The Holistic Approach to Endometriosis
A recent client of mine was struggling with endometriosis, experiencing painful cramps and spotting throughout the month.
When she went to the ER for unbearable pain, she was diagnosed with a “chocolate cyst”. Doctors prescibed painkillers and instructed her to return if it ruptured (which can be life-threatening). Her gynecologist later suggested she undergo surgery (a laparoscopy) or start hormone-suppressing medication, which would put her in temporary menopause and cause numerous side effects, such as hot flashes, headaches, nausea, difficulty sleeping, anxiety, joint pain, depression, and long-term bone loss. Frustrated by her limited options, she chose neither.
When we began working together, our primary focus was to alleviate her endometriosis pain. Within three months, her symptoms improved by 40 percent. Most notably, her overall abdominal pain decreased, she no longer had spotting between periods, and she no longer experienced pain during penetrative sex, which in turn helped to improve her relationship with her partner.
“OMG, nutrition is magic!” she exclaimed during one of our sessions. I chuckled. “Seriously, it was tough to find alternatives to surgery or medication. Now, I need neither,” she beamed. “Why isn't nutrition integral to all endometriosis care?”
It's an excellent question.
Approximately 10% of women in their reproductive years have endometriosis, a condition where endometrial tissue migrates outside the uterus and attaches to various parts of the pelvis. As a result, those with endometriosis may experience pelvic pain, irregular periods, pain during sex, infertility, low back pain, fatigue, bloating, constipation, and diarrhea.
When seeking help from their doctors, patients with endometriosis may be presented with options such as over-the-counter NSAIDs like ibuprofen, birth control to suppress estrogen production, IUDs, medications like Lupron or Orlissa that cause early and temporary menopause (but have a host of symptoms, listed above), localized painkillers like lidocaine, and surgical intervention such as laparoscopic excision and ablation surgeries and even hysterectomy.
The options above vary in both effectiveness and risks. One of the “best treatments” is surgery, which, of course, comes with risks and is not 100% effective. Medications may provide temporary relief but carry longer-term risks. For example, medications like Orlissa suppress a hormone called GnRH, which in turn suppresses estrogen. However, this may ultimately exacerbate the condition when patients discontinue medication due to its impact on gut health (further explained in this article).
Endometriosis is a challenging condition to treat conventionally. Still, holistic approaches are minimally invasive, have no side effects, and will be more beneficial in the long run than medications that merely mask the problem.
As a functional medicine practitioner, I examine the underlying cause of pain and discomfort. Treating endometriosis is complicated because it's an idiopathic condition, meaning there's no known cause. People with endometriosis tend to have higher levels of circulating estrogen, which is why conventional treatments focus on suppressing estrogen production. However, recent research is focused on endometriosis as an inflammatory condition.
In holistic treatments, we address both aspects. Thus, the core holistic treatment of endometriosis includes:
Reducing inflammation, which is elevated in those with endometriosis
Promoting detoxification, which not only reduces inflammation but also reduces circulating estrogen. Conventional medications such as birth control, IUDs, Lupron, and Orlissa focus on estrogen levels, which are higher in those with endometriosis.
This article outlines a holistic approach to treating endometriosis. It includes a combination of evidence-based research and what I have personally found helpful in working with people with endo in my nutrition practice.
What is the best diet for endometriosis?
While diet and lifestyle don’t cause endometriosis, they play key roles in improving the quality of life for women with the condition. What we eat plays a critical role in the development and prevention of inflammation.
Limit Meat Intake & Optimize Dietary Fat
Fat quality is a modulating factor for endometriosis. A higher intake of saturated and trans fats is associated with elevated estrogen concentrations and endometriosis symptoms. Main sources of saturated fat include meat, especially red meat, which also increases the expression of pro-inflammatory markers.
Omega-3 fats are anti-inflammatory fats that mainly come from fish. A higher intake of these kinds of fats is associated with less inflammation and a lower likelihood of endometriosis. Sources of omega-3 fats include fatty fish like salmon, tuna, and sardines, as well as plant-based sources like flax, chia, and walnuts.
Like omega-3s, omega-6 fats are essential fats that we need for nervous system health. However, the Standard American Diet is incredibly high in omega-6 fats because they are used in many packaged foods and conventional animal feed (which is yet another reason meats can be inflammatory). Unlike omega-3s, omega-6s feed inflammatory pathways and should be limited when possible.
Key Takeaway:
Limit meat consumption, especially red meats.
