Endometriosis is a disease affecting women in their reproductive years. The name comes from the word “endometrium,” which is the tissue that lines the inside of the uterus and builds up and sheds each month in the menstrual cycle. In endometriosis, tissue like the endometrium is found outside the uterus, in other areas of the body. In these locations outside the uterus, the endometrial tissue develops into what are called “nodules,” “tumors,” “lesions,” “implants,” or “growths.” These growths can cause pain, infertility, and other problems. Overall, between 3-10% of women aged between 15- 45 years have endometriosis in women who have difficulties conceiving, this rises to about 25-35%.
The most common place to find endometriosis is on an ovary, the back of the uterus and the ligamentous supports that hold the uterus in its normal position (uterosacral ligaments). It can also be found on the thin lining of the pelvic organs (the peritoneum), on the fallopian tubes, between the vagina and rectum (rectovaginal septum), in or on the bladder, in abdominal scars from previous surgery and even as far away from the pelvis as the lungs. Each time that the woman has a normal menses, so the endometriosis does also, leading to cyclical swelling, stretching of tissues, inflammation and scarring. Eventually the scarring and inflammation can lead to symptoms even when no menses is present.
Increased menstrual pain Abdominal bloating
Pelvic pain outside menses Infertility
Painful sexual intercourse Painful bowel movements Blood in urine during menses Painful and frequent urination
There are several possible causes of endometriosis; one possible cause is called retrograde menstruation. Normally during a menses, the menstrual blood comes out of the cervix and into the vagina. In around 75% of women, a small amount of blood flows backwards down the fallopian tubes and into the pelvic cavity. This blood contains tiny seedlings of the lining of the womb – endometrium.
It is not known why in some women this might implant and lead to endometriosis, but not in others – it may have something to do with a woman’s immune response and ability to fight off & remove these seedlings.
The metaplasia theory suggests that because the uterus, tubes, peritoneum and part of the ovary are all developed from the same area in the fetus, endometriosis might be caused by genetic factors and some cells taking the wrong turn during development.
The vascular theory rests on the fact that endometrial tissue from the lining of the womb can be found in the blood stream. It might be that these small deposits end up in other areas far from the womb and grow from there. This would explain the rare finding of endometriosis in sites such as the lung.
Most likely there is no one simple answer to explain it, and the true cause is a composite of all these. None have been proven to any degree of acceptable scientific research to date and much more research will be required to uncover the actual cause of this awful disease.
There are several options for treating endometriosis:
- Management of symptoms
- Pharmaceutical drug management
- Treatment with a range of complementary medicine
The symptoms of endometriosis can be managed to some extend with Non Steroid Anti Inflammatory Drugs. (NSAID’s). The degree of response depends on the individual woman’s reaction to NSAID’s and the degree of endometriosis present. Treatment of endometriosis with drugs can result in great improvement of symptoms such as painful menses, pain on intercourse and pelvic pain. Drug treatment does not improve the chances for pregnancy. Drug treatment suppresses endometriosis, rather than removing it and is effective only for short term management of symptoms, the active endometriosis returning gradually over 12-24 months after stopping the drugs involved. The aim of drug treatment is to break the cycle of stimulation and bleeding. By stopping the ovary’s usual hormonal cycle and reducing oestrogen levels, the endometriosis deposits shrink and become inactive. Endometriosis is still there, and will gradually become reactivated when the normal menstrual cycle starts again. Ovarian endometriomas of greater than 3cm diameter are unlikely to respond to medical treatment.
Conventional Drug Treatment
There are four types of drugs used in orthodox medical treatment, they are:
- The oral contraceptive pill, Progestogens
- GnRH antagonists Goserelin (Zoladex), Nafarelin (Synarel), Buserelin (Suprecur)
- Leuprorelin (Prostap)
The contraceptive pill is one of the most commonly used treatments for endometriosis, and is usually used on a continuous (back-to-back) basis with no withdrawal bleed in between each packet. If used continuously, it should be for 6-12 months’ maximum. Progestogens are the most commonly used orthodox medical treatment and are effective in about 80% of cases. Examples include the drugs medroxyprogesterone acetate (Provera), dydrogesterone and norethisterone. They work by thinning out and shrinking down the endometriosis and by suppressing the normal cycle of the ovary. They can be used either continuously or in a cyclical way (eg. taken for 3 weeks, with one week off).
Side effects of progestogens can include: irregular bleeding or breakthrough spotting – which affects around one third of users, weight gain, breast tenderness, water retention and rarely depression. It has long been known that progestogens can alter the blood lipids (fats) in an unfavourable way, which has been shown to lead to an increased risk of blood clots (thrombosis)..
GnRH stands for Gonadotrophin Releasing Hormone and an agonist is a drug that acts the same way as the bodies own hormone. The body normally makes GnRH in a small gland in the brain (the pituitary) and it is this hormone that stimulates the ovary to develop eggs and produce oestrogen, leading to the normal menstrual cycle. If you give GnRH agonists, this floods the system and confuses the delicately controlled balance, leading to a complete block of egg development, oestrogen production and menstrual cycle.
