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endometriosis2

Impaired Immunity, Hormone Imbalance, and Inflammation: Endometriosis as the Standard American Diet Triple Threat

August 3, 2012
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Endometriosis is a widely encountered but poorly understood condition (as is the case with most hormonal disorders, such as PCOS.)  It affects, by some estimates, up to 20 percent of women of reproductive age,  and by more modest estimates, around 5-10 percent.  In either case this population comprises millions of women.

Moreover, no one is really sure how the endometriosis situation varies between countries–I have struggled for a while to dig up any information–but in general everyone seems to agree that endometriosis happens to everyone, but to Western, and, in particular, American, women the most.  And the most painfully.

Endometriosis is usually diagnosed in women through inspection of their infertility or their menstrual pain.  The reason this is the case is that endometriosis is the condition in which endometrial tissue grows in places outside of the endometrium.  Common locations include the ovaries, the fallopian tubes, and the abdominal cavity and bowels.    The fact that endometrial tissue may be found in important reproductive areas is in part why many women find out they have endometriosis when they have trouble conceiving children.  With tissue blocking a fallopian tube, sperm and eggs have a hard time communicating, and fetuses, growing.

Why endometriosis is painful  

Endometrial tissue can cause women pain first because they are abnormal tissue growth that can hinder normal physiological function.  And secondly, they grow over time.  Yet the most important reason endometriosis causes pain is that ectopic (misplaced) endometria act in the same way as the true endometrium does, just spread out throughout the entire body, wherever they are located.  

Endometrial tissue responds to hormonal changes in the blood in the same exact manner no matter where it is located in the body.  For this reason, ectopic (misplaced) endometria become inflamed, pulse, grow, and bleed throughout the course of a woman’s menstrual cycle.  This magnifies the pain of menstruation and distributes it wherever a woman might have endometrial tissue.  If a woman ordinarily has premenstrual cramps, but then the cramps occur also on her ovaries and in her intestines, she may be in for an increasing difficult menstrual cycle throughout her life.

How endometriosis happens

Medical professionals are not sure how these endometrial implants manage to escape the fallopian tubes and to plant themselves around the abdominals like mini-tumors.   Three seemingly less likely candidates are 1) Mullerianosis, in which the potential for cells to become endometrial is laid down in tracts during embryonic development and organogenesis.   In this theory, an endometriosis patient is made in the first 8-10 weeks of life.   2) Coelomic metaplasia, which asserts that some tissue types transform into others, perhaps triggered by inflammation, and 3) vasculogenesis, in which tissue grows de novo (or from new) via abnormal vascular growth.  Wikipedia et. al have plenty to say about these theories.

The emerging front-runner amongst these candidates, however, retrograde menstruation.  Retrograde menstruation is the phenomenon in which a woman’s monthly flow does not exit the body entirely smoothly southward via the vagina, but instead can flow “backwards” out the fallopian tubes and escape into the abdominal cavity.   From here, the tissue attaches itself to the lining of the abdominal cavity.  It then becomes a more or less permanent fixture.

But do all women with retrograde menstruation experience endometriosis?

No.  In fact, retrograde menstruation is pretty common, occurring in many women who experience no endometrial abnormalities.

So what has to be coupled with retrograde menstruation in order for endometriosis to occur?

This is where the Standard American Diet “triple threat” comes into play.  Immune system malfunction, hormone imbalance, and inflammation all appear to play significant roles.

The extent to which each factor impacts endometriosis is not clear, and certainly not all doctors are on board with this theory. Many medical professions believe that genetics are a dominant factor (they are at least important), or that one of the aforementioned developmental issues is the most important.  What is emerging from the literature, however, is the strong influence the varying factors of impaired immune system function, inflammation, and hormone imbalance have on endometrial development and pain.  The general idea is that impaired immune system function enables the tissue to implant itself, and inflammation and hormone imbalance exacerbate tissue growth, infertility, and pain.