Try to limit vegetable oils like canola oil or sunflower oil in packaged foods (these are sources of excessive omega-6 fats).
Focus on including fish, chia seeds, hemp seeds, walnuts, and other plant-based fats and proteins when possible.
Avoid Reactive Foods
Food sensitivities occur when food proteins slip into the bloodstream and cause a cascade of inflammation. Eliminating foods that you are sensitive to helps reduce inflammation and associated pain.
Gluten - People with endometriosis have a similar genetic makeup to those with celiac disease. One study found that eliminating gluten actually reduces endometriosis symptoms in 75% of patients.
Dairy - Dairy is not only a common food sensitivity but also contains saturated fat and estrogen that are associated with an increased risk of endometriosis pain. Casein is one of the main proteins in dairy. Depending on the source, casein can either be A1 or A2. A1 casein, which mostly comes from cows, is more inflammatory and reactive, whereas casein A2 that comes from goats, sheep, and a special breed of cows tends to be less reactive.
These tend to be the most common sensitivities, however, other highly reactive foods include eggs, corn, soy, alcohol, and high histamine foods. There are many foods that are randomly reactive, which is why I like to run food sensitivity testing for clients so we can truly individualize their program.
If you’d like to read more about food sensitivities, here’s the link to a blog post where I explain food sensitivities more in depth!
Include Plants and Other Functional Foods
Certain foods can be particularly helpful for those with endometriosis. This includes:
Seaweed - Seaweed has an estrogen-modulating activity. A high seaweed intake is associated with lower estradiol concentrations.
Dietary fiber - In general, a high fiber diet reduces circulating estrogen by binding it in the gut and eliminating it in the stool. Without enough fiber, estrogen can be reabsorbed into the bloodstream, leading to higher estrogen levels and associated symptoms.
Brazil nuts - Just two raw brazil nuts a day can help replete low selenium. Selenium is a powerful immune-modulating nutrient that reduces inflammation. It also repletes glutathione, one of the most potent antioxidants in the body.
Pumpkin seeds - Pumpkin seeds contain zinc, which supports the low levels common among women with endometriosis. Other wonderful sources of zinc include fish and meat like oysters, lamb and eggs (to name a few).
Turmeric - Turmeric is a powerful spice that can also be taken as a supplement. Curcumin, the active medicinal compound in turmeric, not only reduces inflammation but also suppresses local production of estrogen.
Cruciferous vegetables such as cauliflower, kale, kohlrabi, cabbage, and broccoli promote the detoxification of estrogen in the liver and provide fiber that helps bind and eliminate estrogen from the body.
What is the connection between endometriosis and digestive health?
There is a close connection between endometriosis, digestive health, and the microbiome.
(1) Estrogen detoxification happens in the gut.
In healthy detoxification processes, circulating estrogen goes to the liver where it binds to specific molecules (such as sulfur), which make it safe to travel to the gut for elimination. However, specific bacteria in the gut can release an enzyme that breaks this bond and causes estrogen to recirculate back into the body, increasing estrogen load on the body and worsening endo symptoms.
The presence of the enzyme beta-glucuronidase can be tested on stool tests.
(2) The makeup of the microbiome matters.
Menstrual blood of women with endometriosis has been found to be highly contaminated with E. coli (this is a different type than the E. coli that causes bloody stool). E. coli is a gram-negative bacteria that releases a compound causing LPS (short for lipopolysaccharides) which binds to immune cells and promotes the release of inflammatory markers.
Ironically, medications for endometriosis that suppress GnRH have been found to increase the production of gram-negative bacteria like E. coli, which is why these medications have the potential to create more problems long term.
The presence of E. coli overgrowth in the gut can be evaluated through stool testing.
(3) Many patients who suffer from irritable bowel syndrome (IBS) also suffer from endometriosis.
Symptoms that overlap include abdominal pain, bloating, constipation, and diarrhea. It is unclear which comes first, but it is apparent that this connection goes both ways: the presence of IBS can worsen endometriosis symptoms, and endometriosis can worsen IBS.
One of the most effective diets to relieve symptoms in IBS is called a "low FODMAP diet", which reduces the fermentation load on the gut, improving digestive symptoms. One study found that patients with both IBS and endometriosis who followed the low FODMAP diet had a significant improvement in symptoms.
If you want to learn more, here is a link to a blog post where we dive deeper into the Low FODMAP diet. Please note that the Low FODMAP diet should not be followed long-term. Fermentable foods are essential for healthy long-term gut health. This diet should be done under the supervision of a dietitian who can help you limit your symptoms while liberating the diet as much as possible.
