Factors and Considerations in Endometriosis
Factors and Considerations in Endometriosis
April 1, 2025
Joy Stepinski, MSN, RN-BC
The month is March nationally devoted to endometriosis awareness. According to the Centers for Disease Control and Prevention (CDC), endometriosis is a condition that affects a woman’s uterus [1]. The uterus is the structure that supports a growing fetus during pregnancy. In endometriosis, the endometrial tissue that normally lines the uterus grows outside the structure. Common sites affected include the ovaries, fallopian tubes, and the gastrointestinal tract [2]. Other organs that may be involved are the lung, heart, and central nervous system. We will explore common symptoms, theories about the condition, and options when faced with endometriosis.
Symptoms often associated with endometriosis are prolonged menstruation, pelvic pain, and infertility [3]. Other findings may be pain during sexual intercourse, urination, or bowel movements.
Several theories describe the origination of endometriosis [3]. A popular theory, developed in the 1920s, proposes a retrograde flow of menstrual blood causes endometrial cells to be implanted outside the uterus. Normally, menstrual blood flows from the uterus, through the cervix, and out the vagina. However, in a retrograde flow, blood flows through the fallopian tubes and into the abdominal lining. Other theories involve the differentiation (or formation into specific cells) of stem cells that may migrate from the uterus into other regions. There, the cells differentiate into tissue similar to the uterine lining.
Hormones that play a role in the condition are estrogen and progesterone [2]. Estrogen supports the spreading and development of the endometrial tissue outside the uterus. At the same time, progesterone lacks its antagonistic effect, which typically would inhibit estrogen.
Other characteristics are noteworthy. Endometriosis leads to chronic inflammation [3] with a complex disrupted immune response. For example, natural killer (NK) cells, responsible for cleaning the abdominal cavity of abnormal endometrial tissue components, are reduced. The formation of ectopic endometrial blood vessels consequently causes nerve growth, which may be a culprit of pain.
The prevalence of endometriosis is approximately 10 to 15% of women of childbearing age. However, the exact frequency is unknown because an examination is required for a definite diagnosis. The literature discusses that medical costs are often higher in the United States and Europe for women experiencing the condition. Risk factors are menarche before age 11, short menstrual cycles, age of 25 to 29, and daily intake of alcohol [2].
The literature has historically reported that body mass index is inversely correlated with endometriosis, with a diagnosis often in women with a low BMI [4]. Yet other studies suggest that obesity is not protective against the disease and women with a high BMI may experience endometriosis at an increasing rate [3, 4]. On a related note, obese women have a 2.6-fold increase in endometrial cancer (severely obese women have a 4.7-fold increase) [5].
A correlation between endometriosis and autoimmune diseases is recognized in studies. Findings from a cross-sectional survey of 3,680 participants surgically diagnosed with endometriosis reported a higher prevalence of autoimmune conditions [6]. These included allergies, asthma, hypothyroidism, chronic fatigue syndrome, and fibromyalgia.
Common treatment includes pharmacological and/or surgical options. The goals of drugs are to improve pain and infertility symptoms [3], although no medication is available that alleviates the disease [2]. Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit prostaglandins, which play a role in inflammation. Although these drugs may alleviate cramping abdominal pain, they have a “substantial risk of adverse effects” including gastrointestinal and neurological [7]
Hormone therapy focuses on inhibiting estrogen production. Among these drugs include oral contraceptives, gonadotropin-releasing hormone agonists (GnRH), and aromatase inhibitors [8]. Hormone therapy is known to cause significant side effects, which often prompt discontinuation. For example, a gonadotropin-releasing hormone agonist, such as danazol, regulates reproductive hormones (follicle-stimulating hormone (FSH) and luteinizing hormone (LH)). Danazol can cause vaginal bleeding, vaginal dryness, breast changes, sexual problems, and mood changes [9]. Aromatase inhibitors disrupt estrogen production in the ovaries and the ectopic endometrial tissue. Among the adverse effects is loss of bone mass.
Surgical options include laparoscopy and ablation to remove or cauterize ectopic lesions [8]. Laparoscopic surgery is a treatment offered for deep infiltrating endometriosis (DIE) [3] where tissue grows into pelvic organs. Surgical complications may include a rectal fistula, loss of proper bladder muscle contraction, and narrowing of the intestines. A Cochrane review determined that “it is uncertain whether laparoscopic surgery reduces overall pain associated with minimal to severe endometriosis” [10]. Hysterectomies may be performed, but lead to infertility [8]. In a study of 138 women who underwent a hysterectomy, 29 participants continued with recurrent pain and 13 required additional surgery [11].
Lifestyle factors should be considered in alleviating endometriosis symptoms, especially diet. An increased level of circulating estrogen is found in the bloodstream of women with endometriosis. Some studies propose that high estrogen is a risk factor for the disease [12]. Foods that contribute to increased estrogen are dietary fat, dairy products, and red meat [8]. Approximately 60 to 80% of estrogen consumption is cow’s milk. Furthermore, eating foods high in fat is also linked with increased estrogen in the blood [13].
Additionally, dietary fats play a role in inflammation. The inflammatory response is a complex characteristic of endometriosis. We have discussed natural killer cells. Another player is cytokines. Cytokines serve as part of the immune system. They are proteins released by one cell to regulate the function of another cell. An example is tumor necrosis factor (TNF). TNF regulates inflammation and provides signals for immune cells to kill tumor cells. In endometriosis, women are found with higher levels of TNF.
