Endometriosis is characterized by the abnormal growth of uterine tissue outside of the uterus. Lesions, called endometriomas, are typically found in the pelvic cavity around the ovaries, but ultimately occur anywhere. A diagnosis of endometriosis is possible when a (typically premenopausal) woman has been consistently experiencing moderate to severe pelvic pain. This can happen during menses, ovulation, intercourse, and even with bowel movements. Heavier bleeding patterns and longer periods are also common.
If you suspect endometriosis your doctor may send you for a pelvic and transvaginal ultrasound to see what’s going on in there—or if you’re already working with a fertility clinic, they may have caught a glimpse of potential lesions during your routine ultrasound monitoring. Most often, an ultrasound technician will describe what they see as a hemorrhagic cyst (a dark mass or lesion that can “bleed”). Even though lesions may be seen with an ultrasound, we don’t really know what we’re looking at, or how much is in there, until a surgeon can get in there and visualize the area laparoscopically.
In endometriosis, a combination of immune dysfunction, genetic predispositions, poor estrogen metabolism and detoxification, and increased inflammation, allows cells of uterine tissue to migrate, evade immune defenses and start growing. They respond to hormones just like your uterus and can “bleed” but it’s a very sticky, slow bleed. So lesions can grow and cause adhesions to form. Now you have these sticky, space-occupying lesions in the pelvic cavity that are incredibly painful and which could impede the function of the ovaries and the fallopian tubes. This is the main concern with fertility in endometriosis.
Does having endometriosis mean you’ll experience infertility? The short answer is no. It is very possible to have a healthy conception, pregnancy and live birth when you have endometriosis, but the state of your endometriosis will impact your fertility journey.
Complication #1: The size, amount and location of lesions
Physically, endometriomas within or on the ovaries can affect ovarian function and ovulation. Lesions and adhesions can also tether down the ovaries or fallopian tubes and make a challenging obstacle course for the egg, or prevent that egg from reaching the fallopian tube altogether.
Strategies: The most common treatment for endometriosis is a progestin-only birth control such as an IUD or oral contraceptive. The synthetic progestin hormone overrides your system and suppresses lesion growth. However, this isn’t an option when you’re trying to conceive, so instead, your doctor may suggest a surgical consult to find out if surgical removal of lesions and adhesions is necessary and possible without damaging the reproductive structures.
Alternatively, there are many nutraceuticals (nutrients, vitamins, orthomolecular compounds) that can help suppress lesions and prevent their growth, including n-acetyl cysteine (NAC), curcumin, epigallocatechin gallate (EGCG), and resveratrol. Depending on the amount and size of endometriomas present, it’s important to allow enough time to manage the endometriosis before trying to conceive. It’s also important to work with a naturopathic doctor who can properly design your treatment protocol.
Complication #2: Immune dysfunction
There is a major inflammatory component to endometriosis, including overall immune dysfunction since your immune system is designed to flag abnormal cells. Some researchers have also reported that endometriosis is associated with autoimmune conditions. In some cases, abnormal histamine reactions (such as in mast cell activation syndrome–MCAS) can also contribute to inflammation and increased pain hypersensitivity as mast cells are found in uterine tissue.
Strategies: Anti-inflammatory support and immune modulators like vitamin D and probiotics can be helpful for managing the lesions and pain associated with endometriosis. Probiotics are especially important for those with IBS and/or gut dysbiosis (having an increased amount of pathogenic bacteria compared to beneficial bacteria in the gut, or having low bacterial diversity).
Since there may be an autoimmune mechanism involved in endometriosis, it’s a good idea to screen for other autoimmune conditions including celiac disease (which, like IBS, can also cause a great deal of lower abdominal pain). Your doctor may additionally suggest a daily antihistamine if they suspect MCAS or histamine involvement.
Complication #3: Issues with estrogen
Endometriosis is an estrogen-dominant disorder: High estrogen levels can increase the severity of the disease while the lesions themselves can produce even more estrogen. The genetic component of the disorder comes from altered enzyme function involved in estrogen metabolism and detoxification including variants of CYP1A1, CYP1A2, CYP1B1, glutathione transferase, and COMT. Slow enzyme pathways can lead to increased levels of estrogen and its metabolites.
Another factor is the consumption of foods that either contain estrogen or cause increases in estrogen, like high fat dairy and alcohol, respectively. The lesions themselves contain an enzyme called aromatase which can convert testosterone into estrogen. Adipose (fat) tissue also contains aromatase, so although women need a good amount (19-25%) of body fat to keep the reproductive system functioning well, having an excessive amount could contribute to higher estrogen levels.
Strategies: Specific foods and supplements can help your body metabolize and detoxify estrogens. 3’-3-diindolymethane (DIM), found in cruciferous vegetables such as broccoli and Brussels sprouts, can induce CYP1A1 and 1A2 activity, while sulforaphane (SGS) found in broccoli sprouts can promote glutathione activity (and help prevent the spread of abnormal cells!).
Avoiding alcohol and dairy products can help prevent rises in estrogen, as will improving body composition if body adipose stores are too high. Equally important is ensuring proper elimination pathways so your body can get rid of excess estrogens and metabolites. This means having an adequate intake of water and fiber to promote regular urination and bowel movements.
Complication #4: Undergoing fertility treatments
This complication won’t apply to everyone with endometriosis trying to conceive. In most cases, addressing the above three complications in addition to dietary and lifestyle modifications can help manage the disorder when trying to get pregnant. However, if your endometriosis was only caught as you were undergoing cycle monitoring at a fertility clinic, or you had been previously diagnosed before starting a medicated cycle, there are a few things to keep in mind.
There are a few supplements such as DIM that should not be used while taking follicle-stimulating medications. Have a fertility-focused naturopath assess all of your supplements and treatments if you’re going to be in a medicated cycle.
Second, don’t ignore endometriomas, even if they are small. If you’ve been cleared to continue your cycle (insemination, egg retrieval or embryo transfer), there is still the chance that either inflammation, excess estrogen or abnormal immune responses could affect the outcome of your cycle. Utilizing dietary and lifestyle strategies is a great way to support your fertility and prevent the disorder from getting out of hand. These include:
- Avoiding: alcohol, red and processed meats, and high-fat dairy products
- Consuming: anti-inflammatory omega-3 fatty acids, brassica vegetables (such as broccoli, cabbage, and brussels sprouts), and fiber-rich ground flaxseeds.
- Reducing exposure to chemicals that can bind to estrogen receptors: bisphenol A, phthalates, and pesticides
If you’re interested in learning more about endometriosis, fertility, and naturopathic treatments for the disorder, you can find out more in Dr. Zadek ND’s new book It takes two… and a uterus, available early 2023.