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Endometriosis and Fertility

What happens to the endometrium in normal women?

The lining of the uterus (endometrium) has the most remarkable growth potential of any tissue in the body.  Various substances, some which are made within the endometrium itself, and some of which are derived from the circulating blood, promote this growth.  The most potent stimulant of endometrial growth is the female hormone called oestrogen. In women, oestrogen is normally produced in the ovary by the egg follicles, and it then circulates in the blood. The endometrial

cells lining the uterus actively and preferentially absorb the oestrogen, which then stimulates the cells to grow and proliferate. As part of the normal function of the endometrium, there is no inflammatory reaction.  The endometrium is normally shed during a woman’s period, after the ovarian follicle has died and the oestrogen level has fallen. In nearly all women, some of the endometrium refluxes up the fallopian tubes. It spills out of the tubes, over the ovaries, and into the

pelvis, which is lined with a thin layer of tissue called the peritoneum. The peritoneum normally absorbs this refluxed tissue with no inflammatory response, as with any other part of the body’s natural response mechanism.  Consequently, the peritoneal lining stays smooth so that the tubes and intestines can function normally.

What happens to the endometrium in women who have endometriosis?

May have a relatively higher level and longer duration of exposure to oestrogen than other women, or may have higher oestrogen receptor sensitivity. These relatively high levels of oestrogens might also be capable of stimulating a thicker endometrium and more substantial pelvic contamination because of increased menstrual volume and higher incidence of retrograde bleeding.

• The endometrium is more vascular;
• More of the endometrial tissue that is shed stays alive, or vital;
• More of the sloughed tissue refluxes up the fallopian tubes, bathing the peritoneum and pelvic organs in more endometrial reflux that is also more vital.

Whether the refluxed endometrium itself grows, or whether it stimulates the tissues in the pelvis to grow endometrium, is uncertain. In any event, there is growth of endometrium in these tissues outside the uterus.  Women who have endometriosis also have an abnormal autoimmune response, because the body’s immune response to the initial spill and growth of the refluxed endometrium is not simply by absorption, but by an inflammatory reaction. Women who have endometriosis may also have other hyperimmune problems – such as asthma, arthritis or colitis – more commonly than other women.

For more information on Endometriosis, see www.endometriosis.org.nz

Endometriosis and fertility

Endometriosis is a significant cause of infertility, because the woman partner is diagnosed with mild endometriosis in 10% of couples that have difficulty conceiving.

Why do women who have endometriosis have more difficulty conceiving?

Women who have endometriosis have more difficulty conceiving for a number of reasons, including:

• The endometrium may be less responsive for implantation. Inflammation within the uterus, induced by the more vascular endometrium, may cause slight bleeding or “spotting” that becomes evident several days before the period is due. The blood within the endometrial cavity oxidises (rusts!), releasing chemicals that inhibit the development of the hatching embryo at the very time that the endometrium needs to have optimum function for implantation.
• Sexual intercourse may occur less frequently because of pain from inflamed growths on pelvic ligaments.
• Fallopian tubes or ovaries may be scarred as a result of inflammation. This can interfere with the ability of the follicle to release the ripe egg into the end of the tube.
• Inflamed pelvic tissues may digest sperm. This may result in insufficient numbers of sperm to digest the cloud of cells around the ripe egg and for one sperm to fertilise the egg.
• It may be physically impossible for the tube to pick up the egg because of a large cyst within the ovary. These cysts can develop from ectopic endometrium on the surface of the ovary, which can engulf deeper ovarian tissue, forming a small cyst lined with endometrium. This endometrium can then bleed regularly into itself, developing into a large endometriotic cyst.
• Ovarian follicles may not develop, rupture and release the eggs well because inflammation in and around the ovaries may interfere with this important function.

Symptoms

In a woman presenting with infertility, endometriosis may be suspected if the woman experiences pain or severe discomfort around the time of her period, ovulation, or during sexual intercourse. She may also experience irritable bowel symptoms if the endometriosis involves the bowel.  In less common cases, endometriosis is completely silent and the woman experiences no symptoms.