Immune system dysfunction

Much of the endometrial research being conducted today is focusing on the possibility that in endometriosis patients, the immune system may not be able to cope with the cyclic onslaught of retrograde menstrual fluid.   It is common for menstrual flow to escape into the abdominal cavity.  But some women’s immune systems are capable of properly dismantling those tissues, while others are not.

The one overarching job of the immune system is to distinguish between “us” (inside our bodies) and “them” (intruders), and to kick the intruders’ asses.  One facet of this job that is less well known, however, is that the immune system also in a healthy body identifies tissue in the wrong location as “foreign” and attacks it.  The immune system works just as well locally as it does spread throughout the whole body.

That is, of course, unless the immune system has been down-regulated.   If the immune system has been impaired in any fashion, whether by stress, by micronutrient and vitamin deficiencies, or by an inflammatory diet, (one way in which inflammation plays a role) then it may not be strong enough to prevent the implantation of this tissue.  Especially because women in the modern world ovulate far and away more often than women have throughout history… so far as we can tell, anyway.  Since we are both pregnant and starving (presumably) less than ancient women.

In any case, the constant onslaught of reproductive tissue is just too much for some women’s impaired immune function to handle.

Might endometriosis be an autoimmune condition?  

Endometriosis may in fact be an autoimmune condition.  The jury is still far away from deciding whether or not it is a matter of impaired or of auto immunity.   One of the primary markers of autoimmunity is the presence of autoimmune antibodies.  In endometriosis, autoimmune antibodies are always present.   However, autoantibodies may also occur  in other conditions, such as cancer, massive tissue damage, and sometimes in healthy individuals.  It is not yet clear whether autoantibody formation in endometriosis is simply a natural response to chronic local tissue destruction, or a pathologic response leading to more generalized autoimmune dysfunction.

That being said, endometriosis fulfills most of the classification criteria for autoimmune disease.  These include polyclonal B cell activation, immunological abnormalities in T and B cell functions, increased apoptosis, tissue damage, and multi-organ involvement.

Yet despite these similarities, endometriosis appears to be, so far as reaserchers can tell, a condition in which the immune system is weak, and therefore endometriosis occurs, not so much that it is up-regulated and wreaking havoc destroying the body’s own tissues (as in the case in autoimmune diseases).  What then, gives?  Perhaps, in many women, autoimmune disease leads to impaired immunity, which leads to endometriosis.  This would explain the correlation that exists between autoimmunity and endometriosis, but it would allow for other factors, such as inflammation or plain old decreased immune activity, to also play causative roles.

Regardless, endometriosis is strongly associated with autoimmune diseases

Autoiummune diseases correlate fairly well with endometriosis, or at least some of them do.  And they may in fact be causative factors, as I just mentioned.   Autoimmune diseases which may be significantly associated with endometriosis include SLE, Hashimoto’s hypothyroidism, rheumatoid arthritis, Sjögren syndrome and multiple sclerosis. The best evidence exists for an association with inflammatory bowel diseases.

Inflammation

There are two ways in which inflammation impacts endometriosis.  First, in the genesis of endometriosis.  Here, inflammation may cause endometriosis by impairing the immune response.   Secondly, however, inflammation is what (coupled with hormones, discussed below) has the capacity to make endometriosis painful.  Just as in some women have painful periods and others do not, so the same phenomenon translates to the endometrial tissue that is located elsewhere in the abdomen.  If a woman has an up-regulated inflammatory response to her menstrual cycle, then her endometriosis will be painful.  If she does not, then her endometriosis can go unnoticed for years–even for her whole life.  It just doesn’t hurt her.  Inflammation partly explains why there is no statistical correlation between the extent of a woman’s ectopic endometrium and her pain level.   Some women have wicked ectopic endometria, but no pain because their inflammation levels are low.

