is a common condition affecting 5% to 10% of women. The name comes
from the word endometrium, the tissue that lines the uterus. In
a woman with endometriosis, this endometrial tissue is found outside
the uterus: on the ovaries, on the fallopian tubes, in the abdominal
cavity, and at other abnormal sites. This tissue found outside the
uterus can respond to the menstrual cycle in the same way the lining
of the uterus responds. At the end of the luteal phase of the menstrual
cycle, when hormones decline and the uterine lining is shed, endometrial
tissue growing outside the uterus will also break apart and bleed.
This blood has no place to go, so the surrounding tissue may become
inflamed and swollen. Scar tissue can form around the endometriosis
sites and develop into areas called implants, nodules, lesions,
Endometriosis typically occurs in women of reproductive age, most
commonly 25 to 30 years old at the time of diagnosis. Diagnosis
is confirmed by laparoscopic surgery typically performed for complaints
of pelvic pain. Endometriosis is a hormonal responsive condition.
Endometriotic lesions contain estrogen, progesterone, and androgen
receptors.1 Risk of endometriosis seems related to the amount of
menstrual flow. Women with a short menstrual cycle (< 27 days),
longer menstrual flow (> 7 days), and spotting before the onset
of menses are at greater risk for developing endometriosis.2 Endometriosis
has been found more commonly in Asian women than Caucasian women.2
The symptoms of endometriosis include:
· pelvic pain
· lower abdominal pain or back pain
· painful bowel movements (especially during menses)
· painful urination (especially during menses)
· pain with exercise
· difficulty conceiving
Diagnosis can often be difficult and
sometimes is delayed. Endometriosis is the underlying cause in 15%
of pelvic pain cases and a common cause of infertility.3 The symptoms
of endometriosis can mimic other conditions that need to be ruled
Differential diagnosis includes:
· pelvic inflammatory disorder (PID)
· vulvar vestibulitis
· neoplasms of colon, ovary, uterus
· musculoskeletal causes
· interstitial cystitis
· other causes of infertility (such as luteal phase defect)
· ovarian cysts
· ectopic pregnancy
· acute appendicitis
· urinary tract infection
In the initial work-up of endometriosis, a physical exam should
be performed. The doctor should perform a bimanual exam and palpate
for pelvic masses; fixed, retroverted uterus; and adenexal and uterine
tenderness.4 A rectovaginal exam should also be performed to identify
masses. However, most women have a normal pelvic exam; and imaging
such as pelvic ultrasound, MRI, or CAT scan is often not helpful.
The gold standard for diagnosis is laparoscopy. Laparoscopy is a
surgical procedure wherein a thin tube with a lens and light is
inserted into the abdomen through a small incision. The laparoscope
allows the physician to see the pelvic area and locate endometrial
growths. The laparoscope can also remove the endometriosis at the
time of examination, thus offering treatment during diagnosis.
A staging system has been developed by the America Society of Reproductive
Medicine based on the location, depth, size, and amount of endometrial
growth found during laparoscopy. The stage sometimes does not correlate
with the amount of pain a woman has, the symptoms present, or whether
fertility is affected.
· Stage I = minimal severity
· Stage II = mild severity
· Stage III = moderate severity
· Stage IV = severe
The exact cause and pathogenesis of endometriosis are unclear. Several
theories exist, but none have been entirely proven. The most common
theory is retrograde menstruation. Endometrial cells flow backward
through the fallopian tubes and land on pelvic organs, where they
start to grow.5 Retrograde menstruation is a common event in women;
more common than endometriosis itself, so there must be some other
immunologic or hormonal reason that leaves women predisposed. Another
theory is metaplasia, or the changing from one type of tissue to
another. The cells in the endometrium are of the same surface as
cells in the peritoneum. This theory suggests that the cells lining
the pelvic peritoneum transform into endometrial tissue in the pelvis.6
Genetic factors cannot be overlooked, as it is known that women
with first-degree relatives with endometriosis are predisposed to
develop the disease, develop symptoms earlier, and have more severe
manifestations.7 Some report that women with a first-degree relative
with endometriosis have a 10-fold increased risk.7
Recent research has suggested the involvement of the immune system
in the pathogenesis of endometriosis. Numerous studies have shown
conflicting results in regard to producing inflammatory cytokines.
