You may have heard of an elusive condition that could be causing your infertility called Endometriosis. This article will define what it is, the theories behind its evolution, why it takes so damn long to diagnose it, how it may be impacting your fertility negatively, how it could cause complications when you do get pregnant, and how to manage endometriosis naturally.
What is Endometriosis?
In several western medical texts Endometriosis is defined as the following. Endometriosis is an estrogen-dependent, benign, inflammatory disease that affects women during their premenarcheal, reproductive, and postmenopausal hormonal stages. It is characterized by the presence and growth of endometrial tissue in locations outside of the uterus. These endometrial growths are typically seen on the ovaries, fallopian tubes, bowel, bladder, peritoneal tissue, the ligaments and other structures of the abdominal cavity. It is also rare, but possible that these growths occur outside the abdominal cavity. The endometrial tissue outside of the uterus responds to the hormonal changes in your body just like it would if it were in the uterine lining with the reaction of growing and then shedding. When they shed, they cause bleeding. Anytime you get blood in the peritoneal cavity it causes intense irritation and systemic inflammation as a result.
If you have suffered the symptoms of endometriosis you will certainly find the irony in the word benign, meaning kindly or gentle, not harmful or not malignant, as there is seemingly nothing gentle or kind when it comes to your symptoms and if you are trying to conceive with a history of diagnosed or suspected endometriosis it can certainly seem harmful to your fertility.
What are the Stages of Endometriosis?
Stage 1, or minimal disease- superficial endometriosis, filmy adhesions.
Stage 2, or mild disease- superficial and deep endometriosis, filmy adhesions.
Stage 3, or moderate disease- superficial and deep endometriosis, filmy and dense adhesions.
Stage 4, or severe disease- superficial and deep endometriosis, dense adhesions.
Endometriosis Stats that Will Help You Understand Why Endometriosis Is So Difficult to Diagnose?
The least bias estimate of the occurrence of Endometriosis is that it affects approximately one in ten women of reproductive age, which is approximately 176 million women in the world. It is considered one of the most common gynecological problems in the U.S. and a leading gynecologic cause of both hospitalization and hysterectomy. This mayb a conservative number due to the fact that so many diagnosis of teenage girls are missed, either due to MD’s normalizing menstrual cramps and pelvic pain as part of a woman’s journey as well as the systematic dispensing of Oral Contraceptives that mask some of the symptoms. All to often, it’s only after coming off of birth control, wishing to conceive, and trying relentlessly to get pregnant that the endometriosis is discovered.
Studies have shown a delay from 3 to 11 years between the onset of symptoms and the final diagnosis of endometriosis, with an average of 9.28 years before receiving a proper diagnosis! A key contributor to this delay are not only those mentioned above, but the fact that symptoms of endometriosis overlap with other conditions leading to misdiagnosis. Women with endometriosis are 3.5 times more likely to receive a diagnosis of IBS (irritable bowel syndrome). Women are also 6x more likely to have diagnosed with PID (pelvic inflammatory disease). 
In affected women, infertility has a 30% rate of prevalence and endometriosis implants increase the risk of ovarian cancer. 
Initially, endometriosis was related to retrograde menstruation, but new theories have been launched, suggesting that chronic inflammation can influence the development of endometriosis because inflammatory mediators have been identified elevated in patients with endometriosis. The immune system as well as genetic predisposition and epigenetic factors, all play important roles in determining whether an individual woman will develop this condition.   While it is currently unknown whether the inflammatory nature of endometriosis is a cause or consequence of the disease process, women who develop endometriosis often exhibit a hypersensitivity to inflammation across multiple organ systems. Endometriosis has also been described in the past as an autoimmune disease, since it is often associated with the presence of autoantibodies, other autoimmune diseases, and possibly with recurrent immune-mediated abortion.
What Are the Factors that Potentially Predispose a Woman to Developing Endometriosis?
Menarche (when your period starts as a young women) before the age of 12, menstrual cycles ( from day 1 of a period to the next period start) that are less than 26 days and a period that lasts longer than 7 days including spotting are all thought to be signs of a higher potential for having endometriosis. Other contributing factors can be a D & C, whether from an abortion or miscarriage, and having carried less than two pregnancies are also thought to predispose a woman to endometriosis. Environmental exposure to toxins like flame retardants, endocrine disruptors life “fragrance” in beauty and cleaning products, exogenous estrogens, pesticides, GMO’s, dioxin, PCBs and phthalates are thought to play a role to trigger on.
