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Endometriosis

Introduction

What should I know about Endometriosis?

Endometriosis is a disease where the tissue that lines the uterus (endometrial tissue) is found outside of the uterus. The tissue attaches itself on other organs and can spread over a larger area over time. It acts just like the tissue inside the uterus during the monthly menstrual cycle. Endometrial implants, as this tissue is called, may be found anywhere in the body, but are mostly found in the pelvic region. (1) Often, these implants are seen on the outside of the ovaries, the fallopian tubes, or the uterus.

The exact cause of endometriosis is unknown, but it occurs almost exclusively in menstruating women. It is rarely seen in women before puberty or after menopause, or in women who are not having monthly periods. One theory that explains how these cells get outside of the uterus is called the transport theory. The transport theory says that endometrial tissue moves to and attaches itself in the abdomen and other areas of the body by something called “retrograde menstruation." This means that the lining of the uterus that is shed at the end of the monthly cycle flows upwards instead of draining out of the body normally. The transport theory also says that the tissue may spread by going through the blood vessel circulation or the lymph nodes. (2)

When the implants act along with the menstrual cycle, it often leads to inflammation in the areas around the implants. These cycles of bleeding and inflammation cause scar and fiber-like tissue to form in the abdomen. The organs may even become attached to each other. (3) Endometriomas are blood filled cysts that range in size from those that are so small that they can only be seen with a microscope to 10 centimeters (about 4 inches). They are often found on the ovaries. These cysts are commonly called “chocolate cysts" because of their dark brown color. Small swellings may form on the muscular tissue around the uterus. Women with endometriosis are often infertile. (4)

The number of women who have endometriosis is unknown. Women with endometriosis may have an increased risk for other diseases such as chronic fatigue syndrome, fibromyalgia, and hypothyroidism among other disorders. (5) This disease can be present without major symptoms, and diagnosis is only possible through looking at the lesions during a surgery called laparoscopy, where a lighted tube is inserted into the abdomen or other affected area. The number of women 15 to 44 years of age with endometriosis is estimated to be between 10 and 20 percent. (6)

Laparoscopic surgery provides a way to place the disease diagnosis into a specific stage, which helps the health care practitioner select an appropriate treatment for the patient. The stages are minimal (Stage I), mild (Stage II), moderate (Stage III), and severe (Stage IV). These stages are based on the location and size of the endometrial lesions, and the presence and extent of adhesions, fibrous structures by which parts abnormally stick together. (7)

Statistic

Endometriosis Research Center, 2002.

  • An estimated 77 million people worldwide have endometriosis.

National Institute of Child Health & Human Development, 2002.

    At least 5.5 million women in North America alone have endometriosis. About 30 percent to 40 percent of women with endometriosis are infertile, making it one of the top three causes for female infertility. Current estimates place the number of women with endometriosis between 2 percent and 10 percent of women of reproductive age. But, it’s important to note that these are only estimates, and that such statistics can vary widely.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

The most frequent symptom of endometriosis is pelvic pain, although it is possible to have endometriosis without any symptoms at all. The pain may occur before or during the menstrual period, or sometimes in the middle of the month when ovulation occurs. Sometimes the pain is reported as pain in the lower back, rectal area, or down the legs. Menstruation can also be abnormal in patients with endometriosis. The menstrual flow may be different than usual, or exceptionally heavy. These women may likely experience very painful menstrual cramps. Women with endometriosis may have painful intercourse and have difficulty becoming pregnant.

Other organ systems can be affected by endometriosis. If the intestines are involved, symptoms may also include painful bowel movements, diarrhea, constipation, or other upsets of bowel habits during menstrual periods. Rectal bleeding may also be present. If the bladder or urinary tract is involved, symptoms may include blood in the urine, an increased feeling of the need to urinate, or painful urination during menstrual periods. Lower back pain may also occur during periods. If the lungs are involved, blood may be seen in sputum that may be coughed up during a menstrual period.

General

  • Pelvic pain
  • Pain during menstruation
  • Abnormal or heavy menstrual flow
  • Difficulty becoming pregnant
  • Pain during bowel movements
  • Pain during urination
  • Rectal bleeding
  • Blood in the urine

Treatment Options

Conventional

Treatment depends upon how serious the disease is and what the patient wants to do to treat the condition. It includes just monitoring a mild form of the disease that does not cause infertility or pain, use of hormone therapy, surgery, or removal of the uterus, tubes, and ovaries in severe disease. (8)

Patients choosing hormone therapy use estrogen-progestin combinations (birth control pills) to cause a state of false pregnancy. When these pills are taken continuously, amenorrhea (no menstrual periods) results. The combination products used are generally given on a continuous basis for six to nine months.

