Endometriosis refers to the growth of endometrial tissue outside of the uterine cavity or into the uterine wall. The cyclic variations of the estrus cycle cause this misplaced endometrial tissue to undergo both proliferative and secretory stages, but without elimination during menstruation. The cyclical hemorrhaging of extrauterine (ectopic) endometrial tissue can give rise to a variety of symptoms, and with repeated hemorrhaging the implanted endometrial tissue begins to enlarge. Endometriosis is a disease of women of reproductive age and regresses with artificially induced or natural menopause. It is believed to affect upwards of 10% of women, and is slightly more common in women in their late 20’s to mid 30’s. It has been estimated that 25-50% of infertile women have endometriosis. The sites most commonly affected, in order of decreasing frequency, are the ovaries, fallopian tubes, uterus, pouch of Douglas, uterosacral ligaments, urinary bladder, ureters, vagina, lower gastrointestinal tract, and rarely, in distant areas such as the lungs, pleura, and extremities. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)
Although the etiology is unclear, there are four possible causes of endometriosis:
- the retrograde flow of menstrual fluid into pelvic cavity
- relative estrogen excess, increasing number of cells and sites receptive to estrogen
- immunological and inflammatory factors
- fetal developmental of ectopic endometrial tissue
The first possible cause of endometriosis is the retrograde flow of menstrual fluid into pelvic cavity, in which foci of the menstrual tissues regurgitate into the fallopian tubes and become implanted upon the various pelvic organs. Factors that can enhance the retrograde flow of menstrual fluid include cervical stenosis, uterine or cervical adhesions, imperforate hymen, exercise during menstruation, and excessive uterine spasm and fallopian dilation during menstruation, mediated by excessive PGE2. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)
The second and third causes are somewhat related, with elevated levels of estrogen having a negative effect upon immune activity that might otherwise ‘clean up’ the regurgitated tissues. Further, women exposed to high levels of estrogen are more likely to develop endometriosis. Women now menstruate far more often then our forebears, and complexed with influence of xenoestrogens and oral contraceptives, women are generally overexposed to estrogen. The immune response too can have a negative impact upon the situation, and an enhanced localized immune response promotes inflammation, and can result in macrophage-induced infertility during the initial stages of endometriosis. Note as well that high levels of circulating estrogen facilitates the production of the antiinflammatory prostaglandins. With the progression of the disease the immune response declines, but the scarring from inflammation remains and inhibits fertility. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)
The fourth possible cause of endometriosis is linked fetal development. All reproductive tissues develop from the same embryonic tissue. During embryonic development the tissues may fail to differentiate properly, giving rise to an ectopic endometrium. The risk factors for endometriosis are numerous, including lifestyle, familial and dietary aspects. As mentioned already, women who menstruate early, and/or who never have children or lactate, have a higher incidence of endometriosis due to the negative effects of excessive estrogen. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)
Sexual intercourse during menstruation is also thought to increase the retrograde flow of endometrial fluid, and many cultures for this and other reasons prohibit sexual intercourse during menses. There also appears to be familial link, and immediate family members of a woman who has endometriosis are seven times more likely to develop it. Additionally, daughters of mothers with endometriosis have an increased risk of endometriosis. The use of an intrauterine device (IUD) is associated with an increased risk of endometriosis, possibly because the device enhances retrograde flow, as do tampons. Women taking oral contraceptives appear to have a negligible risk for endometriosis, but former OC users are at a higher risk of developing endometriosis than women who have never taken the Pill. Other risk factors include the regular use of caffeine and alcohol in the diet. Factors that appear to decrease the risk of endometriosis include pregnancy and lactation, with the risk of endometriosis decreasing with each successive pregnancy. Exercise too appears to have a beneficial effect because it can reduce estrogen production, but strenuous exercise, and in particular aerobic exercise, is though to enhance retrograde flow. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)