Signs and Symptoms of Endometriosis
The most common symptoms of endometriosis include killer cramping at the time of the menstrual cycle that sometimes won’t even go away with NSAIDS (motrin, ibuprofen, that kind of stuff), periods from hell (long. heavy), often with chronic and sometimes severe pain between periods, constipation and bloating, painful sex, urinary problems, low back ache, and chronic fatigue. pain with bowel movement or urination, pelvic burning, aching not limited to menstruation, referred pain in distant sites, especially shoulder blades or top of collar bone, PMS. Additionally, women may experience: constipation, swollen abdomen, intestinal gas, depression, insomnia, lethargy, rarely, bleeding after bowel movements or after intercourse.
Endometriosis is one of the most common causes of infertility, leading to as many as 50% of cases. Some women may have endometriosis without symptoms, only to discover that they have the problem when they experience difficulty becoming pregnant. As many as 30-40% of women with endometriosis will experience fertility problems.
Endometriosis typically progresses and worsens over time as the chronic inflammation leads to accumulation of scar tissue causing “adhesions” that cause the organs like the intestines and bladder to become fixed in place leading to frequent or even pain with bowel movements and urination, and painful sex.
Root Cause Approach to Managing Endometriosis Naturally
The adhesions associated with endometriosis can wax and wane on the their own, but several natural remedies have been shown to shrink endometrial adhesions and are worth trying for 6-9 months. There is no need to do another laparoscopy to see if they are gone. Experiencing less severe or less frequent symptoms or the ability to fall and stay pregnant, suggest they have had a positive effect on the condition. I suggest trying one or two from the root cause categories that you feel you have the most issue in. Remember, some need to be stopped immediately upon falling pregnant or not taken in the luteal phase of your cycle if you are trying to fall pregnant.
Natural Pain Management For Endometriosis
Devil’s Claw is helpful to alleviate inflammation associated with endometrial pain, back pain, and arthritis. Dose: 400 mg 4x/day. Do not take during the luteal phase of your cycle if you are trying to conceive, so after your fertile window as it could interfere with implantation and proper development due to its blood thinning qualities.
Ginger root powder (or the equivalent in extract form) -Dose of 500 mg 2-4 times/day has been shown to reduce pain equal to the effects of ibuprofen. I highly recommend taking it daily, or in the few days prior to and during your menses, at the higher dose for best pain relief. After transfer of embryo or successful natural pregnancy, your dose in a day should not exceed 1000 mg and and should only be used as needed for the natural control of pain and inflammation.
Melatonin has been shown to reduce endometriosis associated pelvic pain and improve sleep quality in some research; 1-3 mg, also shown recently to be a natural detoxifier and a sweet spot for infertility in it’s otherwise broad dosage of 1-10mg. Stop upon falling pregnant.
Herbs to Relax the Nervous System to Manage Endometriosis
Adaptogens are particularly helpful at regulating the Nervous and Immune System to help manage the growth of endometrial lesions. In order of importance for endometriosis they are Eleuthero, Reishi, Cordyceps, shitake, and Maitake. The Soothe and Nourish Adrena blends by Herb-Pharm and formulated by Dr. Aviva Romm are excellent choices for adaptogenic blends.
Detoxing Your System to Manage Endometriosis
According to Traditional Chinese Medicine, the best times to engage in a detox are spring and fall. These are the times the body has adequate energy to purse toxic hormonal buildup. Of course, the best detox is prevention all year long. Here are some best practices.
Avoid exogenous hormones in foods, pesticides, and endocrine disruptors such as “fragrance” in your beauty and cleaning products. For a list of fertility friendly beauty product recommendations check out these two Fertile Minds Podcasts. For natural cleaning products I use Norwex in my home and business and absolutely love them!
Avoid exposure to PCBs, flame retardants, BPA, phthalates, dioxins, triclosan and heavy metals.
Triclosan is often found in toothpaste, especially common brands like crest and colgate. I use Tom’s brand.
BPA can increase estrogen levels and is commonly found in the ink on receipts unless you live in California where it has been outlawed. It’s also found in the lining of many cans like LaCroix unfortunately. Also found in our water supply unfortunately. I use Berkey Water filters for my drinking water at home, in my office and even on my showers. Unfortunately our water tests high for chlorine and could easily have BPA and phthalates in it from plastic contamination.
Phthalates are found in flexible plastics. Use glass or silicone for your kitchen products and avoid teflon at all costs
Dioxins are bleach byproducts and are thought to cause endometriosis progression. Avoid bleach and bleached products like tampons and pads. There are many natural alternatives on market along with the Diva Cup. If you are eating a typical American diet, you are most likely getting dioxin exposure from beef and diary. Eat organic non GMO fruits and veggies when possible and only clean cuts of dairy and meats from a source you trust. A mediterranean is the only diet found in the literature to prove helpful for endometriosis. Think pescetarian with healty fats and ample veggies.
