Endometriosis: A Call to Action

Did you know that endometriosis affects 1 in 10 women, yet many go undiagnosed for years? Recent studies show that the statistics are much larger. It affects 5-10% of reproductive-aged women which translates to approximately 176 million women worldwide. Endometriosis is an inflammatory condition characterized by tissue that resembles the uterus’ endometrium located elsewhere in the body. Common locations for the endometriosis implants include the ovaries, pelvic wall, pelvic ligaments, bladder, and rectum. Although the endometriosis lesions are similar to endometrium which is normally located in the uterus, these lesions are located in out-of-norm locations and are chemically varied. The lesions are sensitive to the menstrually cycling hormones and various chemicals that the lesions are exposed to from both the internal and external environments of the woman. An example of internally exposed chemicals include inflammatory proteins called cytokines, and examples of externally exposed chemicals are endocrine disrupting chemicals (EDCs) like polychlorinated bisphenols (PCBs), phthalates, dioxins, and bisphenol A and its analogs. Its pathogenesis is not fully understood until retrograde menstruation in a favorable environment of altered immunity, epigenetic susceptibility, and varied endocrine and metabolic changes.

My symptoms started as cyclical pain in the lower right pelvis when I was ten years old. My periods began a year later and my mom thought that the pain just meant that I would attain my first period soon. The realization that this was the first glimpse of endometriosis came many years later, as I started practicing medicine. I remember feeling sick with diarrhea and vomiting the day that I got my first period. My periods were always painful and had a slew of other symptoms like nausea, vomiting, diarrhea, body aches, and migraines.

Often each period was bad; they were not the same each month, but horrible in their own way.

When I was nineteen and in my first year of medical school in India, I remembered final boards in anatomy, biochemistry, and physiology were coming up. I had a week of right-sided pelvic pain that was so intense, that I went to the hospital and tried various specialty physicians like internal medicine, general surgery, gynecology, etc. to figure out my symptoms. One doctor thought it was a UTI and another thought it was a mild case of appendicitis. Eventually, I went to a larger hospital with reputable surgeons who agreed that it was likely appendicitis. I remember certain family members hinted that I might have been

faking to get out of board exams or that they might be somatic symptoms due to the stress of exams. Surgeons often say that patients feel much better after an appendectomy due to the removal of the source of inflammation and infection. My pain intensified the day after the surgery as my period emerged. I remember that my doctors were shocked to see my disposition so ill-like.

My pain did not improve and continued to worsen with each menstrual cycle, then including my left pelvis as well. After a few months, I came home to California and saw my local gynecologist. She was the first to mention the word “endometriosis” to me. She said that it was a presumptive diagnosis and that I likely had mild disease since I was so young and that is why the surgeons did not see it during laparoscopy. She recommended continuous oral contraceptive pills, skipping the placebo pills so that my period was suppressed. My pain slowly improved over several months and I thought that my endometriosis was in control. It took another eleven years and three more surgeries for me to get an official diagnosis of endometriosis.

Endometriosis has an unfathomable impact on women’s lives. Pelvic pain and infertility are the most common symptoms but are often in correlation with a multitude of other symptoms like diarrhea, body aches, vomiting, headaches, fevers, etc. Symptoms include pain during and outside of menstruation that is often exacerbated by intercourse, defecation, and urination. Chronic fatigue, mental health diseases, infertility, and low quality of life are direct consequences of this exhausting disease. Thus, this disease affects not only the women, but also their partners and society as well. This leads to increasing health care and non-healthcare expenses. The varied symptomology and the gold standard for diagnosis, which is an invasive surgical procedure called laparoscopy, leads to the well established delay in diagnosis of 4-11 years from symptom onset to surgical diagnosis.

Lately, there has been a call to action to bridge disparities and clinically diagnose these patients, instead of waiting for diagnosis by surgery, in order to detect these cases earlier and start effective treatments earlier. The nonspecific nature of the symptoms, lack of clinically relevant biomarkers, and the lack of awareness in both the medical system and publically is known as the “unhappy endometriosis triad” and hypothesized as the reason for the common delay in diagnosis for these patients.

Conventional treatments include surgical resection, pharmaceutically lowering estrogen levels and suppression of ovulation, and treatment with non-steroidal

anti-inflammatory drugs to lower inflammation. These may be effective temporarily but often not long-term solutions and come with a slew of side effects. Plant based diets contain many bioactive compounds and molecules like flavonoids and polyphenols which can act as potent phytoestrogens and cause improvements in symptomology and inflammation associated with endometriosis. Some dietary methods of preventing and treating endometriosis include reducing dietary fat and increasing dietary fiber. Endometriosis is known to be an estrogen dependent disease and these methods are known to reduce circulating estrogen levels.

Other dietary methods include reducing meat consumption and increasing seaweed intake is known to reduce estradiol levels in women with endometriosis. Increasing vitamin intake like vitamins D, C, and E seem to have a pain relieving effect via their anti-inflammatory effects.

Functional medicine tries to get to the root cause of the disease and treat it with diet and herbs to heal the disease from within. Root causes can include gut dysbiosis, food intolerance, leaky gut, nutritional deficiencies, medication impacts, environmental toxins, detoxification overload, stress, immune system dysfunction, mitochondrial dysfunction, and genetics/epigenetics. Specific laboratory testing can find the individual root causes affecting a woman with endometriosis and targeted therapies can help with endometriosis symptom reduction and improvement in quality of life. Integrative medicine includes the use of herbs and various modes of treatment like acupuncture and mind/body medicine to improve endometriosis symptomology and improve quality of life.

Conventional treatments only seemed to help me temporarily and this clashed with my professional value of conventional medicine. My journey to functional medicine wasn’t easy. My pain was semi-controlled with contraceptive pills/ estrogen lowering medications but these came with side effects. Ultimately, I had given up on pain improvement and was just focused on getting pregnancy. Trying for natural conception was very painful for me as my pain increased with each month I was off of the contraceptive pill. We tried and failed assisted fertility treatments like Clomiphene citrate, letrozole, and intrauterine insemination. Eventually we moved to in vitro fertilization and seemed blessed to have been pregnant right away. However this pregnancy ended in a stillbirth in the sixth month of pregnancy. This devastation of losing my daughter made me realize that I needed to improve my own health so that I could have a healthy child. My research led me to functional medicine which led to immediate natural conception upon trying. The functional medicine and pregnancy has driven my endometriosis into remission and I now have my miracle rainbow son.

I hope that this blog resonated with you on some level. I look forward to giving you the space to share your journey and help guide you towards a healthier future, together.

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