Although endometriosis may also be suspected because of tenderness on examination, an ovarian cyst, or abnormal fluid collections seen during an ultrasound scan, endometriosis can only be diagnosed by the presence of characteristic flared, haemorrhagic or scarred lesions (like a burn) during a laparoscopy. This procedure needs to be done under general anaesthetic.

 

Endometriosis – normal vs not

Normal	Not normal – seek help*
If you don’t exhibit the symptoms listed over, but have Endometriosis and have been trying to conceive for longer than 9 months (if under 30) and 6 months (if over 30), seek help	You have taken time off school or work due to period pain
	Sex is avoided due to pain experienced
	Intermittent pain or spotting/bleeding throughout cycle
	Intermittent pain or spotting/bleeding at ovulation
	Heavy menstruation – if you have to change tampon/pad more than every three hours

*these symptoms may not be caused by endometriosis

Medical Treatment

For rational treatment of endometriosis, the major triggers to the development of endometriosis need to be addressed. These are:
• A genetic effect of growing more vital hypervascular endometrium; and
• An inherent ability to develop an inflammatory over-reaction to the abnormal endometrial stimulus.

This means that the treatment of endometriosis needs to:
• Restrict the ability of the endometrium to grow; and
• Ensure the immune system is not stressed.

Unfortunately, our understanding of the immune system and the inflammatory over-reaction is more primitive even than our understanding of endometrial growth. This makes it very difficult to treat in a rational way the cause of endometriosis in women who have infertility or pain.

As endometriosis is usually diagnosed at laparoscopy, it is often convenient to destroy or remove the inflamed tissue growths or scars at the time, especially if it provides relief from pain; surgical treatment may also assist fertility. However, other ‘seeds’ of ectopic endometrium may grow subsequently, so any benefits of surgery may be short-lived.  Fortunately, some women’s bodies heal themselves of endometriosis, although the reason why this occurs only in some women is as uncertain as the initial development of the disease.  Medical treatments such as progestogens, which block follicle development and thereby inhibit growth of the endometrium (including ectopic endometrium), are reasonably effective in controlling pain and reducing cyst formation.

However, medical treatments also block the body’s ability to conceive, so women who wish to conceive only use them to settle inflammation prior to specific fertility treatments.

What fertility treatments can assist women who have endometriosis?

• Lipiodol (poppy seed oil) endometrial bathing / tubal flushing
• Intra-uterine insemination with mild hyperstimulation using fertility drugs
• In-vitro fertilisation.

Laparoscopic surgical removal of endometriosis has been shown to improve fertility, as well as helping to resolve pain symptoms.

Alternative treatments – such as herbs – may have an effect, although this is not scientifically proven.

Is medicine likely to find better treatments for endometriosis?

The immune system has the ability to heal itself, so the inflammation associated with endometriosis can be overcome. But there is no treatment yet that will heal over-active immune systems. Nor is there any genetic treatment that will make the endometrium behave more normally. Hopefully medicine will soon be able to identify the exact problems within the genetic and immune systems that occur in women who have endometriosis. Then there will be better treatments of endometriosis that remedy the major problems and inhibit the growth of ectopic endometrium and the consequent inflammation that can be so damaging.

Contributed by Dr Neil Johnson

Self help

Age is a factor for women with endometriosis, as is time that you have been trying to conceive.  If you have endometriosis, you should seek help earlier than someone without.  If circumstances allow, start trying for a family by age 30.

The following summarises the naturopathic approach to endometriosis.

Estrogen and progesterone work in synchronisation with each other to achieve hormonal harmony. In women with endometriosis there is a relative dominance of estrogen that contributes to the growth and inflammation of the endometrial implants.

Certain lifestyle choices and conditions can contribute to this estrogen dominance syndrome, especially a low- fibre diet, overloading the liver with internal toxins and absorbing toxins from the environment (referred to as xenoestrogens or endocrine disruptors).

