also positive in women with uterine fibroids and cancerous growths; so it is not used by most clinicians. Although, it can be used to track to the progression and/or monitor treatment of the condition.
Classification of Endometriosis
According to the American Society for Reporductive Medicine, endometriosis is classified by stage I (minimal), II (mild), III (moderate), or IV (severe), based on number, location, and depth of implants and presence of filmy or dense adhesions (4).
Stage I (Minimal): Only a few superficial implants present
Stage II (Mild): More and slightly deeper implants
Stage III (Moderate): Many deep implants, small endometriomas on one or both ovaries, and some filmy adhesions
Stage IV (Severe): Many deep implants, large endometriomas on one or both ovaries, and many dense adhesions, sometimes wit the rectum adhering to the back of the uterus
Conventional Treatment Options
There has yet to be a cure discovered for endometriosis in conventional medicine. Women who experience chronic painful periods or pelvic pain are usually given an over-the-counter non-steroidal anti-inflammatory (NSAID); such as Ibuprofen, or Naproxen. If symptoms progress, than typically prescription analgesics or hormones suppression is initiated (7). Due to the fact that estrogen is known to stimulate the growth of endometriosis, treatment is usually directed at suppressing estrogen synthesis. This is done by creating a pseudopregnancy (through birth control pills) or pseudomenopause (through cessation of the body’s own production of estrogen and progesterone) (7). The most frequently prescribed medications are Gonadotropin-releasing hormone agonists (ex: Lupron), oral contraceptive pills, and synthetic progestin agents (4). Many women experience relief once treatment is initiated, however, there are adverse effects that occur from treatment; including insomnia, depression, weight gain, and osteoporosis.
Surgical therapy is also available, and has even resolved pain for some women. Laparoscopy and laparotomy, are considered conservative surgery options. Conservative surgery involves removing superficial lesions while keeping the uterus and ovaries intact. Success rates are high, however, recurrence develops in 28% of patients 18 months following surgery, and in 40% of patients 9 years post surgery (4). Furthermore, adhesions recur in 40-50% of patients. More invasive surgery includes a full hysterectomy, in which both the uterus and ovaries are removed. This results in an abrupt cessation of hormone production, and would require hormone replacement therapy for the rest of your life. It is important to seek out an expert in endometriosis to determine the best course of action.
Alternative Treatment Options
There are other therapy options to help decrease symptoms from endometriosis. I will go into greater detail on each in separate blogs, however, below you will find an overview.
Diet: Research has shown an increased risk of developing endometriosis in women with diets high in red meat (7). Conversely, women who ate diets higher in green vegetables and fresh fruits had lower rates of endometriosis.
Environment: Environmental toxins called endocrine disruptors (alter hormonal balance within body) have been implicated in the cause of endometriosis. These toxins increase inflammation in the body, as well as, disrupt the immune system. Eating an anti-inflammatory diet, and detoxing are great ways to reduce pain, and balance hormones.
Supplementation: There are many supplements and herbs that can also help to decrease inflammation, balance hormones and support the immune system. Curcumin (from turmeric), bromelain (from pineapple), and quercetin (from apples, onions, and other plant sources) are great options to decrease inflammation. Medicinal mushrooms, such as rieshi, and chaga, are excellent options for immune support.
Alternative therapies should be a vital focus in the treatment of endometriosis. Contact me to see how I can help you with the treatment of your condition.