So what is it about inflammation that is painful?  It is the prostagladins and other inflammatory markers that are produced in endometrial tissue at the time of menstruation.  These inflammatory molecules act locally.  This means that they create painful signals both in the endometrial tissue as well as in the surrounding tissues.  Hence why a phenomenon in such a specific place– ie, the endometrium– can hurt an entire abdomen.

When a woman has endometriosis, this inflammatory signalling and induction might be happening in various locations throughout her entire lower abdomen.

Hormones

Hormones play an intricately linked role in the genesis of and pain generation within endometriosis.  Estrogen plays many roles throughout a woman’s body and in her cycle, yet one of the most important ones is to stimulate the thickening of the endometrium.  This is an important, normal process that happens in all women.  If estrogen levels are high, however, the endometrium grows very thick, and much larger than normal.  This provides  a) more tissue out of which ectopic endometria can be made, and 2) more tissue from which prostaglandins and other inflammatory markers can be released.   The more endometrial tissue a woman has, the more places pain can come from.  This is in fact the direct cause of most of the “normal” pain women experience with menstrual cramps…and therefore with endometriosis, too.

Estrogen dominance is caused by being overweight, possibly by consuming too many xeno- and phytoestrogens (though that is a complicated issue), and by systemic inflammation.  It can also be caused by having clinically low progesterone levels, since progesterone acts as a bit of a counterbalance to estrogen in the body.   Estrogen and progesterone need to be properly balanced in order for reproduction to proceed smoothly and painlessly.

See Danny Roddy’s view on estrogen as an inflammatory molecule (in excess.)

Endometriosis is usually treated with…

Surgery, birth control pills that raise progesterone levels, birth control pills that lower estrogen levels, or specific estrogen antagonistic medications.  Each of these fixes has its own problems, least of which is the fact that dosing with these kinds of hormones can lead to greater hormonal dysfunction further down the road.  Moreover, it does not get at the underlying cause, which is in many cases very serious.

Endometriosis might not go away entirely, but it can subside, and the pain can be minimized. 

Usually women who have painful endometriosis experience a soothing of their symptoms once they undergo menopause.  This is because their estrogen levels drop, and naturally.

There are other ways to naturally decrease estrogen levels.  Losing weight and decreasing stress are the two biggest factors.  Removing phytoestrogens, which include soy, flax, and all nuts and seeds, as well as xenoestrogens, such as BPA found in plastics, have also been implicated in throwing estrogen levels out of balance.

Yet there are even better ways to work with endometriosis.  And all of them, holistically, are enabled with a paleo diet.

Endometriosis probably– at least according to the majority of medical research and speculation– would not affect women’s health if they did not have compromised immune systems.  In endometriosis, it is unclear whether the women suffer autoimmunity, or if they just have the problem because their immune systems are functioning at a sub-optimal level.  In either case, a paleo diet mitigates the problem.

If endometriosis is autoimmune (a theory I am not sold on), an anti-inflammatory, gut-friendly diet should ameliorate its genesis and symptoms.  This means eliminating potential gut irritants such as wheat, dairy, legumes, and possibly nightshades and eggs from the diet.  Eliminating omega 6 vegetable fats should also be helpful.  A GAPS diet is appropriate in extreme cases.

If endometriosis is from impaired immunity (a theory I am more comfortable with), correcting gut imflammation in this case also goes a long way.  Having a vitamin-rich diet including many meats, organ meats, vegetables, and fruits, low in sugar and processed carbs, with plenty of stress reduction and sleep, with moderate exercise, and with vitamin D from sun exposure, should help boost immune function over time.   It is important to know that I am not promising a cure-all.  These problems can be complex hurdles to get over, and may take several months if not years of troubleshooting and patience and healing in order to get right.

So endometriosis will not necessarily go away.  Tissues might shrink, but they may be too far implanted to ever disappear.   But endometriosis can be mitigated, and with a diet and lifestyle focusing on nourishment, and whole, natural foods and activities.  The importance of stress cannot be under-emphasized, either.   Stress plays a large role in inflammation and in immune system functioning.  So moving forward with holistic healing–with stress-reduction, with love, with healthful foods and with a nourishing lifestyle–goes a very long way in propelling us forward into healthful, natural, kickass womanhood.