Another option of hormone therapy is progestin therapy alone. Medroxyprogesterone may be taken either by mouth or by injection to stop ovulation (release of eggs from the ovaries). The most common dose is 10mg by mouth three times daily for three months. Usually, pelvic pain and tenderness begin to disappear within a few days of starting therapy. Also, medroxyprogesterone acetate injection can be given into the muscle in doses of 100mg every two weeks for eight weeks, followed by 200mg every month for four months. (9)

A drug called danacrine can also be used. This stops the release of specific hormones from the pituitary gland in the brain and is generally given in doses of 400 to 800mg per day for a period of six to nine months.

The drug nafarelin can be used for pelvic pain and implant shrinkage in endometriosis. The dose is usually 200mcg every 12 hours administered into the nose as a nasal spray. It works to stop the release of a specific hormone from the hypothalamus, a part of the brain.

Nutritional Suplementation

This category contains no therapies clinically applicable to this disease state.

Herbal Suplementation


Chasteberry

The chasteberry tree originated in the Mediterranean area. It's fruit is harvested and dried for use as a medicine. It has a long folk history of use in women’s health. Chasteberry is now used for a variety of female complaints, such as PMS, amenorrhea (no menstruation), menopausal symptoms, and endometriosis. (10) , (11) , (12) , (13) Several clinical studies have reported using chasteberry in treating women with infertility. (14)


Evening Primrose

Evening primrose oil (EPO) contains gamma-linolenic acid which is an omega-6 fatty acid. (15) , (16) Omega-6 fatty acids may decrease inflammation. Using essential fatty acids such as EPO may prevent zinc deficiency, possibly improving the immune system. (17) Fatty acids are an important part of the normal functions of the human body. The human body can produce all of the fatty acids it needs except for two - omega-3 and omega-6 fatty acids. Both of these must come from the diet or with the use of supplements. A balance of these two fatty acids is very important. Essential fatty acids are needed for building cells and hormones. Modern diets often do not have quality sources of fatty acids.


Red Clover

Red clover has been used as a medicine by Asian, European, and Native American people as an expectorant (helps to clear mucous), in asthma, and to treat psoriasis, eczema, and other chronic skin conditions. (18) There has been much research on the effects of phytoestrogens (or plants that contain chemicals that act like natural estrogens in the body) like red clover for use to relieve menopause symptoms. (19) Recently, an extract of red clover has been marketed for menopause symptoms. This product contains four phytoestrogens, all with reported estrogen-like activity. (20)


Olive Leaf

Olive leaf extract has been reported to be useful as an antimicrobial, effective against bacteria that cause intestinal or respiratory tract infections. (21) The active ingredient in olive leaf is oleuropein. (22) , (23) Olive leaf extract has reported actions against viruses. (24) , (25) As an antifungal and antiviral agent, olive leaf extract is used to maintain bowel flora, which can decrease Candida (bacteria that can cause female problems). Recent laboratory studies in animals reported blood sugar lowering and cholesterol lowering effects with the use of olive leaf. (26) , (27)


Cat's Claw

Cat’s claw may affect the immune system and act as a free radical scavenger. (28) Cat’s claw may decrease inflammation and edema (swelling). (29) Cat’s claw is reported to be able to soothe irritated and inflamed tissues and help remove bad bacteria from the gastrointestinal (GI) tract. (30)