Avoid heavy metal exposure when possible. 
My favorite supplement to detox the body of exogenous estrogens is N-acetyl cysteine (NAC). In combination with alpha lipoic acid (may also help egg quality) and bromelain it is used in the prevention of endometriosis 
Short for N-acetyl-cysteine, NAC is a powerful supplement that increases glutathione, one of the most important detoxifiers naturally produced in our bodies. However, many of us aren’t producing quite enough to keep up with the demands put on our bodies by chronic exposure to environmental toxins and even overproduction of our own natural hormones – including estrogen. NAC has some impressive data behind it specifically for endometriosis. In a 2013 study of 92 women in Italy, 47 took NAC and 42 took a placebo. Of those who took 600 mg of NAC three times a day, three consecutive days each week for three months: 
24 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
8 had a complete disappearance of their symptoms – and lesions
21 had pain reduction
1 became pregnant. In the control group, only 1 patient cancelled surgery. There were 4 endometriomas that disappeared. Overall, more cysts reduced and fewer cysts increased in size in the NAC group. There were 4 newly formed cysts in the NAC group vs. 4 in the untreated group. After the observation period, a total of 8 pregnancies occurred in the NAC treated group and 6 in the untreated group.
In the other group, only 1 patient cancelled surgery. A total of 8 women got pregnant in the NAC group, while 6 did in the placebo-only group.
The results of this study are impressive and actually compares to the results reported in a randomized placebo controlled study on 100 women treated for 4 months with oral contraceptives. In addition, there was one pregnancy during the study period and more after, which is of course a contrast with women who stay on oral contraceptives to manage their endometriosis. NAC does not negatively affect fertility, and if one looks to other research on insulin resistance and PCOS, we will find that NAC improves ovulation and thus fertility, similar to metformin, in PCOS patients. Previous evidence shows that NAC modulates the pathogenesis of endometriosis via several pathways. NAC decreases abnormal cell proliferation, decreases the invasive behavior of the endometriosis cells, decreases inflammatory substances, regulates expression of inflammation related genes, and stimulates cell differentiation. I will be interested in using NAC for not only treatment of current endometriomas, as well as endometriosis, as well as prevention of recurrence after a surgery.
Dose- I recommend taking 600 mg in the morning and 1200 mg at night when the liver is most able to actively detox itself (not just 3x/week as in the study). Continue for at least 3 months (the timeframe for seeing substantial reduction of cysts in the above study), and if you experience improvement, this very safe supplement can be taken on an ongoing basis if needed. For ongoing detoxing after this period 6 weeks duration should be efficient as long as there hasn’t been a massive reexposure.
Decreasing Inflammation May Help Prevent Endometriosis
Diet and lifestyle are two of the biggest causes of inflammation in the body. Avoid inflammatory foods such as sugar, excess meat consumption, foods high in omega 6, dairy, caffeine and possibly gluten. Avoid all GMO’s . Optimize fiber to ensure natural detoxification via the gut. Supplements that are likely to reduce inflammation are
Omega 3’s are helpful to reduce inflammation. I typically recommend all of my fertility clients take Nordic Naturals Prenatal DHA at 1,000 mg for their proper dose of omega 3’s.
Curcumin- Curcumin is a known anti inflammatory and may help with estrogen metabolism. 
Resveratrol is a phytoestrogen, a natural polyphenolic compound with antiproliferative and anti-inflammatory actions, found in many dietary sources such as grapes, wine, peanuts, soy, berries, and stilbenes. Resveratrol possesses a significant anti-inflammatory effect via inhibition of prostaglandin synthesis and it has been proved that resveratrol can exhibit apoptosis-inducing activities. From the studies reviewed in this paper, it is clear that the anti-inflammatory effect of this natural compound can contribute to the prevention of endometriosis, this phenolic compound now being considered a new innovative drug in the prevention and treatment of this disease. 
Pycnogenol could be helpful for mild cases of endometriosis. In women with surgically diagnosed endometriosis, treatment with pycnogenol slowly but steadily reduced symptom scores. Patients with smaller endometriomas responded better to treatment as compared to patients with larger endometriomas.