 

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Managing director of Paleo for Women and author of Sexy by Nature.

28 Comments

  1. ” Removing phytoestrogens, which include soy, flax, and all nuts and seeds, as well as xenoestrogens, such as BPA found in plastics, have also been implicated in throwing estrogen levels out of balance.”

    One thing that is confusing to me is that in studies, vegan and vegetarian women often have lower estrogen levels. There is a theory that this has to do with higher fiber in the diet.

    • It probably has to do with estrogen recycling in the liver:
      http://www.chiro.org/nutrition/FULL/Estrogens_Two-Way_Street.shtml

      Brassica vegetables are especially good for this.

    • Yes! Higher fiber is associated with increased estrogen clearance. Do you know why this is? I can’t seem to unearth more other than vegetables being good for the activation of some liver enzymes.

      • Because adequate fiber intake enables good bowel motility, it is thought that good digestion and subsequent elimination aids the timely clearance of toxins/byproducts/estrogens so they don’t have a chance to build up in the body over time. On the other hand, constipation (chronic or otherwise, and a condition many women face) frequently caused by poor dietary choices allows a buildup of toxic material, estrogens, etc in the bowel that can be reabsorbed into the body causing a slew of health problems. So women with high(er) fiber diets/diets enabling good digestion for their particular needs have less excess estrogen circulating in the body, and women with poor digestion/bowel motility tend to have higher levels of circulating estrogen.

      • Another factor is: Estrogen is also affected by LDL levels. LDL is cleared out of the body by fiber in the digestive tract.

    • one thing about phytoestrogens is that there are more than one kind of estrogen. phytoestrogens *tend* to be beta estrogens, whereas xenoestrogens *tend* to be alpha estrogens. alpha estrogens are associated with estrogen-dominant cancers, cysts/fibroids, and with inflammatory problems. beta estrogens “turn off” the alpha estrogens. of course, we need both kinds, and the body produces both on its own, but too much of the alphas cause problems.

      that’s not exactly here or there with regard to your comment, but it’s worth considering.
      what is more relevant to your comment, though, is that vegans and vegetarians often don’t have a cycle at all: as a clinical herbalist, a big chunk of work that i do is with women who have been veg*n for a while and now they don’t have a cycle, but they feel uncomfortable with that, either because they want to have children or just because they think it’s not ok to not bleed.
      but, no bleeding, less endometriosis pain, less retrograde menstruation, etc.

      i don’t think it’s because the veg*ns are healthier, i think it’s actually that they’re less healthy, just that in this case the malfunction (no cycle) leads to also not getting a cycle-related ailment.

    • Treatment with Bovine Colostrum 2 to 3 Gram per day gives execellent results in Endometriosis. Main reason of Endotriosis is low immune status. Colostrum contains Proline rich plypeptides ( PRP )which regulate the activity of immune system. Use of bovine Colostrum is also effective in trteating Hypo-immune as well as hyper-immune conditions. Bovine colostrum is 20 times more rich in IgG content as well as in PRP content. 3 months administration of Colostrum 2-3 gm per day gives positive results in the Treatment of Endometriosis

      • Sanjay: thanks for ur comment about the colustrom. Are their testimonies of women thay have been helped by this or can u point me to a website??

  2. Hi Stefani. Thanks so much for writing this, it’s cleared up a lot of questions for me. I just had an additional one – I recently started using progesterone cream (a good natural one, no parabens etc) for my symptoms. It hasn’t helped so far (been on it a few months), in fact this cycle seems like one of my worst ever :(
    Do you think there’s any merit in the cream or is it setting me up for more hormonal dysfunction in the long term?
    Thanks!