References

  1. Sagraves R, Letassy NA. Gynecologic Disorders. In: Koda-Kimble MA, Young LY, et al, eds. Applied Therapeutics, The clinical use of Drugs, 5th ed. Vancouver, Washington: Applied Therapeutics Inc; 1992:70-14 to 70-16.
  2. Ridley JH. The validity of Sampson’s theory of endometriosis. Am J Obstet Gynecol. 1961;62:777.
  3. Talbert LM, Kauma SM. Endometriosis. In: Scott JR, et al, eds. Danforth’s Obstetrics and Gynecology. Philadelphia: JB Lippincott Co; 1990:845.
  4. Talbert LM, Kauma SM. Endometriosis. In: Scott JR, et al, eds. Danforth’s Obstetrics and Gynecology. Philadelphia: JB Lippincott Co; 1990:845.
  5. View Abstract: Sinaii N, et al. High rates of autoimmune and endocrine disorders, fibromyalgia, chronic fatigue syndrome and atopic diseases among women with endometriosis: a survey analysis. Hum Repr. Oct 2002;17(10):2715-24.
  6. National Institutes of Health, NIH Publication number 91-2413.
  7. Buttram VC. Evolution of the revised American Fertility Society classification of endometriosis. Fertil Steril. 1985;43:347.
  8. Talbert LM, Kauma SM. Endometriosis. In: Scott JR, et al, eds. Danforth’s Obstetrics and Gynecology. Philadelphia: JB Lippincott Co; 1990:845.
  9. View Abstract: Wellbery C. Diagnosis and treatment of endometriosis. Am Fam Physician. Oct1999;60(6):1753-62,1767-8.
  10. Hillebrand H. The Treatment of Premenstrual Aphthous Ulcerative Stomatitis with Agnolyt. Z Allgemeinmed. 1964;40(36):1577.
  11. McGibbon D. Premenstrual Syndrome. CMAJ. 1989;141(11):1124-25.
  12. View Abstract: Jarry H, et al. In Vitro Prolactin But Not LH and FSH Release Is Inhibited by Compounds in Extracts of Agnus castus: Direct Evidence for a Dopaminergic Principle by the Dopamine Receptor Assay. Exp Clin Endocrinol. 1994;102(6):448-54.
  13. View Abstract: Loch EG. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend Based Med. Apr2000;9(3):315-20.
  14. Propping D, et al. Diagnosis and Therapy of Corpus Luteum Deficiency in General Practice. Therapiewoche. 1988;38:2992-3001.
  15. View Abstract: Chapkin RS, et al. Dietary Influences of Evening Primrose and Fish Oil on the Skin of Essential Fatty Acid-deficient Guinea Pigs. J Nutr. 1987;117(8):1360-70.
  16. View Abstract: Dutta-Roy AK, et al. Effects of Linoleic and Gamma-linolenic Acids (Efamol Evening Primrose Oil) on Fatty Acid-binding Proteins of Rat Liver. Mol Cell Biochem. 1990;98(1-2):177-82.
  17. View Abstract: Dib A, et al. Effects of Gamma-linolenic Acid Supplementation on Pregnant Rats Fed a Zinc-deficient Diet. Ann Nutr Meta. 1987;31(5):312-19.
  18. Newall CA, et al. Herbal Medicines: A Guide for Health Care Professionals. London: The Pharmaceutical Press; 1996:227.
  19. View Abstract: Chiechi LM. Dietary Phytoestrogens in the Prevention of Long-term Postmenopausal Diseases. Int J Gynaecol Obstet. Oct1999;67(1):39-40.
  20. View Abstract: Knight DC. A review of the clinical effects of phytoestrogens. Obstet Gynecol. May1996;87(5 Pt 2):897-904.
  21. View Abstract: Bisignano G, et al. On the in-vitro antimicrobial activity of oleuropein and hydroxytyrosol. J Pharm Pharmacol. Aug1999;51(8):971-4.
  22. Petkov V, Manolov P. Pharmacological analysis of the iridoid oleuropein. Drug Res. 1972;22(9):1476-86.
  23. Juven B, et al. Studies on the mechanism of the antimicrobial action of oleuropein. J Appl Bact. 1972;35:559.
  24. Renis HE. In vitro antiviral activity of calcium elenolate. Antimicrob. Agents Chemother. 1970;167-72.
  25. Heinze JE, et al. Specificity of the antiviral agent calcium elenolate. Antimicrob Agents Chemother. Oct1975;8(4):421-5.
  26. View Abstract: Bennani-Kabchi N, et al. Effects of Olea europea var. oleaster leaves in hypercholesterolemic insulin-resistant sand rats. Therapie. Nov1999;54(6):717-23.
  27. View Abstract: Gonzalez M, et al. Hypoglycemic activity of olive leaf. Planta Medica. 1992;58:513-515.
  28. View Abstract: Aquino R, et al. Plant Metabolites. Structure and in Vitro Antiviral Activity of Quinovic Acid Glycosides from Uncaria tomentosa and Guettarda platypoda. J Nat Prod. 1989;52(4):679-85.
  29. View Abstract: Aquino R, et al. Plant Metabolites. New Compounds and Anti-inflammatory Activity of Uncaria tomentosa. J Nat Prod. 1991;54(2):453-59.
  30. View Abstract: Sandoval-Chacon M. Antiinflammatory actions of cat's claw: the role of NF-kappaB. Aliment Pharmacol Ther. Dec1998;12(12):1279-89.