Endometriosis happens when tissue similar to the lining of the uterus (womb) grows outside of the uterus. It is a chronic condition affecting women. Did you know it takes an average of 7.5 years for someone to be diagnosed - heart-breaking we know!
This article examines the newer findings about endometriosis – a poorly understood complex condition, affecting all parts of the body. Thank goodness, more research is finally being conducted – for example the Endometriosis Action Plan from Endometriosis Australia.
As a result, our awareness and understanding of the condition is improving. It’s important to raise awareness and education about these newer findings, especially as our understanding of condition broadens. This is so that women can be diagnosed faster and treated more effectively. #1in9.
*There are many more aspects to endo not discussed here such as genetics and oestrogen - this article covers some of the newer findings of endo drivers that are not just hormonal. Spoiler alert! The hypothesis that endo is cause by ‘retrograde flow’ has been debunked. So what’s left? Let’s go deeper.
1 - Endo is not just a hormonal issue.
Sure, oestrogen drives proliferation and bleeding of endometrial lesions, but this is a small part of the endo picture. A picture we are only now beginning to understand.
While there is a hormonal component to endo, it’s so much bigger thank that. Hormonal dysregulation does not cause endometriosis. While your genetics and epigenetics influence oestrogen metabolism, and progesterone resistance issues can make symptoms worse - hormones are small part of the picture.
Because of the above, the hormonal methods for treating endo via the pill or Mirena does not do much for the condition. Whilst this may (not always) reduce symptoms by shutting off hormonal pathways, this will not cure endometriosis. Furthermore, it is likely that when you come off these medications - your endo will come back.
2 - Endo is an immune and inflammatory disorder.
Endometriosis at its very core is an inflammatory condition. When there is inflammation – the immune system is involved, as the immune system either induces or resolves inflammation as a means to heal. Sometimes, something happens and the immune system gets confused.
With endometriosis, the intricate balance of the immune system has become deranged, and this causes a mass influx of inflammatory molecules (called cytokines) and immune cells. Cue pain, inflammation and scar tissue.
There are two main parts of your immune system - the Innate (we are born with this) and the Adaptive (we develop and inform this as we get older and experience microbes). In endo - your immune system is not doing its job. The innate is meant to assess and remove unwanted materials, microbes or material in the wrong place - such as endometrial-like tissue outside the endometrium.
The cells of the innate immune system (called macrophages and natural killer cells) are meant to clear or ‘gobble up’ endometrial-like tissue that’s in the wrong place. With endo - this doesn’t happen effectively, and instead there is an increased production of inflammatory molecules. But why?
Research is discovering that this initial immune derangement can be caused by bacterial imbalances or a triggering infection. For example bacteria can translocate from the gut into the peritoneal cavity (especially if there is leaky gut or a microbial imbalance in the gut). The peritoneal cavity is the space where all your abdominal organs sit, and are bathed in peritoneal fluid - anything that touches this fluid can be affected like the kidneys, bowel, ligaments, ovaries, uterus etc.
It has been found that endo sufferers have a different immune profile in the peritoneal environment to non-endo.
Such as: - Impaired activity of natural killer cells and macrophages - Increased amounts of pro-inflammatory molecules (IL-6, TNF-a and VEGF) - Presence of autoantibodies - Abnormal T regulatory cells that regulate inflammation (1-3).
So, not only do we have a reduced ability to clear endometrial-like tissue form the places it’s not meant to be, but inflammation is increased. Any inflammation on top of existing endometrial lesions is like pouring gasoline on a fire.
Considering the above part of our treatment aims will be to: - Reduce lesions - Support the immune system - Reduce oestrogen and increase progesterone - Reduce microbial load, usually via gut.
How we address this naturally: - Zinc - Anti-inflammatories like turmeric, boswelia and Khaya sengalensis (Khapregesic) - NAC: Down regulates NF-kB which reduces inflammatory cytokines.
3 - Endo women have different microbiomes to non-endo women.
Here, we are generally talking about either the gut microbiome or the pelvic microbiome. Any microbiome or microbial imbalance in the gut - like a parasite, SIBO, leaky gut or general dysbiosis can cause gram-negative bacteria to translocate or 'leak from the gut into the peritoneal cavity, causing initial immune derangement and inflammation. Gram-negative bacteria produce a substance called lipopolysaccharide (LPS), which is extremely toxic and inflammatory. This in turn stimulates the immune system to release inflammatory cytokines.
The microbiome of the endometrium of the uterus should be dominated by lactobacilli bacterial strains. In endo patients - less lactobacilli are found. This species determines the pH and immune sensitivity of uterus, and protects against harmful bacteria. This is one example of how the microbiome of an endo sufferer differs.
Another example of this is in menstrual fluid. Studies culturing menstrual fluid of endo patients found it more likely to be highly contaminated with e-coli bacteria and other gram-negative strains, and measured LPS at 4-6 times higher in their blood (4). Additionally, endometriosis appears to be associated with an increased presence of Proteobacteria, Enterobacteriaceae, Streptococcus spp. and Escherichia coli across various microbiome sites (5).
4 - Balancing the gut microbiome is the first step to address endometriosis.
There is a direct link between negative changes of the gut microbiota and the onset of endometriosis, and many clinical studies such as the ones mentioned above have demonstrated that there are differences in the microbiome compositions between endo and non-endo suffers.