In general, Il-8, TNF-alpha, and IL-10 appear to be elevated with
endometriosis. A recent study showed that women with endometriosis
have higher levels of IL-10, IFN-gamma, and IL-4, showing a shift
toward increased inflammatory cytokines.8
Recent studies have also shown that women with endometriosis have
higher rates of autoimmune disease. A study published in Human
Reproduction (Sept. 27, 2002) showed that women with endometriosis
had higher rates of systemic lupus erythematosus, Sjögren's
syndrome, rheumatoid arthritis, and multiple sclerosis.
Other causes of endometriosis include iatrogenic, wherein endometriosis
develops after gynecological procedures, abdominal surgery, or cesarean
sections. Diet is linked to endometriosis as well. In a study of
504 women with laparoscopic-confirmed endometriosis compared to
504 women without endometriosis, it was found that there was a 40%
decreased risk of endometriosis in women with higher consumption
of green vegetables and fresh fruit. There was an 80% increased
risk in women who ate high amounts of beef and other red meats.9
Women with endometriosis have higher serum levels of vitamin D.10
Vitamin D may influence endometriosis by locally modulating the
immune system within the peritoneal cavity.
Lastly, environmental factors must be considered. Since endometriosis
is a steroid-responsive disease with an immunological component,
environmental exposures that affect a woman's hormonal and
immune systems need to be addressed. Such toxins include bisphenol-A,
parabens, phthalates, pesticides, dioxins, PCBs, solvents, and formaldehyde.
Organochlorine compounds such as dioxin and PCBs contaminate our
food and water, and women are often exposed to low doses on a daily
basis. Deep endometriotic nodules are associated with high blood
levels of dioxin and PCBs.11 Phthalates are used in the plastic
industry and are in everything from plastic water bottles with the
"3" on the bottom to cling wrap. A recent study showed
that 55 women with endometriosis had blood levels of phthalates
compared to controls.12 Most women are exposed to environmental
toxins on some level every day; however, not all women get endometriosis.
Single nucleotide polymorphisms (SNPs) might provide an explanation
as to why some women clear exposures easily and others do not, making
them more susceptible to the hormone-disrupting effects. A SNP is
a change in which a single base in the DNA is altered. This simple
change can affect how the body detoxifies environmental toxins.
Since most toxins are cleared through the liver, it is important
to look at what SNPs in the liver are associated with endometriosis.
Recent studies have shown that women with a polymorphism of the
cytochrome P450 1A1 gene and the glutathione S-tranferase M1 gene
have increased risk of endometriosis.13
Many theories exist as to what causes endometriosis, and likely
it is a combination of all these factors that not only determines
the cause but also the severity of the disease. It is important
to consider them all in developing a treatment strategy for patients.
The conventional medical treatment approach to endometriosis typically
begins with estrogen suppression through medications such as Danazol
and Lupron. Other hormonal therapies often initiated are oral contraceptives
and progestins to suppress ovulation. Nonsteroidal anti-inflammatory
drugs (NSAIDS) are used to decrease inflammation and pain as well
as other analgesics. Laparoscopic surgery is the main treatment
to remove the endometrial lesions from the pelvic area. A hysterectomy
is performed to remove the uterus and sometimes the ovaries in severe
In developing a treatment plan for endometriosis, the patient's
overall health should be considered and the treatment individualized.
Is fertility a goal, or merely symptom management? Is the patient
in severe pain with each menstrual cycle, or is she in constant
pain? Is there pain with intercourse? Is she constipated, or is
the patient asymptomatic? Often the patient has already undergone
laparoscopic surgery for endometriosis and now wants to focus on
The goals of naturopathic treatment include:
• decreasing inflammation
• pain management
• shrinkage of endometriosis lesions/implants
• decreasing body burden of environmental toxins
• immune modulation
• fertility support
Methods used to achieve these goals:
• herbal analgesics
• anti-inflammatory herbs and nutrients
• natural immune support
• hormonal support
• liver detoxification and cleansing
Diet plays an important role in treating endometriosis. Decrease
foods that are high in saturated fat and arachidonic acid, which
are pro-inflammatory, and increase series 2 prostaglandins (PGE2).