  3. Could be the DIM in vegetables that promotes conversion of Estradiol to the less potent Estriol. http://www.dimfaq.com/site/healthyem.htm

    There seems to be a genetic component explained here http://www.drfrances.co.nz/images/pdfs/What-is-Endometriosis.pdf

  4. I really found this article interesting. As a woman who may have endometriosis (I am experiencing many of the same symptoms that my mother did, and she had an emergency historectomy due to endometriosis), I find it reassuring to know that following a paleo diet may be helping me with this. On another note, I believe that I may actually be proof of this as I had started to have pain that my doctor thought may have been endometriosis, but when I started the paleo diet, many of the symptoms went away!

  5. Magnesium oil is a possible remedy because deficiency causes all manner of hormonal imbalances and connective tissue disorders. I think that the sea-side treatment of old was curative in many cases because of the repletion of Mg from sea water, that relieved the symptoms of mislabeled disease that was really just symptoms of Mg deficiency.

    Paleo eating would go a long way to increase Mg in the diet, but we are evolved to get it through our skin primarily, and primarily through contact with ocean water, where it is most plentiful.

    Anyone with any disease or disorder who assures adequate Mg absorption first, will then begin to get a better I idea of what is really going wrong, because when the body isn’t getting enough nutrients of any essentials, really (ingested *and* absorbed), then there is no reason to presume that one should be healthy. Mg is an easy one to go to, because unless you are in the ocean nearly daily, or absorb Mg oil through the skin, you absolutely are deficient. Same with vitamin D3, unless you live close to or at the equator.

    These are diseases of civilization and *displacement* from our evolutionary natural habitat. Not to say anything of the lifestyles we lead that necessitate so much more Mg than our ancestors…

    :)

  6. what a great article!
    i run an herb school and clinic in Boston, and we deal a lot with endo. we have found that paleo is the single biggest factor in complete remission of all symptoms, even in very extreme cases. we have multiple case studies that we use for teaching (in fact, these women have also become students at our school!) in which the women had had laparoscopies, were addicted to vicodin, were vomiting two and three times a day from pain, were completely unable to have sex without vomiting from the intensity of the pain, etc – and it was diet that had far more impact than any herbs, in each case.
    even though we expect that some of the ectopic endometrial tissue is still there in each case, these women are now living symptom free – which says to me that we can at least reduce the inflammation, the cyst-formation, and possibly even the quantity of the ectopic tissue.
    we have not yet had a case that has not improved drastically. maybe at some point we’ll find one, but in our experience, what you’ve said here is right on the money.

  7. Can you give me more info on the paleo diet?

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  10. Thank you for writing this article. I have been on the GAPS diet now for 2 months, and the changes I have experienced are amazing. My skin has cleared up, I no longer have painful menstruation and the PMS blues and anxiety are greatly diminished. In fact, I’m always more happy, patient, and no longer feel anxiety at all times. I feel more connected to other people. I want to say that I think a large part of the change is from the proper functioning of the gut, not only improved hormone levels. It’s the whole package. I absorb nutrients better now, and my quality of life is better. No more joint pain, which had been plaguing me, a “healthy,” organic, “crunchy” and knowledgeable woman for years! I even had been getting acid reflux recently before I made this switch. Now my digestion is problem-free. What makes GAPS the ideal healing diet for many is the focus of replenishment of good bacteria along with eating easy to digest, whole, simple foods. I never thought I could live without rice, pasta, potatoes, sweets, starchy beans, non-dairy products laden unfortunately with thickeners (carrageenan). People don’t realize carrageenan it is pro-inflammatory! Before, I tried veganism for 12 years, gluten free, dairy free for the past 17 years (have to be dairy-free due to an allergy that GAPS may be able to cure), probiotic supplementation on its own, raw food, pretty much anything to feel good, and none worked. Who would have thought a diet so far from the norm would be the solution. All needed to make the switch is changing the grocery list and learning a few new recipes to get started.