The beneficial gut bacteria is not only essential for healthy gastrointestinal function, but acts as a central regulator of a variety of inflammatory and proliferative conditions, like endo (9).
Your gut microbiome composition also profoundly affects the way oestrogen is metabolised in your body. If there is an imbalance (dysbiosis), certain gut bugs may produce a substance called beta-glucuronidase. This enzyme actually reverses all the work the liver has done to detox oestrogen - and sends oestrogen back into circulation instead of out through your poop (9). This leads to increased levels of oestrogen. Not a hormonal issue - but a microbial issue!
Lastly, your gut microbiota significantly influences histamine - an immune, inflammatory molecule that has a close relationship to oestrogen. Histamine is often found to be deregulated in endometriosis. Gut bacteria can both make and use histamine; and histamine and oestrogen both increase each other. High histamine leads to immune disfunction inflammation. That is why doing a low histamine or a FODMAP diet and using natural antihistamines can help to quell endo symptoms.
Clinically I see most, if not all endo patients have some sort of gut dysfunction. Investigating and treating this with the appropriate antimicrobials, or pre and probiotics, or anti-inflammatories will be at the top of my endo protocol.
5 - Endo may be a driven by microbes.
Given the above - it becomes quite clear that there is a large ‘infective’ or microbial component to endometriosis. This is why some cases of endo improve after a course of antibiotics, and also why herbal antibiotics and antivirals help to reduce symptoms.
Microbial drivers of endometriosis could be in the form of: - Gynaecological infections such as mycoplasma, chlamydia, BV, herpes - Any gut issues like SIBO, parasites, dysbiosis - A triggering infection like herpes, glandular fever, cytomegalovirus virus.
Yes…. all very common!
All of the infections mentioned above can trigger the initial immune and inflammatory response. In fact, one large study found that patients with lower genital tract infections have a two-fold increased risk of developing endometriosis (6).
This potentially could be root cause for endometriosis but there will always be additional factors that contribute: Genetics, environmental toxins, trauma….we just don’t understand the full picture yet.
Quite often I may include antimicrobial herbs in my herbal prescriptions due to the above, such as berberine containing herbs: Goldenseal, coptis, philodendron, red root, or calendula.
6 - Chemicals and toxins make endo worse.
This one is well established but deserves a mention!
Environmental toxins like glyphosate (the ubiquitous RoundUp), dioxin, and the endocrine disrupting chemicals (EDC’s) of plastics such as phthalates and BPA are some of the chemicals linked to endo (7).
Glyphosate has been implicated intestinal permeability and we have just discussed how leaky gut contributes to endo. Dioxin can affect gene expression and immune system. Dioxin can be found in tampons, and while the dioxin hazard has been reduced because of new bleaching methods, dioxin is still detected in tampons — even those made of 100% cotton (11). Use a cup!
EDC’s which are everywhere mimic oestrogen, causing havoc in the hormonal pathways. EDC’s molecularly look like oestrogen but don’t exert the correct response when they bind at the receptor sites - this results in the wrong hormonal signalling so is implicated in endometriosis-like lesions. We just don’’t know the full extent of this and more human studies are desperately needed.
WORK WITH US TO OVERCOME YOUR ENDO
What are your thoughts on the above? Do you have endometriosis or a history of any of the above infections or gut issues? If you are needing help with your condition - book a consultation or send us a DM with any questions you have.
In good health,
BHSc Naturopath (Distinction) The Feel Good Society Founder & Head Practitioner
1 - Macrophages display proinflammatory phenotypes in the eutopic endometrium of women with endometriosis with relevance to an infectious etiology of the disease (DOI: 10.1016/j.fertnstert.2019.08.060)
2 - Involvement of immune cells in the pathogenesis of endometriosis https://pubmed.ncbi.nlm.nih.gov/29316073/ DOI: 10.1111/jog.13559
3 - Decreased Cytotoxicity of Peripheral and Peritoneal Natural Killer Cell in Endometriosis https://pubmed.ncbi.nlm.nih.gov/27294113/ PMCID: PMC4880704
4 - Increased Risk of Endometriosis in Patients With Lower Genital Tract Infection: A Nationwide Cohort Studyhttps://pubmed.ncbi.nlm.nih.gov/26962775/ DOI: 10.1097/MD.0000000000002773
5 - Endometriosis and the microbiome: a systematic review https://obgyn.onlinelibrary.wiley.com/.../1471-0528.15916
6 - Increased Risk of Endometriosis in Patients With Lower Genital Tract Infection https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998856/ PMC4998856
7 - Endocrine disrupting chemicals and endometriosis https://www.fertstert.org/.../S0015-0282(16)61389-4/fulltext
8 - Gut microbiota and neurological effects of glyphosate https://pubmed.ncbi.nlm.nih.gov/31442459/ PMID: 31442459
9 - The gut microbiota: A puppet master in the pathogenesis of endometriosis https://pubmed.ncbi.nlm.nih.gov/26901277/
10 - Correlation between dioxin and endometriosis: an epigenetic route to unravel the pathogenesis of the disease https://link.springer.com/article/10.1007/s00404-015-3739-5
11 - National Centre for Health Research, Tampon Safety here.