There are two primary forms of endometriosis, adenomyosis, and extrauterine or ectopic endometriosis. Adenomyosis is the growth of endometrial tissue into the muscular wall of the uterus. It is more likely to occur in women over the age of 35 and in women who have carried more than one full term pregnancy. In 50% of cases it is associated with fibroids. When the uterus is palpated it feels hard, large and may have an irregular shape. The symptoms of adenomyosis include severe dysmenorrhea (related to implants of ectopic endometrium on the uterosacral ligaments that swell just before menstruation), infertility, menorrhagia, increased frequency of menstruation, and uteral enlargement. Extra-uterine or ectopic endometriosis is the growth of endometrial tissue outside of uterine cavity. If implanted upon the ovaries it can lead to the development of ovarian cysts, which occurs in about 60% of all cases. The formation of the cyst is due to the ovary trying to contain endometrial growth by encapsulating it. These endometrial cysts are called endometriomas, and are filled with clotted dark brown blood that gives rise to their more common name of chocolate cysts. The size of an endometrioma varies from a small cyst that has a tendency to rupture at each period, to large cysts which do not rupture, but only get larger, upwards of 20 cm in diameter. When large cyst rupture there is acute abdominal pain and shock, and require immediate surgery. Small rupturing cysts cause on the other hand cause chronic irritation, inflammation, and pain within the pelvic cavity. Other sites of implanted endometrial tissue often include the fallopian tubes, pouch of Douglas, the uterosacral ligaments, and other pelvic organs such as the bowel, urinary bladder, ureters, and urethra. The implanted tissue forms raspberry-like clusters of endometrial tissue that are in various stages of development. Typically the implanted endometrial tissue may bleed for a few months, and then be replaced by fibrous tissue called adhesions. Endometriomas that occur peripherally may manifest as bluish swellings under the skin that because increasingly painful and may even bleed as menstruation approaches. The symptoms of extrauterine endometriosis includes severe dysmenorrhea, infertility, pain with sexual activity, increasing pain as luteal phase progresses, pain at ovulation, one sided pelvic pain, pelvic heaviness, and irritable bowel syndrome. (Trickey 1998, 239-249; Berkow 1992, 1809-12; Rubin 2001, 518-19)
The treatment of endometriosis utilizes a broad array of medicinal herbs. Phytoestrogens such as Red Clover (Trifolium pratense) and Black Cohosh (Cimicifuga racemosa) are an important part of treatment, to reduce the negative effects of excessive estrogenic stimulation. The primary treatment of endometriosis however is to improve the uterine tone to promote orderly contraction and the proper elimination of menstrual fluid, to relieve excessive or abnormal uterine spasm, and to regulate eicosanoid synthesis. Uterine tonics that regulate the contraction of the uterus include Dan Gui (Angelica sinensis), Raspberry leaf (Rubus idaeus), Blue Cohosh (Caulophyllum thalictroides), and False Unicorn root (Chamaelirium luteum). Emmenagogues such as Mugwort (Artemisia vulgaris), Pennyroyal (Mentha pulegium), and Rue (Ruta graveolens) are used just prior to menstruation to facilitate the elimination of menstrual fluid, particularly with menstruation that is slow to start, accompanied by pelvic heaviness and cramping. Antispasmodics such as Cramp Bark (Viburnum opulus) and Wild Yam (Dioscorea villosa) can also be used to alleviate excessive uterine spasm that is uncoordinated and painful. Regulators of prostaglandin synthesis in the uterus are an important aspect of treatment to improve uterine tone, and are chosen based on the underlying symptoms of the patient. For feelings of heat and irritability the cooling properties of Feverfew (Tanacetum parthenium) is a better choice, whereas symptoms of coldness and depression are best resolved by using warming and stimulating botanicals such as Ginger (Zingiber officinalis). Another regulator of prostaglandin synthesis is Turmeric (Curcuma longa), which is neutral in energy.
A general treatment for many female reproductive ailments, and no less for endometriosis are pelvic decongestants. This class of botanicals helps to relieve symptoms of pelvic congestion by relieving portal vein congestion, enhancing lymphatic drainage, and promoting liver metabolism. Included in this category are White Dead Nettle (Lamium album), Yarrow (Achillea millefolium), Stone root (Collinsonia canadensis), and Ocotillo (Fouquieria splendens). Additional treatments for endometriosis may resemble those for PMS, such as the use of hormonal regulators such as Peony root (Paeonia lactiflora) and Chasteberry (Vitex agnus castus), and mood-elevating botanicals such as St. John’s Wort (Hypericum perforatum), Skullcap (Scutellaria lateriflora), Passionflower (Passiflora incarnata), Vervain (Verbena officinalis), and Kava (Piper methysticum).
The treatment of adhesions may be a necessary aspect of treatment, and botanicals such as Plantain (Plantago lanceolata), Selfheal (Prunella vulgaris), St. John’s Wort (Hypericum perforatum), Astragalus (Astragalus membranaceus), Bilberry (Vaccinium myrtillus), and Calendula (Calendula officinalis) have all been used traditionally for their wound-healing properties. Vitamins A, C, E, and zinc are also important in this regard.
For the bowel related issues that often accompany endometriosis, a treatment for IBS may need to employed. Phrased succinctly, it is important to ensure the correct function of the liver, the health of the gut flora, and the proper tone of the bowel wall in bowel-related issues in endometriosis.
Important supplements in the treatment of endometriosis include the use of oils rich in GLA and EPA and oligomeric proanthocyanidins such as pycnogenol (150 -300 mg daily) to inhibit the inflammatory cascade and promote wound healing. Vitamin E at a dose between 500-1000 IU may be helpful to reduce adhesions, as is the use of a castor oil pack. In regards to diet it is important to increase dietary fiber, reduce saturated fat intake, and increase phytoestrogenic foods.