High Fibre Diet

A low-fiber diet causes estrogen levels to be higher, while a diet high in fiber results in decreased estrogen levels in the bloodstream. Why? Excess estrogen is excreted in the bowel. When stool remains in the bowel for a longer time, as in constipation, the estrogen is reabsorbed. Studies have shown that women on a high fiber diet have lower levels of circulating estrogen.

Overloading the Liver

The liver detoxifies our body, protecting us from the harmful effects of chemicals, elements in food, environmental toxins, and even natural products of our metabolism, including excess estrogen. Anything that impairs liver function or ties up the detoxifying function will result in excess estrogen levels, whether it has a physical basis, as in liver disease, or an external cause, as with exposure to environmental toxins, drugs, or dietary substances. Estrogen is produced not only internally but also produced in reaction to chemicals and other substances in our food. When it is not broken down adequately, higher levels of estrogen build up.

The estrogen dominance syndrome can be evoked in women by too much alcohol, drugs, or environmental toxins, all of which limit the liver's capacity to cleanse the blood of estrogen. It has been found that circulating estrogen levels increase significantly in women who drink. In one study, blood and urine estrogen levels increased up to thirty-two percent in women who drank just two drinks a day.

Environment

We live in an estrogenic or feminising environment. "Xenoestrogens", such as PCBs, phthalates, pesticides and DDT, cause estrogenic effects. Chlorine and hormone residues in meats and dairy products can also have estrogenic effects.

Resetting the Balance

1. Optimise your weight

2. Limiting environmental exposure to xenoestrogens along with implementing a proper diet, exercise and supplements can help reverse the syndrome of estrogen dominance

3. Exercise regularly

4. Eat plenty of fibre

Healthy Hormone Foods  (choose at least one from each group daily)

Herbs and Spices  - ginger, rosemary, turmeric, dill fennel, parsley

Nuts and Seeds  - pumpkin seeds, sesame seeds, sunflower seeds, almonds, cashews, brazil nuts

Grains and Legumes  - chickpeas, quinoa, millet, bulgur, buckwheat, brown rice

Fruits – blueberries, strawberries, oranges, grapes, avocados, bananas, figs, blackberries

Meat, poultry, fish, dairy – yoghurt and deep sea fish

Vegetables  - broccoli, cauliflower, brussel sprouts, kale, spinach, cabbage, celery, onion, alfalfa sprouts

Beverages  - water, green tea, dandelion tea, chamomile tea

Lifestyle   - regular aerobic and weight bearing exercise, time out, relaxation techniques. Limit alcohol to <1 drink daily

Xeno-estrogens

It is beneficial to reduce the exposure to the chemicals in our environment that mimic estrogen. Below is a list of the more common forms.

BPA (Bisphenol A) – used to harden polycarbonate plastics, found in plastic containers, canned food,       white fillings

Phthalates – plasticizers, used in the production of plastics. Found in cosmetics, perfumes, aerosols, paints, air freshners, shampoos, skin moisturizers, nail polishes, shower curtains, plastic toys, ‘fragrances’

PCBs (Polychlorinated biphenyls) - fat soluble, accumulate in our body fat and in animal fats we consume. Found in fluorescent lighting, electrical equipment, hydraulic fluids

Parabens – chemical additives widely used in cosmetics, pharmaceuticals and food production as preservatives, antibacterial and antifungal agents

Volatile Solvents – inhaled as fumes or vapours. Found in gas, exhaust, paints, polyurethanes, dry cleaning chemicals

PFAs (perfluorinated compounds) – these are persistent organic pollutants that make products stain, grease and water repellent. Found in paper food containers, fast food wrappers, Teflon, Scotchguard

PBDEs (polybrominated diphenyl ethers) – flame retardants found in home and building materials, insulation, cars, furnishing, bedding, textiles e.g pyjamas

Pesticides and Insecticides – used in the home, garden and sprayed on our fruit and vegetables

Alternative Therapies

Naturopathy, medical herbalism, nutrition and acupuncture are all modalities that can help support and guide women who have endometriosis.

Self Help section contributed by Loula George