Arachidonic acid comes almost entirely from animal-derived foods
and should be avoided due to its inflammatory effects.14 Increase
therapeutic foods such as soy. Soy contains the isoflavones genistein
and daidzein. A recent study showed that women with high dietary
intake of soy had high urinary levels of genistein and daidzein,
and had decreased risk of endometriosis compared to controls.15
Increase fruits and vegetables in order to lower risk of endometriosis.16
Increase foods high in the omega-3 fatty acids, eicosapentaenoic
acid (EPA) and docosahexaenoic acid (DHA), which are found in fish
and are anti-inflammatory.17 Lastly, increase foods that support
liver detoxification to decrease the body's burden of environmental
toxins and help metabolize estrogens. The cruciferous vegetables,
broccoli, cabbage, kale, cauliflower, and brussels sprouts, support
liver detoxification and contain indole-3-carbinol (I3C), which
helps break down estrogen in the liver.
Herbs and nutrients that act as analgesics or are antispasmodic,
thus offering symptomatic relief, include:18,19
· Jamaican dogwood
· white willow bark
There are many options for decreasing inflammation with herbs and
nutrients, and every physician has his or her favorites. Here are
a few to consider:20
· fish oil
One herb that might be overlooked in
treating endometriosis is Pycnogenol. A study published in 2007
in the Journal of Reproductive Medicine
looked at women with laparoscopic-confirmed endometriosis who took
30 mg b.i.d. of Pycnogenol for 6 months. They were compared to women
with endometriosis who took leuprorelin acetate depot 3.75 mg IM
6 times every 4 weeks for 24 weeks. Women in the Pycnogenol group
had a 33% reduction in symptoms of endometriosis, which lasted after
stopping the treatment. The Pycnogenol group maintained regular
menses and normal estrogen levels, and 5 women became pregnant.
The women in the leuprorelin acetate depot group also had reduction
of symptoms but relapsed 24 weeks posttreatment. The leuprorelin
group had suppressed menses, lowered estrogen during treatment,
and no pregnancies. Pycnogenol is an extract from French maritime
pine bark with anti-inflammatory and antioxidant properties.
Several studies link elevated inflammatory cytokines to endometriosis.
IL-8 and TNF-alpha are elevated in women with endometriosis in the
pelvic region, regardless of ovarian involvement.21 As mentioned
earlier, IL-10 and IL-4 also are elevated with endometriosis. Since
IL-4 and IL-10 are produced by Th2 cells and IL-8 and TNF-alpha
are produced by macrophages, treatment is aimed at modulating these
cells. There are many herbs proven to modulate the immune system;
here are a few to consider with endometriosis, along with treatments
to decrease inflammation produced by cytokines:22
· Panax ginseng
· Coriolus versicolor
· Withania somnifera
Estrogen has been shown to support the growth of endometriosis,
while progestins and androgens induce atrophy.23 A main part of
a naturopathic treatment plan is therefore to decrease estrogen
and increase progesterone or androgens. There are various ways to
increase estrogen metabolism, some of which have already been mentioned.
I3C, or diindolylmethane (DIM), helps the liver metabolize estrogen.
Flaxseed, fish oil, and soy also increase the breakdown of estrogen
in the body. Progesterone therapy can decrease estrogen levels in
the blood by decreasing the retention of estrogen receptors.24 Progesterone
also can decrease uterine contractions and pain. Natural, bioidentical
progesterone can be part of a comprehensive treatment plan for women
with endometriosis. There are many ways to prescribe natural progesterone:
creams applied topically, oral pills, and sublingual pellets. Typically,
the dose is started low, 50 to 100 mg before bed and timed with
the menstrual cycle. The dose can be given 3 weeks on, and off the
week of menses. Some women just need to take it 7 to 10 days before
their menses. This can vary depending on the severity of symptoms,
length, and quality of menstrual cycle.
Since environmental toxins are linked to endometriosis, a thorough
environmental exposure history should be performed to identify possible
toxins. Testing for heavy metals, pesticides, solvents, phthalates,
and parabens is available through various labs. Every patient should
be educated on how to avoid hormone-disrupting chemicals in food,
water, air, and personal care products. Every woman I see with endometriosis
is put on a plan to cleanse toxins from her body with sauna therapy,
colonics, a detox diet, castor oil packs, and supplements to support
liver detoxification and elimination from the body.
· fish oil: 3,000 mg of EPA+DHA
· calcium and magnesium: 1,000 mg and 500 mg
· crampbark tincture: ½ tsp every 3 hours as needed
· Pycnogenol: 30 mg b.i.d.
· curcuma: 400 to 600 mg t.i.d.
· Panax ginseng or Astragalus tincture: ¼ tsp b.i.d.
· DIM or I3C: 100 to 200 mg q.d. DIM or 300 to 400 mg q.d.