What supplements are helpful for endometriosis?
NAC, or N-Acetyl-Cysteine, is a sulfur-containing nutrient that is a precursor to glutathione, which is the body’s most potent antioxidant and immune modulating compound. One 2014 study that tested NAC supplementation on women with endometriosis found that 24 out of 47 women in the treatment group canceled their laparoscopy due to the disappearance of cysts, reduction of pain, or pregnancy.
Fish oil contains a potent amount of omega-3 fats, which are anti-inflammatory fats. These can be taken as a supplement, which is especially helpful for those who do not eat fish or who are low in omega-3 fats.
Berberine is a natural antimicrobial that helps to neutralize LPS, which is that compound that increases inflammation. It also inhibits the release of other pro-inflammatory compounds like cytokines and repairs intestinal permeability. However, berberine supplementation should always be taken under the care of a provider because it is an antimicrobial. Taking it unnecessarily or longer than needed can have negative impacts on the microbiome.
Turmeric - As explained in the functional foods section, curcumin is the active ingredient in turmeric and helps to regress endometriosis. It promotes healthy cell death, downregulates inflammatory markers, and suppresses local production of estrogen by endometrial lesions.
Selenium - Women with endometriosis have lower tissue levels of selenium, which is a powerful anti-inflammatory compound that has immune modulating activities.
Zinc - Similar to selenium, women with endometriosis have lower levels of zinc, which can exacerbate stress and inflammation in the body. It’s unclear whether low zinc levels are a cause of endo or a consequence of endo, but supplementing can help support immune health.
Probiotics - When it comes to treating specific conditions, understanding the specific strain of probiotic is key. Not all probiotics will work for every condition. For endometriosis, one study found that supplementation with Lactobacillus gasseri OLL2809 helped to significantly reduce pain in the treatment group after 12 weeks.
Vitamin C + E - These are antioxidants that help to reduce endometriosis symptoms. These will be in multivitamins; however, they can be taken in higher amounts in individual supplements.
Vitamin D is still being researched for its widespread health effects, especially regarding immune health and inflammation. Many Americans are either vitamin D deficient or have suboptimal levels. One trial looked at women with endo and found that supplementing with 50,000 IU every other day for 12 weeks reduced pain and discomfort, reduced CRP levels (an inflammatory marker), and increased antioxidant capacity. If your doctor doesn’t routinely test vitamin D, this is something you can request. Ideally, vitamin D levels will be at least 50 ng/dL.
Are there other holistic strategies to support endometriosis?
Get moving! Physical activity is associated with lower levels of pain. If you're new to exercise, set small but achievable goals. For example, start with a step count goal and work your way up to 10,000 steps a day. If you're already doing that, consider adding intentional exercise 3-4 days a week (even if it's just for 10-30 minutes!). Consistency is key when it comes to movement.
Castor oil packs can also be helpful. Castor oil can penetrate the pelvic cavity and can stimulate the lymphatic system to break up lesions. To do a castor oil pack:
Get a piece of organic cotton or flannel cloth that is large enough to cover your lower abdomen and pelvic area.
Fold the cloth into two or three layers to make it thick enough to hold the castor oil.
Place the folded cloth on a clean surface and pour some castor oil over it. Make sure that the entire cloth is saturated with the oil, but not dripping.
Lie down on a towel or an old sheet to protect your bedding. You may also want to wear old clothes or wrap a towel around your waist to protect your clothing.
Place the castor oil cloth on your lower abdomen and pelvic area.
Cover the castor oil cloth with a flannel or cotton cloth to help insulate the heat.
Use a heating pad or hot water bottle to provide warmth to the area.
Relax for at least 30 minutes to an hour while the castor oil pack works its magic.
After the treatment, remove the cloth and wipe off any excess oil with a clean cloth.
While some sources may suggest using plastic to reduce messiness when using castor oil packs, I recommended avoiding plastic due to the potential for additional toxin exposure when plastic is heated.
The information provided in this blog post is for educational and informational purposes only and should not be interpreted as medical advice. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this blog. The author and publisher of this blog are not liable for any damages or negative consequences from any treatment, action, application, or preparation, to any person reading or following the information in this blog post.
References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737931/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9983692
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9528818
https://pubmed.ncbi.nlm.nih.gov/23334113/
https://pubmed.ncbi.nlm.nih.gov/28303579/
https://pubmed.ncbi.nlm.nih.gov/24986816/
https://pubmed.ncbi.nlm.nih.gov/21153437/