Insights from the Endometriosis Symposium

I recently attended the ATMS Endometriosis Symposium, and boy did I nerd out. I have always had an interest in women’s health and period pain, having dealt with my own personal issues in this area but also because I have seen countless women who were dismissed, told to ‘put up’ with their pain, or given medication that the woman didn’t feel comfortable with.

During the seminar I went from feelings of excitement about the emerging research and treatment possibilities, to frustration that there is still so much we don’t know, to sadness about the extent to which this condition can affect a woman’s life, and anger at the issues women face in seeking effective diagnosis and treatment. A key statement during this Symposium was that women with endometriosis were frequently ‘missed and dismissed’.

What is Endometriosis?

For those that have never heard of endometriosis before, it is a condition that is currently considered to be an inflammatory disease where women can experience extremely painful periods, and 1 in 3 women with endometriosis have fertility difficulty. It is diagnosed when the tissue that is normally present in the lining of the uterus is present elsewhere, such as within the pelvis however it can possibly travel elsewhere in the body.  The only way to definitively diagnose endometriosis with via a laparoscopy, a surgical procedure, however for many women the diagnosis of endometriosis is suggested without having a laparoscopy, particularly is the risks associated with the surgery outweigh the benefits of the diagnosis.

I have written about endometriosis before here, however I would like to expand on some of the points made previously and discuss some of the newer information I received from this seminar.

A key point to remember is that endometriosis is a complex condition that we still don’t 100% understand or know the best treatment for, however we do know that holistically addressing the condition by working on it like a jigsaw puzzle provides better results.

The importance of a good laparoscopic surgeon, and excision vs. ablation.

One of the key speakers, Professor Jason Abbott who is one of the leaders of surgical treatments for Endometriosis in Australia imparted the importance of seeking an advanced laparoscopic surgeon if choosing to undergo a laparoscopy, and discussed his preference for excision (cutting) rather than abalation (lasering off of tissues), something that will hopefully become more commonplace as research supports this as well.

Neither pregnancy nor hysterectomy will cure endometriosis

If you’ve got endometriosis, chances are you’ll be told to get pregnant to cure the condition. Or maybe to have a hysterectomy.

Well unless either of these options are just what you want to do, don’t rush into it! It seems that neither option really provides long lasting relief, as the underlying causes of the condition will not be addressed and symptoms can come back, or still exist.

In the case of pregnancy, many women will find that not having a period for 9+ months is a welcome relief, and the hormonal and immunological shifts that occur during pregnancy also allow many endometriosis symptoms to ease. But the condition can come back, especially if the condition is driven from an imbalance in your immune system or pelvic muscles.

A hysterectomy should theoretically address endometriosis, but unfortunately many women with endometriosis experience problems that aren’t directly related to their period and so these issues can remain. Bowel problems, muscular problems and hormonal imbalances can still persist.

Nerve or Muscular issues in the pelvis can drive endometriosis

Having worked alongside osteopaths my entire naturopathic career I am well versed in the impact that tight muscles or structural imbalances can have on internal health. Seeing the ways that pelvic muscle tightness and nerve signalling issues can contribute to endometriosis was a lightbulb moment, as for many of my patients I have felt there was something ‘missing’ in my understanding of their complete picture, and I think this was it.

A physiotherapist who specialises in women’s health can assess the internal muscles of the pelvis to assist with conditions such as vulvodynia (pain in the vulva), dyspareunia (pain during intercourse) and dyschezia (pain with bowel motion), but it can also be extremely helpful for those with endometriosis. In my clinical experience I have also found that chronic vaginal and bladder infections may benefit from a women’s physio, as tight pelvic floor muscles can cause ongoing inflammation and tension which affects the bladder from eliminating properly.

think about what a muscle cramp in your foot or your calf feels like, then imagine this feeling as happening inside your pelvis or the vagina. The normal contraction and relaxation of a muscle allows blood to flow through, but if the muscle does not effectively contract and then relax it can cause hypoxia (reduced blood flow) which is itself very painful, and it also makes the pH of the muscle more acidic. In itself this can cause pain, but the lightbulb moment for me was realising the way this sort of issue can feed, and be fed by the inflammatory nature of endometriosis.

The constant pain in the pelvis that occurs in something like endometriosis can sensitise the nerves, so that even things which aren’t normally pain can become unbearable. The sensitised nerves can make you more likely to get pelvic pain, period pain and bladder pain, and there is actually an increase of inflammatory chemicals being produced, which worsens endometriosis, an inflammatory based condition.

On a side note, vulvodynia and dyspareunia, like endometriosis is an issue that many women feel ‘missed and dismissed’ about. These problems can have big impacts on a relationship. There may be an issue with the skin such as in chronic candida or lichen sclerosis  or there may be nerve sensitisation worsening the muscle spasms and pain signalling. If you experience these issues, or if your pelvic pain occurs at times other than ovulation and menstruation, consider that there may be a muscular component. If you experience pain when your bladder is full, then again when you have finished weeing, or pain during intercourse, a women’s physio may be able to help you.