· progesterone: 100 mg q.d. 3 weeks on, 1 week off
· diet: increase flaxseed, wild salmon, cruciferous vegetables,
fruits and other vegetables; decrease ham, other red meat, dairy
products, alcohol, saturated fats, sugar
· cleanse: sauna, colonic, castor oil pack, liver support
In summary, endometriosis is a common
condition affecting many women, but it is often misdiagnosed or
diagnosis is delayed. Women complaining of dysmenorrhea, dyspareunia,
chronic pelvic pain, or difficulty conceiving should be evaluated
for endometriosis. The modalities of naturopathic medicine –
addressing the cause and not the symptom, and treating the whole
person – make for successful outcomes with this complicated
Dr. Marianne Marchese is
a clinician, author, and educator. She graduated from Creighton
University in 1990 with a BS in Occupational Therapy and received
her Doctorate of Naturopathic Medicine from the National College
of Naturopathic Medicine. She completed a two-year postgraduate
residency in Integrative Medicine and Women's Health and completed
a six-month post-graduate training in Environmental Medicine.
Dr. Marchese has been an
adjunct faculty member at a postgraduate college since 2003. Currently,
she is clinical supervisor at the Southwest College of Naturopathic
Medicine. She is frequently interviewed by ABC news channel 15 and
Fox news channel 10 for her expertise in environmental medicine.
Dr. Marchese has had articles published on environmental medicine
and women's health in magazines and journals. She is a well recognized
speaker and is currently vice president of the Arizona Naturopathic
Medical Association. Please visit her website to learn more about
her and her practice: www.drmarchese.com.
1. Frackiewicz E.J. Endometriosis: an overview of the disease and
its treatment. J AM Pharm Assoc.
2. Spaczynski RZ, Duleba AJ. Diagnosis of endometriosis. Semin
Repro Med. 2003;21(2):193-207.
3. Prentice, A. Endometriosis; regular review. BMJ. 2001 Jul 14;323(7304):93-95.
4. Wellbery C. Diagnosis and treatment of endometriosis. Am
Fam physician 1999;60:1753-1768.
5. Saul T, Dave AK. Endometriosis. emedicine.medscape.com [website].
Accessed Nov 12, 2008.
6. Olive DL, Schwartz LB. Endometriosis. NEJM.
7. Frackiewicz EJ. Endometriosis: an overview of the disease and
its treatment. J AM Pharm Assoc.
8. Podgaec S et al. Endometriosis: an inflammatory disease with
a Th2 immune response component. Hum
9. Parazzini F et al. Selected food intake and risk of endometriosis.
10. Somigliana E et al. Vitamin D reserve is higher in women with
endometriosis. Hum Reprod.
11. Hellier JF et al. Organochlorines and endometriosis. Chemosphere.
12. Cobellis L et al. High plasma concentrations of di-(2-ethylhexyl)-phthalate
in women with endometriosis. Hum
13. Hadfield RM et al. Linkage and association studies of the relationship
between endometriosis and genes encoding the detoxification enzymes
GSTM1, GSTT1, and CYP1A1. Mol Hum
14. Marz R. Medical Nutrition from
Marz. Portland, OR: Omni-press;1999.
15. Tsuchiya M et al. Effect of soy isoflavones on endometriosis:
interactions with estrogen receptor 2 gene polymorphism. Epidemiology.
16. Parazzini F et al. Selected food intake and risk of endometriosis.
17. Duda MK et al. Fish oil, but not flaxseed oil, decreases inflammation
and prevents pressure overload-induced cardiac dysfunction. Cardiovasc
18. Marz R. Medical Nutrition from
Marz. Portland, OR:Omni-press;1999.
19. Hudson T. Women's Encyclopedia
of Natural Medicine. Lincolnwood,
Il: Keats Publ;1999.
20. Murray M, Pizzorno J. Encyclopedia
of Natural Medicine. 2nd
ed. Roseville, CA: Prima Publishing: 1998.
21. Bedaiwy MA et al. Effect of ovarian involvement on peritoneal
fluid cytokine concentrations in endometriosis patients. Reprod
22. Spelman K et al. Modulation of cytokine expression by traditional
medicines: a review of herbal immunomodulators. Altern
Med Rev. 2006;11(2):128-150.
23. Frackiewicz EJ. Endometriosis: An overview of the disease and
its treatment. J AM Pharm Assoc.
24. Hudson, T. Women's Encyclopedia
of Natural Medicine. Lincolnwood,
Il: Keats Publ;1999.