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A Guide to Understanding—and Holistically Treating—Endometriosis

If you have endometriosis or know a friend who does, know this: The chronic pain that can come with a diagnosis is hard to overstate, and the number of people suffering is large. By some estimates, one in ten women and girls in the US have endometriosis, and Dr. Aviva Romm—a women’s health and obstetrics specialist (see more on Romm here)—says that likely many more are affected, particularly teenage girls, who she explains have been under-diagnosed.

Endometriosis is an inflammatory, hormonal condition in which the tissue lining the uterus grows outside of the uterus (i.e. in the abdominal cavity); that tissue continues to bleed in sync with your menstrual cycle. This can result in a buildup of scar tissue, which in turn can result in organs (like the intestines and bladder) sticking together. Again, we can’t overstate the pain, or the complexity, of attempting to narrow in on a root cause and pick the right treatment option.

The latter is a highly individual choice; there are many treatment options, some of them diametrically opposed. In her NYC-based practice, Romm has found that a holistic approach—targeted at reducing inflammation and oxidative damage, and supporting healthy hormone levels, as well as the body’s natural detoxification processes—is the most effective. Here, she shares her (incredibly useful) best practices, plus some helpful diet, supplement, and physical therapy recommendations.

A Q&A with Dr. Aviva Romm

Q

What is endometriosis and what causes it?

A

Endometriosis is an inflammatory and hormonal condition in which the tissue that normally lines the uterus, called the endometrium, can be found growing in other locations on the body where it’s not supposed to be. The most common place is inside the abdominal cavity, where it can land on the thin layer of tissue, called the peritoneum, that covers the intestines, bladder, ovaries, and fallopian tubes.

Just like the uterine lining during our monthly cycles, this misplaced endometrial tissue is triggered to shed by the hormonal changes that signal your period to start—and it causes this tissue to bleed, as well. This blood is extremely irritating to the nerves in the abdomen, causing much of the pain associated with endometriosis.

Over time, this irritation and associated inflammation leads to the formation of scar tissue that can cause the pelvic and abdominal organs to develop abnormal adhesions—meaning the organs stick to other organs and become less mobile. This can cause bladder and bowel pain, constipation, pain with ovulation, severe menstrual cramping and pain, trouble with conception, chronic pelvic pain, and pain with sex.

Though there are many theories, from a medical perspective, the exact causes of endometriosis are not known. We do know that it is an inflammatory condition with an abnormal immune response, and it can be triggered by cyclic hormonal changes, environmental exposure to endocrine disruptors (which are found in plastics, fragrances, personal care and household products, and not only harmfully alter hormone balance, but disrupt the immune system and cause inflammation), diet, and other factors like stress and too little sleep, that also cause inflammation and disrupt the immune system.

Q

How many girls/women does it affect? Is there a typical onset age or any early warning signs?

A

Astonishingly, at least one in ten women and girls in the US have endometriosis, with severe pain and cramping from this condition affecting 6.5 million in the US and Canada alone. Further, given rampant under-diagnosis of endometriosis in teenage girls, current rates of the condition are likely significantly higher than previously thought.. The most common early warning sign that this condition might be present is very painful periods, however, for many women, it is not recognized until pelvic pain and other symptoms become problematic.

Q

What are the symptoms?

A

The most common symptoms of endometriosis are:

  • Painful periods

  • Chronic or intermittent pelvic pain

  • Pain with sex

  • Bowel problems, especially constipation, diarrhea, bowel pain, or IBS-like symptoms

  • Infertility

  • Ovarian endometrial mass/tumor (affects about 20 percent of people with endometriosis)

  • Pain with urination and other urinary problems

Q

What treatments are available for endometriosis—and what are the pros and cons?

A

Unfortunately, there isn’t a single agreed-upon approach to endometriosis treatment, or one that works consistently for everyone. Further, most treatments suppress or temporarily eliminate, rather than heal, the problem, and all have risks.