It effectively makes the patient ‘menopausal’ for the time that they use the treatment and without the oestrogen stimulation, endometriosis shrinks down and becomes inactive. GnRH agonists work by lowering oestrogen levels and the main side effects of the treatment are due to this: hot flushes, reduced sex drive, vaginal dryness, emotional symptoms, depression and headaches. It really is like going through the menopause for a short time.
The other main problem is that bone thinning is a side effect, with around 5-6% reduction in bone density in the spine. This is usually reversed by 9 months after stopping treatment, but is not always the case
Danazol is a drug that was once used, as first-line medical treatment for endometriosis and it is effective in 80-90% of cases. Fortunately, there is now good evidence demonstrating other drugs as equally effective, as Danazol can have some quite unpleasant side effects. It works by preventing ovulation and reducing oestrogen levels as well as having a directly suppressive effect on the endometriosis itself. It has some properties that are similar to the male hormone testosterone and possible side effects include: weight gain, water retention, tiredness, decreased breast size, hot flushes, acne, oily skin, growth of facial hair and emotional symptoms. It is also important to use an effective contraceptive, as accidental use in early pregnancy can masculinise a female fetus.
Surgery can either be conservative or radical. The aim of conservative surgery is to return the appearance of the pelvis to as normal as possible. This means destroying any endometriotic deposits, removing ovarian cysts, dividing adhesions and removing as little healthy tissue as possible. Radical surgery means doing a hysterectomy with removal of both ovaries and is usually reserved for women with very severe symptoms, who have not responded to medical treatment or conservative operations. Sometimes, if there are other reasons to carry out a hysterectomy it is done earlier than this.
Oriental medicine and endometriosis
Oriental medicine classifies endometriosis as a liver disorder. Studies have shown that chronic exposure to dioxins (TCDD) is directly correlated with an increased incidence in endometriosis in rhesus monkeys. Unfortunately, we all live in an environment contaminated with dioxins (90% of it in fish, meat and dairy products according to a report from the World Health Organization). Why do some women get endometriosis but not others? Apart from genetic factors, the difference may lie in the state of their liver health. The liver is a major target organ for TCDD (2,3,7,8 Tetrachlorodibenzo-p- dioxin) and is severely affected by the chemical”; “TCDD will cause extensive necrosis (tissue decay or death) of the liver in rabbits”; “one of the main toxic effects of TCDD in the rat and rabbit is damage to the liver”. Studies and observations also showed that up to 50% of the nearly 1000 persons who may have had exposure to dioxins since 1949 in industrial accidents have enlarged liver and impairment of liver function.
Substantial evidence exists that endometriosis is dependent on estrogen for continued growth and proliferation. Estrogen therapy has been shown to worsen gynecological conditions such as fibroids and endometriosis and to have a pronounced effect upon the endometrium and induce endometrial mitoses (hyperplasia).
Research also suggested that regular exercise may help to protect against endometriosis by decreasing the rate of estrogen production. Orthodox medical therapies for endometriosis try to lower estrogen levels either by suppressing estrogen production or suppressing the serum estrogen level by derivatives of testosterone. The liver regulates estrogen by inactivating it through oxidation and conjugation with sulfate or glucuronide.
The conjugated estrogens are excreted mostly in the bile with a small amount excreted in the urine. The fact that hyper-estrogenism accompanies certain types of liver disorders confirms the important role of the liver in estrogen inactivation. “The hyper-estrogenism occurs because of failure of hepatic (liver) removal of estrogen from the circulation”.
As a matter of fact, the symptoms often associated with endometriosis such as chronic fatigue, allergy, emaciation and poor complexion are not caused directly by endometriosis but are signs of liver disorders and are well treated using Chinese medicine.
According to Chinese medicine, the liver is the most emotion sensitive organ. It serves important regulatory functions which affect emotional and mental activity.
When the liver is affected by stress, it becomes tense and its vitality is repressed, the bowels may become constipated or sleep is disturbed, accompanied by nightmares or insomnia.
Could it be that the western linkage of endometriosis with “career women” simply means “stressed woman”. As we all know, “stress” is damaging to every part of our body especially to the liver. Long periods of stress result in liver congestion which lead to restricted bile and blood flow. The weakened liver becomes unable to remove sufficient estrogens, resulting in their accumulation.
Other than stress, liver weakness can also be caused by taking too much medication as most of them are damaging to the liver or kidneys, or intakes of toxins such as dioxins from various sources. It may also be caused by eating too many liver weakening foods such as refined flour, refined sugar, deep fried foods, caffeine or ice cold foods or drinks which chill the liver and kidneys especially if the liver is already genetically weak.
Many endometriosis sufferers take painkillers regularly to control their pain. Since painkillers are damaging to the liver and kidneys, they make their problems worse in the long run and too many painkillers may make the liver disorder irreversible.
Source Credit: Dr. Trevor A. Wing, The Women’s Natural Health Clinic