Women with Endometriosis have a different type of immune system

There are many different types of cells with different responsibilities within our immune system, and the interplay between all of these can determine whether someone can fight off infections well, or if they are more prone to inflammatory type reactions. For women with endometriosis there have been an increase of some types of immune cells and inflammatory chemicals observed, and less activities of some immune cells which are responsible for ‘keeping things in check’. Interestingly, there is also communication between the hormones progesterone and oestrogen and our immune cells, and as women with endometriosis tend to experience progesterone resistance, the type of immune cells that these hormones normally work on are not able to be reined in.

Bacteria may affect endometriosis

The balance of bacteria within our digestive system has a dramatic effect on our immune system. Normally it can affect things such as how well we can fight off infections or whether we are likely to experience an allergic reaction, however for women with endometriosis there is also a reaction that occurs that worsens their inflammation.

On the coating of some bacteria there are substances which can break off, and the immune system reacts to this by releasing a lot of inflammatory chemicals. This substance is known as endotoxins, or lipopolysaccharides (LPS) and has been shown to be present in higher quantities in women with endometriosis, and the LPS works hand in hand with the higher levels of oestradiol  to then increase certain inflammatory chemicals.

The link between the gut bacteria and hormonal actions and subsequent severity of endometriosis is interesting. If there is an imbalance of good and bad bacteria (dysbiosis) which is very likely for those with endometriosis, it appears to be a key player that needs to be addressed for a holistic approach to endometriosis.

One of the papers referenced suggested that “there may be a direct link between pathological changes of the gut microbiota and the onset and progression of endometriosis”.

Addressing the gut bacteria can improve the severity of endometriosis, as this reduces inflammation and improves immune regulation. Specifically, using herbs that are antimicrobial to gram negative bacteria (such as those containing berberine) and using herbs and nutrients to support digestive lining health and motility, as well as promoting the presence of good bacteria are helpful treatment aims.

The role of histamine

Histamine is a chemical that works in a lot of different areas in the body. It acts a neurotransmitter affecting mood, and it is involved in immune and inflammatory responses. It’s well known for it’s role in allergic responses, causing dilation of blood vessels and stimulating white blood cell activity.

Histamine also has a role in endometriosis and period pain, as high levels of histamine stimulation oestrogen, and also feed the growth of dysbiosis. Oestrogen feeds back into this cycle by reducing the DAO enzyme, which is responsible for clearing histamine, and stabilising mast cells, one of the main white blood cells involved in the histamine response. There is also a stimulation of a chemical called VEGF (vascular endothelial growth factor) which causes the endometrial cysts to grow faster, and attracts more inflammation.

Methylation, involved yet again

Once again, methylation rears its head and as player. I have spoken about methylation before here and here, and while I consider it important to understand the role it has when not working properly, I firmly believe that addressing methylation by itself won’t solve everything.

Problems with methylation can worsen inflammation pathways, and dysbiosis can worsen methylation. Methylation problems can also affect oestrogen levels, histamine processing, and sensitivity to chemicals and toxins (such as mould, viral infections and parasites), all of which affect dysbiosis, immune balance and the inflammation levels.

Where to go from here?

It may seem confusing and overwhelming, realising how much is going on that needs to be addressed. That is completely understandable, but if you are able to find a naturopath or other health care practitioner that can help you, they will be able to guide you in your health journey. Ideally, having a team of practitioners such as a GP, a naturopath, a women’s physio, an acupuncturist and a gynaecologist and/or advanced laparascopic surgeon will mean that you are getting all your bases covered.

The first thing that should be address is pain. After the level of pain is scaled down to a bearable amount, then looking at the drivers of the condition such as gut health, diet, immune imbalance, infections, methylation, stress etc can be done.

Not everyone may want to or be able to afford the testing that can be done to get a clearer picture of the underlying imbalances and that’s okay. Your practitioner should be able to get a lot of information and ideas as to what needs addressing from a thorough case history.

The decision of what form of treatment to use is also very individual, and entirely up to you as the patient. I have not gone into detail about the forms of treatment, but there are many different options in terms of natural medicine, a variety in conventional medicine as well. Natural medicine can potentially be used alongside conventional medicine, or on its own. This is always something that is best discussed with your health care practitioner.

Resources:

Endometriosis Australia

The post Updates on Endometriosis appeared first on Alison Mitchell Naturopath.

Endometriosis is the cause of up to 80% of pelvic pain or infertility. It is the most common cause of infertility in women over 25 years. It is estimated 10-20% of all women during their reproductive life are affected by endometriosis with or without symptoms, with a peak incidence at 25-35 years.