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  12. Endometriosis is typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 6–10% of women.Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility*;.,

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  13. Ahh Stefani. No surprise that your article would answer some vexing questions for me about this mysterious disease process. I have a high familial risk for ovarian cancer & will soon find out if I carry the so called ‘cancer gene’. I work as a professional ultrasound model & it was through my job I recently discovered I have endometriosis & a very large endometrioma in one ovary. I have learned that removal of one’s ovaries is NOT an easy fix as this can lead to heart disease & other cancers. So an antinflammatory diet has been recommended to me & surprise: I’ve been paleo for 2 yrs already! My prob is food addictions & falling off the wagon constantly. Now the pressure to “achieve” is really intense. I just dont know how to keep away from the everpresent junk.
    Its frustrating when you know & understand EXACTLY what to do & have great motivation ( what mum wants to die from ovarian cancer?) but still cant manage to do it. Thank you so much for caring about us women folk as you do. Your non judgemental understanding for the challenges we face is very comforting: a little torch shining in a very dark place. I will keep trying & failing as I do: giving up on this diet is no longer an option.

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  15. I’m 43, had 3 healthy sons from normal pregnancies (oldest is 18, youngest 11) and just had surgery yesterday. I never had problems until I stopped taking hormonal contraception (nuvaring) 2,5 years ago. Then I had very irregular periods and lots of pain the first 2 days of menstruation. But I thought my body just had to regulate after years of hormonal contraception. I turned paleo 6 months later (2 year paleoversary this month) and it still took more than a year before the pain got less. The last year or so the painw as bearable, so I thought I was ok. 2 weeks ago I started having pain in my right kidney. Doctor first thought it was a bladde infection, but antibiotics didn’t work. She eventually sent me in to take an ultrasound, which revealed nothing was wrong with my kidneys but there was ‘something’ around my uterus. She got me an appointment with the gynecologist that same evening (last Thursday) and he found a cyst the size of a goose egg on my right ovary, pressing against my kidney. So I had surgery yesterday late afternoon. Saw the gynecologist today and he said I have severe endometriosis, my uterus and bowels were sticking together…I’ll have to get back on hormonal contraceptio for 1 year, he says :( . As 2 years of paleo didn’t cure it, do you think AIP or GAPS will do better and I can avoid taking hormonal pills?

    • It depends entirely on what the underlying problem is. Sometimes paleo naturally addresses them and sometimes it needs more help. Some people think endometriosis is an autoimmune condition (though others do not), so it might not hurt to try a gut healing protocol a la Sarah Ballantyne’s “The Paleo Approach.” Perhaps you are over stressed so you became sick and inflamed that way. Perhaps you are nutrient deficient in some regard that effects the immune system like vitamin D or zinc. I cannot say anything at all for certain. Your doctor knows much better than I, and one year on the pill should not do you any harm. If you go on it, it may in fact be helpful while you do your best to de-stress and correct nutrient deficiencies and heal your gut. Then you can come off of it and hopefully be in a much better place to handle the endometriosis

      • Stress is indeed a big problem, and reducing it won’t be easy (I’m back in school to become a kindergarten teacher), but indeed I think I’ll combine the hormonal therapy with AIP and supplements and hope for the best :) . Thanks for your answer!

    • Can I recommend this Institute: http://www.naprotechnology.com/
      They have been leading researchers of fertility care for 30 years, detecting and correcting abnormalities, and restoring normal function – they do not lean of the crutch of proscribing birth control pills for irregularities – they go after the root problems, with medical, diet,wholistic approach.

      • I’m so glad someone recommended the Pope Paul VI Institute in Omaha.
        The advice provided in this article is certainly good regarding diet, as I firmly believe diet and stress can have a lot of effects on our health, but in many cases of severe endometriosis it won’t cure the problem.
        I had a very good experience with the Pope Paul VI Institute in Omaha, and would highly recommend any women suffering from pain and infertility to visit there. It was the first time I visited a doctor who I felt truly cared about my physical health and well-being and wanted to not mask symptoms but address and eliminate the underlying cause.

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