TNF and other pro-inflammatory cytokines are released by macrophages, a type of white blood cell involved in the immune response. When molecules trigger the immune system, macrophages recognize, engulf, and destroy them. In women with endometriosis, there are a heightened number of macrophages, yet a limited ability to engulf the foreign particles [3] in the peritoneum (the cavity that contains the abdominal organs).
Maintaining a high-quality diet is discussed in the health literature as essential to endometriosis. Foods high in fiber are important for several reasons. Estrogen levels are regulated in the gut. [14]. Fiber lowers estrogen levels that support the development of endometrial tissue outside the uterus. Furthermore, fiber is essential to the gut microbiota. When the proper microbial balance is lacking, the body is prone to inflammatory disease [15]. Constipation increases pelvic pain, and consistent bowel movements lessen discomfort. Finally, fiber helps lower weight. Increased weight contributes to higher estrogen levels. High-fiber foods include fruits, vegetables, whole grains, and legumes.
Another protective food is soy [14]. Soy is an isoflavone, a type of phytoestrogen. Phytoestrogen is a plant compound that binds to estrogen receptors in the body. Thus, phytoestrogens help to regulate estrogen levels. Isoflavones competitively binds to estrogen receptors, which consequently reduces estrogen. Phytoestrogens also help to control the immune response by inhibiting pro-inflammatory cytokines. Furthermore, this compound contributes to a healthy gut microbiome. Although the literature on the benefits of soy on endometriosis is limited, one study of 9,514 American and Chinese breast cancer survivors showed a statistically significant inverse correlation between reduced recurrence of breast cancer [16] and soy consumption due to phytoestrogen action.
As we have seen, a low-fat diet is also considered essential. One systematic review concluded that diets rich in saturated fat have a negative effect on endometriosis [17]. The NHSII prospective cohort study of 116,430 registered nurses showed that women with a laparoscopic-confirmed endometriosis diagnosis had a greater risk of high cholesterol and high blood pressure [18].
In conclusion, endometriosis can be a debilitating disease that affects fertility, comfort, and overall quality of life in women. Pharmacological and surgical treatments may address symptoms, but do not solve endometriosis and may lead to serious side effects and complications. A low-fat, high-fiber diet can lower circulating estrogen, weight, and cardiac issues associated with the disease. This includes fruit, vegetables, whole grains and legumes. Foods high in fat, red meat, and dairy should be avoided. For women with endometriosis, a strict low-fat, high-fiber dietary pattern may offer effective prevention and treatment without troublesome complications.
References:
1. Centers for Disease Control and Prevention. (2024). Common reproductive health concerns for women. https://www.cdc.gov/reproductive-health/women-health/common-concerns.html
2. Tsamantioti, E. S., & Mahdy, H. (2023). Endometriosis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK567777/
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5. Shaw, E., Farris, M., McNeil, J., & Friedenreich, C. (2016). Obesity and endometrial cancer. Obesity and cancer, 107-136. https://doi.org/10.1016/j.ejogrb.2004.11.019
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7. Marjoribanks, J., Ayeleke, R. O., Farquhar, C., & Proctor, M. (2015). Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. The Cochrane Database of Systematic Reviews, 2015(7), CD001751. https://doi.org/10.1002/14651858.CD001751.pub3
8. Barnard, N. D., Holtz, D. N., Schmidt, N., Kolipaka, S., Hata, E., Sutton, M., ... & Kahleova, H. (2023). Nutrition in the prevention and treatment of endometriosis: A review. Frontiers in Nutrition, 10, 1089891.
9. Drugs.com. (2023). Danazol. https://www.drugs.com/danazol.html#side-effects
10. Bafort, C., Beebeejaun, Y., Tomassetti, C., Bosteels, J., & Duffy, J. M. (2020). Laparoscopic surgery for endometriosis. The Cochrane database of systematic reviews, 10(10), CD011031. https://doi.org/10.1002/14651858.CD011031.pub3
11. Namnoum, A. B., Hickman, T. N., Goodman, S. B., Gehlbach, D. L., & Rock, J. A. (1995). Incidence of symptom recurrence after hysterectomy for endometriosis. Fertility and sterility, 64(5), 898-902.
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13. Stepinski, J. (2025, March). Implications on health: The lurking quandaries of dairy. A Nurse’s Perspective, 4(3), p. 2.
14. Szczepanik, J., & Dłużewska, M. (2024). The Importance of Diet in the Treatment of Endometriosis. Women, 4(4), 453-468.
15. Makki, K., Deehan, E. C., Walter, J., & Bäckhed, F. (2018). The impact of dietary fiber on gut microbiota in host health and disease. Cell Host & Microbe, 23(6), 705-715. https://doi.org/10.1016/j.chom.2018.05.012
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17. Marcinkowska, A., & Górnicka, M. (2023). The role of dietary fats in the development and treatment of endometriosis. Life, 13(3), 654.
18. Mu, F., Rich-Edwards, J., Rimm, E. B., Spiegelman, D., Forman, J. P., & Missmer, S. A. (2017). Association between endometriosis and hypercholesterolemia or hypertension. Hypertension, 70(1), 59-65.