Chronic-use pain medications like ibuprofen and other NSAIDS are commonly recommended and can provide temporary relief, but have risks including long-term damage to the gut lining and heart attack. It’s also best to avoid regular use of aspirin; even doses as low as 81 mg a day over a period of weeks have been associated with increased risk of gastric bleeding. Hormonal therapies, such as oral contraceptives, progestins, and GnRH agonists can relieve symptoms of mild to moderate pain but also have potential short- and long-term side effects.

While laparoscopic removal of endometrial tissue can alleviate symptoms for as a long as two years, in most cases, the symptoms do eventually return, and the procedure itself increases the risk of forming scar tissue.

Hysterectomy is sometimes recommended, but this is not an option for women who want to become pregnant, and it’s important to recognize that this is one of the most over-performed unnecessary surgeries in the US—including as treatment for endometriosis. While it is sometimes helpful when all else fails, or if symptoms are unbearable, it is major abdominal surgery—so get more than one opinion if you’re not sure you want this done.

Q

What have you found to be most effective for patients?

A

I’ve found a holistic, body-system-based functional medicine approach to healing the root causes of endometriosis to be the most effective in reducing pain and unhealthy tissue, and healing damage. Unlike a pharmaceutical or surgical approach, this is a long-term, sustainable approach and includes reducing inflammation and oxidative damage (the tissue damage caused by chronic inflammation), supporting healthy hormone levels, and improving the body’s natural detoxification processes—through diet, supplements, and physical therapies. [More on all below.]

Q

What kind of diet do you recommend?

A

A diet that is anti-inflammatory and low in toxins is essential.

An anti-inflammatory diet includes:

  • 8-10 cups combined fresh vegetables daily—especially leafy greens like kale, collards, broccoli, brussels sprouts

  • 1 handful of nuts (especially almonds, walnuts, pecans) daily

  • ½ to 1 cup cooked plant-based proteins (legumes especially) daily

  • ½ to 1 cup cooked whole grain daily

  • 4-6 oz. fish or poultry daily

Add fiber:

Getting enough fiber and having a daily bowel movement are essential for reducing inflammation, overall body toxin load, and eliminating excess estrogen from your system. For this, I recommend having 1-2 tablespoons of freshly ground flax seed daily in a smoothie, or mixed into food.

Remove the most common inflammatory dietary triggers:

  • Dairy products

  • Gluten-containing products

  • All corn

  • Most sugar

  • Red meat is also inflammatory, so if you are suffering from endometriosis, a plant-based diet with no red meat, and small amounts of poultry and fish is preferable

Caffeine caution:

Caffeine may add to endometriosis symptoms in some women, so if you’re drinking coffee each day, try a couple of months without it. Green tea is a good antioxidant-rich alternative if you just must have some caffeine.

Aim for organic:

Going as close to 100 percent organic as you can for at least three months is ideal because the common environmental toxins ubiquitous in food and food packaging can have a big impact on endometriosis. All meat should be organic to avoid chemicals and hormones used in meat production that might be adding to your problem.

Do your best to avoid potential toxins in:

  • Food that comes in soft plastic wrap

  • Food stored or microwaved in plastic

  • Food contaminated with pesticides and herbicides—i.e., many fruits and vegetables, and even more so if imported from another country where highly toxic chemicals that have been banned in the US are still used

  • Plastic water bottles (even if BPA-free, because we might find that the substitutes are just as problematic!)

A note on blood sugar and weight:

The above guidelines will help keep your blood sugar steady, which is important for keeping inflammation in check, and also keeps you from binging on sugar and baked goods.

Being overweight increases the likelihood of being estrogen-dominant; appropriate weight loss can also be very helpful in reducing general inflammation. The anti-inflammatory diet is a great way to lose weight without having to work too aggressively at it.

Q

What about herbs and supplements?