Managing the Immune System to Manage Endometriosis
As I mentioned earlier in the article, the immune system was a leading theory on the cause of endo for some time in the literature. Like inflammatory markers, there are often markers in the endometrial tissue that suggest the immune system has started and over active process. It is unclear if this is the cause or an effect of the process itself. There is growing experimental and clinical evidence for a strong interaction between immunologic processes in the gut and endometriotic lesions.
In addition to the massive impact it has on fertility, appears to negatively impact pregnancy outcomes. In a retrospective population based study of over 82,000 singleton pregnancies, endometriosis was associated with an increased risk of preterm birth, preeclampsia, and Cesarean delivery compared to women who had no endometriosis. Preterm birth and preeclampsia are associated with immunologic dysregulation. 
Medicinal mushrooms mention above under the nervous system heading are an excellent way to improve non specific immunity. If you have other autoimmune issues and/or anxiety or insomnia medicinal mushrooms are must in the treatment of managing endometriosis naturally.
The Role of the GI System & Endometriosis
If you want to improve your immunity to help your Endometriosis you must also consider GUT health as that is where all immunity in humans begins. There is even a hypothesis that gut microbiota may be involved in the onset and progression of endometriosis.  This is further driven by the excess intake of insulin producing carbohydrates and a lack of essential fatty acids.  Further evidence that the Gut is an important system to manage with endometriosis is the interesting fact that many women are likely to be given a diagnosis of OBS or IBD long before getting to the diagnosis of endometriosis.
Avoiding Histamine producing foods may also be of great benefit in managing gut health in individuals that have experienced symptoms of histamine intolerance in addition to endometriosis.  The theory behind the connection has to do with the fact that you see increased macrophages, dendritic cells, and all kinds of inflammatory cytokines and mast cells. Mast cells produce histamine in the body. If you have had hives or unexplained urticaria I suggest you take the following foods out of your diet for at least one menstrual cycle and notice if your symptoms decrease.
fermented foods like yogurt, kraut, kombucha, and alcoholic beverages
peanuts, cashews, and walnuts
left over foods
tomatoes, avocados, spinach, lemon, chocolate and eggplant
Quercetin may help to reduce histamine in the body. It is naturally found in onions, cauliflower, apple skin, lettuce and chili peppers. In recent studies, quercetin is reported as a functional compound and shows a wide range of biological effects such as antioxidant, anti-inflammatory and antiangiogenic properties in obesity, diabetes, cardiovascular diseases and various cancers.  Dose is 500mg a day for 8-12 weeks. Do not take while pregnant or TTC past your fertile window.
Treatment Strategies for Endometriosis
When considering treatment options for women actively trying to conceive, alternative therapies are often turned to as most western therapies are contraindicated when trying to get pregnant. Oral contraceptives, IUD, Hysterectomy and Laparoscopic surgery are the current standards of treatment in the US.
Alternative methods such as botanical therapies mentioned above, acupuncture, Arvigo Pelvic massage, castor oil packs, and vaginal steams are all practices I recommend to my fertility clients. Traditional Chinese Medicine (TCM) has been effectively treating subfertility associated with endometriosis for thousands of years, and the treatment gives positive results in achieving pregnancy. With acupuncture treatment, blood circulation is promoted, the blood stasis (adhesions) are dissolved, the menstrual cycle is regulated, and inflammation is diminished. A meta analysis of complementary therapies for managing pelvic pain associated with endo found that Numerous complementary treatments have been used to alleviate the symptoms of endometriosis, but only acupuncture has demonstrated a significant improvement in outcomes. Nevertheless, other approaches demonstrated positive trends toward improving symptoms; this should encourage investigators to design controlled studies to support their applicability.  My favorite Chinese herbal blend for managing Endometriosis is Jade Disperse 2 by Kan Herbs. When actively trying to conceive only take it during menses and in the follicular cycle. For best results, take a few months off of TTC and take it all month until symptoms regress dramatically then discontinue in the luteal phase and begin trying again.
You can get any of the herbs and supplements mentioned in this blog or my podcast at my full script dispensary. Click the button below. All supplements and herbs are 20% and 15% of the remaining profit goes to Farmer’s Footprint to aid in regeneration farming in the US. This is farming without chemicals where the land is completely rehabbed.
Porpora M, Brunelli R, Costa G, et al. A promise in the treatment of endometriosis: an observational cohort study on ovarian endometrioma reduction by N-acetylcysteine. Evidence-Based Complementary and Alternative Medicine. 2013; April. Article ID 240702
You must not rely on the information in this podcast as an alternative to medical advice from your doctor or other professional healthcare provider.If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. If you think you may be suffering from any medical condition you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website or in this podcast.
Photo Credit Christian Newman