Causes

Endometriosis is caused by endometrial tissue growing in an incorrect place, such as the ovaries, tubes, outer wall of uterus, bladder or bowel. It is not well understood by this occurs.  Some theories include:

• Retrograde flow.  The menstrual blood moving back into the pelvic cavity during the period.  Interestingly, most women who do not have blocked fallopian tubes      do experience backward flow, but not everyone develops endometriosis.
• Immune dysgregulation.  There are some elements of auto-immunity in endometriosis.  Immune systems of endometriosis patients have shown impairment of natural killer cells to destroy misplaced tissue, autoimmune antibodies to endometrial tissues as well as increased T-helper cell activity and reduced T- suppressor cell capacity. There is a direct correlation between the severity of endometriosis and the extent to which natural killer cell function is impaired. Endometriosis also secretes an unidentified substance that destabilizes surrounding capillaries and brings white blood cells to the region to release irritating chemicals, thereby showing increased numbers and activity of macrophages. Macrophages can prevent fertilization of eggs, reduce sperm motility, engulf and destroy sperm, eggs and embryo, increase adhesions and stimulate the growth of endometriosis.
• Genetics.  The endometrial tissue is incorrectly located from birth.
• It is known that endometriosis is a condition of oestrogen excess, as oestrogen is responsible for the development of endometrial tissue. Since oestrogen signals the body the regrow the endometrium each month the endometrium which has been moved keeps growing.  This is usually      associated with a lack of progesterone.
• Other factors that can be involve toxin build up (certain toxic chemicals can act as xeno-oestrogens, such as dioxin, Bisphenol A, pesticides and herbicides which all lead to more oestrogen receptors); liver stagnation (the liver breaks down and removes oestrogen and toxins); past exposure to glandular fever (this impairs the immune system and can predispose the woman to auto-immunity); and an imbalance in the inflammatory      prostaglandins (these are the bodies inflammation balancing hormones, and problems will lead to increased pain, increased endometrial adhesion growth and irregular ovulation).

Signs and Symptoms

• Severe, painful periods which worsen towards the end of the period
• Infertility, decreased success rates for in vitro fertilization and increased miscarriage
• Long and heavy periods (more than 7 days) with darker, brownish blood to start. Spotting and mid-cycle bleeding can be common
• Pain before period and at ovulation
• Feelings of pressure in pelvis, one-sided pelvic pain, pain during bowel movements, pain during intercourse
• PMS symptoms, including anxiety, mood swings, bloating, breast tenderness, constipation, food/sugar/chocolate cravings, headaches

Management

Orthodox Medical Treatment

• Laparoscopic removal of lesions and cysts: reduces or resolves both period pain and other pelvic pain significantly. However, there is increased risk of adhesions and scar tissue and the endometriosis tends to reoccur with about 50% of women developing the condition again within 2-5 years.
• Hormones to inhibit ovulation and suppress menstruation results in atrophy of the endometrium, eg. the Oral Contraceptive Pill: given continuously without a breakthrough bleed. Side effects include blood clots, stroke, heart attach, especially for smokers, abnormal cholesterol ratios. However, the Pill compares favourably with other drug regimes for endometriosis that have more serious side effects. The Pill is not as effective for advanced endometriosis and is not suitable for women who want to fall pregnant. Most women have a return of symptoms within 6 months of stopping the Pill.  Other options include implants, such as Depo Provera, which are a stronger form of the Pill and although they have same side effects, have the benefit that it cannot be forgotten.
• Progestogens: side effects of nausea, bloating, acne, breast tenderness, weight gain, mood changes, increased facial and body hair, effects of the drugs as well as abnormal cholesterol ratios. About 30% of women have spotting or breakthrough bleeding until the drug starts to work or the dose is adjusted. These drugs are relatively inexpensive and give significant pain relief. Fertility is not improved by these drugs, menstrual cycle may be delayed for many months and endometriosis may reoccur after stopping therapy.
• GnRH agonists induce a temporary menopausal state. They are effective in reducing symptoms and the size of endometrial growths but obvious side effects are less severe. There is early and significant bone density loss, although this causes no symptoms until later in life but should be considered      in the decision to use these drugs. On average, endometrial cysts return to their original size, 4 months after stopping treatment, so additional      treatment is necessary.
• Hysterectomy, pregnancy.

Naturopathic Perspective

 Treatment length for endometriosis usually requires 6-12 months, depending on the severity and duration of the condition.

 Dietary and lifestyle changes are essential for successful treatment and for maintenance of the condition long term to prevent reoccurrences.

 Herbal medicines and nutritional supplements are individually prescribed to:

• Balance hormones to improve the relative oestrogen excess and prevent reoccurrences by correcting underlying hormonal imbalance, rather than superseding the body’s own hormones
• Ensure normal menstrual flow and uterine function
• Improve fertility if required
• Decrease constriction of blood vessels and muscular spasm, thereby decreasing pelvic congestion and pain
• Rebalance immune system dysfunction to address auto-immunity basis
• Improve liver function which breaks down and removes excess oestrogen, other hormones and toxins
• Soften and heal scar tissue and adhesions, and drain cysts
• Decrease heavy bleeding and spotting
• Regulate bowel habits and decrease constipation. Women with endometriosis commonly experience irritable bowel syndrome symptoms which complicate their pain and hormonal imbalance.
• Address any bacterial or fungal overgrowth
• Calm and nourish the nervous system to cope with chronic pain and anxiety as well as balance mood swings

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