A

The anti-inflammatories that I treat my endometriosis patients with include:

  • Curcumin (an extract from turmeric, also a great antioxidant)—1200-2400 mg/day

  • Bromelain (an enzyme from pineapple)—200-800 mg/day

  • Quercetin (an extract from apples, onions, and omega 3 fats from fish oil)—250 mg three times/day

  • Omega 3 fats from fish oil (a DHA and EPA combination)

I recommend a combination of these antioxidants to help prevent and reverse local tissue damage from inflammation:

  • N-acetylcysteine (NAC)—600 mg three times/day

  • Pine bark (pycnogenol)—30 mg twice/day

  • Green tea (ECGC)—up to 300 mg three times/day

NAC is a powerful antioxidant with some impressive data behind it specific to endometriosis. In a 2013 study of ninety-two women in Italy, forty-seven took NAC and forty-two took a placebo. Of those who took 600 mg of NAC three times a day, three consecutive days each week for three months, twenty-four patients cancelled their scheduled laparoscopy due to a decrease or disappearance of endometriosis, improved pain reduction, or because they had gotten pregnant! Fourteen of the women in the NAC group had decreased ovarian cysts, while eight had a complete disappearance; twenty-one had pain reduction and one became pregnant. In the other group, only one patient cancelled surgery. A total of eight women got pregnant in the NAC group, while six did in the placebo-only group.

Another herbal antioxidant, pycnogenol (from pine bark), also led to promising results in a study. Women who took 30 mg twice daily for forty-eight weeks showed a 33 percent reduction in pain, including severe pain. While the pain reduction was not as strong as in the group receiving hormonal therapy (a gonadotropin-releasing hormone agonist, Gn-RHa), it persisted without relapse. Five women in the pycnogenol group became pregnant—an important result as endometriosis is a common cause of fertility problems.

For detoxification, I suggest:

  • Indole-3-carbinol, an extract from broccoli, is excellent for supporting the detoxification and elimination of excess hormones, and can be taken as a supplement.

  • NAC and curcumin as above, plus quercetin, all of which support natural detoxification, too, so you can be ahead of the game.

Q

Are there any endometriosis-related conditions to be aware of?

A

Women with endometriosis and extensive adhesions are more likely to develop bowel problems, especially constipation, fertility challenges, and chronic bladder problems. Further, because of chronic pain, women are at risk of complications associated with the overuse of pain medications, from Tylenol (liver toxicity) and ibuprofen (leaky gut, GI bleeding, heart attack), to becoming dependent on prescription pain medications.

Q

Do you have any tips for reducing pain?

A

Herbal and nutritional supplements can help with pain, and are safer than using ibuprofen, which can wreck your gut; and even taking ibuprofen for just one week may increase risk of heart attack.

My go-tos for pain include:

  • Ginger root: 500 mg, 2-4 times/day has been shown to reduce pain equal to the effects of ibuprofen, with none of the risks

  • Melatonin: 10 mg of melatonin per day significantly reduces chronic pelvic pain (including pain with sex) due to endometriosis. (One study found that women taking melatonin had an overall 80 percent reduction in the need for pain medication). In animal studies, melatonin led to regression and shrinkage of endometriosis tissue. I recommend starting at 1-3 mg/day, and building up. Preferably take it in the evening, as it can make you feel drowsy.

  • Curcumin: 1200 mg/day, for its pain-relieving, anti-inflammatory effects.

For those open to the option, and with legal access, medical use of marijuana can be very beneficial in the relief of pain both acutely and chronically.

Acupuncture has been shown to possibly be helpful for endometriosis pain and I also suggest working with an Arvigo massage therapist or a physical therapist skilled in pelvic pain from endometriosis.

Aviva Romm, M.D. is a Manhattan-based integrative women and children’s physician, and author of The Adrenal Thyroid Revolution. Romm did her medical training and internship in Internal Medicine at Yale School of Medicine and her residency in Family Medicine with Obstetrics at Tufts Family Medicine Residency. She’s also a midwife and herbalist, and a graduate of the University of Arizona Integrative Medicine Residency program.

The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.


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